Ethical priority setting for universal health coverage: challenges in deciding upon fair distribution of health services

Norheim BMC Medicine (2016) 14:75 DOI 10.1186/s12916-016-0624-4 COMMENTARY Open Access Ethical priority setting for universal health coverage: challenges in deciding upon fair distribution of health services Ole F. Norheim1,2 Abstract Priority setting is inevitable on the path towards universal health coverage. All countries experience a gap between their population’s health needs and what is economically feasible for governments to provide. Can priority setting ever be fair and ethically acceptable? Fairness requires that unmet health needs be addressed, but in a fair order. Three criteria for priority setting are widely accepted among ethicists: cost-effectiveness, priority to the worse-off, and financial risk protection. Thus, a fair health system will expand coverage for cost-effective services and give extra priority to those benefiting the worse-off, whilst at the same time providing high financial risk protection. It is considered unacceptable to treat people differently according to their gender, race, ethnicity, religion, sexual orientation, social status, or place of residence. Inequalities in health outcomes associated with such personal characteristics are therefore unfair and should be minimized. This commentary also discusses a third group of contested criteria, including rare diseases, small health benefits, age, and personal responsibility for health, subsequently rejecting them. In conclusion, countries need to agree on criteria and establish transparent and fair priority setting processes. Keywords: Ethics, Priority setting, Global health, Universal health coverage, Health technology assessment, Health economics Background Worldwide, people now have a reasonable expectation of living long and healthy lives [1]. Avoiding premature mortality is no longer impossible for the majority of people in high-income countries, while the bottom billion still lag behind [2, 3]. In 2015, UN Member States signed Sustainable Development Goal 3: Good health and wellbeing. The most important sub-target and instrument to reach the remaining targets is universal health coverage (UHC). The Director General of the World Health Organization (WHO) recently said that “UHC is the ultimate expression of fairness” and defined it as “ensuring that everyone can obtain essential health services of high quality without suffering financial hardship” [4]. Correspondence: 1 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway 2 Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA This is a radical message – given resource constraints, essential health services cannot entail all possible services but rather a comprehensive range of key services that are well-aligned with other social goals. Priority setting is therefore unavoidable on the path to UHC. Most ethicists even argue that it is unethical to ignore it; indeed, since healthcare needs exceed resource availability, not setting priorities may lead to unfairness. Priority setting ranks services according to their importance and will therefore, by necessity, determine the distribution of services in such a way that it creates winners and losers. How is this done? WHO and the World Bank have championed costeffectiveness as a key criterion for global and national priority setting [5, 6]. In the UK, the National Institute for Health and Care Excellence (NICE) identifies the most cost-effective services through health technology assessment, aiming to be open and accountable whilst taking social value judgments into consideration, as recommended by their Citizen’s Council. Priorities are then © 2016 Norheim. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Norheim BMC Medicine (2016) 14:75 Page 2 of 4 implemented through clinical practice guidelines and reimbursement rules [7]. In Thailand, the Health Intervention and Technology Assessment Program (HITAP) appraises a wide range of health technologies and public health programs by six criteria: size of the population affected, severity of the disease, effectiveness of health interventions, variation in practice, economic impact on household expenditure, and equity and social implications [8]. In some Latin American countries, including Colombia, Brazil, and Costa Rica, the courts have intervened and ruled that the right to health or healthcare should be the overriding concern [9]. In the US and Germany, comparative effectiveness analysis is widely performed, but cost-effectiveness analysis is not accepted or is seen as unethical [10, 11]. Needless to say, priority setting decisions are controversial in all countries, highlighting the need for clarity and further agreement with regards to priority-setting criteria and processes. The present commentary aims to describe and discuss criteria for fair and ethical priority setting, building on two guidance documents developed by ethicists, economists, health policy experts, and public health and clinical doctors [12, 13]; nevertheless, the views expressed here are my own. The commentary lists three widely accepted cross-cutting criteria and a group of largely unaccepted criteria for priority setting (Table 1), followed by a discussion and rejection of a group of contested criteria. Finally, it argues that countries need transparent processes for priority setting. Discussion Priority setting occurs at the macro-, meso-, and microlevel of decision making, with a multitude of criteria that could be relevant and have different weights at the various levels. Three widely accepted criteria for ethical priority setting There is agreement among ethical theories that priority setting should be impartial and treat people as equals. There is growing consensus that the aims should be to Table 1 Criteria for priority setting Accepted criteria Unacceptable criteria Contested criteria Cost-effectiveness Gender Size of the population affected (rarity) Priority to the worse-off Race Size of the benefit (very small benefits are ‘irrelevant’) Financial risk protection Ethnicity Age Religion Responsibility for own health Sexual orientation Social status Area of residence promote health maximization, fair distribution, and protection against poverty [12, 13]. From these guiding principles three criteria for ethical priority setting arise, namely (1) cost-effectiveness, (2) priority to the worseoff, and (3) financial risk p (...truncated)