Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage

Abstract

This article discusses what ethicists have called "unacceptable trade-offs" in health policy choices related to universal health coverage (UHC). Since the fiscal space is constrained, trade-offs need to be made. But some trade-offs are unacceptable on the path to universal coverage. Unacceptable choices include, among other examples from low-income countries, to expand coverage for services with lower priority such as coronary bypass surgery before securing universal coverage for high-priority services such as skilled birth attendance and services for easily preventable or treatable fatal childhood diseases. Services of the latter kind include oral rehydration therapy for children with diarrhea and antibiotics for children with pneumonia. The article explains why such trade-offs are unfair and unacceptable even if political considerations may push in the opposite direction.

Universal Health Coverage – The Critical Importance of Global Solidarity and Good Governance Comment on "Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage"

“…AAR is the single author of the paper. [1] Remarks of Dr. Margaret Chan at a WHO/World Bank ministerial-level meeting on UHC in Geneva on February 18, 2013.…”

“…I n his editorial, 1 Norheim argues that policy decisions relating to universal health coverage (UHC) are fraught with ethical dilemmas and involve difficult trade-offs for health policy-makers. The author, former Chairperson of the World Health Organization's (WHO's) Consultative Group on Equity and Universal Health Coverage, reminds the reader that there is an urgent need to frame UHC not only in economic (financing) terms but to place it within a rigorous ethics framework, as countries address difficult prioritysetting issues in moving towards UHC.…”

Achieving Universal Health Coverage by Focusing on Primary Care in Japan: Lessons for Low- and Middle-Income Countries

“…[1][2][3] Hard decisions must be made to deny services which are effective, but not cost-effective, in order to stay within the budget. In practical terms, it would mean prioritizing primary care in rural areas over specialist services in big urban hospitals.…”

Defining Pathways and Trade-offs Toward Universal Health CoverageComment on "Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage"

“…Yet, in both the debate on the practical implications of UHC and the discourse of the SDGs, there is limited emphasis on the "budget constraint. " In other words, we find little discussion of the fact that these grand objectives would have to be fulfilled with highly restricted financial resources, and that therefore, difficult choices and politically sensitive tradeoffs, such as the ones described by Norheim,3 would have to be examined. With five case studies, Norheim 3 forcefully illustrates some of the difficult real-world situations which may be faced by policy-makers on the way to UHC.…”

“…In other words, we find little discussion of the fact that these grand objectives would have to be fulfilled with highly restricted financial resources, and that therefore, difficult choices and politically sensitive tradeoffs, such as the ones described by Norheim,3 would have to be examined. With five case studies, Norheim 3 forcefully illustrates some of the difficult real-world situations which may be faced by policy-makers on the way to UHC. Even before ethical considerations are addressed, his descriptions fundamentally point us to the critical importance of the budget constraint, an essential element for decision-makers in charge of allocating resources on the way toward UHC.…”