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

Document Type : Editorial


Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway


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.


Commentaries Published on this Paper

  • 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”

          Abstract | PDF

  • Defining Pathways and Trade-offs Toward Universal Health Coverage; Comment on “Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage”

          Abstract | PDF

  • Policy Choices for Progressive Realization of Universal Health Coverage; Comment on “Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage”

          Abstract | PDF


Main Subjects

World Health Organization (WHO). Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage. Geneva: WHO; 2014.
Voorhoeve A, Ottersen T, Norheim OF. Response to our critics. Health Econ Policy Law. 2015. doi:10.1017/S1744133114000590
Voorhoeve A, Ottersen T, Norheim OF. Making fair choices on the path to universal health coverage: a précis. Health Econ Policy Law. 2015. doi:10.1017/S1744133114000541
Rawls J. A Theory of Justice. Cambridge, MA: Harvard University Press; 1999.
Daniels N. Just Health: Meeting Health Needs Fairly. Cambridge: Cambridge University Press; 2008.
Sen A. Why health equity? Health Econ. 2002;11:659-666.
World Health Organization (WHO). Health Systems Financing: The Path to Universal Coverage. Plan of Action. Geneva: WHO; 2011.
Chan M. Universal coverage is the ultimate expression of fairness. Acceptance speech at the Sixty-fifth World Health Assembly, Geneva, Switzerland, 23 May 2012. Accessed June 13, 2013.
Frenz P, Vega J. Universal health coverage with equity: what we know, don't know and need to know. Published 2010.
United Nations Children's Fund (UNICEF). National health insurance in Asia and Africa: Advancing equitable Social Health Protection to achieve universal health coverage. Published 2012.
Eyal N, Norheim OF, Hurst SA, Marchand S, Wikler D. Inequalities and inequities in health. In: Eyal N, Norheim OF, Hurst SA, Wikler D, eds. Inequalities in Health: Concepts, Measures, and Ethics. New York: Oxford University Press; 2013:1-10.
Lippert-Rasmussen K, Eyal N. Equality and egalitarianism. In: Chadwick R, ed. Encyclopedia of Applied Ethics. Vol 2. 2nd ed. San Diego: Academic Press; 2012:141-148.
Parfit D. Equality or Priority? Kansas: University of Kansas; 1995.
Brock DW. Priority to the worse off in health-care resource prioritization. In: Rhodes R, Battin MP, Silvers A, eds. Medicine and Social Justice: Essays on the Distribution of Health Care. New York: Oxford University Press; 2002:362-372.
Williams A. Intergenerational equity: An exploration of the 'fair innings' argument. Health Econ. 1997;6(2):117-132.
Wolff J. The Human Right to Health. New York: WW Norton & Co; 2012.
Ottersen T. Lifetime QALY prioritarianism in priority setting. J Med Ethics. 2013;39:175–180. doi:10.1136/medethics-2012-100740 
UN General Assembly. International Covenant on Economic, Social and Cultural Rights; 1966.
Tobin J. The Right to Health in International Law. Oxford: Oxford University Press; 2012.
Potts H. Accountability and the right to the highest attainable standard of health. Human Rights Centre, University of Essex; 2008.
World Health Organization (WHO). Universal Health Coverage: Supporting Country Needs. Geneva: WHO; 2013.
Schmidt H, Gostin L, Emanuel E. Public health, universal health coverage, and Sustainable Development Goals: can they coexist? Lancet. 2015;386(9996):928-930. doi:10.1016/S0140-6736(15)60244-6
O'Connell T, Rasanathan K, Chopra M. What does universal health coverage mean? Lancet 2014;383(9913):277-279. doi:10.1016/S0140-6736(13)60955-1
World Health Organization (WHO). Social health insurance: Sustainable health financing, universal coverage and social health insurance. Geneva: WHO; 2005.
World Health Organization (WHO). World Health Report. Health systems financing: The path to universal coverage. Geneva: WHO; 2010.
Daniels N, Sabin JE. Setting Limits Fairly: Learning to Share Resources for Health. 2nd ed. Oxford: Oxford University Press; 2008.
Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet. 2000;356(9235):1093-1098. doi:10.1016/S0140-6736(00)02741-0
Jamison D, Summers L, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet. 2013;382:1895-1955. doi:10.1016/S0140-6736(13)62105-4
Yamin AE. Will we take suffering seriously? Reflections on what applying a human rights framework to health means and why we should care. Health Hum Rights. 2008;10(1):45-63.