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'

This article provides a commentary to Ole Norheim’s editorial entitled “Ethical perspective: Five unacceptable trade-offs on the path to universal health coverage.” It reinforces its message that an inclusive, participatory process is essential for ethical decision-making and underlines the crucial importance of good governance in setting fair priorities in healthcare. Solidarity on both national and international levels is needed to make progress towards the goal of universal health coverage (UHC).

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. UHC as a major global health goal is not only a political, but also an ethical endeavor. The WHO, as the United Nations specialized agency for international public health, has a unique mandate and longstanding history of advocating for access to healthcare for all. WHO's 1946 Constitution proclaimed as one of its basic value statements that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. " 2 In 1978, the Declaration of Alma Ata called for primary healthcare for all people, 3

and WHO's 2008 World
Health Report re-emphasized the commitment to primary healthcare. 4 For the last few years, motivated by a firm belief in the ethical principle of fair access to health services for all, the push for UHC has been on top of WHO's agenda. In fact, in 2013, WHO's Director-General Margaret Chan stated that "… I regard universal coverage as the single most powerful concept that public health has to offer…. It operationalizes the highest ethical principles of public health. It is a powerful social equalizer and the ultimate expression of fairness. " [1]

Solidarity and Universal Health Coverage
Besides the key ethical concepts of fairness, equity, and benefit maximization put forward in Norheim's article and the WHO report "Making fair choices on the path to universal health coverage, " 5 solidarity is an important underlying concept that can help explain and justify the drive for reaching UHC both at national as well as international levels. The Charter of Fundamental Rights of the European Union includes its provisions for access to healthcare under the section of "Solidarity": "…Everyone has the right of access to preventive healthcare and the right to benefit from medical treatment under the conditions established by national laws and practices…. " 6 Similarly, in other social and cultural contexts, concepts like neighborliness (eg, in New Zealand 7 ) and Ubuntu (South Africa) are deeply rooted in local values and motivate mutual action towards a collective goal. A recent influential report by Prainsack and Buyx, (published by the British Nuffield Council on Bioethics) on solidarity defines it as "shared practices reflecting a collective commitment to carry 'costs' (financial, social, emotional or otherwise) to assist others. " 8 Although there is no consensus on a precise definition of "solidarity, " in different forms it is a key underlying notion of many healthcare and social systems throughout the world and provides the moral basis for financing mechanisms such as redistribution and pooling of funds, as well as progressive revenue raising. 9 If any further proof was needed, the recent epidemic of Ebola virus disease clearly demonstrated the crucial need for national as well as international solidarity in support of failing health systems. The international community witnessed once more that the global response to epidemics can only be as strong as its weakest link in a country, as distant as it may seem. It is widely recognized that the limited capacity of health systems in Guinea, Liberia, and Sierra Leone greatly facilitated the rapid spread of Ebola. Consequently, major efforts are now underway to support countries in increasing the resilience of their respective health systems to future potential threats, 10 which is fully in line with the WHO Constitution: "The achievement of any State in the promotion and protection of health is of value to us all. " 2 However, the international community does not only have self-interested reasons for working towards strong health systems in all countries, but also a moral obligation to support lower-and middle-income countries in the promotion of UHC. 11 Retrospectively, the Alma Ata Declaration can be seen as essentially a call for global solidarity: "All countries should cooperate in a spirit of partnership and service to ensure primary healthcare for all people, since the attainment of health by people in any one country directly concerns and benefits every other country. " 3

The Need for Participatory Processes and Good Governance at Country Level
Norheim clearly lays out the arguments that some policyoptions, while theoretically possible, are in fact unfair and out of bounds from an ethical perspective, eg, coverage for lowor medium-priority services before there is near universal coverage for high-priority services. In addition, his article and the WHO Consultative Group on Equity and UHC rightly argue that public accountability and participation are crucial prerequisites for fair priority-setting. People and communities should not only be put at the center of health services provision, they should also be engaged in decisions on which services are provided, and with which level of quality. 12 Besides the principle of solidarity, good governance at country level must be regarded as a cornerstone of the movement towards UHC. While there is no universally accepted definition of "good governance, " and some indeed prefer the term "effective governance, " the general consensus is that the governance function characterizes a set of processes to distribute responsibility or accountability among the actors of the health system. 13 Although fair priority-setting is clearly needed, the fiscal space also needs to be enlarged, both in absolute terms, but also through the transparent use of available funds, even if they are deficient. Not only do many countries still lag behind the internationally recommended levels of spending on healthcare, but unfortunately, the health sector often suffers from unethical practices and leakages out of the health system. The corruption found in the health sector is often a reflection of more general problems of governance in the public sector. Corruption and fraud due to lack of effective governance mechanisms have been found to be among the top ten causes of health system inefficiency, 14 and an estimated 10%-25% of public spending on health linked to procurement is lost to corrupt practices. 15 These practices also decrease the volume and increase the cost of the provided services and have been shown to have a direct impact on health outcomes. 16 WHO has developed a number of important initiatives to promote transparency and good governance, eg, regarding health technology assessment and managing health workforce migration. In the pharmaceutical sector, already in 2004 the "Good Governance for Medicines" programme was started, an initiative which aims at promoting transparency and ethical practices in the pharmaceutical sector, and which by now has been embraced by 37 countries. 17 The concept of good governance is a core element of the implementation of resolution WHA64.9 on UHC and the improvement of equitable and sustainable access to quality assured medicines in countries. 18 Similar initiatives are needed beyond the pharmaceutical sector for health systems more generally in order to facilitate accountability to the public and participation in priority-setting. 19 It is crucial that countries base their decision-making on the principles of good governance, accountability, transparency, and fairness. 20 Finally, in addition to good governance in the health sector, there is a need for better coordination and governance between related sectors which are key for tackling the social, economic, environmental, and political determinants of health ("health in all policies"). 21

The Need for Ethics Capacity-Building in Countries
Norheim's editorial and the underlying work describe an essential and innovative theoretical framework and important arguments at an opportune moment in the history of UHC. While some trade-offs are clearly unacceptable from an ethical perspective, policy-makers will still have to make difficult choices in progressing towards UHC. In practice, in order to facilitate ethical priority-setting on the path to UHC at country level, policy-makers will need to engage meaningfully with key stakeholders and communities, and to promote good governance in their countries. There is a need for professionals who can facilitate and ensure a fair, deliberative process and its management. Yet many countries still suffer from a lack of adequate capacity in health ethics. While most, if not all countries now have ethics committees for the review of research with human subjects, few will have knowledge in public health ethics and ethical questions related to resource allocation and priority-setting. This is why there is a great need for capacity-building in this area. Where they exist, National Ethics Committees have potentially an important role to play in the adaptation of the WHO report on "Fair Choices, " as well as in the training of human resources and the ethical implementation of UHC. Based on global solidarity, countries should support each other in working towards reaching the goal of UHC in a fair way.