1. Introduction
Universal Health Coverage (UHC) involves all people receiving quality health services that meet their needs without being exposed to financial hardship in paying for them. Decisions on health financing for UHC – how to raise, pool and spend funds for this purpose – involve two aspects of fairness. Substantive fairness is equity in who gets what and in who pays for it. Procedural fairness, in contrast, is equity in how decisions are made – who can engage with decision-making, which information is used, whose opinions are heard and whose interests are considered and what weight they are given, as well as how decisions are justified and implemented. Substantive fairness is widely recognised as a central value in decision-making on the path to UHC, and prominent attempts have been made by international organisations to advance practical criteria of substantive equity (see, e.g., WHO, 2014). The Report Open and Inclusive: Fair Processes for Financing UHC aims for similar recognition of the importance of procedural fairness in health financing (World Bank, 2023). Specifically, it has three aims. First, to put forward a comprehensive account of procedural fairness in terms of foundational principles and practicable standards and show how these can be used to evaluate decision-making on every aspect of health financing (revenue raising, pooling and purchasing). Second, to explain the value of procedural fairness. Third, to provide insight into instruments that countries can use to improve procedural fairness in health financing.
The Report is a collaboration between the World Bank, the Norwegian Institute of Public Health and the Bergen Center for Ethics and Priority Setting in Health. Its development involved consultations with policymakers, health financing experts and researchers from low-, middle- and high-income countries. Its framework for procedural fairness is based on a scoping review of a multidisciplinary literature (Dale et al., Reference Dale, Peacocke, Movik, Voorhoeve, Ottersen, Kurowski, Evans, Norheim and Gopinathan2023). Its conclusions about the value and cost of open and inclusive decision-making as well as how it can be successfully pursued were informed by seven commissioned case studies of health financing decisions in Kerala (India), Mexico, South Africa, Tanzania, Thailand, The Gambia and Ukraine (Gopinathan et al., Reference Gopinathan, Dale and Evans2023). In the remainder of this paper, we summarise the Report's key findings.
2. Framework for procedural pairness
The proposed framework is represented in Figure 1. At its heart are three foundational principles: equality, impartiality and consistency over time. Equality calls for equal access to pertinent information, equal capacity for participants to express their views and an equal opportunity to influence decisions, regardless of factors that often create disparate abilities to do so. These include social and economic status, health, gender, sexual orientation, ethnicity and religious affiliation. It also requires that people's views are treated with respect, that is, taken seriously and evaluated on their merits. Respect does not require accepting a person's views as valid. Instead, it demands engagement with each participant as a potentially reasonable person who is entitled to contribute to decision-making, capable of putting forward a perspective worthy of serious consideration, and responsive to evidence and argument. Impartiality requires that decision processes are unbiased and that those with a personal or organisational interest in the decision do not unduly influence it. Consistency over time demands that the way in which decisions are made should be stable and predictable and should not change on an ad hoc basis.
Figure 1. A framework for procedural fairness.
These principles provide the inspiration for seven practical criteria for decision-making systems, which are organised in three domains. The information domain encompasses reason-giving, transparency and accuracy and completeness of information. In its strongest form, reason-giving involves a dialogue in which policymakers and stakeholders put forward their reasons for and against a policy, evaluate each other's reasons and freely revise their views in the light of this exchange on rationally acceptable grounds. Reason-giving may also take a more limited, monological form, in which decision-makers simply offer public justifications for their decisions. Transparency requires that key information is provided about the decision process and about what has been decided and for which reasons. It also requires that information about the implementation of decisions and their impact be made available. Finally, accuracy and completeness of information demands that the decision process draws on a range of sources of evidence, informed opinion and knowledge and assesses all this collected information by its likely degree of correctness.
The voice domain encompasses two criteria. Participation concerns the extent to which stakeholders and members of the public (or their representatives) can acquire and use pertinent information, communicate their views and get involved with the decision process. Inclusiveness demands that a wide range of viewpoints is acknowledged and scrutinised and that all relevant parties have an opportunity to put forward their conception of their own interests as well as their ideas of the common good. It also requires that governments reduce barriers to being able to join in that are faced by the poor and marginalised.
The oversight domain likewise comprises two criteria. Revisability requires that decision systems are open to new evidence and arguments and that there are avenues to challenge and reexamine decisions when adequate grounds for doing so are presented. Enforcement calls for structures that give teeth to the other practical criteria of procedural fairness and that provide assurance that decisions are in fact implemented.
The Report emphasises that procedural fairness is a matter of degree and that the relative importance of these criteria will depend on context and the nature of the decision.
3. Value of procedural fairness
The Report argues that procedural fairness can be valuable in four ways. First, it can advance substantive equity by mitigating one common source of inequitable outcomes, namely the fact that powerful, vested interests, if left unchecked, tend to use decision processes to their advantage and to the detriment of the marginalised.
Second, it can contribute to the legitimacy of health financing institutions. A fair process ensures that policy choices are justified through public reasons. It allows for public participation, thereby enhancing the democratic basis of decisions. It also tempers the degree to which those impacted by health financing policies are placed in an objectionably inferior position to those who determine these policies. For it ensures that decisions are made for shareable reasons rather than decision-makers' personal benefit, it safeguards equal, respectful consideration of interests and views, and creates mechanisms by which policymakers are accountable to citizens.
Third, procedural fairness builds trust because institutions in which open, inclusive decision-making is enforced offer the public assurance that pertinent evidence is weighed and interests are properly considered and that decisions, once made, are executed.
Fourth, procedural fairness can bolster the sustainability of reforms on the path to UHC. Fair public deliberation aims for consensus where it can be found, and decisions that are based on consensus are more likely to endure. Even where policy consensus is unattainable, the fact that an open and inclusive process was followed can lessen the resentment of those who would have preferred a different policy and can heighten their degree of acceptance of the selected policy.
While the Report and its associated case studies offer evidence that fairer procedures can be valuable in these ways, they also indicate that it is challenging to establish the socio-cultural conditions in which open and inclusive decision-making can succeed. For example, one such precondition is a modicum of trust in the willingness and ability of stakeholders and the public to engage in a deliberative process. The case study on the implementation of a new Programme of Medical Guarantees in Ukraine in 2017 shows that this precondition is not always met. Reformers were reluctant to engage with some stakeholders (in particular, leaders of associations of medical professionals) because they did not trust that they would participate in good faith (Dzhygyr et al., Reference Dzhygyr, Dale, Voorhoeve, Gopinathan and Maynzyuk2023).
Procedural fairness might also come at a considerable cost in terms of time and other resources. For example, the case study of South Africa's sugar tax revealed that the relatively high degree of public reason-giving that was achieved required substantial resources from the Treasury, which responded point-by-point to all public submissions received in response to their consultation (Kruger et al., Reference Kruger, Goldstein and Hofman2023).
4. Instruments for improving procedural fairness
The Report draws four general lessons about countries' use of tools to promote procedural fairness. First, regulation and legislation at every level are crucial. Valuable examples include foundational frameworks like South Africa's Constitution, laws that apply to the full public sector such as Ukraine's Freedom of Information Law and health-specific legislation such as the National Health Security Act in Thailand.
Second, legal and regulatory instruments need to be backed by adequate resources and capacity-building in the civil service and civil society. For example, in The Gambia, lack of knowledge among civil servants tasked with organising consultations on a new National Health Insurance scheme inadvertently led to the Nursing and Midwives Council (a regulatory body) being invited to participate, rather than the association representing nurses and midwives (Njie et al., Reference Njie, Dale and Gopinathan2023). In contrast, successful public involvement in coverage decisions in Thailand is the result of years of learning in the civil service and considerable expenditures to facilitate the participation of marginalised groups (Viriyathorn et al., Reference Viriyathorn, Sachdev, Suwanwela, Wangbanjongkun, Patcharanarumol and Tangcharoensathien2023).
Third, the nature of the decision matters to which criteria of procedural fairness are most important. For example, public participation is, fittingly, more often employed in decisions that determine which values should direct the construction of a health insurance system. In contrast, such participation is, naturally, less often employed in purely technical decisions that involve the use of expert knowledge within a pre-determined framework of values. In the latter type of case, criteria such as transparency and public reason-giving take on greater significance.
A central lesson of the Report is that in decision-making on the path to UHC, procedural fairness matters alongside substantive fairness. Decision systems should be assessed using a complete conception of procedural fairness that embodies core commitments to impartial and equal consideration of interests and perspectives. These commitments demand that: comprehensive information is gathered and disclosed and justifications for policies are publicly debated; participation in decision-making is enabled; decisions can be challenged and revised on valid grounds, but are otherwise implemented; and these characteristics of the decision system are institutionalised. Procedural fairness can improve equity in outcomes, raise legitimacy and trust and help make reforms last. While it can be challenging and costly to achieve more open and inclusive decision-making, the range of instruments that countries at varying levels of income and institutional capacity have used with some success shows that, in many contexts, advances in procedural fairness in health financing are possible and worthwhile.
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1. Introduction
Universal Health Coverage (UHC) involves all people receiving quality health services that meet their needs without being exposed to financial hardship in paying for them. Decisions on health financing for UHC – how to raise, pool and spend funds for this purpose – involve two aspects of fairness. Substantive fairness is equity in who gets what and in who pays for it. Procedural fairness, in contrast, is equity in how decisions are made – who can engage with decision-making, which information is used, whose opinions are heard and whose interests are considered and what weight they are given, as well as how decisions are justified and implemented. Substantive fairness is widely recognised as a central value in decision-making on the path to UHC, and prominent attempts have been made by international organisations to advance practical criteria of substantive equity (see, e.g., WHO, 2014). The Report Open and Inclusive: Fair Processes for Financing UHC aims for similar recognition of the importance of procedural fairness in health financing (World Bank, 2023). Specifically, it has three aims. First, to put forward a comprehensive account of procedural fairness in terms of foundational principles and practicable standards and show how these can be used to evaluate decision-making on every aspect of health financing (revenue raising, pooling and purchasing). Second, to explain the value of procedural fairness. Third, to provide insight into instruments that countries can use to improve procedural fairness in health financing.
The Report is a collaboration between the World Bank, the Norwegian Institute of Public Health and the Bergen Center for Ethics and Priority Setting in Health. Its development involved consultations with policymakers, health financing experts and researchers from low-, middle- and high-income countries. Its framework for procedural fairness is based on a scoping review of a multidisciplinary literature (Dale et al., Reference Dale, Peacocke, Movik, Voorhoeve, Ottersen, Kurowski, Evans, Norheim and Gopinathan2023). Its conclusions about the value and cost of open and inclusive decision-making as well as how it can be successfully pursued were informed by seven commissioned case studies of health financing decisions in Kerala (India), Mexico, South Africa, Tanzania, Thailand, The Gambia and Ukraine (Gopinathan et al., Reference Gopinathan, Dale and Evans2023). In the remainder of this paper, we summarise the Report's key findings.
2. Framework for procedural pairness
The proposed framework is represented in Figure 1. At its heart are three foundational principles: equality, impartiality and consistency over time. Equality calls for equal access to pertinent information, equal capacity for participants to express their views and an equal opportunity to influence decisions, regardless of factors that often create disparate abilities to do so. These include social and economic status, health, gender, sexual orientation, ethnicity and religious affiliation. It also requires that people's views are treated with respect, that is, taken seriously and evaluated on their merits. Respect does not require accepting a person's views as valid. Instead, it demands engagement with each participant as a potentially reasonable person who is entitled to contribute to decision-making, capable of putting forward a perspective worthy of serious consideration, and responsive to evidence and argument. Impartiality requires that decision processes are unbiased and that those with a personal or organisational interest in the decision do not unduly influence it. Consistency over time demands that the way in which decisions are made should be stable and predictable and should not change on an ad hoc basis.
Figure 1. A framework for procedural fairness.
These principles provide the inspiration for seven practical criteria for decision-making systems, which are organised in three domains. The information domain encompasses reason-giving, transparency and accuracy and completeness of information. In its strongest form, reason-giving involves a dialogue in which policymakers and stakeholders put forward their reasons for and against a policy, evaluate each other's reasons and freely revise their views in the light of this exchange on rationally acceptable grounds. Reason-giving may also take a more limited, monological form, in which decision-makers simply offer public justifications for their decisions. Transparency requires that key information is provided about the decision process and about what has been decided and for which reasons. It also requires that information about the implementation of decisions and their impact be made available. Finally, accuracy and completeness of information demands that the decision process draws on a range of sources of evidence, informed opinion and knowledge and assesses all this collected information by its likely degree of correctness.
The voice domain encompasses two criteria. Participation concerns the extent to which stakeholders and members of the public (or their representatives) can acquire and use pertinent information, communicate their views and get involved with the decision process. Inclusiveness demands that a wide range of viewpoints is acknowledged and scrutinised and that all relevant parties have an opportunity to put forward their conception of their own interests as well as their ideas of the common good. It also requires that governments reduce barriers to being able to join in that are faced by the poor and marginalised.
The oversight domain likewise comprises two criteria. Revisability requires that decision systems are open to new evidence and arguments and that there are avenues to challenge and reexamine decisions when adequate grounds for doing so are presented. Enforcement calls for structures that give teeth to the other practical criteria of procedural fairness and that provide assurance that decisions are in fact implemented.
The Report emphasises that procedural fairness is a matter of degree and that the relative importance of these criteria will depend on context and the nature of the decision.
3. Value of procedural fairness
The Report argues that procedural fairness can be valuable in four ways. First, it can advance substantive equity by mitigating one common source of inequitable outcomes, namely the fact that powerful, vested interests, if left unchecked, tend to use decision processes to their advantage and to the detriment of the marginalised.
Second, it can contribute to the legitimacy of health financing institutions. A fair process ensures that policy choices are justified through public reasons. It allows for public participation, thereby enhancing the democratic basis of decisions. It also tempers the degree to which those impacted by health financing policies are placed in an objectionably inferior position to those who determine these policies. For it ensures that decisions are made for shareable reasons rather than decision-makers' personal benefit, it safeguards equal, respectful consideration of interests and views, and creates mechanisms by which policymakers are accountable to citizens.
Third, procedural fairness builds trust because institutions in which open, inclusive decision-making is enforced offer the public assurance that pertinent evidence is weighed and interests are properly considered and that decisions, once made, are executed.
Fourth, procedural fairness can bolster the sustainability of reforms on the path to UHC. Fair public deliberation aims for consensus where it can be found, and decisions that are based on consensus are more likely to endure. Even where policy consensus is unattainable, the fact that an open and inclusive process was followed can lessen the resentment of those who would have preferred a different policy and can heighten their degree of acceptance of the selected policy.
While the Report and its associated case studies offer evidence that fairer procedures can be valuable in these ways, they also indicate that it is challenging to establish the socio-cultural conditions in which open and inclusive decision-making can succeed. For example, one such precondition is a modicum of trust in the willingness and ability of stakeholders and the public to engage in a deliberative process. The case study on the implementation of a new Programme of Medical Guarantees in Ukraine in 2017 shows that this precondition is not always met. Reformers were reluctant to engage with some stakeholders (in particular, leaders of associations of medical professionals) because they did not trust that they would participate in good faith (Dzhygyr et al., Reference Dzhygyr, Dale, Voorhoeve, Gopinathan and Maynzyuk2023).
Procedural fairness might also come at a considerable cost in terms of time and other resources. For example, the case study of South Africa's sugar tax revealed that the relatively high degree of public reason-giving that was achieved required substantial resources from the Treasury, which responded point-by-point to all public submissions received in response to their consultation (Kruger et al., Reference Kruger, Goldstein and Hofman2023).
4. Instruments for improving procedural fairness
The Report draws four general lessons about countries' use of tools to promote procedural fairness. First, regulation and legislation at every level are crucial. Valuable examples include foundational frameworks like South Africa's Constitution, laws that apply to the full public sector such as Ukraine's Freedom of Information Law and health-specific legislation such as the National Health Security Act in Thailand.
Second, legal and regulatory instruments need to be backed by adequate resources and capacity-building in the civil service and civil society. For example, in The Gambia, lack of knowledge among civil servants tasked with organising consultations on a new National Health Insurance scheme inadvertently led to the Nursing and Midwives Council (a regulatory body) being invited to participate, rather than the association representing nurses and midwives (Njie et al., Reference Njie, Dale and Gopinathan2023). In contrast, successful public involvement in coverage decisions in Thailand is the result of years of learning in the civil service and considerable expenditures to facilitate the participation of marginalised groups (Viriyathorn et al., Reference Viriyathorn, Sachdev, Suwanwela, Wangbanjongkun, Patcharanarumol and Tangcharoensathien2023).
Third, the nature of the decision matters to which criteria of procedural fairness are most important. For example, public participation is, fittingly, more often employed in decisions that determine which values should direct the construction of a health insurance system. In contrast, such participation is, naturally, less often employed in purely technical decisions that involve the use of expert knowledge within a pre-determined framework of values. In the latter type of case, criteria such as transparency and public reason-giving take on greater significance.
A central lesson of the Report is that in decision-making on the path to UHC, procedural fairness matters alongside substantive fairness. Decision systems should be assessed using a complete conception of procedural fairness that embodies core commitments to impartial and equal consideration of interests and perspectives. These commitments demand that: comprehensive information is gathered and disclosed and justifications for policies are publicly debated; participation in decision-making is enabled; decisions can be challenged and revised on valid grounds, but are otherwise implemented; and these characteristics of the decision system are institutionalised. Procedural fairness can improve equity in outcomes, raise legitimacy and trust and help make reforms last. While it can be challenging and costly to achieve more open and inclusive decision-making, the range of instruments that countries at varying levels of income and institutional capacity have used with some success shows that, in many contexts, advances in procedural fairness in health financing are possible and worthwhile.
Acknowledgements
We are grateful to Suzanne Bloks and Rocco Friebel for comments.
Financial support
Alex Voorhoeve's work on this paper was supported by the ‘Deliberation and Cohesion’ project, as part of the ‘Cohesive Capitalism’ programme at the London School of Economics and Political Science funded by the Open Society Foundation.
Competing interests
None.