Ethical Issues on the Path to Universal Coverage

Nine questions for the WHO Consultative Group on Ethical Issues in UC

Ole F. NorheimProfessor in Medical Ethics and Philosophy of Science

Dept. of Global Public Health and Primary CareUniversity of Bergen

ole.norheim@igs.uib.no

T h e e t h i c s o f p r i o r i t y s e t t i n g i n g l o b a l h e a l t h

Coverage of antiretroviral therapy among people with advanced HIV infection (CD4 < 350): 56 % (Ethiopia: WHO Global Health Observatory, 2013)

Coverage for antibiotics for children with suspected pneumonia: < 10% (EDHS, 2011)

Coverage for antihypertensiva: < 10% (Tesfaye F. Umeå University, 2008)

Source: World Bank. 2012. Health Equity and Financial Protection Datasheet. Washington D.C: World Bank

Three simple questions

1. Is it fair that people pay a large proportion of the costs for key services out-of-pocket?

2. Is it fair that coverage is far below 100% for so many key services?

3. Is it fair if some citizens have access to open heart surgery while others do not have access to key priority services like treatment for pneumonia?

Three hard questions

1. Should governments reduce direct payments or expand services?

2. Should governments include more people or expand services?

3. Should governments include more people or reduce direct payments?

Three even harder questions

1. What criteria for including more people for key services?

• Priority to sickest, the poor, the marginalized, those hard to reach?• Civil servants, military personnel, labor force, farmers

2. How to rank and choose key services?• Cost-effectiveness?• Priority to the worse off?• Financial risk protection?

3. For which patient groups should direct payments for key services be reduced first?

• The lowest quintile?• Everyone?