Fairness in service choice: an important yet underdeveloped path to universal coverage.

Achieving universal coverage – defined as access to needed health services without the associated risk of financial hardship (World Health Organization 2010) – is at the core of international discussion on strengthening health systems and the struggle to achieve the health MDGs. WHO’s most recent World Health Report (WHR) ‘Health systems financing: the path to universal coverage’ (World Health Organization 2010) highlights the importance of strengthening health systems and health financing mechanisms to ensure access to services for everyone. As argued in the WHR, universal coverage incorporates three dimensions: population coverage, service coverage and cost coverage. Although the definition of universal coverage requires that all three dimensions eventually be satisfied, they are conceptually distinct and choices about which to privilege will define distinct paths to achieving universal coverage. Current discussions (e.g. in the WHR) have focused on how to achieve coverage of a greater proportion of the population and protection from the financial consequences of ill health through prepayment and pooling of resources, thereby concentrating on population and cost coverage (World Health Organization 2010). We believe that consideration of factors related to service coverage i.e. ‘which services are covered’, and ‘for which services should coverage be improved’ should also play a critical role in setting policy directions, as the choice of services has a profound impact on the coverage by the health system. Obviously, a choice to use mobile clinics in HIV/AIDS control much improves service coverage among remote areas. Likewise, a choice to provide food subsidies to foster the adherence to antiretroviral treatment improves service coverage among the poor. Prioritizing services that target disadvantaged groups in society, even if more costly, may be a fairer way to foster universal coverage. This strategy goes one step further than what is advocated in the WHR, ensuring access to the same services for all. It recognizes the important principle of fairness in health that all people – irrespective of health status and socio-economic status – should have as much of a fair chance to live a healthy life (Daniels 2008). In other words, we flag an important but yet underdeveloped path to universal coverage – through fairness in service choice. Fairness in service choice may require that policy makers give higher priority to those in rural areas that are hard to reach, to the youngest who have enjoyed least life years, to the poorest who disproportionally die from pneumonia, diarrhoea or malaria – compared to older, richer and less hard-to-reach persons with increased risk of cardiovascular disease. For example, researchers from the Lives Saved Tool collaboration have estimated that in Burkina Faso, Ghana and Malawi achieving national coverage targets for just four or five high-impact childhood interventions could reduce under-five mortality by at least 20% by 2011, relative to 2006 levels (Bryce et al. 2010). In Malawi, current coverage for treatment with antibiotics for pneumonia is only 29%, treatment with ORS and zinc for diarrhoea is 55%, malaria prevention with insecticidetreated nets is 23% and malaria treatment with artemisinin combination therapy (ACT) is 27%. The national coverage target for pneumonia is 67%, for diarrhoea 85%, for mosquito nets and ACTs 69% (Bryce et al. 2010). These are all feasible and cost-effective strategies with high impact on child mortality. Contrast this with improving coverage for treatment of hypertension among the adult, urban, richer population of the capital Lilongwe. Offpatent antihypertensive drugs may be equally cost-effective in Malawi as the above-mentioned strategies to reduce child mortality (Robberstad et al. 2007). For which services should coverage be improved? Tropical Medicine and International Health doi:10.1111/j.1365-3156.2011.02780.x