The path from nowhere?

Framing the Problem The major intellectual framing of Making Fair Choices on the Path to Universal Health Coverage is implicit in its title. The report concerns fairness and efficiency 'on the path' to universal coverage. In other words, the approach is to think about securing universal coverage as a journey in which the task is to guide and steer the process in some directions rather than others, avoiding ethically unacceptable routes. The ultimate goal of a comprehensive, high quality system of universal health care without financial barriers to access is seen as central, but there is a sober realisation that compromises in practice will need to be made during the progressive realisation of that ideal. The report addresses some of the complex issues involved in those compromises, and one of its major contributions is to define various 'unacceptable trade-offs' to guide policy makers and policy choices. Unacceptable trade-offs are ways of balancing competing objectives in a way that threatens fundamental values. For example, the report argues, it is an unacceptable trade-off to expand coverage for low and medium priority services, that is to say services, like dialysis, that deliver relatively small health gains for their cost, before establishing near universal access for high priority services, like vaccines against tuberculosis. Similarly, the report argues that it is unacceptable to expand coverage for well-off groups before doing so for worse-off groups when the costs and benefits are not vastly different, including expanding coverage for those who are already highly covered before groups with lower coverage (pp. 38-40).