Ethics and equity in priority-setting

As countries worldwide explore health system reforms to progress toward UHC, policymakers face challenging, morally complex decisions about what and whom to cover with their limited health budgets. Because priority-setting is inherently driven by values, and decisions about whether to cover a health intervention have ethically important consequences for those in need of services, an ethics framework for priority-setting can be a critical tool to inform better decision making for health on the path to UHC. Attention to clearly defined ethics commitments can improve the design and delivery of a health benefits package across the entire policy cycle, including: setting strategic goals for UHC reforms, selecting the set of health services to cover, and measuring impacts on ethically important indicators — such as equity.

Chapter 13 in What’s In, What’s Out: Designing Benefits for Universal Health CoverageA Matter of Morality: Embedding Ethics and Equity in the Health Benefits Policyoffers a how-to guide for countries to develop ethics frameworks for priority-setting tailored to their specific contexts and policy objectives. The Chapter covers a range of ethics commitments that countries may want to adopt as they pursue UHC goals. These may include:

  • addressing various types of inequities
  • optimizing value-for-money through efficient health spending
  • enhancing evidence-based decision-making, and
  • assessing to how coverage decisions may affect other important aspects of wellbeing not directly related to health — such as social relationships, respect, and financial protection.

The Chapter also covers the need for evidence to inform ethics analyses, and how monitoring, evaluation, and learning activities for UHC policies and programs can be designed to enhance the evidence base and track progress on important ethics dimensions.

Why is ethical analysis important in priority-setting?

One particularly important function of ethical analysis in designing HBPs is to clarify and critically examine its aims or goals.

Careful consideration of ethics will safeguard the HBP from unintentionally introducing egregious harms or contributing to the exacerbation of existing inequities.

An ethics framework can help ensure that ethical considerations other than equity are not overlooked – such as dignity in healthcare provision, respect for patient autonomy, and how care delivery can impact and interact with the broader experience of disadvantage.

Ethical analysis will support development of a defensible package that not only takes account of political realities but also of ethical norms. Building careful assessment of ethical considerations into the policymaking process for the HBP will support the development of a package that is both morally sound and justifiable to the public.

Policymakers can demonstrate how ethical considerations informed their decisions and the processes they used to reach them, providing explicit moral rationales for selected courses of action and conferring legitimacy on the policy choices ultimately pursued.