Priorities are then implemented through clinical practice guidelines and reimbursement rules. In the UK, the National Institute for Health and Care Excellence (NICE) identifies the most cost-effective services through health technology assessment, aiming to be open and accountable whilst taking social value judgments into consideration, as recommended by their Citizen’s Council. WHO and the World Bank have championed cost-effectiveness as a key criterion for global and national priority setting. Priority setting ranks services according to their importance and will therefore, by necessity, determine the distribution of services in such a way that it creates winners and losers. Most ethicists even argue that it is unethical to ignore it indeed, since healthcare needs exceed resource availability, not setting priorities may lead to unfairness. Priority setting is therefore unavoidable on the path to UHC. This is a radical message – given resource constraints, essential health services cannot entail all possible services but rather a comprehensive range of key services that are well-aligned with other social goals. The Director General of the World Health Organization (WHO) recently said that “ UHC is the ultimate expression of fairness” and defined it as “ ensuring that everyone can obtain essential health services of high quality without suffering financial hardship”. The most important sub-target and instrument to reach the remaining targets is universal health coverage (UHC). In 2015, UN Member States signed Sustainable Development Goal 3: Good health and well-being. Avoiding premature mortality is no longer impossible for the majority of people in high-income countries, while the bottom billion still lag behind. Worldwide, people now have a reasonable expectation of living long and healthy lives. In conclusion, countries need to agree on criteria and establish transparent and fair priority setting processes. This commentary also discusses a third group of contested criteria, including rare diseases, small health benefits, age, and personal responsibility for health, subsequently rejecting them. Inequalities in health outcomes associated with such personal characteristics are therefore unfair and should be minimized. It is considered unacceptable to treat people differently according to their gender, race, ethnicity, religion, sexual orientation, social status, or place of residence. Thus, a fair health system will expand coverage for cost-effective services and give extra priority to those benefiting the worse-off, whilst at the same time providing high financial risk protection. Three criteria for priority setting are widely accepted among ethicists: cost-effectiveness, priority to the worse-off, and financial risk protection. Can priority setting ever be fair and ethically acceptable? Fairness requires that unmet health needs be addressed, but in a fair order. All countries experience a gap between their population’s health needs and what is economically feasible for governments to provide. Priority setting is inevitable on the path towards universal health coverage.
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