Open and inclusive: Fair processes for financing universal health coverage © 2023 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 www.worldbank.org All rights reserved. This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank, with external contributions. The findings, interpretations, and conclusions expressed in this volume do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Citation Please cite this work as follows: World Bank. 2023. 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Cover design: Publicis Kitchen Cover image: © Panuwat Sikham/GettyImages Editorial design: Publicis Kitchen 2 Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 List of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 About this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.1 The case for fair process in health financing for universal health coverage . . . . . . . . . . . . . . . . . . . . . . . 12 1.2 Human rights as the moral and legal foundation for fairer processes in health financing . . . . . . . . . . . . 14 1.3 Fair processes in health financing: strengthening decision support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.4 Report objectives, methodology, and structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2. Health financing decisions with equity implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 2.1 Revenue mobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 2.2 Pooling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2.3 Purchasing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3. What is a fair process? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.1 Principles and criteria for fair processes in financing UHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.2 Policy context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.3 Implementing participation and inclusiveness: differentiating between directional and technical decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 4. Principles and criteria in practice: examples from country experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 4.1 Legislative and regulatory instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 4.2 Organizational arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 4.3 Financing and capacity strengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 4.4 Information management and monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.5 Global initiatives and external support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.6 General observations from country experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 5. The way forward: working together for fairer decisions on the path to UHC . . . . . . . . . . . . . . . . . . . . . . . . . 39 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 3 List of Figures Figure ES1 Principles and operational criteria of procedural fairness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Figure 1 Principles and criteria for procedural fairness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 List of boxes Box 1 In focus: Public participation and inclusiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 List of Tables Table 1 Revenue mobilization decision types and equity implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Table 2 Pooling decision types and equity implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Table 3 Purchasing decision types and equity implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table 4 Principles for fair processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Table 5 Criteria for fair processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table 6 Policy instruments for promoting procedural fairness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 4 Acknowledgments This report was prepared by a team from the Health, Nutrition and Population (HNP) Global Prac- tice of the World Bank (WB), the Norwegian Institute of Public Health (NIPH), and the Bergen Centre for Ethics and Priority Setting (BCEPS) at the University of Bergen in Norway, under the overall guidance of the HNP Global Director Juan Pablo Uribe. The core report team comprised Christoph Kurowski and David B. Evans (WB); Unni Gopinathan, Elina Dale and Trygve Ottersen (NIPH); Ole F. Norheim and Alex Voorhoeve (BCEPS). The extended team included Steve French, Espen Movik and Elizabeth Peacocke (NIPH). The report would not have been possible without extensive inputs from the following experts during successive expert consultations: Kalipso Chalkidou (The Global Fund to Fight AIDS, Tuberculosis and Malaria); Lydia Baaba Dsane-Selby (National Health Insurance Authority, Ghana); Yuriy Dzhygyr (independent consultant); Tessa Tan-Torres Edejer (WHO); Getachew Teshome Eregata (Federal Ministry of Health of Ethiopia); Oyebanji Filani (Ministry of Health & Human Services, Government of Ekiti State, Nigeria); Karen A. Grépin (School of Public Health, University of Hong Kong); Eduardo Gonzalez-Pier (Palladium, USA); Ayako Honda (Hitotsubashi Institute for Advanced Study, Hitotsubashi University); Gita Sen (Ramalingaswami Centre on Equity & Social Determinants of Health, Public Health Foundation of India); Peter C. Smith (Centre for Health Economics, University of York); Viroj Tangcharoensathien (International Health Policy Program, Ministry of Public Health, Thailand); and Alicia Ely Yamin (Harvard University). Their participation in expert consultations played a key role in determining the direction and topics addressed by the report. The core report team benefited from their valuable guidance and their extensive comments on multiple iterations of the report. We especially thank Alicia Ely Yamin for providing the first draft of the section about the relationship between human rights and fair process and guiding subsequent revisions. The team also would like to thank Claudia Chwalisz (OECD), John S. Dryzek (Centre for Delib- erative Democracy and Global Governance, University of Canberra), and Erik Oddvar Eriksen (ARENA Centre for European Studies, University of Oslo) for reviewing early drafts and discuss- ing their comments during digital consultations. Their contributions on key concepts in deliber- ative democracy and new ways of engaging with citizens played an important role in informing the report. The report was greatly enriched by the insights and expertise of the authors of the case studies from India, Mexico, South Africa, Tanzania, Thailand, The Gambia, and Ukraine: Ramachandran Anju (Health Action by People, India); Ravi Prasad Varma (Sree Chitra Tirunal Institute for Medical Sciences and Technology, India); Krishnapillai Vijayakumar (Health Action by People, India); Rekha Melathuparambil Ravindran (Department of Health and Family Welfare, Government of Kerala, India); Rajeev Sadanandan (Health Systems Transformation Platform, India); Mariana Barraza-Lloréns and Rafael Adrián Arceo-Schravesande (Blutitude, Mexico); Eduardo González- Pier (Palladium, USA); Petronell Kruger, Susan Goldstein and Karen Hofman (South African 5 Medical Research Council/ Wits Centre for Health Economics and Decision Science, University of the Witwatersrand, South Africa); Peter Binyaruka and John Maiba (Ifakara Health Institute, United Republic of Tanzania); Gemini Mtei (USAID Public Sector Systems Strengthening Plus (PS3+) Project, United Republic of Tanzania); Shaheda Viriyathorn, Saranya Sachdev, Waritta Wangbanjongkun, Walaiporn Patcharanarumol and Viroj Tangcharoensathien (International Health Policy Program, Ministry of Public Health, Thailand); Waraporn Suwanwela (National Health Security Office, Thailand); Hassan Njie (Ministry of Health, The Gambia); Yuriy Dzhygyr and Katya Maynzyuk (independent consultants, Ukraine). The report benefited from inputs provided by the WBG HNP team, in particular Tseganeh Amsalu Guracha and Patrick Hoang-Vu Eozenou, during the internal consultation process. The authors also would like to thank the teams at the Department of Health Systems Governance and Financing and the Special Programme on Primary Health Care, Universal Health Coverage/ Life Course Division, World Health Organization for their detailed comments during the prepara- tion of the report. We especially thank Fahdi Dkhimi for coordinating this engagement. The authors would like to express special thanks to Alexander Irwin for thorough editing of the report. Without his support, the report would have been difficult to publish. Carmen del Rio Paracolls (WB) provided overall coordination to finalize the report. Alexandra Humme, Christina Michelle Nelson, and Dasan Norman Bobo (WB) supported external commu- nications. The report benefited from questions and comments received during various consultation and dissemination events, including the 13th International Society for Priorities in Health Conference (2022); the Annual Health Financing Forum (2022); an internal consultation event with Global Fund staff (2022); the London School of Economics Department of Philosophy, Logic and Scientific Method Workshop "Citizen Panels and Health Policy" (2022); and, finally, a public seminar on “Open and Inclusive: Fair Processes for Financing Universal Health Coverage” (2023) convened by the Norwegian Institute of Public Health, the World Bank and the Bergen Centre for Ethics and Priority Setting in partnership with the Norwegian Agency for Development Cooperation and the University of Oslo. Generous financial support was provided to the University of Bergen and the Norwegian Institute of Public Health by the Norwegian Agency for Development Cooperation (Norad) under the programme “Decision support for universal health coverage” (grant no. RAF-18/0009). The authors regret any individuals or organizations that may inadvertently have been omitted from these acknowledgments and express their gratitude to all who contributed to this report. 6 List of abbreviations A4R Accountability for Reasonableness PBAC Pharmaceutical Benefits Advisory Committee (Australia) CHF Community health fund (Tanzania) CHSB Council Health Services Boards (Tanzania) CSO Civil society organization CBTS County Budget Transparency Survey (Kenya) EHIF Estonian Health Insurance Fund HITAP Health Intervention and Technology Assessment Program (Thailand) HPL Health Promotion Levy (South Africa) HTA Health technology assessment IHPP International Health Policy Program (Thailand) IBP International Budget Partnership iCHF improved Community Health Fund (Tanzania) JCVI Joint Committee on Vaccination and Immunisation (United Kingdom) NHIS National Health Insurance Scheme (The Gambia) NHSO National Health Security Office (Thailand) NHSU National Health Service of Ukraine NICE National Institute for Health and Care Excellence (United Kingdom) NLGFC National Local Government Finance Committee (Malawi) OECD Organisation for Economic Co-operation and Development OOP Out-of-pocket payments PEFA Public Expenditure and Financial Accountability PMG Program of Medical Guarantees (Ukraine) SDGs Sustainable Development Goals SHI Social health insurance SIS Comprehensive Health Insurance (Peru) SSA Sub-Saharan Africa SSB Sugar-sweetened beverages UCS Universal Health Care Coverage Scheme (Thailand) UHC Universal health coverage UK United Kingdom UN United Nations UNHCR United Nations High Commissioner for Refugees WHO World Health Organization 7 About this report Who is this report for? financing and economics, law, ethics and philosophy, This report is written for policy makers and health finan- health policy). The report incorporates a comprehensive cing experts in ministries of health and finance, other literature review and original country case studies reflect- relevant government agencies, such as national purchasing ing different country income groups, geographic areas, agencies, and international development partners support- health financing arrangements, and types of health finan- ing health financing reforms. cing decisions. It also addresses members of civil society and researchers This report complements two earlier milestone pub- in the fields of economics, ethics, health financing pol- lications on fairness in health financing. The first, Making fair icy, and political theory who are interested in inter- choices on the path to universal health coverage (World Health disciplinary work that aims to support fairer processes in Organization 2014), analyzed critical choices that countries decision-making. face when advancing UHC across three key dimensions: expanding priority services, including more people, and What does this report contribute? reducing out-of-pocket payments. The second, the World This report has been developed to support countries across Bank’s 2018 report Equity on the Path to UHC: Deliberate different income levels and regions in building a fairer Decisions for Fair Financing, extended the logic of the World process around health financing decisions for universal Health Organization (WHO) publication to address equity health coverage (UHC). Its overarching aim is to provide in all areas of health financing (resource mobilization, policy makers with evidence on why fair processes matter; pooling, and purchasing) and identified specific types of what constitutes a fair process for health financing decisions in these domains that may worsen inequalities. decisions; and policy instruments that countries have used We recommend that our report be read with these earlier to advance fair processes in health financing. publications as a companion document. The report makes four main contributions. First, it clarifies How does this report address the diversity of the case for fair processes in decisions about health financing cultural and political contexts? on the path to UHC. To do so, it draws on sources from For many, the question of what a fair process involves diverse research disciplines, synthesizes their arguments, cannot yield a single, universal answer, but is shaped by and contextualizes them to health financing decision- historical, political, and cultural conditions. Thus, what is making. Second, it describes key health financing decisions proposed in this report may not be universally agreed. To that can improve or worsen inequalities across individuals be more responsive to the diversity of interpretations, this or groups in health service coverage or financial protection. report has pursued expert consultations involving wide The report argues that because of the important equity geographic, cultural, political, and disciplinary represen- implications, it is critical for policy makers to consider tation and framed its literature review and case studies to aspects of procedural fairness as they make these decisions. span diverse contexts. Third, the report offers principles and criteria for designing and assessing health financing processes and making them The report is based on the premise that it is valuable to fairer. It anchors its proposals in interdisciplinary research, understand what criteria could be used to define a fair expert consultations, and country case studies. Finally, the process, even when political realities in some settings report shows how countries are using diverse instruments prevent these criteria from being fully applied. Deliberation to operationalize fair process principles and criteria in health and decision-making about health financing are shaped by financing, something that policy makers in other countries the political environment and power asymmetries in socie- can use or adapt to their own settings to improve procedural ty — which differ widely between settings. An understand- fairness under real-world conditions. ing of stakeholder interests, value systems, and institutional structures in each setting is critical to be able to apply the How was this report developed? principles and criteria proposed by this report. Focusing The report builds on a series of consultations conducted on fair process does not mean that political dynamics and with a wide range of country policy makers, health financ- power imbalances are ignored. On the contrary, designing ing experts, and researchers from low-, middle- and high- decision-making processes that are fair and legitimate can income countries. The scholars and experts engaged span help to address some of these imbalances in the search for different disciplines and areas of expertise (e.g., health fairer outcomes. 8 Executive summary Does fairness matter? This report argues that, in key areas The concern for a fair process is motivated by the many of public policy making, it does. And that, in policy deci- potential benefits such a process can deliver. This report sions related to health financing, there are reliable ways for highlights four. First, fair processes can contribute to more countries to bring fairness about. equitable outcomes because they can help address common sources of inequitable outcomes. Specifically, a fair process The report offers decision support on fair processes for can prevent powerful stakeholders from shaping the de- policy choices relating to health financing for universal cision process to suit their own interests and instead help health coverage (UHC). It opens by making the case for promote the voices of the poor and marginalized. Second, why fair processes matter for health financing. It argues procedural fairness can strengthen the legitimacy of pro- that procedural fairness contributes to fairer outcomes, cesses by encouraging decision-making that follows accept- strengthens the legitimacy of decision processes, builds ed rules and procedures and by requiring authorities and trust in authorities, and promotes the sustainability of institutions to justify policy choices through public reason- reforms on the path to UHC. The report then describes ing, the rational exchange of ideas, and public communi- key health financing decisions with an impact on equity cation. Third, fair processes can build trust in authorities in service coverage and financial protection, where issues across society at large. Trust is built by treating people of procedural fairness are particularly important. Next, affected by decisions with respect; explaining the rationale it offers principles and criteria for designing and assess- for decisions reached; and ensuring that all affected constitu- ing the processes around these health financing decisions encies are heard, with no one’s interests misrepresented or and provides suggestions for how to make them fairer. neglected. Fourth, fair processes promote the implemen- Finally, the report examines country experiences with tation and sustainability of reforms. By creating space for diverse instruments that can be used to operationalize voice from all constituencies, including those whose pre- principles and criteria for fair processes in health financing ferred solutions are not finally adopted, support for carry- decision-making. ing through decisions is increased. The case for fair process Key decisions for equity UHC means that all people can use the promotive, Key health financing decisions across revenue mobili- preven-tive, curative, rehabilitative, and palliative health zation, pooling, and purchasing have especially important services they need, of sufficient quality to be effective, equity impacts. while also ensuring that the use of these services does In revenue mobilization, such decisions include: not expose people to financial hardship. Health financing changes to the range of taxes and charges, their rates, • is pivotal for progress towards the two pillars of UHC – and any exemptions from payment coverage with services and financial protection. How decisions on eligibility for public/state transfers to • well health financing arrangements can support progress households and the size of these payments or in-kind towards these goals depends on choices in the three health transfers financing functions of revenue mobilization, pooling, choices on budget allocations to health at all levels of • and purchasing. The overall level of health spending and government. the sources of revenue matter. Without adequate and In pooling, equity may be affected by changes in: sustainable levels of public spending on health, pro- • who is covered from pooled funds gress towards UHC goals will stall. Policies which • out-of-pocket payments on services in a guaranteed set promote sufficiently large pools to allow cross-subsidi- • differences across pools in the range of services zation and spreading of financial risks enable progress covered or out-of-pocket payments levied on the towards UHC. In purchasing, efficient use of resources, package, or changes in risk equalization procedures equitable service coverage, and financial protection or the size of government subsidies to different pools for all people can be promoted through the develop- in an effort to equalize benefits ment of guaranteed packages and the definition of pay- • decisions to develop a new pool(s), where the new ment methods, contracting conditions, and benefits. pool has different benefits or contributions. 9 Figure 1. Principles and operational criteria of procedural fairness OVERSIGHT Revisability Enforcement of process CORE PRINCIPLES: Equality Impartiality Consistency INFORMATION over time VOICE Reason-giving Inclusiveness Transparency Participation Accuracy of information In purchasing, areas especially important for equity transparency, and accuracy of information. The second include: domain, covering participation and inclusiveness, is about • decisions on what personal services are specified and creating opportunities for the public to express diverse delivered (range, location, quality) under the guaran- opinions and perspectives. The third domain, which teed set, including conditions of access includes revisability and enforcement, is about oversight • choices that modify the range, location, or quality of the process. of essential public-health operations • changes in provider contracting, monitoring, payment Country experiences and lessons methods, and rates. Examining diverse country experiences, the report identifies a variety of instruments that countries have used to develop or strengthen fair processes across the three Principles and criteria for fairer processes health financing functions. These tools, which address the This report proposes principles and criteria for fairer range of procedural fairness principles and criteria, can be processes in financing UHC (Figure ES1). Three principles – organized into four broad types: legislative and regulatory equality, impartiality, and consistency over time – form the instruments, organizational arrangements, financing and foundations of a fair process. Equality calls for equal access capacity-strengthening measures, and tools related to to information, equal capacity to express one’s views, and information management and monitoring. equal opportunity to influence decisions. Impartiality re- quires that vested interests — including corporate powers Four general observations can be made about countries’ — do not unduly influence the outcomes of decision- experiences in applying these instruments. First, legislative making processes. Consistency over time requires rules and regulatory mechanisms provide an important basis for and procedures by which decisions are made to be stable promoting fairness in decision-making processes. These and predictable, at least over the medium term, and not to mechanisms include high-level legal frameworks like change on an ad hoc basis and without justification. South Africa’s Constitution; laws governing the public sec- tor like the Freedom of Information Law in Ukraine; and Guided by these principles, the report proposes seven health-specific legislation like Thailand’s National Health criteria organized in three domains that can help design Security Act. Second, countries can use a combination of and assess decision-making processes (Figure 1). The first instruments to improve procedural fairness. For example, domain, information, is concerned with reason-giving, countries like Ethiopia and Thailand have benefited from 10 applying organizational instruments for public participa- with other stakeholders to adapt indicators, making them tion together with capacity-strengthening measures for locally meaningful and actionable. They can also work with civil servants, aimed at enhancing their ability to generate governments to engage the public more actively and di- and use evidence. Third, public participation is often elic- rectly in decisions that will benefit from broad participation. ited to a greater degree for decisions that set overall direc- tions for health financing. In contrast, for some technical International partners can use the report’s criteria to health financing decisions, like determining provider pay- examine their own processes, particularly for decisions ment rates and making choices about the public financing relating to what to fund and how to channel money to of vaccines, countries draw to a greater extent on technical activities in recipient countries. Using the report’s findings, experts. In these cases, the importance of instruments pro- international partners can provide technical and financial moting criteria beyond participation, such as transparency, resources to enable countries to strengthen regulatory accuracy of information, and reason- giving, becomes even frameworks and set up robust institutional mechanisms more pronounced. Finally, the availability and applicabil- to meet procedural fairness criteria. In some cases, this ity of diverse instruments to all parts of health financing, may mean longer timelines – for example, for developing along with their successful implementation across differ- a health financing strategy or a new tax law – but rushing ent countries, indicate that every country can advance to- timelines can result in unfair processes and inequitable wards achieving fairer decisions for UHC. outcomes. The way forward Finally, scholars from different disciplines can use the Fair process contributes to fairer outcomes, strengthens report’s interdisciplinary lens to consider how their legitimacy, builds trust, and promotes the sustainability of respective fields can contribute to fair processes for health financing policies on the path to UHC. In closing, financing UHC and expand their future contributions. this report highlights opportunities for four key groups This may involve gaining deeper understanding of how of actors to foster this agenda: governments, civil society, the principles and criteria proposed in the report can international partners, and scholars. support fairer policies and outcomes; how they can be applied in various settings in a feasible and sustainable Governments can use the report’s principles and criteria way; and how to improve them over time. as a framework to review their existing regulations, institutions, and processes. While it may sometimes appear In sum, this report presents common ground and an expedient to make decisions behind closed doors or to opportunity for policy makers, practitioners, researchers, fast-track reforms, evidence suggests clear benefits of an and civil society to come together, collaborate, and take open and inclusive process. Country examples in the report forward fair processes for financing UHC. Building on can facilitate knowledge sharing and illustrate how previous publications that emphasize the value of public governments in diverse settings have strengthened engagement and inclusive representation in building trust procedural fairness in health financing. and enhancing the sustainability of political systems, this report takes a comprehensive view of procedural fairness. While oversight functions rest with governments, civil It describes how countries can apply the range of criteria society actors play a key role. They can use the report’s proposed to improve the fairness of their health financing principles and criteria to monitor procedural fairness decision-making for UHC. In so doing, countries and in health financing and hold governments accountable. partners can advance UHC through open and inclusive To measure progress, civil society actors can collaborate processes that are responsive to the needs of all. 11 1 Introduction This introductory chapter explains why this report is global economic uncertainty. Advancing UHC contributes needed, outlines its conceptual foundations, and describes to more effective management of pandemics (Sachs et its aims and structure. The chapter has four parts. First, al. 2022); fosters sustainable economic growth (World it discusses why fair processes are vital for sound health Bank 2019); reduces poverty associated with out-of-pock- financing decisions, showing the benefits that fair et health payments (Das and Samarasekera 2011; World processes yield for the countries that implement them on Bank 2019); and increases societal cohesion (Levy 2019). the path toward universal health coverage (UHC). Second, it explains how the effort to strengthen fairness in health Health financing decisions are critical for UHC goals, including equity financing is grounded in and advances a human rights- based approach to health. Third, the chapter highlights UHC is fundamentally about equity – all people receive gaps in currently available evidence and decision support the health services they need without financial hardship. for policy makers on how to achieve fairer processes in UHC features as a prominent target in the Sustainable health financing. Finally, to show how this report will Development Goals (SDGs), adopted by all United Nations help bridge the gaps, the chapter summarizes the report’s member states. On the path to UHC, however, inequities objectives, methodology, and structure. persist. Getting health financing strategies right across the functions of revenue mobilization, pooling, and purchasing 1.1 The case for fair process in health is critical not only to making progress towards UHC but financing for universal health coverage also to reducing those inequities (World Bank 2019). This report speaks to a context in which economies and This report uses the three health financing functions of health systems face historic challenges. The dual impact revenue mobilization, pooling, and purchasing to organize of COVID-19 and the invasion of Ukraine by the Russian its discussion of key health financing decision types Federation has resulted in rising poverty, surging inflation, affecting equity.1 Decisions under all three functions and reductions in real per capita government spending have significant equity impacts. For example, in revenue across much of the globe. Years of global progress in mobilization, trade-offs between allocation to health care poverty reduction were abruptly reversed in 2020, with vis-à-vis other sectors can lead to decreased public spending some evidence that inequality has also widened in many on health as part of government budgeting processes. This parts of the world (World Bank 2020). Forty-one countries is likely to result in increased reliance on direct out-of- where real per capita government spending has dropped pocket (OOP) payments for health services (Thomson et are unlikely to see their spending reach pre-pandemic al. 2015). Increased OOP payments in turn impact equity levels even by 2027 (Kurowski et al. 2022). In this context, in financial protection and service coverage, since poorer while government health budgets are under pressure, the households have lower capacity to pay and are more likely goals of UHC are more relevant than ever. to forego needed health services (Barasa, Maina, and Ravishankar 2017; Xu et al. 2003; Wagstaff et al. 2018). In UHC means that all people can use the promotive, pre- contrast, increasing central government financial transfers ventive, curative, rehabilitative, and palliative health services for health to poorer sub-national units can reduce the gaps they need, of sufficient quality to be effective, while also in service availability between richer and poorer areas. ensuring that the use of these services does not expose peo- ple to financial hardship (WHO 2014). Progress toward In pooling, allowing richer people to opt-out of contributing UHC brings additional benefits that matter at all times, financially to pools reduces the ability to cross-subsidize and particularly in a context of successive shocks and from rich to poor, and probably from healthy to sick. 1 Questions about the nature of the guaranteed set of health services available to all, often termed the benefits package, are a critical component of health financing. In some analytical frameworks, they are seen as part of the purchasing function (Hanson et al. 2019; World Bank 2019), while others classify them as a separate function (Jowett et al. 2022; Kutzin 2013). In this report, decisions affecting the set of services available to everyone – e.g., benefit design – are summarized under purchasing. 12 On the other hand, countries can strengthen equity by On a different but related front, the imperative to strike harmonizing benefits across multiple funding pools in a balance between individualism and solidarity has been which some groups (e.g., people working in the informal a prominent feature of recent discussions around health sector) have access to a more limited set of services than financing reform in Chile. On the one hand many citizens other groups (e.g., civil servants) (McIntyre et al. 2013; have historically placed high value on free individual Kutzin et al. 2010). choice, meaning that they prioritized being able to join private health insurance plans, which were also viewed as Purchasing involves a wide range of decisions that can an “indicator of improvement in [people’s] economic status directly improve or worsen existing inequities in coverage and their social mobility” (Vélez et al. 2020, 188). On the with health services or financial protection. An example other hand, there has been a growing dissatisfaction with relates to decisions on co-payments for outpatient pre- inequality in access to services, which government policies scription medicines: co-payments with no exemptions for have not been able to address (Bossert and Villalobos the poor reduce their access and increase financial hardship Dintrans 2020; Ayala and Alarcon 2020). when they need to purchase medicines. Exemptions for the poor reverse this effect, improving equity (Honda and Such examples underscore the political importance of Obse 2020; Ottersen and Norheim 2014; Thomson, Cylus, health financing decisions, as well as their complexity and and Evetovits 2019). the potential for conflict. In such cases, it is not only the final policy choices that matter for stakeholders, but the Health financing policy does not operate in isolation from processes through which decisions are reached. the rest of the health system or the broader socioeconomic and political environment. For example, introducing fi- The benefits of fairer processes for health financing and UHC nancial incentives to improve performance among health workers is unlikely to result in improved service coverage Value- and interest-driven disagreements around health without ensuring adequate supply of medicines or ba- financing choices, as in the examples just considered, sic equipment (Engineer et al. 2016). Wider governance suggest how important fair processes in this area can be. and economic contexts, including the influence of inter- Pursuing that insight, this report identifies four key bene- national finance and trade, play an important role in de- fits of fair processes in health financing. termining a country’s capacity to mobilize revenues for financing public services, including health (International First, existing evidence suggests that fair processes can Monetary Fund 2018). However, the focus of this report contribute to more equitable outcomes because they is on health financing decisions at national or sub-national ensure that steps are taken to address common sources of levels—where crucial policy levers remain in country de- inequity (Bartocci et al. 2022; Bollyky et al. 2019; Touchton cision-makers’ hands and, with them, the opportunity to and Wampler 2014; Williams, Denny and Bristow 2017; implement fairer processes towards UHC. Woolcock and Gibson 2007). A key source of inequity is power differences among stakeholders, which can lead Health financing decisions are often contested, to powerful stakeholders’ shaping the decision process to underscoring the importance of fair process suit their own interests, at the expense of the voices and Many health financing decisions are subject to disagree- interests of the poor and marginalized (Kim and Lee 2022; ments shaped by the values and interests of people with a Sparkes et al. 2019). By broadening participation and stake in these decisions. Recent country experiences help representation in the decision-making process and by bring the practical importance of this consideration into promoting respect among people, fairer processes can focus. For example, the financial sustainability of small contribute to leveling the playing field towards greater hospitals in the rural or remote areas of many countries is equity. Empirically, studies on participatory budgeting, for one domain where such debates frequently occur (Rechel instance, suggest that it can lead to more pro-poor spending et al. 2016). On the one hand, there are concerns about ef- decisions. In Brazil, participatory budgeting contributed to ficiency in terms of both capital expenditure and running higher allocations for health and sanitation in local budgets costs for these hospitals, which typically serve very small and less waste due to more effective monitoring of publicly portions of a population. Tied to population size is the funded projects (Gonçalves 2014). Another source of challenge of securing high-quality services when patient inequity is corruption, which can undermine public volumes are low. On the other hand, local populations of- decisions and benefit those with the power to influence ten resist the closure of hospitals, arguing that such clo- choices. Key features of fairer processes, like transparency, sures undermine their equitable access to services (Rechel have been shown to curb the potential for corruption et al. 2016; Milne and Sullivan 2014; Moore 2009). (Onwujekwe and Agwu 2022). Evidence from procurement 13 processes of medicines suggests that by improving Finally, fair processes can promote the implementation oversight by auditors and civil society, transparency and sustainability of adopted policies. For example, many can reduce corruption and prevent the waste of limited health financing decisions are intended to be long-term public resources (Brown 2016; McDevitt 2022). solutions, with the benefits of adopted policies and created institutions being felt over an extended period. By creating Second, fair processes strengthen the legitimacy of a de- space for voice and buy-in to the decision-making process cision process, which generally refers to the level of ac- from potential opponents and the people they represent, ceptance people have towards the authority of the govern- including those whose preferred solutions are not finally ment and of a polity’s laws and institutions (Rawls 2012; adopted, fairer processes can contribute to the sustainabil- Langvatn 2016). Legitimacy is shaped by authorities, laws, ity of decisions (Chwalisz 2020).2 The literature on delib- and institutions coming about through well- established erative democracy, and frameworks inspired by it, contend and accepted procedures (Langvatn 2016; Rawls 2012). that processes characterized by public reasoning, including Justification of policy choices through public reasoning, securing participation and inclusiveness when decisions the rational exchange of ideas, and public communication are considered and justified, can generate broad popular plays a vital role in enhancing legitimacy (Chambers 2018; support even under conditions of disagreement (Gutmann Habermas 1996). Evidence from social psychology sug- and Thompson 1998; Daniels 2008c). gests that people are more likely to accept decisions when choices are made through participatory procedures, with 1.2 Human rights as the moral and authorities perceived as neutral, honest, and trustworthy legal foundation for fairer processes (Nakatani 2021; Tyler 2000). The value of procedural fair- in health financing ness is also highlighted in the literature on tax compliance: decisions made by tax authorities that are perceived as im- A foundational argument for UHC and fair process comes partial, based on factual information rather than personal from a human rights perspective. Health is a fundamental opinions, are more likely to be accepted and complied with human right “indispensable for the exercise of other by taxpayers (van Dijke, Gobena, and Verboon 2019; Mur- human rights” (CESCR 2000). This section clarifies the phy 2005). links between countries’ human rights commitments and the pursuit of UHC through fair processes, including in Third, fair processes help build trust in public institutions health financing. by treating people affected by decisions with respect, ex- plaining the underlying core rationale for the decisions, The right to health and UHC and ensuring that all affected constituencies are heard, The right to health is enshrined in multiple international with no group’s interests misrepresented or neglected. and regional treaties, and there is no state in the world While definitions of trust vary across disciplines, the that has not ratified and agreed to be bound by at least one term generally refers to whether “political authorities treaty that embeds aspects of the right to health (UNHCR or institutions are performing in accordance with the 2008, 660). These legal standards are underpinned by a normative expectations held by the public” and strong philosophical foundation for claiming a moral right whether they will continue to do so, “even in the absence to health. Health is considered to be “among the most of constant scrutiny” (Miller and Listhaug 1990, 358). important conditions of human life,” while “any conception In terms of trust in government, research in social of social justice that accepts the need for a fair distribution psychology and taxation literature indicates that people’s as well as efficient formation of human capabilities cannot perceptions of fairness in the decision-making process is ignore the role of health in human life and the opportunities as important as their perceptions of the outcomes (OECD that persons, respectively, have to achieve good health” (A. 2017; Prichard et al. 2019). The COVID-19 pandemic has Sen 2002, 660). Therefore, health has special moral value, highlighted afresh the importance of trust in government as it enables people to participate as full and equal members (Bollyky et al. 2022; Norheim et al. 2021), with several of their polities. contributions underscoring the value of inclusive, trans- parent, and accountable decision-making to ensure trust The right to health provides an overarching framework for in political and scientific authorities and adherence to UHC.3 United Nations (UN) General Assembly and World public-health recommendations (Norheim et al. 2021; Health Assembly resolutions on UHC have consistently Sachs et al. 2022). reiterated the centrality of the right to health, often citing 2 While the focus of this report is on health financing, some of these characteristics are clearly shared with public-policy decisions in other sectors. 3 According to WHO, “states should not allow the existing protection of economic, social, and cultural rights to deteriorate unless there are strong justifi- cations for a retrogressive measure.” For example, introducing user fees in primary care which was formerly free of charge would constitute a deliberate retrogressive measure. Therefore, a state would have to demonstrate and explain to the public that it had adopted the measure only after carefully consider- ing all options, assessing impact, and fully using its maximum available resources. See: https://www.who.int/news-room/fact-sheets/detail/human-rights- and-health 14 the Universal Declaration of Human Rights (Nygren-Krug emphasis not only on outcomes, but also on the processes 2019). Therefore, the principles of non-retrogression, a by which decisions are made (UNHCR and WHO 2008). minimum core content that must be provided regardless The UN High Commissioner for Human Rights empha- of resources, and equality and non-discrimination are sizes that human rights standards and principles – such central to the UHC agenda. Securing equitable financing as participation, equality and non-discrimination, and and eliminating financial barriers to health, especially for accountability – guide the entire health policy cycle, from poor people and other vulnerable populations, represent a situation analysis to policy development and adoption, significant contribution towards realization of the right to as well as implementation and evaluation. According to health (Rumbold, Baker, et al. 2017; WHO 2015). General Comment 14 on the Right to the Highest Attain- able Standard of Health,4 when facing trade-offs between Enforcing health rights through the courts health interventions, states need to make these decisions Since the 1990s, health-related rights have become in- fairly (CESCR 2000; Rumbold, Baker, et al. 2017). Impor- creasingly subject to judicial enforcement, through inter- tant trade-offs may concern, for example, investments in preting the right to a life of dignity to include aspects of expensive curative health services that typically benefit a health, including healthy environmental conditions and small, privileged fraction of the population, as compared specific medical therapies under certain circumstances. to primary and preventive health care accessible to a far While some cases of the judicial enforcement of individual larger population share. health care rights have revealed tensions between the right to health and the need for prioritization of scarce health Procedural fairness is especially important in relation to care resources (Yamin, Pichon-Riviere, and Bergallo 2019; health rights because epidemiological and demographic Andia and Lamprea 2019), international human rights law trends are constantly evolving, as are innovations in is generally consistent with fair priority setting and pro- diagnosis, prevention, and treatment. This makes it vital gressive realization of UHC (CESCR 2000; Rumbold, Bak- to interpret the contents of the right to health through er, et al. 2017). an open and inclusive process based on evidence (Yamin and Boghosian 2020). The choices for health financing to For example, high courts have struck down cuts to the promote an equitable distribution of benefits across plu- budgets of subsidized health programs as impermissible ral populations therefore require continual reevaluation retrogression. In some cases, differentiated benefit packages and adjustments (Yamin and Boghosian 2020). Because for contributory and subsidized insurance regimes have reasonable people can disagree about normative priori- been determined inconsistent with guarantees of equality ties in health, the contours of health rights are inherently in countries’ constitutions. In 2008, a landmark decision connected to the negotiation of competing claims and in- from the Constitutional Court of Colombia ordered terests through fair and legitimate processes. equalization of the benefit plans for two health insur- ance schemes: the country’s contributory regime for those The human rights-based approach in health requires de- formally employed or earning more than twice the cision-making processes to respect reasonable substan- minimum wage (the Plan Obligatorio de Salud, or POS) tive criteria, such as non-discrimination, as well as pro- and a subsidized health insurance scheme that had offered a cedural criteria, including meaningful participation and significantly less generous set of services (Plan Obligatorio transparency. Thus, for example, decrees or tokenistic de Salud Subsidiado, POSS) (Yamin and Parra-Vera 2009). legislative discussions without quorums have been found This equalization had previously been promised, but not to pass constitutional muster. In the above-men- funding had been deferred multiple times by Colombia’s tioned example from Colombia, the Constitutional Congress. The decision was made on the grounds that the Court also included aspects of process in the remedies it two-tiered system, where fewer than half the entitlements ordered, calling for the then National Commission for were accessible to the subsidized regime, violated norms Health Regulation to adopt a transparent, participatory, of equality and non-discrimination (Arrieta-Gómez 2018). and evidence-informed approach that can be subject to revision and appeal when updating the benefits to be in- Fair processes are vital to fulfill health rights cluded in the contributory and subsidized schemes and A human rights-based approach to health as articulated in the process of unifying them (Yamin and Parra-Vera through international treaties and obligations puts 2009; Arrieta-Gomez 2018). 4 The UN human rights treaty-monitoring bodies, including the Committee on Economic, Social and Cultural Rights, publish documents known as General Comments or General Recommendations, which explain their interpretations of the provisions of their respective human rights treaties. These documents provide guidelines for states on the interpretation of specific aspects of a human rights treaty and clarify the content of the rights set out in the treaty in question. They sometimes outline potential violations of those rights and offer advice to states parties on how best to comply with their obligations under the given human rights treaty. 15 In short, respecting, protecting, and fulfilling health rights 1.4 Report objectives, methodology, involves due consideration of procedural fairness when and structure deciding on the financing and delivery of health services. Further, a human rights framework in relation to health The primary aim of the report is to provide policy mak- calls for effective oversight and regulation of both process ers with evidence on why fair processes matter; what and outcomes, together with provision of adequate constitutes a fair process for health financing choices on information that allows decisions affecting health (made the path to UHC; and policy instruments that countries by governments and commercial actors alike) to be can use to advance fair processes in health financing. subjected to democratic scrutiny. In pursuit of this aim, the report makes four main contributions. First, informed by an interdisciplinary 1.3 Fair processes in health financing: evidence base, it shows how fair processes can improve Strengthening decision support results in decision-making around health financing. Developing that argument has been the main task of this Despite growing evidence of the multiple benefits of fair introduction. Second, the report describes key health decision-making processes, health policy makers and financing decisions with an impact on equity. Doing so is a experts do not currently have access to a unified, necessary step toward identifying priority health financing comprehensive, and clear set of principles and criteria for policy decisions to which procedural fairness criteria can fair decision processes, described in practical terms that be applied. Third, the report offers principles and criteria policy makers can readily adapt to country contexts, with for designing and assessing decision processes in health examples of their application to health financing. This financing and guiding how to make them fairer. Finally, it report aims to help bridge these gaps. presents a diverse range of policy instruments that can be used to implement fair process principles and criteria for To date, the most comprehensive and conceptually clear health financing decisions. discussion of procedural fairness is found in the literature on deliberative democracy (Bachtiger et al. 2018; Gutmann The report builds on a series of consultations conducted and Thompson 2004; Chambers 2018). However, this with global and country experts; a comprehensive body of work has not been widely accessed to inform literature review; and a set of case studies in countries the process of health financing decisions. The primary and jurisdictions including India, Mexico, South Africa, framework for examining procedural fairness in health Tanzania (Mainland), The Gambia and Ukraine. These financing has been the Accountability for Reasonableness case studies were selected to reflect a variety of income (A4R) framework, which has been applied to examine groups, geographic areas, health financing arrangements, decisions for determining health benefit packages across and types of health financing decisions. different settings, including Mexico (Daniels 2008a), Tanzania (Maluka, Kamuzora, San Sebastian, Byskov, The structure of the remaining parts of the report is as fol- Olsen, et al. 2010; Byskov et al. 2014), and the UK (Rumbold, lows. Chapter 2 describes the key health financing decisions Weale, et al. 2017; Mitton et al. 2006; Daniels and Sabin with equity implications, with a view to illustrate a wide 2008). This is an ethical framework that specifies key range of health financing decisions where fair processes criteria for a fair process, namely: publicity, relevance, merit greater attention. Chapter 3 examines the meaning revision and appeals, and enforcement (Daniels 2008b). of “fair process” as a concept guided by three main princi- However, some have argued that the A4R framework ples: equality, impartiality, and consistency over time. The places insufficient emphasis on public participation and realization of these core principles relies on the implemen- that there is a lack of clarity about how different kinds tation of seven criteria that decision- making processes of arguments are meant to be included or excluded in a can be compared against. These criteria are reason-giv- deliberative process guided by A4R (Rid 2009; Friedman ing, transparency, accuracy of information, inclusiveness, 2008). Moreover, there has been little systematic thinking public participation, revisability, and enforcement of the about whether A4R criteria apply equally well to revenue process. Chapter 4 examines country experiences with a mobilization and pooling, or to the aspect of purchasing diverse selection of instruments, applied across the core that concerns how to contract and pay for inputs or health financing functions of revenue mobilization, pool- services. It remains debatable whether additional criteria, ing, and purchasing, that can enable countries to better applied to processes for other public policy decisions, meet the principles and criteria for procedural fairness. should also be considered (World Bank 2018). In sum, there Finally, Chapter 5 provides a broad outline of the agenda is a need to further specify what constitutes a fair process for action to support progress towards UHC through a fair in health financing; detail the benefits that fair process process. can bring across the three core health financing functions; and deliver decision support to policy makers and partners as they work to institutionalize fairer health financing. 16 2 Health financing decisions with equity implications Health financing policies have important equity implica- The first type of health financing decision with im- tions, and there are frequent disagreements about the sub- plications for substantive fairness concerns changes to stantive fairness of outcomes associated with them. This sources of government revenue, most frequently made underscores the importance of creating decision processes in the search for increased revenue. This can come from in health financing that stakeholders can recognize as fair. introducing new taxes or charges; increasing contribution Indeed, the more substantial the potential equity impact of rates for taxes, charges, or obligatory health insurance; or a health financing policy choice, the more important a fair expanding the range of people or firms who should make process around the decision becomes. financial contributions. These decisions modify the dis- tribution of financial contributions to the system across The aim of this chapter is to identify policy decisions under people and groups, and they include but are not limited to the three core health financing functions of revenue health per se. mobilization, pooling, and purchasing that have high stakes for equity. Such decisions will be priority candidates Some sources of revenue – e.g., income taxes – lend them- for applying the fair-process principles and criteria that are selves to making contributions progressive (where the derived later in this report. The point for now is not to proportion of income that people contribute increases debate the substantive fairness of specific policy options, with their income). However, in countries with large but to set the scene for the subsequent analysis of how fair informal sectors, income taxes are difficult to levy, and process criteria can inform health financing decisions. In those on the formal sector raise relatively little. These this chapter, we identify key equity-relevant decision types countries therefore often rely on tax sources such as under the three health financing functions in turn. To keep value-added taxes that may be easier to administer but tend the conceptual discussion grounded in political reality, for to be less progressive (Jouini et al. 2018; Younger 2018; each of the health financing functions, we present country Thomas 2020). examples that illustrate how the decisions discussed can influence substantive equity. Overall fiscal fairness is, however, judged not solely in terms of the financial contributions to the system, but in 2.1 Revenue mobilization terms of the distribution of net contributions – i.e., payments minus transfers back in cash or kind (Inchauste The road to universal health coverage (UHC) lies through and Lustig 2017). Particularly in circumstances where government spending (Kurowski et al. 2022; Kutzin 2013). taxes are not sufficiently progressive, governments can No country can make meaningful progress towards UHC compensate people for inequities in contributions by without predominant reliance on government health targeting transfers from government revenues to the poor. spending, defined as spending derived from general Accordingly, decisions that change the distribution of government funds and from obligatory health insurance financial contributions, or the distribution of transfers contributions. Government revenues come from taxes and from these revenues, both influence substantive fairness charges of various types and may be collected at the various (Inchauste and Lustig 2017). levels of government in a country, and in some countries from on-budget external financing. Government funding A third type of revenue mobilization decision influencing can also come from borrowing, something that was widely equity concerns allocations from general government seen during the COVID-19 pandemic (Kurowski et al. funds to health, at all levels of government. The level of 2021; International Monetary Fund 2021). general government expenditure sets the size of the overall 17 Table 1. Revenue mobilization decision types and equity implications Revenue mobilization decision type Equity implication Changes to the types of taxes, contribution rates, and Differences across people and groups in net contributions who should pay. to the public finance system. Who is eligible to receive public/state transfers in cash Differences across people and groups in net contributions or kind and the size of these payments. to the public finance system. Changes to the allocations from general government Differences across people or groups in the availability of funds to health at all levels of government, and by health services, quality, or level of financial protection. central government to lower levels. government spending envelope. Government health tem. For example, in Tanzania, according to one analysis, spending is then determined by the decision about how electricity subsidies are considered to be regressive despite much of this is allocated to health - taking into account attempts to make them more pro-poor, while the country’s budget allocations from general government funds and any direct and indirect taxes are largely progressive (Younger, earmarked revenue, such as social health insurance and Myamba, and Mdadila 2016). In Indonesia, energy sub- health taxes. External financing is often channeled through sidies are also considered regressive, disproportionately government, as well, either earmarked for health or able benefiting higher-income groups (Lontoh, Beaton, and to be allocated as part of the usual budget process. These Clarke 2015). They also represent a significant fiscal bur- decisions jointly determine how much is available to spend den on the government and use up resources which could on health. be spent on health. From the perspective of a sub-national unit, the revenue Allocation from central government to sub-national units mobilization function covers not just transfers from the (e.g., regions or states) is an important decision in health central level, but also how much funding can be raised financing, determining equity of resource distribution locally and how much is allocated to health. Inter-regional across sub-national units. In Malawi, the allocation of inequities in health spending reflect, therefore, decisions the operational budget for health across districts was long made at the central level about transfers to each sub- based on historical allocation—that is, based on last year’s national unit, the capacity of different local governments allocation with some incremental change (Twea, Manthalu, to raise revenue, and how much local governments allocate and Mohan 2020). After district assemblies recognized to health. inequities in existing resource allocation, the National Local Government Finance Committee (NLGFC)—the The three types of revenue mobilization decisions which central decision-making body responsible for resource impact on substantive equity are summarized in Table 1. allocations to local government—developed a new resource allocation formula linked to key drivers of service delivery An example of the first decision type comes from Norway. costs and tied explicitly to the costs of delivering the Health In 2022, Norway increased its wealth tax, which is assessed Benefit Package (Twea, Manthalu, and Mohan 2020). on the basis of net wealth, from 0.85 percent to 1.1 percent at the top tier (The Norwegian Tax Administration 2022). 2.2 Pooling The wealth tax on its own does not generate substantial revenue (Thoresen et al. 2021), limiting its impact on the Pooling is defined as the accumulation and management overall level of government revenues and its capacity to of prepaid financial resources—meaning resources con- increase transfers to the poor. However, the revenue tributed before an episode of illness—with the purpose of collected comes from people who are in the upper income spreading the financial risk of health care expenses from group; thus, together with the personal income tax, the individuals who fall ill to all members of the pool (World decision to increase the wealth tax enhances overall tax Health Organization 2010b). Pooling facilitates the capaci- progressivity in Norway (Thoresen et al. 2021). ty to use health services in the first place, as people are con- fident that they will not be faced with costly out-of-pocket Who is eligible to receive public or state transfers in cash payments (OOPs) for the services they receive. The most or kind and the size of these payments is the second feature effective way to protect against the financial risk is to share determining the distribution of net payments into the sys- it, “and the more people who share, the better the protec- 18 Table 2. Pooling decision types and equity implications Pooling decision type Equity implication Differences between people or groups in service coverage or Changes in who is covered from pooled funds or how the distribution of the financial burden associated with access entitlements are activated for a guaranteed package. to a set of guaranteed services. Changes to laws or regulations regarding out-of-pocket Differences across people or groups in the extent of financial payments for services in a guaranteed set. protection related to the guaranteed set of services. Differences across people or groups in quality and/or scope of Where multiple pools exist, changes that services, and/or in the extent of financial protection related to modify differences across pools. the guaranteed set of services. Decisions to develop a new pool(s) alongside existing Differences across people or groups in quality and/or scope of pool(s), where the new pool has different benefits or services, and/or in the extent of financial protection related to contributions compared to existing pool(s). the guaranteed set of services. tion” (World Health Organization 2010b, 47). To promote at least ensuring that effective exemption mechanisms equity, pooling requires subsidies from the healthy to the exist to protect the poorest population groups, will sick and from the rich to the poor, and contributions need undermine equity (World Health Organization 2014). The to be obligatory. General government funds that finance Lancet Global Commission on Financing PHC noted that, national health systems are one form of obligatory pre- regardless of the level of total health spending, a shift from payment and pooling. Obligatory health insurance contri- OOP spending towards pooled arrangements would have butions are another, although in reality the distinction is a significant positive impact on the equity and efficiency of often blurred – most systems where pooling is based on health financing (Hanson et al. 2022). obligatory health insurance contributions have their reve- nues supplemented from general government funds (Levy Where multiple pools exist, changes that modify differences 2019; World Bank 2019; Giuffrida, Jakab, and Dale 2013; across pools constitute a third type of pooling decision Sakamoto et al. 2018). with important equity implications. Frequently, the peo- ple in some pools are “better” protected than others – they A first pooling decision type with equity implications re- obtain more or higher-quality health services, with more lates to who is covered from pooled funds for a guaranteed financial protection. This is inherently unfair, and many package, including decisions to increase the size of the pool. governments have modified the subsidies they give to the In many low- and middle-income countries, increasing the different pools in response or introduced risk equalization size of the pool to include the informal sector or the poor procedures, whereby funds from one pool are transferred has been extremely challenging, contributing to inequi- to others. Harmonization of benefits is another policy that table service coverage and financial protection (Kutzin, Yip, seeks to equalize benefits across pools. This decision type and Cashin 2016; Kwarteng et al. 2019). This decision type also includes rules on whether and how people can opt out also includes rules on how entitlements are activated, e.g., of obligatory health insurance. whether one needs to have special documentation, which at times may be difficult to obtain, and actively enroll with Decisions to develop a new pool(s) alongside existing a health insurance provider instead of being automati- pool(s), where the new pool has different benefits or cally included based on a national identification number. contributions compared to existing pool(s), can contribute Making complicated rules on activating one’s entitlements to fragmentation but can also improve equity in service can contribute to some people “falling through the cracks” coverage and financial protection. In many low- and in the system and not having access to health services when middle-income countries, it has been challenging to they need them (Kwarteng et al. 2019). expand the existing generous health insurance programs for formal sector workers to the poor and the informal A second decision type important for equity concerns sector. In this context, creating a new program that is not changes to laws or regulations about out-of-pocket based on contributions and provides coverage for those payments for services in a guaranteed set. Increasing or previously not included in other programs is seen as a introducing OOPs for a guaranteed set of services, without positive step towards fair access to health services, even if 19 in the early stages the benefits are not as extensive as those 2010, this ratio had fallen to only 1.2 time more, a sub- of the existing schemes (Tangcharoensathien et al. 2020). stantial gain for equity (Knaul et al. 2012). The four groups of pooling decisions that can have impor- 2.3 Purchasing tant equity implications are summarized in Table 2. Purchasing involves the allocation of funds to obtain the Some examples of these decisions follow. Tanzania recently guaranteed set of services. In national health services, sought to reduce differences across its population in the purchasing traditionally has involved buying the inputs to range of health services available and the extent of financial make health services, such as health workers, medicines, protection through the introduction of the improved and medical equipment. In insurance-based systems, Community Health Funds (iCHF) (Lee, Tarimo, and Dutta purchasing generally involves buying the health services. 2018). While the implementation of the iCHF has not Purchasing decisions can be divided into what to purchase, unfolded as expected (Mselle et al. 2022), the increase of who to purchase from, and how to pay for the inputs or ser- the size of the pool from district to regional level is an vices. Decisions in purchasing can contribute to equitable important step in reducing fragmentation and reducing delivery of the set of quality services while keeping costs differences across communities when it comes to access to under control (World Bank 2019). health services. Decisions on what personal services are guaranteed and An example of the second type of decision in Table 2 comes delivered, including conditions of access, are probably from pre-war Ukraine. The purchase of medicines was one of the most widely examined decision types in the a key driver of OOPs in the country, disproportionately health financing literature from an equity perspective affecting lower-income groups and patients with chronic (Norheim 2015, 2016). These decisions can increase or illnesses (Goroshko, Shapoval, and Lai 2018). To address reduce differences across people or groups in coverage this, in 2017, the government introduced the Affordable with personal health services. Covering expensive high- Medicines Programme (AMP). Initially, the AMP covered technology services for a small group of the population three selected conditions: cardiovascular diseases (CVDs), while the majority lacks access to basic health services is bronchial asthma (BA), and type 2 diabetes (DM-2). The recognized as extremely inequitable (Ottersen and Nor- program was then expanded, so that by 2021, it included 27 heim 2014; World Bank 2018; World Health Organiza- international nonproprietary names (INNs) and 297 medi- tion 2010a). cines, including additional INNs for mental and neuro- logical disorders (Bredenkamp et al. 2022). Moreover, the What to purchase also includes questions about the range number of contracted pharmacies also increased steadily. To of public-health services to provide, including population- the extent possible, AMP has continued to function despite based prevention such as screening and public-health the war, reducing OOPs through increased pooling. functions such as surveillance for epidemic preparedness and response. This is the second type of decision in An example of the fourth type of equity-relevant pooling purchasing which is considered important from an eq- decision is a policy decision to establish budget-funded, uity perspective. Differences across people or groups in explicit coverage programs for persons not covered by their capacity to maintain or protect their health can be existing social security health insurance schemes for the reduced through decisions modifying the range, location, formal sector. This can promote equity, if the new programs or quality of public-health services. are adequately funded (Kutzin, Yip, and Cashin 2016; Tangcharoensathien et al. 2013; Knaul et al. 2012). Thus, in Lastly, equity can be improved or undermined through Mexico until 2020,5 additional public resources for health contracting, monitoring, and paying providers. Provider coverage were mainly allocated to Seguro Popular (Popular payment mechanisms create incentives for providers that Health Insurance), a publicly funded program providing can contribute to differences across people or groups in access to health services without co-pays to individuals effective coverage with personal health services, including with no employment-based health insurance (Reich 2020). by type of condition or disease. An example is a situation Additional resources were channeled to Seguro Popular in which providers are compensated on a fee-for-service in preference to the social security schemes covering basis for certain types of patients, e.g., those enrolled in a the country’s formal sector. At the beginning of Seguro social insurance scheme, while for other patients providers Popular, in 2000, public spending per capita for people receive per capita payment. This is likely to result in covered by the social security schemes (generally, Mex- insured patients enjoying priority and better care or at ico’s better-off citizens) was 2.1 times the public spend- least more services (Barasa et al. 2021). ing per capita for the rest of the population. However, by 5 In 2020, Seguro Popular was replaced by a new system under the Instituto de Salud para el Bienestar. 20 Table 3. Purchasing decision types and equity implications Purchasing decision type Equity implication Decisions on what personal services are speci- Differences across people or groups in coverage or effective coverage fied and delivered under the guaranteed set.6 with personal health services, including by type of condition or disease. Differences across people or groups in their capacity to maintain or Decisions modifying the range, location, or protect their own health; differences in the effective operation of the quality of essential public-health services. health system with consequences for population health. Decisions modifying contracting and Differences in coverage or effective coverage with personal health ser- provider-payment methods and rates. vices, including the quality of services for different people or groups. Monitoring instruments can help counterbalance or services for their communities, while other jurisdictions did reinforce the incentives created through different pay- not (Buck 2020). ment methods. Thus, three types of purchasing decisions can be identified that have clear implications for equity An example of how provider-payment methods can improve (Table 3). equity can be found in the Kyrgyz Republic. Starting with the establishment of a purchasing agency in the late 1990s, Recent country experience illustrates some of these pur- the Kyrgyz Republic gradually moved from input-based chasing choices. In Tanzania, services included in the guar- payments financing buildings and doctors to more output- anteed set for those enrolled in the Community Health In- oriented provider-payment methods, improving equity in surance Fund (CHF) were very limited. In most districts, access and quality of care across geographical areas (Kutzin CHF membership only covered preventive and curative et al. 2010). Specifically, from 2001 to 2004, the total num- services at the primary health care level (dispensaries and ber of buildings decreased by 47 percent and floor space health centers), with very limited portability, which meant decreased by 40 percent, with the savings re-allocated to that beneficiaries had access to services only in the facility direct patient care, accompanied by a shift in spending where they were registered (Wang and Rosemberg 2018). from hospital to primary health care (Fuenzalida-Puelma Moreover, benefits and conditions for accessing various ser- et al. 2010). Investments in PHC are critical to ensuring vices differed by district, even within the same region. Under that all people receive the health services they need with- the new improved CHF (iCHF) program described earlier, ser- out suffering financial hardship, and generally such in- vices were expanded whereby beneficiaries became entitled to vestments are considered to promote equity (Hanson et services available up to the regional hospital level, subject to al. 2022). Shifting spending away from large hospitals also an exclusion list comprised predominantly of specialized pro- improved geographic equity in per capita public spending cedures and medicines (Lee, Tarimo, and Dutta 2018). While on health. the equity impact of the iCHF may so far have been limited due to the slow scale-up of the program (Mselle et al. 2022), the decision to harmonize and expand benefits at regional level is aimed at reducing differences across people in coverage with This chapter has identified key decisions across the three personal health services. core health financing domains that impact substantive fairness. The purpose at this stage was not to debate which Decisions modifying the range, location, or quality of policy options lead to fairer outcomes, but to identify the essential public-health services are not always made expli- key decisions under each health financing function so that citly, but may be a result of reduced central funding, as was the principles and criteria of fair process can be applied documented following the 2013 public-health reforms in to them. But what actually is a fair process, and how can England (Buck 2020). As a result of reform, which shifted policy makers and stakeholders be confident that health responsibility for funding public-health services to local level financing choices are being reached fairly? Chapter 3 with significant reduction in central funding, areas with high- examines these fundamental questions. Chapter 4 will er revenue-raising capacity at the local level, or which assigned then look at policy instruments to advance fair processes higher priority to public health, were able to maintain more in health financing and country experiences in using them. 6 Importantly, purchasing includes acquiring inputs to produce health services, as well as purchasing the services themselves. 21 3 What is a fair process? Consider the following stylized case, based on a real- engagement with affected stakeholders and giving those world example. In late spring 2010, the reform-oriented who may oppose certain policies a chance to express their leadership of the ministry of health of a lower-middle- views sends the message that the solutions to public issues income country is uncertain if it will stay in power beyond do not belong exclusively to a narrow “insider” group. This a few more months, due to upcoming parliamentary can ultimately build greater trust in the decision made elections. However, health leaders are determined to tackle (Matasick 2017). The question is, then, what does it mean longstanding structural problems in the country’s health to have a fair process? Are there principles and criteria by financing system. Important decisions have already been which policy makers can judge whether their decisions are made through a fast-paced reform based on good global fair from a procedural point of view and that can support and country evidence, driven largely by technical experts, them in improving current decision-making processes? though with little involvement of the public. Now, the leadership determines to move even faster and make This chapter takes up these questions. It proceeds in three important decisions on the next reform phase. Leaders steps. First, based on a review of learning and practice in perceive seizing the political window of opportunity multiple fields, it proposes three core principles of fairness and accelerating decision-making and implementation as and seven criteria that actors can use to determine whether more important than inclusivity, transparency, and important decisions are being made in a way that is genu- extensive justification of policy choices to those affected inely fair. Second, it discusses how leaders and stakehold- by the decisions. The goal is to bring reforms to a point ers can advance fairness in health financing in real-world where a new government cannot easily reverse the policy contexts, amid asym- metrical power relationships. choices made. Finally, it draws a distinction between directional and technical decisions in health financing, clarifying the prac- The decisions taken through the subsequent months are tical implications of this difference for advancing fairness technically sound and in line with UHC principles and in health financing policy. lessons from other countries. Yet the lack of transparency and inclusiveness in the process leaves these advances politically vulnerable. Decisions are not fully understood or accepted by many of those affected by them and become 3.1 Principles and criteria for fair processes subject to widespread criticism, including on the grounds in financing UHC of an unfair process. In an environment where trust in the government was already low, this weakens the legitimacy An extensive literature spanning different disciplines — of the reform decisions. Paradoxically, the evidence-based political theory and public administration (including de- health financing reforms likely to benefit the large majority liberative democracy), public finance, environmental of citizens spur broad resentment and inflict political costs. management, psychology, and health financing — has informed this report’s characterization of key principles This example from recent country experience illustrates and criteria guiding procedural fairness (Dale et al. the relevance of fair process to improving results in forthcoming). These principles and criteria have appeal health financing. While a fair process does not guarantee across a diverse range of settings, and an extensive and that painful decisions creating winners and losers will be interdisciplinary literature demonstrates their use (He and accepted by all, meeting principles and criteria for Warren 2011; Byskov et al. 2014; Leventhal, Karuza, and procedural fairness can increase the likelihood of broad Fry 1980; Bachtiger et al. 2018; Daniels and Sabin 1997; acceptance (newDemocracy Foundation and The United Murphy 2005; P. Smith and McDonough 2001; Gutmann Nations Democracy Fund 2019; OECD 2017). Meaningful and Thompson 1995). However, this report recognizes 22 Figure 1. Principles and criteria for procedural fairness OVERSIGHT Revisability Enforcement of process CORE PRINCIPLES: Equality Impartiality Consistency INFORMATION over time VOICE Reason-giving Inclusiveness Transparency Participation Accuracy of information that these concepts do not represent universally agreed advisors, or members of the public, appreciate each features of a policy making process, and that the concepts other’s moral and social worth and uphold a favorable are likely to be valued differently depending on a country’s attitude towards each other, even if they disagree among dominant value system, political regime, and social factors. themselves about substantive matters (Beauvais 2018; Gutmann and Thompson 1990). It implies creating con- The report proposes to distinguish between core guiding ditions for anyone, regardless of their social status and principles and more practically oriented criteria for power, to bring forward relevant considerations, with procedural fairness (Figure 2). The three core principles the expectation that these will be heard, discussed, and of equality, impartiality, and consistency over time form addressed (Beauvais 2018; Gutmann and Thompson 1990). the foundations of a fair process. To allow them to be operationalized in practice, seven criteria are derived Impartiality implies that the vested interests of decision- from them, organized in three domains; information, makers should not influence the outcomes of decision- voice, and oversight. The criteria can inform the design making processes, and that prior beliefs should not prevent and assessment of decision-making processes. different views from getting equal and objective consider- ation (Leventhal 1980). Likewise, the vested interests of, Three principles inform all aspects of a fair process for example, commercial and corporate actors, must be Equality has multiple dimensions (Bachtiger et al. 2018). managed so as not to unduly influence decision outcomes First, equality implies that we pay particular attention (de Lacy-Vawdon and Livingstone 2020). Following the to groups that empirically tend to face social, economic, principle of impartiality, conflicts of interest must be ad- and political barriers to participating, deliberating, and dressed, and those making decisions should not hide or expressing their views (Mansbridge et al. 2012; Beauvais distort evidence in pursuit of self-serving goals. The con- 2018). To this extent, the principle of equality may imply cern for impartiality should, however, not lead to the ex- a clear pro-poor orientation and special emphasis on how clusion of relevant voices. In health financing, the extent disadvantaged and marginalized groups are treated in the to which patients should be represented when determin- decision-making process. Second, equality involves mutual ing the services to include in a health insurance scheme respect, which means that participants in a decision- is heavily debated, especially since many patient organi- making process, whether they are policy makers, scientific zations receive industry funding that can bias their views 23 Table 4. Principles for fair processes Principle Short explanation Equality involves mutual respect and requires that people have equal opportunity to access Equality information and articulate their views during a decision-making process, regardless of social status, gender, ethnicity, religion, or power. Impartiality requires decision-makers to be unbiased and stipulates that their decisions Impartiality not be driven by self-interest or unduly influenced by stakeholders with vested interests in the outcome. Consistency over time requires procedures for decision-making to be stable and predictable, Consistency over time and that changes to decision-making procedures are explained and justified. (Fabbri et al. 2020; Mandeville et al. 2019). However, for Fair-process criteria help translate principles equity reasons it can be important to pay attention to the into practice values, needs, and preferences of patient populations that The seven criteria for procedural fairness are reason- are marginalized for economic, social, or political reasons. giving, transparency, accuracy of information, inclu- A strict interpretation of conflicts of interest to secure im- sivness, public participation, revisability, and enforce- partial decision-making can risk excluding such relevant ment, summarized in Table 5. These criteria should not voices. be seen as binary; meaning that they are not either com- pletely fulfilled or completely absent from most decision- Consistency over time is about requiring decision-making making processes. Rather, they are often present in par- processes to be stable and predictable, i.e., based on rules tial or volving forms that provide some benefits yet leave which are not altered too frequently or on an ad hoc ba- scope for further development. Each of these criteria has sis (Leventhal, Karuza, and Fry 1980). Sudden and poor- different mechanisms that can support its implemen- ly explained changes can be perceived as unfair (van de tation, and sometimes a single mechanism can support the Graaf 2021). If changes must be made to decision-making implementation of multiple criteria. For example, a well- procedures, they should be thoroughly justified and in- designed citizens’ panel can promote both participation volve the wider public (Gutmann and Thompson 2004). and inclusiveness. This report groups the criteria into Consistency should be applied in how participation and three domains: information, voice, and oversight. representation are secured, how evidence is used, how in- formation about the process is disclosed, the use of mech- Information: a requirement for reasoned debate anisms for revisability, and the enforcement of similar The first domain, information, covers reason-giving, processes across similar kinds of decisions (Hasman and transparency, and accuracy of information, which is con- Holm 2005; Ford 2015). Consistency is a fundamental cri- cerned with the content and presentation of information. terion across different policy making domains. For legal systems, consistency has been shown to play a significant Reason-giving requires that those promoting a policy role in shaping people’s perception of fairness. In priority- or legislation justify it to others, including government setting processes that involve the use of health technology institutions, the public, and other stakeholders (Gutmann assessment (HTA), consistency brings structure to the and Thompson 2004). This should be done through a process, both with respect to how information is presented process with mutual exchange of reasons and ex- and how it is used. For these decisions, definitive and planations. Reason-giving encompasses respect, a fun- consistently used procedures and structures have been damental value for a fair process from the perspective emphasized by decision-makers as forming a key feature of of theories of deliberative democracy, because only with a fair process (Kapiriri, Norheim, and Martin 2009). respect does one listen actively, try to understand the meaning of a speaker’s statements, and value these The three core fair-process principles are summarized views. Reason-giving is also verifiable: for example, in Table 4. a budgetary document can be checked for explanations that justify proposed changes in the health budget. This can prevent such changes from being perceived as arbitrary (Lakin 2018). 24 Table 5. Criteria for fair processes Domain Criterion Short explanation Reason-giving involves decision-makers’ justifying decisions to those affected by them. Reason-giving It requires that disagreements be resolved by reasons being exchanged, listened to, and accepted or rejected by free and equal persons. Transparency is about making information accessible, including information on Information the decision-making process (e.g., steps in the budget cycle); justifications during deliberations on the issue at hand (e.g., reasons for a proposed budget, any alternatives, Transparency and discussions around these); and reasoning on the decisions taken (e.g., why this particular budget is adopted), as well as the output of the decision itself (e.g., a budgetary document with actual figures in it). Accuracy Accuracy of information is about decisions’ being based on a comprehensive array of infor- of information mation sources, encompassing a diverse spectrum of evidence, perspectives, and views. Public Public participation is about enabling members of the public to access information, participation express their opinions, and directly engage in the decision-making process. Voice Inclusiveness entails considering a broad range of views and concerns, necessitating mechanisms to involve individuals who typically do not contribute to public policy and Inclusiveness decision-making and ensuring the inclusion of diverse perspectives and arguments, even in cases where stakeholders are unable to directly participate. Revisability means accepting that new reasons—such as new evidence and new understandings of the issue at hand—can be given greater weight in the future, and Revisability therefore justify revised decisions. Mechanisms must therefore exist for those who Oversight disagree with the decision to challenge it and for decision-makers to respond to reasons and to consider revising the original decision. Enforcement has two aspects. One aspect concerns the presence of mechanisms to ensure that the criteria for procedural fairness are upheld. The second aspect pertains to Enforcement the outcomes of the decision-making process and having laws, regulations, and oversight mechanisms to ensure that outcomes are implemented. Transparency is about disclosing timely and clear informa- tice that stipulates the importance of making its work open tion about the decision to everyone affected by it. It in- to public scrutiny (JCVI 2013). At the same time, members volves being open about the evidence base informing deci- of JCVI usually meet in a closed session to enable the free sions, how the evidence has been generated, and how it will exchange of opinions and a sound deliberative process pri- be used. Transparency is crucial to fulfilling reason-giving: or to reaching conclusions (JCVI 2013). Transparency is information used to justify decisions must be accessible so therefore primarily implemented in terms of providing full that people can assess whether the information provided justification through a public statement once a decision has is sufficient and challenge the reasoning when required. been reached. Moreover, since JCVI subsequently releases Moreover, the transparency of a process allows the pub- the minutes of its deliberations, the public can gain insight lic to judge whether procedures for decision-making are into the reasoning process that led to the committee’s con- working according to stated intentions: for example, pub- clusions, including points of disagreement and the partici- lication of minutes of a discussion can show that people pation or otherwise of members with a conflict of interest. with a conflict of interest withdrew from participation. If persons with conflicts of interest did participate, making Accuracy of information requires decision-making that information accessible can enable people to object to processes to be informed by a comprehensive array of the process. information sources, encompassing a diverse spectrum of evidence, perspectives, and views. Sources should be However, the positive influence of transparency on rea- trustworthy and contribute to an informed opinion. For son-giving depends on the decision situation, and there example, when deciding on sound measures to combat the may be justified limits placed on transparency during a de- COVID-19 pandemic, governments were expected to cision-making process. For example, the UK’s Joint Com- provide their reasoning to the public, based on accurate mittee on Vaccination and Immunisation (JCVI), an inde- information collected from diverse scientific sources pendent vaccine advisory committee that advises the UK (Eriksen 2022a). Reasons based on biased or inaccurate government about the prioritization and introduction of information can mislead participants and unsettle the vaccines in the immunization program, has a code of prac- deliberative process. 25 Voice: Mitigating power imbalances to Oversight: Securing fair process in the real world achieve inclusion The third domain, comprising revisability and enforce- The second domain covers participation and inclusiveness ment, is about oversight of the process. Revisability means and is about creating opportunities for voice. Public that new reasons — such as new evidence about the benefits participation implies creating opportunities for the pub- and harms of a policy and new understandings of the issue lic to directly participate in the decision-making process at hand — can be given greater weight in the future and and influence the outcome (P. Smith and McDonough so justify revised decisions ww(Gutmann and Thompson 2001; Weale et al. 2016). Meaningful engagement between 2004; Leventhal, Karuza, and Fry 1980). Mechanisms for decision-makers and the public requires forums that secure revising decisions will vary depending on the decision type mutual respect and provide space for the public to express as well as a country’s legal and political system. However, views, share evidence, and challenge official positions and in all cases, mechanisms must exist for those who disagree for those making decisions to defend their arguments, with the decision to challenge it and bring updated evidence respond to objections, and, if necessary, revise their and reasons to bear on the issue, and for decision-makers to decisions (Eriksen 2022b). Power imbalances between respond to these reasons and consider revising the original participants, shaped by social, political, and economic decision (Maluka, Kamuzora, San Sebastian, Byskov, factors in society, must be mitigated to create a supportive Ndawi, et al. 2010; Gibson, Martin, and Singer 2004; environment for respectful deliberation (Gutmann and Barasa et al. 2017). Equality implies that mechanisms for Thompson 2004; Masefield, Msosa, and Grugel 2020; challenging and revising decisions must be accessible to Razavi et al. 2019). For example, direct representation of all. Promoting impartiality requires special attention to community members through mechanisms such as Brazil’s ensuring that mechanisms for revision are not misused to health management councils enables citizens’ voice and has counter the public interest. Finally, consistency prescribes potential for promoting fairer decision-making processes that procedures for evaluating new arguments should (Barnes and Coelho 2009, 230). be predictable. Inclusiveness is about securing the representation, directly Finally, whether fairer processes can be achieved is or indirectly, of all relevant voices and interests that are determined to a large extent by enforcement with respect affected by the decision (Baber and Bartlett 2018; Bohman to processes and outcomes. Without enforcement, none 2012). Promoting inclusiveness involves ensuring that of the principles and criteria can be expected to achieve the diversity of views expressed in the public sphere is their stated intentions, ultimately undermining fairness. channeled to formally organized institutions that have Legislation is a key tool for securing enforcement of fair decision-making power, like parliamentary assemblies processes. For example, consistency over time can be and government departments (Dryzek 2009). It requires partially enforced through primary legislation regulating a mechanisms—tailored to the needs of the specific decision process for adopting new taxes. However, if the legislation and the affected audience—for bringing in voices that has many loopholes that result in frequent changes to the typically would not contribute to public policy and rules on how new taxes are adopted, then consistency over decision-making unless barriers to their participation time is difficult to achieve. With respect to outcomes, are removed and their views and experiences are actively the literature on deliberative democracy and partici- sought (Razavi et al. 2020). Special attention is therefore patory budgeting emphasizes the critical role that enforce- given to securing the views and perspectives of ment plays in securing respect for the binding nature of disadvantaged populations. However, achieving this goal decisions (Gutmann and Thompson 2004). For example, requires attention to financial, social, and cultural sources officials who make decisions on behalf of other people of power differences that constrain or prevent inclusive have responsibility to ensure that these decisions processes (Razavi et al. 2020; World Health Organization are implemented. 2019; Mulvale et al. 2019). Moreover, inclusiveness goes beyond a single-minded focus on the numerical 3.2 Policy context representation of different groups, i.e., simply counting who and how many are directly present in participatory Crucial to the application of the fair-process concepts is and decision-making forums. Inclusiveness requires en- a thorough consideration of the political culture in which suring that diverse perspectives, experiences, and under- they are applied and embedded (Sparkes et al. 2019; Reich lying discourses are reflected, even when stakeholders are 2002). Critical factors to consider include the distribution unable to directly participate in the process (Milewa 2008; and exercise of power when policies are discussed and Dryzek and Niemeyer 2008; Rajan et al. 2019). formed (Gore and Parker 2019; Sparkes et al. 2019; 26 Box 1. In focus: Public participation and inclusiveness Not all forms of public participation od. Citizens’ juries, which have been To ensure inclusiveness in these par- meet the standards for procedural fair- used in health (Moretto et al. 2014; ticipatory mechanisms, it is recom- ness proposed by this report. In fact, Street et al. 2014), are seen as ideal mended to use strategies for ran- there is a vast literature showing that for developing well-informed citizen dom recruitment of citizens. This can mechanisms for public participation recommendations on complex policy achieve representativeness of the can actually be used to exclude certain questions, but they require significant group with respect to defined socio- groups or to rubber stamp decisions resources to implement. The OECD economic characteristics (e.g., level (Williamson and Scicchitano 2014; recommends on average a minimum of income, ethnicity, rural/urban) and Wilkinson et al. 2019). Too frequently, of four days, and often longer, to allow demographic traits (e.g., age, gender). public participation becomes equated citizens participating in such a body ad- Removing participation barriers such with engagement of interest groups equate time to develop considered and as cost of child-care or transportation and people with a specific agenda, detailed collective recommendations is also a means of ensuring that partici- rather than citizens overall (Chwal- (Česnulaitytė 2020). patory mechanisms are not dominated isz and Česnulaitytė 2020). A recent by the affluent (Česnulaitytė 2020). An important aspect of representative OECD policy paper on deliberative Facilitators must ensure that vested deliberative bodies is that self- selec- democracy therefore calls for “repre- interests do not dominate the delib- tion should not drive who participates. sentative public deliberation” where erations, and procedures for enabling Many health financing decisions in- “deliberative bodies like citizens’ as- participation and resolving disagree- volve mechanisms for public partici- semblies create the democratic spaces ments should be consistently applied pation, like public hearings or consul- for broadly representative groups of (Mansbridge et al. 2011; Curato et al. tations, organized within legislative people to learn together, grapple with 2017). However, there may be signifi- processes. However, a key objection to complexity, listen to one another, and cant challenges in implementing these these mechanisms is that they typically find common ground on solutions” methods, especially in low-income set- involve self-selection of stakeholders (OECD 2021, 5). tings. and insufficient facilitation of discus- Different methods for public participa- sions; for this reason, they tend to fall tion exist, and what is most appropriate short of mitigating power differences in each case will depend on the issue or and securing meaningful engagement type of policy decision, its complexity, (Chwalisz and Česnulaitytė 2020; time constraints, and the availability of Guttman et al. 2008; Marais, Quayle, resources for implementing the meth- and Petersen 2020). Hayward 2021); the supportive environment for and the 2018). Specific stakeholders in health financing also wield strength of civil society (Francés and Parra-Casado 2019); greater power than others. In revenue mobilization deci- and the specific political regime, including the state of open sions, some of the most powerful stakeholders are various political discussion and good governance in the country industry representatives. For example, in several coun- (N. Smith et al. 2014; Herrera et al. 2017). tries working to address the burden of non-communica- ble diseases and raise revenues for health, recent analyses Fair process takes power relations seriously identified the sugar-sweetened beverage (SSB) industry as The exercise of power and the power relations that operate a powerful policy actor, given its significant resources as at different levels lie at the heart of policy making (Gore well as the industry’s positioning as a contributor to eco- and Parker 2019; Sriram et al. 2018; G. Sen et al. 2020). nomic growth and employment in some contexts (Thow The design of fair processes cannot be separated from the et al. 2021). In pooling decisions, particularly in low- and role of power within political institutions or the imbalance middle-income countries, organized and better-resourced of power among those who participate in decision- mak- groups can resist the creation of a single pool if that means ing processes (Abelson et al. 2003; Rohrer-Herold, Rajan, less generous benefits for them (Kutzin 2012; Savedoff and Koch 2021). Financial or political power can be con- 2004). In other settings, health insurance companies wield centrated among elite groups in the population who can considerable financial, informational, and lobbying power have greater ability to shape health financing policy at the and have vested interests in maintaining health insurance expense of the interests of other stakeholders (Chemouni arrangements that promote their market share and profits, 27 even if these are not the most efficient and equitable for defined, there is empirical evidence that processes that populations (Crancryn 2019; The Center for Public Integ- partially meet key criteria for a fair process, for example rity 1995). inclusive public participation, reason-giving, and transparency, can be implemented in these jurisdictions. The principles and criteria for fair processes fulfill a key For example, in China, public hearings are required for function in creating checks and balances and addressing new legislation, including on income taxes (He and Warren these power differences. For example, transparency can 2011). Another example from China concerns the country’s contribute to levelling the playing field by ensuring that 2006-2009 health care reforms (Korolev 2014). The stakeholders have access to the same information and Reform Commission overseeing that process created a by revealing biases or conflicts of interests among deci- special internet-based platform for soliciting critical inputs sion-makers. Participation and inclusiveness can ensure during the reform discussion and received thousands of that a diverse range of stakeholders are able to express comments and suggestions (Korolev 2014). In Iran, the views; challenge the reasoning of decision- makers; and High Council for Health Insurance, a body within the create conditions such that a fair and objective evaluation Ministry of Health that has responsibility for health in- of reasons and evidence, rather than the interests of pow- surance benefits, has used working groups that foster de- erful stakeholders, drive decisions. liberation among technical experts, medical professionals, patients, scientists, and insurance company representatives Civil society plays a critical role in realizing when selecting services for evaluation and appraising the fair-process principles and criteria evidence for recommendations on the selection of health The strength of civil society — understood here as the var- benefits (Nouhi et al. 2022). ious ways people’s interests are organized and represented — is vital for realizing fair-process principles and criteria. While establishing legal requirements for public partici- By advancing the voice and interests of marginalized com- pation is a good first step, a large body of evidence shows munities (Okonjo-Iweala and Osafo- Kwaako 2007; De that in some cases, such participation becomes a tokenis- Vos et al. 2009; Daniels et al. 2000), civil society can pro- tic exercise (Lakin and Nyagaka 2016; Glimmerveen, mote equality, participation, and inclusiveness. Civil so- Ybema, and Nies 2022). Nominal participation may ciety in many settings presses for transparency, relays the even be deliberately instrumentalized to exclude certain views of members of the public in mutual exchange with groups (Glimmerveen, Ybema, and Nies 2022) or to cre- decision-making authorities, and demands justification for ate a safety valve to preempt social unrest and avoid ad- decisions (Levine, Fischer, and Kumar 2021). With respect dressing larger issues (Leib and He 2006, 7). Thus, “par- to impartiality and consistency over time, civil society ex- ticipation” is not a panacea, and what it signifies must be ercises an important monitoring function in uncovering scrutinized in each case. the influence of vested interests and advocating for equal treatment. Finally, the revisability criterion is meant to 3.3 Implementing participation and inclu- facilitate opportunities for civil society to challenge, shed siveness: differentiating between direction- new light on, and revise decisions when people’s interests al and technical decisions are affected. In most settings, civil society plays an impor- tant monitoring role to ensure enforcement of principles Not all health financing decisions demand the same level of procedural fairness in decisions. In the absence of strong of public participation to yield a process that most citi- civil society movements, the value and implementation of zens will accept as fair. Empirical examples suggest that fair-process criteria are greatly diminished. many countries enable greater public participation, usu- ally through mechanisms within their legislative pro- Some features of fair process can operate in settings cesses, in decisions that set the key directions for health where democratic governance falls short financing (Agyepong and Adjei 2008; Kim and Lee 2022; While open political discussions and good governance Mayka 2019). In contrast, countries may delegate deci- are central prerequisites, there is growing evidence sions that are more technical in nature to government demonstrating that at least certain elements of a fair process officials and technical bodies. can be present in settings which do not meet traditional standards of democratic governance (Sass 2018; Kaufman Directional versus technical decisions: country examples clarify the distinction and Kraay 2021). In these contexts, the domain and scope of issues put forward for deliberation are typically carefully Decisions that span the gamut from directional to technical determined by the authorities, which can lead to weakening exist across all three key health financing domains of the quality of participation and its claims to be truly described in Chapter 2. Examples from countries at deliberative (Stokes 2006, 61). However, once parameters, different income levels underscore the distinction between such as the scope of questions to be deliberated, are these types and indicate that the principles and criteria 28 for fair process are likely to be reflected in varying ways, insurance programs. In comparison, the decisions on depending on context. design and allocation of funding to various budgetary programs (e.g. nutrition, maternal and neonatal health, In Estonia, the Estonian Health Insurance Fund (EHIF) Act cancer prevention and control), as part of the budget- replaced regional health insurance funds and established ing for results process (referred to as “Presupuesto por the EHIF as the independent public body responsible for Resultados”), is a highly technical exercise, driven by purchasing health services using a combination of experts and government officials (Dale et al. 2020). earmarked payroll contributions and general taxes (Habicht, Habicht, and van Ginneken 2015; Jesse 2008). In health financing, the establishment of independent In the Estonian legal context, these types of acts are purchasers stands out as an example where countries tend the second-highest level of legal documents after the to strive for the separation of technical decisions from Constitution. All such acts are adopted by the parliament broader political processes. These institutions are usual- only after public consultations with all related ministries ly set up to make technical decisions, in some cases with and stakeholders, as well as three readings in parliament, the involvement of civil society, but at arm’s-length from reflecting these laws’ direction-setting character. In con- the day-to-day political process. As described in a recent trast, the pricing methodology that serves as the basis for UK government review of these types of bodies (Comp- setting provider payment rates in Estonia represents a troller and Auditor General 2021), they are established technical exercise defined by the Ministry of Social when it is appropriate for the body to be distanced from Affairs. Similarly, the Health Service List which sets government and seek input from external technical provider payment methods and rates is a government- expertise. The National Health Service of Ukraine (NHSU) level act which is mainly driven by the EHIF staff, provides a good example of such a body. The NHSU although the proposals are reviewed by the supervisory was established as a Central Executive Agency with board of the Fund, consisting of state, employer, autonomy in technical and operational matters, and employee representatives (Lai et al. 2013). including specification of services within the overall Program of Medical Guarantees, selection of providers, Ethiopia provides another example of the two different and developing payment methods and rates. During types of decisions. The most recent revision of the the formulation of policy options and decision-making Ethiopian essential health services package was by an arm’s-length body or similar kinds of expert- characterized by broad stakeholder participation, taking driven institutions, the scope for direct public approximately 18 months, with active engagement of a participation and representation tends to be limited. wide range of stakeholders, including government Accordingly, the legitimacy of such bodies depends heavily representatives at various levels, experts, and members on the quality of public reasoning, which refers to their of the public. Thirty-five consultative workshops were capacity to justify publicly the reasons for their decisions convened to define the scope of the revision, select and the public’s acceptance of this justification (Eriksen health interventions for review, agree on the 2022b). prioritization criteria, gather evidence on the performance of the selected interventions on the Practical implications for operationalizing the fair process criteria agreed criteria, and compare health interventions (Joint Learning Network for Universal Health Coverage 2022). The distinction between directional and technical health In comparison, provider payment methods and rates are financing decisions is not always clear cut, and the way it seen as a largely technical exercise and are set through is interpreted across countries will vary according to their a routine process that includes health facilities and political and legal systems. Broadly, however, distinguish- finance offices/bureaus without involvement of the public ing among different degrees of directional and technical and civil society (SPARC 2022). decisions provides valuable insights for the practical ap- plication of fair-process criteria, especially when assess- Another example of a directional decision comes from ing the appropriate level of public participation in health Peru, where in 2002 the National Accord (Acuerdo financing decisions and determining the extent to which Nacional) was signed by representatives of religious expert-led processes should be the main driver of these de- and civil society organizations, political parties, and the cisions. government. The agreement affirmed the goal of ensuring universal access to health care services and social security Ambitious methods like citizens’ panels and other ap- (Seinfeld, Montanez, and Besich 2013). This was a mile- proaches to implementing representative deliberative stone in developing the country’s Comprehensive Health processes are well suited to address direction-setting Insurance (SIS), which was based on consolidation of two questions, particularly those that may be divisive and are existing schemes—the mother-child insurance and school subject to conflicting public values; that involve trade-offs 29 marked by uncertainty, with no evidently “right” answer accuracy of information — become key drivers of people’s for achieving resolution; and that represent long-term perceptions of procedural fairness (Eriksen 2022b). issues that go beyond the short-lived incentives of electoral cycles (OECD 2020; Solomon and Abelson 2012; Abelson et al. 2013; Raisio 2009; Degeling, Carter, and Rychetnik 2015). Such a level of participation is deemed particularly useful in situations where there is a need to make hard This chapter has described what a fair process is, based on choices that may yield potentially unpopular decisions a wide review of learning and practice from multiple fields. (Abelson et al. 2003). In these cases, if a representative It has identified three core principles of fairness and seven group of people is given the time and resources to learn, criteria that actors can use to determine whether important deliberate, find common ground, and collectively develop decisions are being made in a way that is consistent with considered recommendations, politicians will have greater these principles, so is genuinely fair. It has explored how legitimacy to overcome political deadlock (OECD 2020; fair decision-making processes in health financing can work Raisio 2009). within the constraints of real-world policy contexts. And it has drawn an operationally important distinction between Of practical importance is evidence suggesting that the directional and technical decisions in health financing, clar- public may not be willing to participate in time-consuming, ifying the implications for advancing fairness in health fi- face-to-face deliberative processes, unless their immediate nancing. The analysis throughout has shown that applying interests are directly affected or they are afraid of losing fair-process criteria in the complex political give-and-take something tangible, like their local hospital (Abelson et al. of health financing decisions is not easy. Yet an impressive 2003; Abelson 2001). In cases where more limited public number of countries are already doing so. Chapter 4 now participation is deemed justified, the criteria of the explores policy instruments that countries can use to ad- information domain — reason-giving, transparency, and vance procedural fairness across the core domains of reve- nue mobilization, pooling, and purchasing. 30 4 Principles and criteria in practice: Examples from country experience Valuable practical insights can be gained from the actions cisions themselves improve substantive fairness. Rather, taken by various countries to strengthen procedural fair- the primary focus of the chapter is to explore how these ness across the core health financing functions of reve- instruments can contribute to procedural fairness. This nue mobilization, pooling, and purchasing. This chap- chapter is also not intended to provide a complete list of ter presents examples of such operational experiences in how every policy instrument has been utilized across every countries. The examples are organized according to four health financing function. Instead, it describes a diverse se- broad types of policy instruments that countries have used lection of instruments that can be used to advance one or to advance procedural fairness: legislative and regulatory more principle and criteria. For example, robust freedom instruments; organizational arrangements; financing and of information laws promote transparency and reason- capacity-strengthening measures; and tools related to in- giving by making information that has informed policy formation management and monitoring (Table 6). decisions accessible. In exploring how countries have used these instruments, The chapter is organized by type of instrument and not this chapter does not try to assess whether the final de- by health financing function because many of these instru- Table 6. Policy instruments for promoting procedural fairness Type of instrument Description Legislative and regulatory instruments refer to legally binding provisions, such as laws and acts, Legislative and enacted by legislative bodies to enforce criteria for procedural fairness, along with their detailed regulatory implementation instructions, such as directives. This category includes court rulings that inter- pret and apply the legislative instruments. Organizational arrangements involve changes to existing decision-making processes, changes in functions or scope of work, or the creation of new processes or organizational entities. Examples Organizational include the establishment of government working groups, citizens’ juries, or organizational arrangements bodies responsible for health technology assessments. In addition, this category includes different types of auditing functions that ensure adherence to policies and procedures, measure perfor- mance against predetermined criteria, and convey results to interested users. Financing and capacity-strengthening instruments include adequate and stable budgets, which Financing are necessary for developing and implementing other instruments promoting procedural and capacity- fairness. Budgets need to cover costs for citizen engagement or maintaining free public access to strengthening legislative and regulatory documents. This category also includes building knowledge and skills in key areas, including health economics and methods for citizen engagement. Information management and monitoring encompasses tools for collecting and systematizing Information information, such as digital platforms for information sharing and soliciting public inputs, management databases, data visualization tools for assessing public sector performance on procedural fairness and monitoring criteria, and instruments for tracking public opinion and progress in policy implementation. 31 ments are cross-cutting, i.e., they can be used to advance Legal frameworks governing the public sector can play procedural fairness in revenue mobilization decisions as an important role in promoting procedural fairness. For well as pooling and purchasing. For example, different example, Freedom of Information Laws exist in a majority methods for citizen engagement, such as citizens’ juries of countries worldwide and are key in promoting or public hearings, have been used for questions related transparency and public reasoning for all types of health to taxes as well as for determining which services to in- financing decisions (World Bank 2020). For example, clude in a health benefit package. While the focus here is Ukraine’s law “On Access to Public Information” (2011) on instruments that countries have used domestically in was pivotal in promoting transparency and public par- the pursuit of procedural fairness, the latter sections of ticipation when the subsequent law on “Government the chapter also describe ways the international commu- Financial Guarantees of Health Care Services” (Law 2168) nity has supported procedural fairness at country level by was drafted, leading to the creation of a single pool to developing global instruments, providing funding, and finance the benefits package provided by the National through capacity-strengthening. Health Service of Ukraine. Although there are gaps in compliance, the public information law is considered to have a powerful impact on strengthening transparency in Ukraine (Dzhygyr et al. forthcoming; Oleksiyuk 2018). It 4.1 Legislative and regulatory instruments mandates that public authorities, as well as publicly owned or publicly funded organizations, regularly disclose infor- A country’s constitution serves as its fundamental legal mation about their operations, activity plans, decisions, framework, and constitutional provisions can promote reports, and service provision rules online and in print. In procedural fairness in health financing. An example from addition, any citizen or organization can request additional South Africa shows how adherence to constitutional rules information, which needs to be provided within five days. can shape revenue mobilization decision-making in a man- ner that strengthens procedural fairness. Section 77 of the In many settings, specific legislation governs and sets the South African Constitution defines “Money Bills,” which legal framework for budgeting processes, providing rules are any laws that involve the allocation of public funds for and regulations that promote transparency, participation, a specific purpose or the imposition of taxes, levies, and and enforcement. Laws pertaining to national budget duties (Parliament of the Republic of South Africa 2023; systems promote transparency in revenue mobilization Government of South Africa 1996). The Constitution decisions by specifying the schedule and procedures by mandates a process with public involvement in the which a country’s budget should be prepared, approved, preparation of “Money Bills.” Based on this mandate, executed, accounted for, and when final accounts should before the introduction of such a bill in Parliament, the be submitted for approval (de Renzio and Kroth 2011; South African National Treasury publishes a discussion Santiso 2004; Lienert and Fainboim 2010). These laws document or a draft bill and invites public comments. It is can also serve as a tool for promoting inclusiveness and customary to host public consultations with stakeholders participation by prescribing what types of stakeholders to engage with the comments and to redraft the bill must participate in various stages of the budgetary process. (Kruger et al. forthcoming). For example, in the Kyrgyz Republic, the Budget Code is a key document describing the roles and responsibilities A recent illustration is the case of the Health Promotion of the Ministry of Finance as well as line ministries and Levy (HPL) on sugar-sweetened beverages (SSBs) (Hofman the parliament, and key steps in the preparation of the et al. 2021). The draft bill and key discussion documents budget, as well as its approval, execution, and the auditing were publicly released by the National Treasury, enabling of expenditure (President of the Kyrgyz Republic 2016). public scrutiny of the justification and supporting scien- The Budget Code also regulates civil society involvement, tific evidence (National Treasury of South Africa 2016). public hearings, and publication of budgetary documents. Four public hearings were conducted, with two taking place before the drafting of the bill (Finance Standing Health sector legislation can incorporate provisions that Committee 2017b, 2017a). This approach fostered mandate the use of specific instruments that promote proce- participation and inclusivity by enabling a broad range of dural fairness. In Thailand, the National Health Security Act stakeholders to engage in the process. During these sessions, of 2002, which established the country’s Universal Cover- representatives from the National Treasury had to explain age Scheme (UCS), includes provisions that mandate citizen the rationale behind the proposed new tax, thereby representation in governing bodies and the implementation promoting reason-giving. Finally, the National Treasury of public participation processes (Kantamaturapoj, Kulthan- substantiated its consideration of all inputs by offering manusorn, et al. 2020; Marshall et al. 2021). For example, a written, point-by-point response in a final response the National Health Security Board, the governing body of document justifying the choices made (National Treasury the UCS, consists of 30 members, with five seats reserved of South Africa 2017). for citizens selected from civil society organizations related 32 to specific health constituencies. Citizens’ participation on the policy process. The composition of these groups is key the board empowers them to influence decisions and ensure for inclusivity. In Tanzania, for example, the Ministry of representation of their diverse interests and needs related to Health led the development of the improved Community the standards and scope of health services provided, admin- Health Fund (iCHF) by establishing a task force that in- istrative policies, budgeting, and other governance matters. cluded government agencies, development partners, and The National Health Security Act’s legislative provisions some of the private organizations supporting the imple- also mandate public disclosure of information pertaining to mentation of CHF schemes. However, this structure pro- the financial, operational, and performance aspects of the vided few openings for community voice (Binyaruka et al. scheme; annual public hearings to gather experiences and forthcoming). Reports suggest that limited inclusivity and opinions from citizens; and mechanisms for handling and transparency in launching the iCHF and communicating responding to citizen complaints (Kantamaturapoj, Kulth- its benefits have led to misunderstanding and mistrust anmanusorn, et al. 2020; Kantamaturapoj, Marshall, et al. among community members regarding key aspects of the 2020; Marshall et al. 2021). scheme (Afriyie et al. 2021). Finally, court rulings can contribute to promoting a fair New permanent bodies can be established to strengthen process by interpreting and enforcing the laws and reg- information, voice, and/or oversight. To set priorities in ulations described above. For example, as discussed in the design of benefits packages, numerous countries in Chapter 1, in 2008, the Constitutional Court of Colombia every region have now established bodies responsible for ordered the unification of benefits plans for the country’s health technology assessments (HTA) (Bertram, Dhaene, contributory and subsidized health insurance schemes and Tan-Torres Edejer 2021). Examples from different (Arrieta-Gomez 2018; Yamin and Parra-Vera 2009). The regions include the National Institute for Health and Care court justified its decision on the grounds that the existing Excellence (NICE) in the United Kingdom (UK) (Cowles two-tiered system, where the subsidized scheme offered et al. 2017), the Health Intervention and Technology access to less than half the entitlements available under the Assessment Program (HITAP) in Thailand (Tantivess, contributory scheme, violated principles of equality and Teerawattananon, and Mills 2009), the National Authority non-discrimination enshrined in the Constitution. The for Assessment and Accreditation in Healthcare in Tunisia Constitutional Court underscored procedural fairness by (Fasseeh et al. 2020), the Pharmaceutical Benefits Advisory calling for transparency and participation in determining Committee (PBAC) in Australia (Kim, Byrnes, and Goodall benefits, the robust use of evidence to inform such de- 2021), and the National Center for Health Technology cisions, and the oversight of provider performance and Excellence in Mexico (Gómez-Dantés and Frenk 2009). health insurance entities through audits (Yamin and Par- Considerable variation exists in these institutions’ legal ra-Vera 2009). foundations, design, relationship to the ministry of health, decision processes, and whether their recommendations are binding. However, they strive for transparency and the inclusive involvement of stakeholders, and a broad and 4.2 Organizational arrangements robust evidence base when making decisions. They typically offer affected parties opportunities for revisions Organizational arrangements can range from temporary and appeal, although the effectiveness of these mechanisms structures with limited scope and participation (e.g., health varies (Bertram, Dhaene, and Tan-Torres Edejer 2021). financing working groups) to creating new bodies (e.g., a Supreme Audit Institution or a separate health technology An organizational feature adopted specifically to strength- assessment body) to broader participatory processes (e.g., en participation and inclusiveness in purchasing decisions national dialogues such as the Societal Dialogue for Health has been the direct representation of civil society members in Tunisia). This section first presents more traditional in purchasers’ supervisory boards. Thailand has a well- and less resource-intensive approaches, which often established practice of civil society participation (Marshall involve limited participation outside of government. It et al. 2021), while the Kyrgyz Republic (Habicht et al. 2020) next describes experiences with establishing new bodies or and Ukraine (World Health Organization and World Bank expanding the functions of existing ones to promote 2019) have introduced these features more recently. procedural fairness principles and criteria. Finally, the section highlights experiences with more ambitious ways Earlier chapters made a distinction between directional and of engaging citizens that can be organized as one-off events technical decisions in health financing: countries typically or established as more permanent structures. ensure more participation in the former than in the latter, where technical committees often draw on subject matter To inform health financing decisions, it is common prac- experts to analyze and interpret complex technical issues tice to set up time-limited task forces, working groups, and and data (Eriksen 2022a). A prime example is National similar organizational structures during the early phase of Immunization Technical Advisory Groups (NITAGS), 33 used in many countries to assess the cost-effectiveness of opportunity to deliberate on a particular issue and provide new vaccines prior to a decision about whether they should recommendations to decision-makers (Street et al. 2014; be publicly financed (Donadel et al. 2021). For these types Reckers-Droog et al. 2020). Random selection enables of committees, organizational rules of procedure can be inclusiveness and favors a diverse range of perspectives an instrument that promotes other criteria of procedural representative of the population at large. This can help fairness. For example, the UK JCVI’s Code of Practice strengthen legitimacy and reinforce trust in the decision specifies management of conflicts of interest to ensure process. In Brisbane, Australia, for example, a citizens’ jury impartiality, transparent appraisal of the evidence base, and was convened to deliberate on the proposal to increase taxes publicly releasing the reasoning underpinning Committee on SSBs (Moretto et al. 2014). The jury was tasked to evaluate decisions, including points of disagreement (JCVI 2013). the acceptability of using taxation to influence the con- sumption of unhealthy drinks and curb the prevalence of Supreme Audit Institutions (SAIs) play an important role childhood obesity. in promoting transparency, citizen participation, inclu- sivity, and enforcement by providing objective, unbiased, A related instrument used to understand how the and accessible information on how public funds are deliberative process influences participants’ views is managed (Castro 2022). Audit reports inform the public as deliberative polling. It involves a representative sample of well as the country’s legislature about how governments citizens who are surveyed before engaging in structured use public funds and the results they achieve. For ex- discussions and deliberations and who then complete a ample, during the Ebola outbreak in 2014-15, the SAIs post-deliberation survey to measure changes in their of Liberia and Sierra Leone conducted real-time audits as opinions. In Chile in 2020, a multi-stakeholder partnership well as retrospective analyses in the aftermath of the involving the Tribu Foundation, academic institutions, outbreak (INTOSAI Development Initiative et al. 2020), and the Chilean senate implemented deliberative polling yielding findings that have proved relevant for managing with a random sample of 514 citizens (Sartor and CDD the COVID-19 pandemic. 2022). The goal was to discuss pension and health financing reform proposals, including an increase in taxes or SAIs can incorporate civil society priorities by aligning insurance premiums to finance treatment for rare diseases, future audits with areas of concern identified by citizens as well as implementing a single insurer for everyone. The and integrating civil society feedback to shape the scope Chilean example demonstrated a crucial lesson from of audit processes. A notable example is Argentina’s SAI, deliberative polling: through the process, citizens adjusted which has held annual meetings with diverse civil society their views on policy proposals in light of new information organizations since 2004, allowing these groups to propose and moderated discussion, with participants in some cases audit topics for inclusion in the subsequent year’s action becoming less favorable toward the proposals under plan (Open Government Partnership 2020). consideration. Results underscore the importance of engaging citizens in informed, deliberative discussions In many contexts, legislative processes for policy proposals and using these processes to ensure that public values and incorporate public hearings (Mikuli and Kuca 2016; preferences are reflected in health financing reforms. Parliament of the Republic of South Africa n.d.). These can provide a platform for stakeholders to give input on Some countries have adopted ambitious, broad-based in- financing choices influencing the expansion of health care struments to promote public participation and strengthen coverage toward UHC. As mentioned above, to fulfil the transparency and other procedural fairness criteria. One legislative requirements under Thailand’s National Health model is often referred to as a “societal” or “national” policy Security Act, annual public hearings have been dialogue. Two examples show how this approach has been implemented to gather input from citizens on priorities used to promote participation and inclusiveness when ex- for new benefits within the Universal Coverage Scheme ploring critical questions related to health financing. One (UCS) (Viriyathorn et al. forthcoming). Through the annual is from Tunisia, which initiated a “Societal Dialogue for public hearings, important changes to UCS benefits Health” in 2012 as part of its post-revolution political re- have been initiated, such as the harmonization of access forms (Ben Mesmia, Chtioui, and Ben Rejeb 2020). The to emergency services and the removal of the two-child objective was to facilitate a transparent and participatory limit on covered birth deliveries (Kantamaturapoj, approach in exploring critical decisions that would shape Kulthanmanusorn, et al. 2020). the country’s health financing system and set its long-term directions. This involved working closely with civil soci- Citizens’ juries and other processes based on random ety groups under the Societal Dialogue for Health and es- selection of participants are increasingly being used to tablishing a Citizen Participation Unit in the Ministry of involve members of the public in decision-making. Under Health to mainstream participation and inclusiveness in these models, a group of randomly chosen citizens have the future decision-making. Morocco adopted a similar mech- 34 anism in the development of its health financing strategy. of the Republic of Korea has set aside the equivalent of The Moroccan model brought together government offi- GBP 1.2 million to fund the national participatory cials, civil society groups, private sector representatives, budgeting group, conduct surveys, raise public awareness, and parliamentarians, with a focus on reducing fragmen- and support the facilitation of participatory budgeting at tation between existing health insurance schemes (Akhnif the national level.7 et al. 2020). Implementing and managing instruments like public hear- Participatory budgeting is a broad-based instrument ings, citizens’ panels, and deliberative polling requires applied specifically to the budgeting process. It has been building administrative capacity to ensure that delibera- implemented across a wide range of settings (Bartocci et tions are well structured and facilitated, and that all partic- al. 2022). It enhances public participation in budget ipants have equal opportunities to express their opinions. decisions; increases the likelihood that public preferences This includes dedicating staff to manage the process, train- and needs will be considered; boosts transparency by ing and incentivizing participants, and allowing the public sharing information on the allocation and use of public adequate time to develop considered collective recommen- funds; and enhances reason-giving by requiring clear dations (Abelson, Warren, and Forest 2012; Calisto Friant justifications from decision-makers. However, evidence 2019; Sintomer, Herzberg, and Röcke 2008). Thailand’s from a range of settings suggests that realizing the potential experience with conducting annual public hearings high- of participatory budgeting requires strategies for securing lights the critical importance of skilled professional facil- diverse and representative groups of participants and itation to ensure meaningful public engagement and up- addressing power imbalances among participants (Bartocci hold the principle of equality (Kantamaturapoj, Marshall, et al. 2022; Calisto Friant 2019; Sintomer, Herzberg, and et al. 2020). Röcke 2008). Examples from Tanzania and The Gambia highlight how While much of the empirical evidence on the use of par- the lack of adequate financing and administrative capacity ticipatory budgeting comes from the local level, the Re- can limit the effectiveness of mechanisms aiming to in- public of Korea offers an instructive case of its application crease transparency and participation. Tanzania’s Council to national budget decisions (Yoon 2021). Following the Health Services Boards (CHSB), the entities responsible for establishment of a dedicated division for the purpose with- reviewing local health plans and budgets, did not have funds in the Ministry of Economy and Finance, oppor- tunities to organize regular meetings and appropriate training for participation have been created by imple- menting a for members representing the community, who were dedicated online platform where participants can rate ex- expected to contribute to priority-setting in their districts isting budget proposals and make their own suggestions. (Maluka et al. 2010). A lack of clearly defined budget for Reason-giving is improved when government officials these activities hampered the effectiveness of the CHSB. responsible for budget decisions are expected to consider In The Gambia, during discussion of the National Health citizen preferences and priorities expressed via the partic- Insurance Scheme (NHIS) bill in the National Assembly, ipatory platform and explain the ulti- mate allocation of the government faced time and resource constraints that budget resources in light of citizen input. prevented officials from organizing public consultations through “Citizen Bantabas” – a traditional practice where community members gather to discuss critical societal issues and that might have boosted public understanding 4.3 Financing and capacity strengthening and trust in the decision process (Njie, Dale, and Gopinathan forthcoming). Instruments in this category include dedicated budgets to cover implementation costs; building administrative Financial incentives can be essential to removing economic capacity to manage organizational arrangements; financial barriers that prevent disadvantaged populations from incentives and skill-building to empower the public to participating in activities like public hearings, citizens’ participate; and building technical capacity on health panels, and participatory budgeting. Without adequate financing in the ministry of health. resources, individuals from low-income backgrounds may find it difficult to take part in these initiatives, which can Experience across different contexts demonstrates the further deepen inequality and exclusion. For example, importance of having dedicated budgets to cover the to strengthen inclusiveness when the citizens’ panel was costs of instruments that promote procedural fairness in implemented in Brisbane to deliberate on taxation of SSBs, decision-making processes. For example, the government participants were offered a stipend of $A 200 and vouchers 7 https://participedia.net/case/7431 35 to assist with their transportation and accommodation Thailand’s progress towards UHC (Tangcharoensathien et needs (Moretto et al. 2014). Similarly, to strengthen al. 2021). representation during annual public hearings in Thailand, expenses such as transportation costs for all attendees are included in the budget of the National Health Security Office (Kantamaturapoj, Marshall, et al. 2020). However, 4.4 Information management achieving greater inclusiveness requires more than just and monitoring financial incentives; it also depends on investing resources to strengthen knowledge among marginalized and Information management and monitoring instruments vulnerable populations. Developing critical thinking, play a key role in promoting transparency, accuracy of communication, research, and analytical skills among information, public participation, and enforcement. these groups can enable them to more effectively engage in They are also important for measuring performance with decision-making processes (Snow, Tweedie, and Pederson respect to the different criteria for procedural fairness. 2018; Montesanti et al. 2017). Some well-recognized tools for monitoring and assessing Building technical capacity in health economics and budget transparency, public participation, and reason- financing policy within the ministry of health itself is giving practices have been developed and led by global considered a key instrument for promoting use of evidence or regional initiatives and are described in the next sec- in health financing decisions for UHC. Ethiopia provides tion. Others, such as Kenya’s County Budget Transparen- a valuable example of how civil servant training can build cy Survey (CBTS), are developed and led locally, though capacity for accuracy of information. Policy makers at the they originated from the Open Budget Survey (OBS), a Federal Ministry of Health and researchers at academic global assessment of budget transparency, participation, institutions have received PhD-level training in ethics, and oversight conducted by the International Budget health economics, and priority setting, partly enabled Partnership (IBP). Kenya’s survey, most recently published through a long-term international partnership with in 2023, has been used to assess transparency and public academic institutions. This capacity was foundational to the participation practices among the 47 county governments revision of the country’s essential health services package (IBP Kenya, 2023). The survey measures county govern- (Eregata et al. 2020). The revision process involved ments' compliance with the national legal and regulatory extensive consultations with technical experts and members framework on budget transparency and participation, in- of the public and relied on evidence concerning seven cluding the Constitution, the Public Finance Management prioritization criteria, including cost-effectiveness, equity Act, and other relevant laws and regulations. By providing impacts, and financial risk protection (Eregata et al. 2020; a transparency scorecard for each county government and Hailu et al. 2021; Verguet et al. 2021). highlighting areas for improvement, the CBTS empowers civil society organizations, policy makers, and citizens to In Thailand, a capacity-strengthening instrument for advocate for more effective and inclusive budget processes. promoting accuracy of information has been the International Health Policy Program (IHPP), a unit within An increasingly used tool is a citizens’ budget, which is Thailand’s Ministry of Public Health. The IHPP was estab- an easy-to-understand document that summarizes and lished to build national capacity for generating research explains to the public the main features of the annual and evidence, including by supporting training in academic budget of a country or subnational jurisdiction (Petrie and institutions abroad (Pitayarangsarit and Tangcharoensathien Shields 2010; IBP 2015). Transparency is promoted by 2009). The unit has been instrumental in enhancing governments’ publishing critical budget information in a capacity to produce HTAs and other sources of infor- manner that is readily accessible to the public. Such access mation needed to inform the inclusion of new benefits is also a prerequisite for participation and reason-giving in and the overall design and development of Thailand’s tax- the budgetary process, since it enables people to ask financed universal coverage scheme (Tangcharoensathien questions and request explanations for the choices made. et al. 2013; Tangcharoensathien, Wibulpholprasert, and For example, as part of its democratic transition, The Nitayaramphong 2004). Thailand’s capacity-strengthening Gambia is piloting citizens’ budgets to provide clear, efforts have also focused on the contributions of civil simplified summaries of the government’s revenue and society organizations and community members, in ad- expenditure plans, thereby enabling citizens to have a dition to policy makers, politicians, local administrative better understanding of how public funds are allocated organizations, government services, academia, think tanks, (Lizundia 2020). and research institutions. This collaborative “triangle that moves the mountain” approach has been pivotal in Certain participation tools also offer opportunities for informing health financing decisions and accelerating monitoring by citizens. One instrument is the use of citi- 36 zen or community scorecards in the health sector to moni- of PMJAY COVID-19 Health Benefit Packages (Guinness tor provider performance and the quality of health services et al. 2020; Prinja et al. 2020). and thereby strengthen transparency and enforcement (Björkman and Svensson 2009). These scorecards, which have been trialed in Afghanistan, the Democratic Republic of Congo, Ghana, Malawi, and Uganda, are based on sur- 4.5 Global initiatives and external support veys among health service users regarding their experi- ences with health service providers (Björkman and Open and inclusive processes in health financing can only Svensson 2009; Kiracho et al. 2021). They typically gain lasting traction at national level if they are country encompass questions on multiple facets of health service owned and led. However, regional and global organizations delivery, including access, quality, medicine availability, can play an important facilitating role in certain contexts, and provider responsiveness. Shared with providers for instance by providing funding, strengthening country and policy makers, these scorecards can trigger plans to capacities, or developing global or regional tools that address citizen concerns. However, they are often imple- supplement domestic strategies and instruments. mented with external support and not routinely as part of regular public sector processes. To overcome this problem, International seed funding and technical support served in Uganda, ongoing discussions led by the government, as a catalyst for Tunisia’s Societal Dialogue for Health, with support from local and international research insti- described above. In Turkey, the integration of Green Card tutions, are focusing on the implementation of community holders8 into the General Health Insurance System was score cards on a routine basis, with the aim of linking based on a thorough technical analysis and evidence them to decision-making processes (Kiracho et al. 2021). produced by a team of both local and international experts. To access the necessary expertise, the Ministry of Health Information management tools can reinforce monitoring commissioned multiple technical reports and received of the key procedural fairness criteria. Online platforms external funding from institutions like the World Bank and other e-government solutions are increasingly recog- (Atun et al. 2013). Similarly, health financing decisions nized as tools for improving public access to information, in Ethiopia and Ukraine, described above, benefited from including detailed information on policy implementation targeted technical assistance and capacity-strengthening and performance, and enabling the public to monitor supported by external partners. public institutions. For example, in Chile, the Council for Transparency developed an online platform to give access Examples of globally developed tools that countries can to data on public officials’ hearings and meetings. All the draw on in revenue mobilization include the IBP’s Open information can be searched and filtered by policy maker, Budget Survey (OBS), previously cited, and the Public participating stakeholders, or dates, and the Council’s da- Expenditure and Financial Accountability (PEFA) tasets can be downloaded for further analysis and/or reuse. approach. The OBS regularly publishes country rankings Moreover, the online tool allows users to visualize time as well as more detailed reports on public participation, trends, compare information across ministries, and see transparency, and oversight around public budgets, infographics on companies, types of interests represented, encouraging countries to consider their performance on and other variables. procedural fairness (IBP 2022). The PEFA framework is another global monitoring instrument. It provides coun- Databases that compile quality-assured cost data are tries with a standardized assessment of how well they fare important for purchasing decisions in health. In India, the on key criteria of procedural fairness, including transpar- Indian National Cost Database, set up in 2015, seeks to fill ency, reason-giving, and enforcement (PEFA 2022). Trans- a gap in the availability of transparent, accurate, and up-to- parency and reason-giving are covered by PEFA in- date information around provider-payment rates. In 2016, dicators on public access to information, good budget data on the unit costs of health services from 167 public documentation, and alignment of strategic plans and health facilities (district-level and below) located in six medium-term budgets, while enforcement of decisions is different states across India were collected and made captured by indicators for budget reliability and oversight available in the database. New waves of data collection (PEFA 2019). followed. The collected cost data were among the sources used to inform reimbursement rates for AB-PMJAY, In purchasing, tools are available to facilitate a systematic India's publicly funded health insurance scheme covering approach to setting health priorities, particularly in low- approximately 10 million families, as well as for the costing and lower-middle-income settings. The Disease Control 8 These were members of a separate non-contributory government-funded health insurance scheme for the poor. 9 https://www.uib.no/en/bceps/130756/fairchoices-dcp-analytics-tool. 37 Priorities (DCP) publications, for example, promote the ing conditions that promote criteria such as transparency, use of evidence-based decision-making in setting health participation, and inclusiveness. priorities. The fourth edition of DCP (DCP4), expect- ed in 2025, will suggest updated essential UHC packages Second, the country examples suggest that countries use a and intersectoral policies using new evidence. It will be combination of instruments to promote procedural fair- accompanied by new tools, like the FairChoices-DCP ness. Reports from Ethiopia and Thailand highlight how Analytics Tool,9 to support countries in their revision of these countries aligned organizational instruments for pub- essential health care packages using evidence-based lic participation and transparency with capacity- strength- evaluations to assess impact on health, equity, and financial ening instruments like civil servant training for managing risk protection. participatory processes and generating and using evidence. This appears to have contributed to a stronger foundation for fairer processes for health financing decisions in these settings. In other cases, such as Tanzania and The Gambia, 4.6 General observations from the effectiveness of organizational instruments has been country experience undermined by a lack of financing and administrative ca- pacity to organize regular meetings at subnational level. The country examples showcased in this chapter highlight the range of tools that countries have used to promote Third, as was also noted in Chapter 3, for some decisions procedural fairness in health financing for UHC, across countries draw to a greater extent on technical experts, settings with diverse income levels and political systems. with limited public participation for those specific The instruments described cut across all three health decisions. Greater public participation is often elicited for financing functions. This chapter has not attempted to higher-level policy decisions that set overall directions for critically analyze the impact of each tool separately or health financing. In the case of decisions largely driven by in combination. Its objective has been to indicate the expert committees, such as the UK’s JCVI for vaccine diversity and potential complementarity of instru- decisions, instruments like organizational rules of ments that countries can draw on and adapt to their own procedure can improve procedural fairness by promoting circumstances. Countries’ use of these instruments enables accuracy of information, transparency, and reason-giving. several general observations, of which we emphasize four. Finally, the range of instruments available, their applica- First, in many countries examined in this report, including bility to all parts of health financing, and the diversity of in South Africa, Thailand, and Ukraine, legislative and countries in which they have been used suggest that all regulatory instruments provide an important basis for countries can make progress towards fairer decisions for procedural fairness. Often, these take the form of broad UHC – with the goals of improving participation, inclu- laws governing the public sector, such as Freedom of siveness, transparency, and accuracy of information in Information Laws. In a few cases, health-specific health financing decisions. legislation builds upon these laws, further strengthen- 38 5 The way forward: Working together for fairer decisions on the path to UHC Building on a clear understanding of the types of health example, where appropriate laws and regulations are in financing decisions that can affect the substantive equity of place, governments can assess how effectively they are im- coverage outcomes, including who accesses health services plemented and whether practice is consistent with intent. and who suffers severe financial hardship from paying out- of-pocket for them, this report has made the case that fair While oversight functions rest with governments, civil processes to reach decisions in these areas have numerous society actors can play a key role in enforcing oversight and benefits. Procedural fairness can contribute to more equi- propelling change. Civil society actors can use the report’s table outcomes, strengthen the legitimacy of the process, principles and criteria to monitor procedural fairness in foster trust in public institutions, and increase the sustain- health financing and hold governments accountable for ability of health financing decisions. implementing laws and regulations. They can also work with governments to engage the public more actively and The foundations of fairer processes in health financing directly in decisions requiring wider participation. are the core principles of equality, impartiality, and consistency over time. Procedural fairness requires that International partners can use the criteria to examine their health financing decisions be guided by these principles. own decision-making processes, as well as the decisions Translating principles into practice involves implementing that are made at country level in programs they support. seven criteria, spanning three domains. The first domain, They can also provide technical and financial resources information, incorporates reason-giving, transparency, to enable countries to strengthen their regulatory and accuracy of information. The second, voice, involves frameworks and data collection and assessment systems applying instruments to enable public participation and and establish robust institutional mechanisms to meet securing inclusive representation in these mechanisms. procedural fairness criteria. The third domain, which includes revisability and enforcement, is about process oversight. Scholars from different fields can use this report to pursue an interdisciplinary research agenda on procedural fairness Governments, civil society, international partners, and in health financing. Future research can help generate scholars can work in complementary ways to apply these deeper understanding of how the principles and criteria principles and criteria and improve procedural fairness proposed in this report can support fairer policies and in countries. outcomes; how they can be applied in different settings in a feasible and sustainable way; and how to improve them This report has described a range of policy instruments that over time. governments are using and adapting to promote procedur- al fairness in health financing decisions. These include leg- Countries face practical constraints in implementing the islative and regulatory tools, organizational arrangements, principles and criteria, and it is not feasible or desirable financing and capacity-strengthening measures, and tools to apply them uniformly across all health financing deci- related to information management and monitoring. As sions. A practical approach to procedural fairness depends they apply these instruments, governments can use the on many factors, with country capacities and specific con- fair-process principles and criteria to systematically exam- textual circumstances being of primary importance. For ine their decision-making processes and address gaps. For example, while most countries encourage some form of 39 public participation in policy development, there might This report has confirmed that, even with limited be reasonable limits to public participation in technical resources, a growing number of countries are taking steps discussions that require specialized expertise. There are towards a fairer process for decisions in health financing. also trade-offs in terms of the urgency of decision-making, These countries have recognized that concerns for a fair since implementing instruments promoting procedural process are not secondary or optional complements to core fairness is likely to take more time than a less open and health financing goals. Translating fair-process principles inclusive approach. Investing in such efforts may result in and criteria into practice can improve countries’ UHC a longer timeline for developing health financing strate- results. By integrating fairer processes into health financ- gies or enacting new tax laws. However, this investment ing, more equitable outcomes can be promoted, while en- increases opportunities to unlock the benefits associated hancing legitimacy, trust, and the long-term sustainability with fair-process principles and criteria. of reforms. 40 References Abelson, Julia, P. G. Forest, J. Eyles, P. Smith, E. 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