Role of priority setting in implementing universal health coverage

When is a country financially ready to implement universal health coverage (UHC), a health policy designed to ensure that all citizens receive the health services they need without financial hardship? Since no standard set of essential health services or a defined benefits package for universal coverage exists, determining financial readiness is challenging. Health priorities must be set knowing what services are to be provided, to whom they will be provided, and how. Priority setting helps determine the financial requirements for UHC, and thus the financial capacity of a country to adopt it. Setting priorities also helps decide on the benefits package that is feasible given current resource constraints. Countries can deliver a limited benefits package and identify priorities for expansion should additional resources become available. In either scenario, priority setting is essential for any country committed to universal coverage. Priority setting can be explicit or implicit. Governments should favour explicit rationing, wherein the decisions and their justifications are clear, rather than strategies of implicit rationing such as denial, deterrence, deflection, delay, and dilution. In 2015, the UN General Assembly made a global commitment to UHC and the sustainable development goals. 4 As such, more emerging economies will commit to UHC. Explicit priority setting, however, requires dedicated resources, which are more readily available in wealthier countries. In 1912, Norwaywas the first country to introduce UHC. Several other high income countries followed, but 64 years passed before Cuba became the first middle income country to introduce UHC legislation in 1976. By 2015, 58 countries had achieved universal coverage, of which 22 did so while they were low or middle income countries (LMICs). 5 Thus, the challenge that remains is supporting countries with limited capacity to implement UHC and set priorities explicitly. Health priority setting in support of UHC requires capacity and resources, as well as persuasive evidence to justify decisions (figure). This involves two major steps: evidence generation and use of evidence in resource allocation, programme management, and quality assurance. Priority setting in health systems is complicated by a wide range of political, economic, ethical, and sociocultural factors. An explicit process requires four building blocks (box).