The Lancet   |  August 26, 2017

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Following endorsement by WHO, 1 , 2 the World Bank, 3 and the UN’s Sustainable Development Goals, 4 the drive towards universal health coverage (UHC) is now one of the most prominent global health policies. As countries progress towards UHC, they are forced to make difficult choices about how to prioritise health issues and expenditure: which services to expand first, whom to include first, and how to shift from out-of-pocket payment towards prepayment. Building on extensive philosophical literature on the ethics of priority setting in health care, a 2014 WHO report provided guidance about how states can resolve these issues. 5 , 6 This report argues that three principles should inform choices on the path to UHC: (1) coverage should be on the basis of need, with extra weight given to the needs of the underprivileged; (2) one aim should be to generate the greatest total improvement in health; (3) contributions should be based on ability to pay, and not need. The report also explains how these principles determine which trade-offs are generally unacceptable: for example, choosing to expand coverage for low-priority or medium-priority services before there is near-universal coverage for high-priority services. However, policy makers also face a further question largely left unanswered by the report: how do states’ moral and legal obligations regarding the right to health fit with their obligations to set health priorities fairly?

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