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1、Open and inclusive:Fair processes for financing universal health coveragePublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure Authorized 2 2023 The International Bank for Reconstruction and Development/The World Bank1818 H Street,NW Washington,DC 2043
2、3www.worldbank.orgAll 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 Execut
3、ive 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 concernin
4、g the legal status of any territory or the endorsement or acceptance of such boundaries.CitationPlease cite this work as follows:World Bank.2023.Open and Inclusive:Fair Processes for Financing Universal Health Coverage.Washington,DC:World Bank.Rights and Permissions The material in this work is subj
5、ect to copyright.Because The World Bank encourages the dissemination of its knowledge,this work may be reproduced,in whole or in part,for noncommercial purposes as long as full attribution to this work is given.Any queries on rights and licenses,including subsidiary rights,should be addressed to the
6、 Office of the Publisher,The World Bank,1818 H Street NW,Washington,DC 20433,USA;fax:202-522-2422;e-mail:pubrightsworldbank.org.Cover design:Publicis KitchenCover image:Panuwat Sikham/GettyImagesEditorial design:Publicis Kitchen 3Acknowledgments.5List of abbreviations.7About this report.8Executive s
7、ummary.91.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,m
8、ethodology,and structure.162.Health financing decisions with equity implications.17 2.1 Revenue mobilization.17 2.2 Pooling.18 2.3 Purchasing.203.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 inc
9、lusiveness:differentiating between directional and technical decisions.294.Principles and criteria in practice:examples from country experience.314.1 Legislative and regulatory instruments.324.2 Organizational arrangements.334.3 Financing and capacity strengthening.354.4 Information management and m
10、onitoring.364.5 Global initiatives and external support.374.6 General observations from country experience.375.The way forward:working together for fairer decisions on the path to UHC.39References.41Contents 4List of FiguresList of boxesList of TablesFigure ES1 Principles and operational criteria of
11、 procedural fairness.10Figure 1 Principles and criteria for procedural fairness.23Box 1 In focus:Public participation and inclusiveness.27Table 1 Revenue mobilization decision types and equity implications.18Table 2 Pooling decision types and equity implications.19Table 3 Purchasing decision types a
12、nd equity implications.21Table 4 Principles for fair processes.24Table 5 Criteria for fair processes.25Table 6 Policy instruments for promoting procedural fairness.31 5AcknowledgmentsThis report was prepared by a team from the Health,Nutrition and Population(HNP)Global Prac-tice of the World Bank(WB
13、),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 Gopin
14、athan,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:Kalip
15、so 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 Heal
16、th&Human Services,Government of Ekiti State,Nigeria);Karen A.Grpin(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 Heal
17、th,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
18、 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 betw
19、een 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
20、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 t
21、he 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);
22、Rekha Melathuparambil Ravindran(Department of Health and Family Welfare,Government of Kerala,India);Rajeev Sadanandan(Health Systems Transformation Platform,India);Mariana Barraza-Llorns and Rafael Adrin Arceo-Schravesande(Blutitude,Mexico);Eduardo Gonzlez-Pier(Palladium,USA);Petronell Kruger,Susan
23、Goldstein and Karen Hofman(South African 6Medical 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 Strength
24、ening 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);
25、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 woul
26、d 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
27、 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.Alexand
28、ra 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
29、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
30、 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 Un
31、iversity 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 omi
32、tted from these acknowledgments and express their gratitude to all who contributed to this report.7A4R Accountability for Reasonableness PBAC Pharmaceutical Benefits Advisory Committee(Australia)CHF Community health fund(Tanzania)CHSB Council Health Services Boards(Tanzania)CSO Civil society organiz
33、ationCBTS County Budget Transparency Survey(Kenya)EHIF Estonian Health Insurance FundHITAP Health Intervention and Technology Assessment Program(Thailand)HPL Health Promotion Levy(South Africa)HTA Health technology assessmentIHPP International Health Policy Program(Thailand)IBP International Budget
34、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 C
35、are Excellence(United Kingdom)NLGFC National Local Government Finance Committee(Malawi)OECD Organisation for Economic Co-operation and DevelopmentOOP Out-of-pocket paymentsPEFA Public Expenditure and Financial Accountability PMG Program of Medical Guarantees(Ukraine)SDGs Sustainable Development Goal
36、sSHI Social health insuranceSIS Comprehensive Health Insurance(Peru)SSA Sub-Saharan AfricaSSB Sugar-sweetened beverages UCS Universal Health Care Coverage Scheme(Thailand)UHC Universal health coverageUK United Kingdom UN United Nations UNHCR United Nations High Commissioner for RefugeesWHO World Hea
37、lth OrganizationList of abbreviations 8About this reportWho is this report for?This report is written for policy makers and health finan-cing experts in ministries of health and finance,other relevant government agencies,such as national purchasing agencies,and international development partners sup
38、port-ing health financing reforms.It also addresses members of civil society and researchers in the fields of economics,ethics,health financing pol-icy,and political theory who are interested in inter-disciplinary work that aims to support fairer processes in decision-making.What does this report co
39、ntribute?This report has been developed to support countries across different income levels and regions in building a fairer process around health financing decisions for universal health coverage(UHC).Its overarching aim is to provide policy makers with evidence on why fair processes matter;what co
40、nstitutes a fair process for health financing decisions;and policy instruments that countries have used to advance fair processes in health financing.The report makes four main contributions.First,it clarifies the case for fair processes in decisions about health financing on the path to UHC.To do s
41、o,it draws on sources from diverse research disciplines,synthesizes their arguments,and contextualizes them to health financing decision-making.Second,it describes key health financing decisions that can improve or worsen inequalities across individuals or groups in health service coverage or financ
42、ial protection.The report argues that because of the important equity implications,it is critical for policy makers to consider aspects of procedural fairness as they make these decisions.Third,the report offers principles and criteria for designing and assessing health financing processes and makin
43、g them fairer.It anchors its proposals in interdisciplinary research,expert consultations,and country case studies.Finally,the report shows how countries are using diverse instruments to operationalize fair process principles and criteria in health financing,something that policy makers in other cou
44、ntries can use or adapt to their own settings to improve procedural fairness under real-world conditions.How was this report developed?The report builds on a series of consultations conducted with a wide range of country policy makers,health financ-ing experts,and researchers from low-,middle-and hi
45、gh-income countries.The scholars and experts engaged span different disciplines and areas of expertise(e.g.,health financing and economics,law,ethics and philosophy,health policy).The report incorporates a comprehensive literature review and original country case studies reflect-ing different countr
46、y income groups,geographic areas,health financing arrangements,and types of health finan-cing decisions.This report complements two earlier milestone pub-lications on fairness in health financing.The first,Making fair choices on the path to universal health coverage(World Health Organization 2014),a
47、nalyzed critical choices that countries face when advancing UHC across three key dimensions:expanding priority services,including more people,and reducing out-of-pocket payments.The second,the World Banks 2018 report Equity on the Path to UHC:Deliberate Decisions for Fair Financing,extended the logi
48、c of the World Health Organization(WHO)publication to address equity in all areas of health financing(resource mobilization,pooling,and purchasing)and identified specific types of decisions in these domains that may worsen inequalities.We recommend that our report be read with these earlier publicat
49、ions as a companion document.How does this report address the diversity of cultural and political contexts?For many,the question of what a fair process involves cannot yield a single,universal answer,but is shaped by historical,political,and cultural conditions.Thus,what is proposed in this report m
50、ay not be universally agreed.To be more responsive to the diversity of interpretations,this report has pursued expert consultations involving wide geographic,cultural,political,and disciplinary represen-tation and framed its literature review and case studies to span diverse contexts.The report is b
51、ased on the premise that it is valuable to understand what criteria could be used to define a fair process,even when political realities in some settings prevent these criteria from being fully applied.Deliberation and decision-making about health financing are shaped by the political environment an
52、d power asymmetries in socie-ty which differ widely between settings.An understand-ing of stakeholder interests,value systems,and institutional structures in each setting is critical to be able to apply the principles and criteria proposed by this report.Focusing on fair process does not mean that p
53、olitical dynamics and power imbalances are ignored.On the contrary,designing decision-making processes that are fair and legitimate can help to address some of these imbalances in the search for fairer outcomes.9Executive summaryDoes fairness matter?This report argues that,in key areas of public pol
54、icy making,it does.And that,in policy deci-sions related to health financing,there are reliable ways for countries to bring fairness about.The report offers decision support on fair processes for policy choices relating to health financing for universal health coverage(UHC).It opens by making the ca
55、se for why fair processes matter for health financing.It argues that procedural fairness contributes to fairer outcomes,strengthens the legitimacy of decision processes,builds trust in authorities,and promotes the sustainability of reforms on the path to UHC.The report then describes key health fina
56、ncing decisions with an impact on equity in service coverage and financial protection,where issues of procedural fairness are particularly important.Next,it offers principles and criteria for designing and assess-ing the processes around these health financing decisions and provides suggestions for
57、how to make them fairer.Finally,the report examines country experiences with diverse instruments that can be used to operationalize principles and criteria for fair processes in health financing decision-making.The case for fair process UHC means that all people can use the promotive,preven-tive,cur
58、ative,rehabilitative,and palliative health services they need,of sufficient quality to be effective,while also ensuring that the use of these services does not expose people to financial hardship.Health financing is pivotal for progress towards the two pillars of UHC coverage with services and finan
59、cial protection.How well health financing arrangements can support progress towards these goals depends on choices in the three health financing functions of revenue mobilization,pooling,and purchasing.The overall level of health spending and the sources of revenue matter.Without adequate and sustai
60、nable levels of public spending on health,pro-gress towards UHC goals will stall.Policies which promote sufficiently large pools to allow cross-subsidi-zation and spreading of financial risks enable progress towards UHC.In purchasing,efficient use of resources,equitable service coverage,and financia
61、l protection for all people can be promoted through the develop-ment of guaranteed packages and the definition of pay-ment methods,contracting conditions,and benefits.The concern for a fair process is motivated by the many potential benefits such a process can deliver.This report highlights four.Fir
62、st,fair processes can contribute to more equitable outcomes because they can help address common sources of inequitable outcomes.Specifically,a fair process can prevent powerful stakeholders from shaping the de-cision process to suit their own interests and instead help promote the voices of the poo
63、r and marginalized.Second,procedural fairness can strengthen the legitimacy of pro-cesses by encouraging decision-making that follows accept-ed rules and procedures and by requiring authorities and institutions to justify policy choices through public reason-ing,the rational exchange of ideas,and pu
64、blic communi-cation.Third,fair processes can build trust in authorities across society at large.Trust is built by treating people affected by decisions with respect;explaining the rationale for decisions reached;and ensuring that all affected constitu-encies are heard,with no ones interests misrepre
65、sented or neglected.Fourth,fair processes promote the implemen-tation and sustainability of reforms.By creating space for voice from all constituencies,including those whose pre-ferred solutions are not finally adopted,support for carry-ing through decisions is increased.Key decisions for equityKey
66、health financing decisions across revenue mobili-zation,pooling,and purchasing have especially important equity impacts.In revenue mobilization,such decisions include:changes to the range of taxes and charges,their rates,and any exemptions from payment decisions on eligibility for public/state trans
67、fers to households and the size of these payments or in-kind transfers choices on budget allocations to health at all levels of government.In pooling,equity may be affected by changes in:who is covered from pooled funds out-of-pocket payments on services in a guaranteed set differences across pools
68、in the range of services covered or out-of-pocket payments levied on the package,or changes in risk equalization procedures or the size of government subsidies to different pools in an effort to equalize benefits decisions to develop a new pool(s),where the new pool has different benefits or contrib
69、utions.10In purchasing,areas especially important for equity include:decisions on what personal services are specified and delivered(range,location,quality)under the guaran-teed set,including conditions of access choices that modify the range,location,or quality of essential public-health operations
70、 changes in provider contracting,monitoring,payment methods,and rates.Principles and criteria for fairer processesThis report proposes principles and criteria for fairer processes in financing UHC(Figure ES1).Three principles equality,impartiality,and consistency over time form the foundations of a
71、fair process.Equality calls for equal access to information,equal capacity to express ones views,and equal opportunity to influence decisions.Impartiality re-quires that vested interests including corporate powers do not unduly influence the outcomes of decision-making processes.Consistency over tim
72、e requires rules and procedures by which decisions are made to be stable and predictable,at least over the medium term,and not to change on an ad hoc basis and without justification.Guided by these principles,the report proposes seven criteria organized in three domains that can help design and asse
73、ss decision-making processes(Figure 1).The first domain,information,is concerned with reason-giving,transparency,and accuracy of information.The second domain,covering participation and inclusiveness,is about creating opportunities for the public to express diverse opinions and perspectives.The thir
74、d domain,which includes revisability and enforcement,is about oversight of the process.Country experiences and lessonsExamining diverse country experiences,the report identifies a variety of instruments that countries have used to develop or strengthen fair processes across the three health financin
75、g functions.These tools,which address the range of procedural fairness principles and criteria,can be organized into four broad types:legislative and regulatory instruments,organizational arrangements,financing and capacity-strengthening measures,and tools related to information management and monit
76、oring.Four general observations can be made about countries experiences in applying these instruments.First,legislative and regulatory mechanisms provide an important basis for promoting fairness in decision-making processes.These mechanisms include high-level legal frameworks like South Africas Con
77、stitution;laws governing the public sec-tor like the Freedom of Information Law in Ukraine;and health-specific legislation like Thailands National Health Security Act.Second,countries can use a combination of instruments to improve procedural fairness.For example,countries like Ethiopia and Thailand
78、 have benefited from CORE PRINCIPLES:EqualityImpartialityConsistency over timeINFORMATIONReason-givingTransparencyAccuracy of informationVOICEInclusivenessParticipationOVERSIGHTRevisabilityEnforcement of processFigure 1.Principles and operational criteria of procedural fairness 11applying organizati
79、onal instruments for public participa-tion together with capacity-strengthening measures for civil servants,aimed at enhancing their ability to generate and use evidence.Third,public participation is often elic-ited to a greater degree for decisions that set overall direc-tions for health financing.
80、In contrast,for some technical health financing decisions,like determining provider pay-ment rates and making choices about the public financing of vaccines,countries draw to a greater extent on technical experts.In these cases,the importance of instruments pro-moting criteria beyond participation,s
81、uch as transparency,accuracy of information,and reason-giving,becomes even more pronounced.Finally,the availability and applicabil-ity of diverse instruments to all parts of health financing,along with their successful implementation across differ-ent countries,indicate that every country can advanc
82、e to-wards achieving fairer decisions for UHC.The way forward Fair process contributes to fairer outcomes,strengthens legitimacy,builds trust,and promotes the sustainability of health financing policies on the path to UHC.In closing,this report highlights opportunities for four key groups of actors
83、to foster this agenda:governments,civil society,international partners,and scholars.Governments can use the reports principles and criteria as a framework to review their existing regulations,institutions,and processes.While it may sometimes appear expedient to make decisions behind closed doors or
84、to fast-track reforms,evidence suggests clear benefits of an open and inclusive process.Country examples in the report can facilitate knowledge sharing and illustrate how governments in diverse settings have strengthened procedural fairness in health financing.While oversight functions rest with gov
85、ernments,civil society actors play a key role.They can use the reports principles and criteria to monitor procedural fairness in health financing and hold governments accountable.To measure progress,civil society actors can collaborate with other stakeholders to adapt indicators,making them locally
86、meaningful and actionable.They can also work with governments to engage the public more actively and di-rectly in decisions that will benefit from broad participation.International partners can use the reports criteria to examine their own processes,particularly for decisions relating to what to fun
87、d and how to channel money to activities in recipient countries.Using the reports findings,international partners can provide technical and financial resources to enable countries to strengthen regulatory frameworks and set up robust institutional mechanisms to meet procedural fairness criteria.In s
88、ome cases,this may mean longer timelines for example,for developing a health financing strategy or a new tax law but rushing timelines can result in unfair processes and inequitable outcomes.Finally,scholars from different disciplines can use the reports interdisciplinary lens to consider how their
89、respective fields can contribute to fair processes for financing UHC and expand their future contributions.This may involve gaining deeper understanding of how the principles and criteria proposed in the report can support fairer policies and outcomes;how they can be applied in various settings in a
90、 feasible and sustainable way;and how to improve them over time.In sum,this report presents common ground and an opportunity for policy makers,practitioners,researchers,and civil society to come together,collaborate,and take forward fair processes for financing UHC.Building on previous publications
91、that emphasize the value of public engagement and inclusive representation in building trust and enhancing the sustainability of political systems,this report takes a comprehensive view of procedural fairness.It describes how countries can apply the range of criteria proposed to improve the fairness
92、 of their health financing decision-making for UHC.In so doing,countries and partners can advance UHC through open and inclusive processes that are responsive to the needs of all.121 Questions about the nature of the guaranteed set of health services available to all,often termed the benefits packag
93、e,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 ava
94、ilable to everyone e.g.,benefit design are summarized under purchasing.This introductory chapter explains why this report is needed,outlines its conceptual foundations,and describes its aims and structure.The chapter has four parts.First,it discusses why fair processes are vital for sound health fin
95、ancing decisions,showing the benefits that fair processes yield for the countries that implement them on the path toward universal health coverage(UHC).Second,it explains how the effort to strengthen fairness in health financing is grounded in and advances a human rights-based approach to health.Thi
96、rd,the chapter highlights gaps in currently available evidence and decision support for policy makers on how to achieve fairer processes in health financing.Finally,to show how this report will help bridge the gaps,the chapter summarizes the reports objectives,methodology,and structure.1.1 The case
97、for fair process in health financing for universal health coverage This report speaks to a context in which economies and health systems face historic challenges.The dual impact of COVID-19 and the invasion of Ukraine by the Russian Federation has resulted in rising poverty,surging inflation,and red
98、uctions in real per capita government spending across much of the globe.Years of global progress in poverty reduction were abruptly reversed in 2020,with some evidence that inequality has also widened in many parts of the world(World Bank 2020).Forty-one countries where real per capita government sp
99、ending has dropped are unlikely to see their spending reach pre-pandemic levels even by 2027(Kurowski et al.2022).In this context,while government health budgets are under pressure,the goals of UHC are more relevant than ever.UHC means that all people can use the promotive,pre-ventive,curative,rehab
100、ilitative,and palliative health services they need,of sufficient quality to be effective,while also ensuring that the use of these services does not expose peo-ple to financial hardship(WHO 2014).Progress toward UHC brings additional benefits that matter at all times,and particularly in a context of
101、 successive shocks and global economic uncertainty.Advancing UHC contributes to more effective management of pandemics(Sachs et al.2022);fosters sustainable economic growth(World Bank 2019);reduces poverty associated with out-of-pock-et health payments(Das and Samarasekera 2011;World Bank 2019);and
102、increases societal cohesion(Levy 2019).Health financing decisions are critical for UHC goals,including equityUHC is fundamentally about equity all people receive the health services they need without financial hardship.UHC features as a prominent target in the Sustainable Development Goals(SDGs),ado
103、pted by all United Nations member states.On the path to UHC,however,inequities persist.Getting health financing strategies right across the functions of revenue mobilization,pooling,and purchasing is critical not only to making progress towards UHC but also to reducing those inequities(World Bank 20
104、19).This report uses the three health financing functions of revenue mobilization,pooling,and purchasing to organize its discussion of key health financing decision types affecting equity.1 Decisions under all three functions have significant equity impacts.For example,in revenue mobilization,trade-
105、offs between allocation to health care vis-vis other sectors can lead to decreased public spending on health as part of government budgeting processes.This is likely to result in increased reliance on direct out-of-pocket(OOP)payments for health services(Thomson et al.2015).Increased OOP payments in
106、 turn impact equity in financial protection and service coverage,since poorer households have lower capacity to pay and are more likely to forego needed health services(Barasa,Maina,and Ravishankar 2017;Xu et al.2003;Wagstaff et al.2018).In contrast,increasing central government financial transfers
107、for health to poorer sub-national units can reduce the gaps in service availability between richer and poorer areas.In pooling,allowing richer people to opt-out of contributing financially to pools reduces the ability to cross-subsidize from rich to poor,and probably from healthy to sick.Introductio
108、n1 13On the other hand,countries can strengthen equity by harmonizing benefits across multiple funding pools in which some groups(e.g.,people working in the informal sector)have access to a more limited set of services than other groups(e.g.,civil servants)(McIntyre et al.2013;Kutzin et al.2010).Pur
109、chasing involves a wide range of decisions that can directly improve or worsen existing inequities in coverage with health services or financial protection.An example relates to decisions on co-payments for outpatient pre-scription medicines:co-payments with no exemptions for the poor reduce their a
110、ccess and increase financial hardship when they need to purchase medicines.Exemptions for the poor reverse this effect,improving equity(Honda and Obse 2020;Ottersen and Norheim 2014;Thomson,Cylus,and Evetovits 2019).Health financing policy does not operate in isolation from the rest of the health sy
111、stem or the broader socioeconomic and political environment.For example,introducing fi-nancial incentives to improve performance among health workers is unlikely to result in improved service coverage without ensuring adequate supply of medicines or ba-sic equipment(Engineer et al.2016).Wider govern
112、ance and economic contexts,including the influence of inter-national finance and trade,play an important role in de-termining a countrys capacity to mobilize revenues for financing public services,including health(International Monetary Fund 2018).However,the focus of this report is on health financ
113、ing decisions at national or sub-national levelswhere crucial policy levers remain in country de-cision-makers hands and,with them,the opportunity to implement fairer processes towards UHC.Health financing decisions are often contested,underscoring the importance of fair processMany health financing
114、 decisions are subject to disagree-ments shaped by the values and interests of people with a stake in these decisions.Recent country experiences help bring the practical importance of this consideration into focus.For example,the financial sustainability of small hospitals in the rural or remote are
115、as of many countries is one domain where such debates frequently occur(Rechel et al.2016).On the one hand,there are concerns about ef-ficiency in terms of both capital expenditure and running costs for these hospitals,which typically serve very small portions of a population.Tied to population size
116、is the challenge of securing high-quality services when patient volumes are low.On the other hand,local populations of-ten resist the closure of hospitals,arguing that such clo-sures undermine their equitable access to services(Rechel et al.2016;Milne and Sullivan 2014;Moore 2009).On a different but
117、 related front,the imperative to strike a balance between individualism and solidarity has been a prominent feature of recent discussions around health financing reform in Chile.On the one hand many citizens have historically placed high value on free individual choice,meaning that they prioritized
118、being able to join private health insurance plans,which were also viewed as an“indicator of improvement in peoples economic status and their social mobility”(Vlez et al.2020,188).On the other hand,there has been a growing dissatisfaction with inequality in access to services,which government policie
119、s have not been able to address(Bossert and Villalobos Dintrans 2020;Ayala and Alarcon 2020).Such examples underscore the political importance of health financing decisions,as well as their complexity and the potential for conflict.In such cases,it is not only the final policy choices that matter fo
120、r stakeholders,but the processes through which decisions are reached.The benefits of fairer processes for health financing and UHCValue-and interest-driven disagreements around health financing choices,as in the examples just considered,suggest how important fair processes in this area can be.Pursui
121、ng that insight,this report identifies four key bene-fits of fair processes in health financing.First,existing evidence suggests that fair processes can contribute to more equitable outcomes because they ensure that steps are taken to address common sources of inequity(Bartocci et al.2022;Bollyky et
122、 al.2019;Touchton and Wampler 2014;Williams,Denny and Bristow 2017;Woolcock and Gibson 2007).A key source of inequity is power differences among stakeholders,which can lead to powerful stakeholders shaping the decision process to suit their own interests,at the expense of the voices and interests of
123、 the poor and marginalized(Kim and Lee 2022;Sparkes et al.2019).By broadening participation and representation in the decision-making process and by promoting respect among people,fairer processes can contribute to leveling the playing field towards greater equity.Empirically,studies on participator
124、y budgeting,for instance,suggest that it can lead to more pro-poor spending decisions.In Brazil,participatory budgeting contributed to higher allocations for health and sanitation in local budgets and less waste due to more effective monitoring of publicly funded projects(Gonalves 2014).Another sour
125、ce of inequity is corruption,which can undermine public decisions and benefit those with the power to influence choices.Key features of fairer processes,like transparency,have been shown to curb the potential for corruption (Onwujekwe and Agwu 2022).Evidence from procurement 14processes of medicines
126、 suggests that by improving oversight by auditors and civil society,transparency can reduce corruption and prevent the waste of limited public resources(Brown 2016;McDevitt 2022).Second,fair processes strengthen the legitimacy of a de-cision process,which generally refers to the level of ac-ceptance
127、 people have towards the authority of the govern-ment and of a politys laws and institutions(Rawls 2012;Langvatn 2016).Legitimacy is shaped by authorities,laws,and institutions coming about through well-established and accepted procedures(Langvatn 2016;Rawls 2012).Justification of policy choices thr
128、ough public reasoning,the rational exchange of ideas,and public communication plays a vital role in enhancing legitimacy(Chambers 2018;Habermas 1996).Evidence from social psychology sug-gests that people are more likely to accept decisions when choices are made through participatory procedures,with
129、authorities perceived as neutral,honest,and trustworthy(Nakatani 2021;Tyler 2000).The value of procedural fair-ness is also highlighted in the literature on tax compliance:decisions made by tax authorities that are perceived as im-partial,based on factual information rather than personal opinions,ar
130、e more likely to be accepted and complied with by taxpayers(van Dijke,Gobena,and Verboon 2019;Mur-phy 2005).Third,fair processes help build trust in public institutions by treating people affected by decisions with respect,ex-plaining the underlying core rationale for the decisions,and ensuring that
131、 all affected constituencies are heard,with no groups interests misrepresented or neglected.While definitions of trust vary across disciplines,the term generally refers to whether“political authorities or institutions are performing in accordance with the normative expectations held by the public”an
132、d whether they will continue to do so,“even in the absence of constant scrutiny”(Miller and Listhaug 1990,358).In terms of trust in government,research in social psychology and taxation literature indicates that peoples perceptions of fairness in the decision-making process is as important as their
133、perceptions of the outcomes(OECD 2017;Prichard et al.2019).The COVID-19 pandemic has highlighted afresh the importance of trust in government (Bollyky et al.2022;Norheim et al.2021),with several contributions underscoring the value of inclusive,trans-parent,and accountable decision-making to ensure
134、trust in political and scientific authorities and adherence to public-health recommendations(Norheim et al.2021;Sachs et al.2022).Finally,fair processes can promote the implementation and sustainability of adopted policies.For example,many health financing decisions are intended to be long-term solu
135、tions,with the benefits of adopted policies and created institutions being felt over an extended period.By creating space for voice and buy-in to the decision-making process from potential opponents and the people they represent,including those whose preferred solutions are not finally adopted,faire
136、r processes can contribute to the sustainabil-ity of decisions(Chwalisz 2020).2 The literature on delib-erative democracy,and frameworks inspired by it,contend that processes characterized by public reasoning,including securing participation and inclusiveness when decisions are considered and justif
137、ied,can generate broad popular support even under conditions of disagreement(Gutmann and Thompson 1998;Daniels 2008c).1.2 Human rights as the moral and legal foundation for fairer processes in health financing A foundational argument for UHC and fair process comes from a human rights perspective.Hea
138、lth is a fundamental human right“indispensable for the exercise of other human rights”(CESCR 2000).This section clarifies the links between countries human rights commitments and the pursuit of UHC through fair processes,including in health financing.The right to health and UHCThe right to health is
139、 enshrined in multiple international and regional treaties,and there is no state in the world that has not ratified and agreed to be bound by at least one treaty that embeds aspects of the right to health(UNHCR 2008,660).These legal standards are underpinned by a strong philosophical foundation for
140、claiming a moral right to health.Health is considered to be“among the most important conditions of human life,”while“any conception of social justice that accepts the need for a fair distribution as well as efficient formation of human capabilities cannot ignore the role of health in human life and
141、the opportunities that persons,respectively,have to achieve good health”(A.Sen 2002,660).Therefore,health has special moral value,as it enables people to participate as full and equal members of their polities.The right to health provides an overarching framework for UHC.3 United Nations(UN)General
142、Assembly and World Health Assembly resolutions on UHC have consistently 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
143、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 retrogress
144、ive 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
145、 15the Universal Declaration of Human Rights(Nygren-Krug 2019).Therefore,the principles of non-retrogression,a minimum core content that must be provided regardless of resources,and equality and non-discrimination are central to the UHC agenda.Securing equitable financing and eliminating financial b
146、arriers to health,especially for poor people and other vulnerable populations,represent a significant contribution towards realization of the right to health(Rumbold,Baker,et al.2017;WHO 2015).Enforcing health rights through the courtsSince the 1990s,health-related rights have become in-creasingly s
147、ubject to judicial enforcement,through inter-preting the right to a life of dignity to include aspects of health,including healthy environmental conditions and specific medical therapies under certain circumstances.While some cases of the judicial enforcement of individual health care rights have re
148、vealed tensions between the right to health and the need for prioritization of scarce health care resources(Yamin,Pichon-Riviere,and Bergallo 2019;Andia and Lamprea 2019),international human rights law is generally consistent with fair priority setting and pro-gressive realization of UHC(CESCR 2000;
149、Rumbold,Bak-er,et al.2017).For example,high courts have struck down cuts to the budgets of subsidized health programs as impermissible retrogression.In some cases,differentiated benefit packages for contributory and subsidized insurance regimes have been determined inconsistent with guarantees of eq
150、uality in countries constitutions.In 2008,a landmark decision from the Constitutional Court of Colombia ordered equalization of the benefit plans for two health insur-ance schemes:the countrys contributory regime for those formally employed or earning more than twice the minimum wage(the Plan Obliga
151、torio de Salud,or POS)and a subsidized health insurance scheme that had offered a significantly less generous set of services(Plan Obligatorio de Salud Subsidiado,POSS)(Yamin and Parra-Vera 2009).This equalization had previously been promised,but funding had been deferred multiple times by Colombias
152、 Congress.The decision was made on the grounds that the two-tiered system,where fewer than half the entitlements were accessible to the subsidized regime,violated norms of equality and non-discrimination(Arrieta-Gmez 2018).Fair processes are vital to fulfill health rightsA human rights-based approac
153、h to health as articulated through international treaties and obligations puts emphasis not only on outcomes,but also on the processes by which decisions are made(UNHCR and WHO 2008).The UN High Commissioner for Human Rights empha-sizes that human rights standards and principles such as participatio
154、n,equality and non-discrimination,and accountability guide the entire health policy cycle,from situation analysis to policy development and adoption,as well as implementation and evaluation.According to General Comment 14 on the Right to the Highest Attain-able Standard of Health,4 when facing trade
155、-offs between health interventions,states need to make these decisions fairly(CESCR 2000;Rumbold,Baker,et al.2017).Impor-tant trade-offs may concern,for example,investments in expensive curative health services that typically benefit a small,privileged fraction of the population,as compared to prima
156、ry and preventive health care accessible to a far larger population share.Procedural fairness is especially important in relation to health rights because epidemiological and demographic trends are constantly evolving,as are innovations in diagnosis,prevention,and treatment.This makes it vital to in
157、terpret the contents of the right to health through an open and inclusive process based on evidence(Yamin and Boghosian 2020).The choices for health financing to promote an equitable distribution of benefits across plu-ral populations therefore require continual reevaluation and adjustments(Yamin an
158、d Boghosian 2020).Because reasonable people can disagree about normative priori-ties in health,the contours of health rights are inherently connected to the negotiation of competing claims and in-terests through fair and legitimate processes.The human rights-based approach in health requires de-cisi
159、on-making processes to respect reasonable substan-tive criteria,such as non-discrimination,as well as pro-cedural criteria,including meaningful participation and transparency.Thus,for example,decrees or tokenistic legislative discussions without quorums have been found not to pass constitutional mus
160、ter.In the above-men-tioned example from Colombia,the Constitutional Court also included aspects of process in the remedies it ordered,calling for the then National Commission for Health Regulation to adopt a transparent,participatory,and evidence-informed approach that can be subject to revision an
161、d appeal when updating the benefits to be in-cluded in the contributory and subsidized schemes and in the process of unifying them(Yamin and Parra-Vera 2009;Arrieta-Gomez 2018).4 The UN human rights treaty-monitoring bodies,including the Committee on Economic,Social and Cultural Rights,publish docum
162、ents 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 ri
163、ghts 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.16In short,respecting,protecting,and fulfilling health rights involves due considerat
164、ion of procedural fairness when deciding on the financing and delivery of health services.Further,a human rights framework in relation to health calls for effective oversight and regulation of both process and outcomes,together with provision of adequate information that allows decisions affecting h
165、ealth(made by governments and commercial actors alike)to be subjected to democratic scrutiny.1.3 Fair processes in health financing:Strengthening decision supportDespite growing evidence of the multiple benefits of fair decision-making processes,health policy makers and experts do not currently have
166、 access to a unified,comprehensive,and clear set of principles and criteria for fair decision processes,described in practical terms that policy makers can readily adapt to country contexts,with examples of their application to health financing.This report aims to help bridge these gaps.To date,the
167、most comprehensive and conceptually clear discussion of procedural fairness is found in the literature on deliberative democracy(Bachtiger et al.2018;Gutmann and Thompson 2004;Chambers 2018).However,this body of work has not been widely accessed to inform the process of health financing decisions.Th
168、e primary framework for examining procedural fairness in health financing has been the Accountability for Reasonableness(A4R)framework,which has been applied to examine decisions for determining health benefit packages across different settings,including Mexico(Daniels 2008a),Tanzania(Maluka,Kamuzor
169、a,San Sebastian,Byskov,Olsen,et al.2010;Byskov et al.2014),and the UK(Rumbold,Weale,et al.2017;Mitton et al.2006;Daniels and Sabin 2008).This is an ethical framework that specifies key criteria for a fair process,namely:publicity,relevance,revision and appeals,and enforcement(Daniels 2008b).However,
170、some have argued that the A4R framework places insufficient emphasis on public participation and that there is a lack of clarity about how different kinds of arguments are meant to be included or excluded in a deliberative process guided by A4R(Rid 2009;Friedman 2008).Moreover,there has been little
171、systematic thinking about whether A4R criteria apply equally well to revenue mobilization and pooling,or to the aspect of purchasing that concerns how to contract and pay for inputs or services.It remains debatable whether additional criteria,applied to processes for other public policy decisions,sh
172、ould also be considered(World Bank 2018).In sum,there is a need to further specify what constitutes a fair process in health financing;detail the benefits that fair process can bring across the three core health financing functions;and deliver decision support to policy makers and partners as they w
173、ork to institutionalize fairer health financing.1.4 Report objectives,methodology,and structureThe primary aim of the report is to provide policy mak-ers with evidence on why fair processes matter;what constitutes a fair process for health financing choices on the path to UHC;and policy instruments
174、that countries can use to advance fair processes in health financing.In pursuit of this aim,the report makes four main contributions.First,informed by an interdisciplinary evidence base,it shows how fair processes can improve results in decision-making around health financing.Developing that argumen
175、t has been the main task of this introduction.Second,the report describes key health financing decisions with an impact on equity.Doing so is a necessary step toward identifying priority health financing policy decisions to which procedural fairness criteria can be applied.Third,the report offers pr
176、inciples and criteria for designing and assessing decision processes in health financing and guiding how to make them fairer.Finally,it presents a diverse range of policy instruments that can be used to implement fair process principles and criteria for health financing decisions.The report builds o
177、n a series of consultations conducted with global and country experts;a comprehensive literature review;and a set of case studies in countries and jurisdictions including India,Mexico,South Africa,Tanzania(Mainland),The Gambia and Ukraine.These case studies were selected to reflect a variety of inco
178、me groups,geographic areas,health financing arrangements,and types of health financing decisions.The structure of the remaining parts of the report is as fol-lows.Chapter 2 describes the key health financing decisions with equity implications,with a view to illustrate a wide range of health financin
179、g decisions where fair processes merit greater attention.Chapter 3 examines the meaning of“fair process”as a concept guided by three main princi-ples:equality,impartiality,and consistency over time.The realization of these core principles relies on the implemen-tation of seven criteria that decision
180、-making processes can be compared against.These criteria are reason-giv-ing,transparency,accuracy of information,inclusiveness,public participation,revisability,and enforcement of the process.Chapter 4 examines country experiences with a diverse selection of instruments,applied across the core healt
181、h financing functions of revenue mobilization,pool-ing,and purchasing,that can enable countries to better meet the principles and criteria for procedural fairness.Finally,Chapter 5 provides a broad outline of the agenda for action to support progress towards UHC through a fair process.17Health finan
182、cing policies have important equity implica-tions,and there are frequent disagreements about the sub-stantive fairness of outcomes associated with them.This underscores the importance of creating decision processes in health financing that stakeholders can recognize as fair.Indeed,the more substanti
183、al the potential equity impact of a health financing policy choice,the more important a fair process around the decision becomes.The aim of this chapter is to identify policy decisions under the three core health financing functions of revenue mobilization,pooling,and purchasing that have high stake
184、s for equity.Such decisions will be priority candidates for applying the fair-process principles and criteria that are derived later in this report.The point for now is not to debate the substantive fairness of specific policy options,but to set the scene for the subsequent analysis of how fair proc
185、ess criteria can inform health financing decisions.In this chapter,we identify key equity-relevant decision types under the three health financing functions in turn.To keep the conceptual discussion grounded in political reality,for each of the health financing functions,we present country examples
186、that illustrate how the decisions discussed can influence substantive equity.2.1 Revenue mobilization The road to universal health coverage(UHC)lies through government spending(Kurowski et al.2022;Kutzin 2013).No country can make meaningful progress towards UHC without predominant reliance on govern
187、ment health spending,defined as spending derived from general government funds and from obligatory health insurance contributions.Government revenues come from taxes and charges of various types and may be collected at the various levels of government in a country,and in some countries from on-budge
188、t external financing.Government funding can also come from borrowing,something that was widely seen during the COVID-19 pandemic(Kurowski et al.2021;International Monetary Fund 2021).The first type of health financing decision with im-plications for substantive fairness concerns changes to sources o
189、f government revenue,most frequently made in the search for increased revenue.This can come from introducing new taxes or charges;increasing contribution rates for taxes,charges,or obligatory health insurance;or expanding the range of people or firms who should make financial contributions.These dec
190、isions modify the dis-tribution of financial contributions to the system across people and groups,and they include but are not limited to health per se.Some sources of revenue e.g.,income taxes lend them-selves to making contributions progressive(where the proportion of income that people contribute
191、 increases with their income).However,in countries with large informal sectors,income taxes are difficult to levy,and those on the formal sector raise relatively little.These countries therefore often rely on tax sources such as value-added taxes that may be easier to administer but tend to be less
192、progressive(Jouini et al.2018;Younger 2018;Thomas 2020).Overall fiscal fairness is,however,judged not solely in terms of the financial contributions to the system,but in terms of the distribution of net contributions i.e.,payments minus transfers back in cash or kind(Inchauste and Lustig 2017).Parti
193、cularly in circumstances where taxes are not sufficiently progressive,governments can compensate people for inequities in contributions by targeting transfers from government revenues to the poor.Accordingly,decisions that change the distribution of financial contributions,or the distribution of tra
194、nsfers from these revenues,both influence substantive fairness(Inchauste and Lustig 2017).A third type of revenue mobilization decision influencing equity concerns allocations from general government funds to health,at all levels of government.The level of general government expenditure sets the siz
195、e of the overall Health financing decisions with equity implications2 18tem.For example,in Tanzania,according to one analysis,electricity subsidies are considered to be regressive despite attempts to make them more pro-poor,while the countrys direct and indirect taxes are largely progressive(Younger
196、,Myamba,and Mdadila 2016).In Indonesia,energy sub-sidies are also considered regressive,disproportionately benefiting higher-income groups(Lontoh,Beaton,and Clarke 2015).They also represent a significant fiscal bur-den on the government and use up resources which could be spent on health.Allocation
197、from central government to sub-national units(e.g.,regions or states)is an important decision in health financing,determining equity of resource distribution across sub-national units.In Malawi,the allocation of the operational budget for health across districts was long based on historical allocati
198、onthat is,based on last years allocation with some incremental change(Twea,Manthalu,and Mohan 2020).After district assemblies recognized inequities in existing resource allocation,the National Local Government Finance Committee(NLGFC)the central decision-making body responsible for resource allocati
199、ons to local governmentdeveloped a new resource allocation formula linked to key drivers of service delivery costs and tied explicitly to the costs of delivering the Health Benefit Package(Twea,Manthalu,and Mohan 2020).2.2 PoolingPooling is defined as the accumulation and management of prepaid finan
200、cial resourcesmeaning resources con-tributed before an episode of illnesswith the purpose of spreading the financial risk of health care expenses from individuals who fall ill to all members of the pool(World Health Organization 2010b).Pooling facilitates the capaci-ty to use health services in the
201、first place,as people are con-fident that they will not be faced with costly out-of-pocket payments(OOPs)for the services they receive.The most effective way to protect against the financial risk is to share it,“and the more people who share,the better the protec-government spending envelope.Governm
202、ent health spending is then determined by the decision about how much of this is allocated to health-taking into account budget allocations from general government funds and any earmarked revenue,such as social health insurance and health taxes.External financing is often channeled through governmen
203、t,as well,either earmarked for health or able to be allocated as part of the usual budget process.These decisions jointly determine how much is available to spend on health.From the perspective of a sub-national unit,the revenue mobilization function covers not just transfers from the central level,
204、but also how much funding can be raised locally and how much is allocated to health.Inter-regional inequities in health spending reflect,therefore,decisions made at the central level about transfers to each sub-national unit,the capacity of different local governments to raise revenue,and how much l
205、ocal governments allocate to health.The three types of revenue mobilization decisions which impact on substantive equity are summarized in Table 1.An example of the first decision type comes from Norway.In 2022,Norway increased its wealth tax,which is assessed on the basis of net wealth,from 0.85 pe
206、rcent to 1.1 percent at the top tier(The Norwegian Tax Administration 2022).The wealth tax on its own does not generate substantial revenue(Thoresen et al.2021),limiting its impact on the overall level of government revenues and its capacity to increase transfers to the poor.However,the revenue coll
207、ected comes from people who are in the upper income group;thus,together with the personal income tax,the decision to increase the wealth tax enhances overall tax progressivity in Norway(Thoresen et al.2021).Who is eligible to receive public or state transfers in cash or kind and the size of these pa
208、yments is the second feature determining the distribution of net payments into the sys-Revenue mobilization decision typeEquity implicationChanges to the types of taxes,contribution rates,and who should pay.Differences across people and groups in net contributions to the public finance system.Who is
209、 eligible to receive public/state transfers in cash or kind and the size of these payments.Differences across people and groups in net contributions to the public finance system.Changes to the allocations from general government funds to health at all levels of government,and by central government t
210、o lower levels.Differences across people or groups in the availability of health services,quality,or level of financial protection.Table 1.Revenue mobilization decision types and equity implications 19at least ensuring that effective exemption mechanisms exist to protect the poorest population group
211、s,will undermine equity(World Health Organization 2014).The Lancet Global Commission on Financing PHC noted that,regardless of the level of total health spending,a shift from OOP spending towards pooled arrangements would have a significant positive impact on the equity and efficiency of health fina
212、ncing(Hanson et al.2022).Where multiple pools exist,changes that modify differences across pools constitute a third type of pooling decision with important equity implications.Frequently,the peo-ple in some pools are“better”protected than others they obtain more or higher-quality health services,wit
213、h more financial protection.This is inherently unfair,and many governments have modified the subsidies they give to the different pools in response or introduced risk equalization procedures,whereby funds from one pool are transferred to others.Harmonization of benefits is another policy that seeks
214、to equalize benefits across pools.This decision type also includes rules on whether and how people can opt out of obligatory health insurance.Decisions to develop a new pool(s)alongside existing pool(s),where the new pool has different benefits or contributions compared to existing pool(s),can contr
215、ibute to fragmentation but can also improve equity in service coverage and financial protection.In many low-and middle-income countries,it has been challenging to expand the existing generous health insurance programs for formal sector workers to the poor and the informal sector.In this context,crea
216、ting a new program that is not based on contributions and provides coverage for those previously not included in other programs is seen as a positive step towards fair access to health services,even if tion”(World Health Organization 2010b,47).To promote equity,pooling requires subsidies from the he
217、althy to the sick and from the rich to the poor,and contributions need to be obligatory.General government funds that finance national health systems are one form of obligatory pre-payment and pooling.Obligatory health insurance contri-butions are another,although in reality the distinction is often
218、 blurred most systems where pooling is based on obligatory health insurance contributions have their reve-nues supplemented from general government funds(Levy 2019;World Bank 2019;Giuffrida,Jakab,and Dale 2013;Sakamoto et al.2018).A first pooling decision type with equity implications re-lates to wh
219、o is covered from pooled funds for a guaranteed package,including decisions to increase the size of the pool.In many low-and middle-income countries,increasing the size of the pool to include the informal sector or the poor has been extremely challenging,contributing to inequi-table service coverage
220、 and financial protection(Kutzin,Yip,and Cashin 2016;Kwarteng et al.2019).This decision type also includes rules on how entitlements are activated,e.g.,whether one needs to have special documentation,which at times may be difficult to obtain,and actively enroll with a health insurance provider inste
221、ad of being automati-cally included based on a national identification number.Making complicated rules on activating ones entitlements can contribute to some people“falling through the cracks”in the system and not having access to health services when they need them(Kwarteng et al.2019).A second dec
222、ision type important for equity concerns changes to laws or regulations about out-of-pocket payments for services in a guaranteed set.Increasing or introducing OOPs for a guaranteed set of services,without Pooling decision typeEquity implicationChanges in who is covered from pooled funds or how enti
223、tlements are activated for a guaranteed package.Differences between people or groups in service coverage or the distribution of the financial burden associated with access to a set of guaranteed services.Changes to laws or regulations regarding out-of-pocket payments for services in a guaranteed set
224、.Differences across people or groups in the extent of financial protection related to the guaranteed set of services.Where multiple pools exist,changes that modify differences across pools.Differences across people or groups in quality and/or scope of services,and/or in the extent of financial prote
225、ction related to the guaranteed set of services.Decisions to develop a new pool(s)alongside existing pool(s),where the new pool has different benefits or contributions compared to existing pool(s).Differences across people or groups in quality and/or scope of services,and/or in the extent of financi
226、al protection related to the guaranteed set of services.Table 2.Pooling decision types and equity implications 202010,this ratio had fallen to only 1.2 time more,a sub-stantial gain for equity(Knaul et al.2012).2.3 PurchasingPurchasing involves the allocation of funds to obtain the guaranteed set of
227、 services.In national health services,purchasing traditionally has involved buying the inputs to make health services,such as health workers,medicines,and medical equipment.In insurance-based systems,purchasing generally involves buying the health services.Purchasing decisions can be divided into wh
228、at to purchase,who to purchase from,and how to pay for the inputs or ser-vices.Decisions in purchasing can contribute to equitable delivery of the set of quality services while keeping costs under control(World Bank 2019).Decisions on what personal services are guaranteed and delivered,including con
229、ditions of access,are probably one of the most widely examined decision types in the health financing literature from an equity perspective(Norheim 2015,2016).These decisions can increase or reduce differences across people or groups in coverage with personal health services.Covering expensive high-
230、technology services for a small group of the population while the majority lacks access to basic health services is recognized as extremely inequitable(Ottersen and Nor-heim 2014;World Bank 2018;World Health Organiza-tion 2010a).What to purchase also includes questions about the range of public-heal
231、th services to provide,including population-based prevention such as screening and public-health functions such as surveillance for epidemic preparedness and response.This is the second type of decision in purchasing which is considered important from an eq-uity perspective.Differences across people
232、 or groups in their capacity to maintain or protect their health can be reduced through decisions modifying the range,location,or quality of public-health services.Lastly,equity can be improved or undermined through contracting,monitoring,and paying providers.Provider payment mechanisms create incen
233、tives for providers that can contribute to differences across people or groups in effective coverage with personal health services,including by type of condition or disease.An example is a situation in which providers are compensated on a fee-for-service basis for certain types of patients,e.g.,thos
234、e enrolled in a social insurance scheme,while for other patients providers receive per capita payment.This is likely to result in insured patients enjoying priority and better care or at least more services(Barasa et al.2021).in the early stages the benefits are not as extensive as those of the exis
235、ting schemes(Tangcharoensathien et al.2020).The four groups of pooling decisions that can have impor-tant equity implications are summarized in Table 2.Some examples of these decisions follow.Tanzania recently sought to reduce differences across its population in the range of health services availab
236、le and the extent of financial protection through the introduction of the improved Community Health Funds(iCHF)(Lee,Tarimo,and Dutta 2018).While the implementation of the iCHF has not unfolded as expected(Mselle et al.2022),the increase of the size of the pool from district to regional level is an i
237、mportant step in reducing fragmentation and reducing differences across communities when it comes to access to health services.An example of the second type of decision in Table 2 comes from pre-war Ukraine.The purchase of medicines was a key driver of OOPs in the country,disproportionately affectin
238、g lower-income groups and patients with chronic illnesses(Goroshko,Shapoval,and Lai 2018).To address this,in 2017,the government introduced the Affordable Medicines Programme(AMP).Initially,the AMP covered three selected conditions:cardiovascular diseases(CVDs),bronchial asthma(BA),and type 2 diabet
239、es(DM-2).The program was then expanded,so that by 2021,it included 27 international nonproprietary names(INNs)and 297 medi-cines,including additional INNs for mental and neuro-logical disorders(Bredenkamp et al.2022).Moreover,the number of contracted pharmacies also increased steadily.To the extent
240、possible,AMP has continued to function despite the war,reducing OOPs through increased pooling.An example of the fourth type of equity-relevant pooling decision is a policy decision to establish budget-funded,explicit coverage programs for persons not covered by existing social security health insur
241、ance schemes for the formal sector.This can promote equity,if the new programs are adequately funded(Kutzin,Yip,and Cashin 2016;Tangcharoensathien et al.2013;Knaul et al.2012).Thus,in Mexico until 2020,5 additional public resources for health coverage were mainly allocated to Seguro Popular(Popular
242、Health Insurance),a publicly funded program providing access to health services without co-pays to individuals with no employment-based health insurance(Reich 2020).Additional resources were channeled to Seguro Popular in preference to the social security schemes covering the countrys formal sector.
243、At the beginning of Seguro Popular,in 2000,public spending per capita for people covered by the social security schemes(generally,Mex-icos better-off citizens)was 2.1 times the public spend-ing per capita for the rest of the population.However,by 5 In 2020,Seguro Popular was replaced by a new system
244、 under the Instituto de Salud para el Bienestar.21services for their communities,while other jurisdictions did not(Buck 2020).An example of how provider-payment methods can improve equity can be found in the Kyrgyz Republic.Starting with the establishment of a purchasing agency in the late 1990s,the
245、 Kyrgyz Republic gradually moved from input-based payments financing buildings and doctors to more output-oriented provider-payment methods,improving equity in access and quality of care across geographical areas(Kutzin et al.2010).Specifically,from 2001 to 2004,the total num-ber of buildings decrea
246、sed by 47 percent and floor space decreased by 40 percent,with the savings re-allocated to direct patient care,accompanied by a shift in spending from hospital to primary health care(Fuenzalida-Puelma et al.2010).Investments in PHC are critical to ensuring that all people receive the health services
247、 they need with-out suffering financial hardship,and generally such in-vestments are considered to promote equity(Hanson et al.2022).Shifting spending away from large hospitals also improved geographic equity in per capita public spending on health.This chapter has identified key decisions across th
248、e three core health financing domains that impact substantive fairness.The purpose at this stage was not to debate which policy options lead to fairer outcomes,but to identify the key decisions under each health financing function so that the principles and criteria of fair process can be applied to
249、 them.But what actually is a fair process,and how can policy makers and stakeholders be confident that health financing choices are being reached fairly?Chapter 3 examines these fundamental questions.Chapter 4 will then look at policy instruments to advance fair processes in health financing and cou
250、ntry experiences in using them.Monitoring instruments can help counterbalance or reinforce the incentives created through different pay-ment methods.Thus,three types of purchasing decisions can be identified that have clear implications for equity(Table 3).Recent country experience illustrates some
251、of these pur-chasing choices.In Tanzania,services included in the guar-anteed set for those enrolled in the Community Health In-surance Fund(CHF)were very limited.In most districts,CHF membership only covered preventive and curative services at the primary health care level(dispensaries and health c
252、enters),with very limited portability,which meant that beneficiaries had access to services only in the facility where they were registered(Wang and Rosemberg 2018).Moreover,benefits and conditions for accessing various ser-vices differed by district,even within the same region.Under the new improve
253、d CHF(iCHF)program described earlier,ser-vices were expanded whereby beneficiaries became entitled to services available up to the regional hospital level,subject to an exclusion list comprised predominantly of specialized pro-cedures and medicines(Lee,Tarimo,and Dutta 2018).While the equity impact
254、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 personal health services.Decisions modifying the range,location,or quali
255、ty of essential public-health services are not always made expli-citly,but may be a result of reduced central funding,as was documented following the 2013 public-health reforms in England(Buck 2020).As a result of reform,which shifted responsibility for funding public-health services to local level
256、with significant reduction in central funding,areas with high-er revenue-raising capacity at the local level,or which assigned higher priority to public health,were able to maintain more Purchasing decision typeEquity implicationDecisions on what personal services are speci-fied and delivered under
257、the guaranteed set.6Differences across people or groups in coverage or effective coverage with personal health services,including by type of condition or disease.Decisions modifying the range,location,or quality of essential public-health services.Differences across people or groups in their capacit
258、y to maintain or protect their own health;differences in the effective operation of the health system with consequences for population health.Decisions modifying contracting and provider-payment methods and rates.Differences in coverage or effective coverage with personal health ser-vices,including
259、the quality of services for different people or groups.6 Importantly,purchasing includes acquiring inputs to produce health services,as well as purchasing the services themselves.Table 3.Purchasing decision types and equity implications 22engagement with affected stakeholders and giving those who ma
260、y oppose certain policies a chance to express their views sends the message that the solutions to public issues do not belong exclusively to a narrow“insider”group.This can ultimately build greater trust in the decision made(Matasick 2017).The question is,then,what does it mean to have a fair proces
261、s?Are there principles and criteria by which policy makers can judge whether their decisions are fair from a procedural point of view and that can support them in improving current decision-making processes?This chapter takes up these questions.It proceeds in three steps.First,based on a review of l
262、earning and practice in multiple fields,it proposes three core principles of fairness and seven criteria that actors can use to determine whether important decisions are being made in a way that is genu-inely fair.Second,it discusses how leaders and stakehold-ers can advance fairness in health finan
263、cing in real-world policy contexts,amid asym-metrical power relationships.Finally,it draws a distinction between directional and technical decisions in health financing,clarifying the prac-tical implications of this difference for advancing fairness in health financing policy.3.1 Principles and crit
264、eria for fair processes in financing UHC An extensive literature spanning different disciplines political theory and public administration(including de-liberative democracy),public finance,environmental management,psychology,and health financing has informed this reports characterization of key prin
265、ciples and criteria guiding procedural fairness(Dale et al.forthcoming).These principles and criteria have appeal across a diverse range of settings,and an extensive and interdisciplinary literature demonstrates their use(He and Warren 2011;Byskov et al.2014;Leventhal,Karuza,and Fry 1980;Bachtiger e
266、t al.2018;Daniels and Sabin 1997;Murphy 2005;P.Smith and McDonough 2001;Gutmann and Thompson 1995).However,this report recognizes Consider the following stylized case,based on a real-world example.In late spring 2010,the reform-oriented leadership of the ministry of health of a lower-middle-income c
267、ountry is uncertain if it will stay in power beyond a few more months,due to upcoming parliamentary elections.However,health leaders are determined to tackle longstanding structural problems in the countrys health financing system.Important decisions have already been made through a fast-paced refor
268、m based on good global and country evidence,driven largely by technical experts,though with little involvement of the public.Now,the leadership determines to move even faster and make important decisions on the next reform phase.Leaders perceive seizing the political window of opportunity and accele
269、rating decision-making and implementation as more important than inclusivity,transparency,and extensive justification of policy choices to those affected by the decisions.The goal is to bring reforms to a point where a new government cannot easily reverse the choices made.The decisions taken through
270、 the subsequent months are technically sound and in line with UHC principles and 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 an
271、d become subject to widespread criticism,including on the grounds of an unfair process.In an environment where trust in the government was already low,this weakens the legitimacy of the reform decisions.Paradoxically,the evidence-based health financing reforms likely to benefit the large majority of
272、 citizens spur broad resentment and inflict political costs.This example from recent country experience illustrates the relevance of fair process to improving results in health financing.While a fair process does not guarantee that painful decisions creating winners and losers will be accepted by al
273、l,meeting principles and criteria for procedural fairness can increase the likelihood of broad acceptance(newDemocracy Foundation and The United Nations Democracy Fund 2019;OECD 2017).Meaningful What is a fair process?3 23advisors,or members of the public,appreciate each others moral and social wort
274、h and uphold a favorable attitude towards each other,even if they disagree among themselves about substantive matters(Beauvais 2018;Gutmann and Thompson 1990).It implies creating con-ditions for anyone,regardless of their social status and power,to bring forward relevant considerations,with the expe
275、ctation that these will be heard,discussed,and addressed(Beauvais 2018;Gutmann and Thompson 1990).Impartiality implies that the vested interests of decision-makers should not influence the outcomes of decision-making processes,and that prior beliefs should not prevent different views from getting eq
276、ual and objective consider-ation(Leventhal 1980).Likewise,the vested interests of,for example,commercial and corporate actors,must be managed so as not to unduly influence decision outcomes(de Lacy-Vawdon and Livingstone 2020).Following the principle of impartiality,conflicts of interest must be ad-
277、dressed,and those making decisions should not hide or distort evidence in pursuit of self-serving goals.The con-cern for impartiality should,however,not lead to the ex-clusion of relevant voices.In health financing,the extent to which patients should be represented when determin-ing the services to
278、include in a health insurance scheme is heavily debated,especially since many patient organi-zations receive industry funding that can bias their views that these concepts do not represent universally agreed features of a policy making process,and that the concepts are likely to be valued differentl
279、y depending on a countrys dominant value system,political regime,and social factors.The report proposes to distinguish between core guiding principles and more practically oriented criteria for procedural fairness(Figure 2).The three core principles of equality,impartiality,and consistency over time
280、 form the foundations of a fair process.To allow them to be operationalized in practice,seven criteria are derived from them,organized in three domains;information,voice,and oversight.The criteria can inform the design and assessment of decision-making processes.Three principles inform all aspects o
281、f a fair processEquality has multiple dimensions(Bachtiger et al.2018).First,equality implies that we pay particular attention to groups that empirically tend to face social,economic,and political barriers to participating,deliberating,and expressing their views(Mansbridge et al.2012;Beauvais 2018).
282、To this extent,the principle of equality may imply a clear pro-poor orientation and special emphasis on how disadvantaged and marginalized groups are treated in the decision-making process.Second,equality involves mutual respect,which means that participants in a decision-making process,whether they
283、 are policy makers,scientific CORE PRINCIPLES:EqualityImpartialityConsistency over timeINFORMATIONReason-givingTransparencyAccuracy of informationVOICEInclusivenessParticipationOVERSIGHTRevisabilityEnforcement of processFigure 1.Principles and criteria for procedural fairness 24Fair-process criteria
284、 help translate principles into practiceThe seven criteria for procedural fairness are reason-giving,transparency,accuracy of information,inclu-sivness,public participation,revisability,and enforce-ment,summarized in Table 5.These criteria should not be seen as binary;meaning that they are not eithe
285、r com-pletely fulfilled or completely absent from most decision-making processes.Rather,they are often present in par-tial or volving forms that provide some benefits yet leave scope for further development.Each of these criteria has different mechanisms that can support its implemen-tation,and some
286、times a single mechanism can support the implementation of multiple criteria.For example,a well-designed citizens panel can promote both participation and inclusiveness.This report groups the criteria into three domains:information,voice,and oversight.Information:a requirement for reasoned debateThe
287、 first domain,information,covers reason-giving,transparency,and accuracy of information,which is con-cerned with the content and presentation of information.Reason-giving requires that those promoting a policy or legislation justify it to others,including government institutions,the public,and other
288、 stakeholders(Gutmann and Thompson 2004).This should be done through a process with mutual exchange of reasons and ex-planations.Reason-giving encompasses respect,a fun-damental value for a fair process from the perspective of theories of deliberative democracy,because only with respect does one lis
289、ten actively,try to understand the meaning of a speakers statements,and value these views.Reason-giving is also verifiable:for example,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 arbitra
290、ry(Lakin 2018).(Fabbri et al.2020;Mandeville et al.2019).However,for equity reasons it can be important to pay attention to the values,needs,and preferences of patient populations that are marginalized for economic,social,or political reasons.A strict interpretation of conflicts of interest to secur
291、e im-partial decision-making can risk excluding such relevant voices.Consistency over time is about requiring decision-making processes to be stable and predictable,i.e.,based on rules which are not altered too frequently or on an ad hoc ba-sis(Leventhal,Karuza,and Fry 1980).Sudden and poor-ly expla
292、ined changes can be perceived as unfair(van de Graaf 2021).If changes must be made to decision-making procedures,they should be thoroughly justified and in-volve the wider public(Gutmann and Thompson 2004).Consistency should be applied in how participation and representation are secured,how evidence
293、 is used,how in-formation about the process is disclosed,the use of mech-anisms for revisability,and the enforcement of similar processes across similar kinds of decisions(Hasman and Holm 2005;Ford 2015).Consistency is a fundamental cri-terion across different policy making domains.For legal systems
294、,consistency has been shown to play a significant role in shaping peoples perception of fairness.In priority-setting processes that involve the use of health technology assessment(HTA),consistency brings structure to the process,both with respect to how information is presented and how it is used.Fo
295、r these decisions,definitive and consistently used procedures and structures have been emphasized by decision-makers as forming a key feature of a fair process(Kapiriri,Norheim,and Martin 2009).The three core fair-process principles are summarized in Table 4.PrincipleShort explanationEquality Equali
296、ty involves mutual respect and requires that people have equal opportunity to access information and articulate their views during a decision-making process,regardless of social status,gender,ethnicity,religion,or power.ImpartialityImpartiality requires decision-makers to be unbiased and stipulates
297、that their decisions not be driven by self-interest or unduly influenced by stakeholders with vested interests in the outcome.Consistency over timeConsistency over time requires procedures for decision-making to be stable and predictable,and that changes to decision-making procedures are explained a
298、nd justified.Table 4.Principles for fair processes 25tice that stipulates the importance of making its work open to public scrutiny(JCVI 2013).At the same time,members of JCVI usually meet in a closed session to enable the free exchange of opinions and a sound deliberative process pri-or to reaching
299、 conclusions(JCVI 2013).Transparency is therefore primarily implemented in terms of providing full justification through a public statement once a decision has been reached.Moreover,since JCVI subsequently releases the minutes of its deliberations,the public can gain insight into the reasoning proce
300、ss that led to the committees con-clusions,including points of disagreement and the partici-pation or otherwise of members with a conflict of interest.Accuracy of information requires decision-making processes to be informed by a comprehensive array of information sources,encompassing a diverse spec
301、trum of evidence,perspectives,and views.Sources should be trustworthy and contribute to an informed opinion.For example,when deciding on sound measures to combat the COVID-19 pandemic,governments were expected to provide their reasoning to the public,based on accurate information collected from dive
302、rse scientific sources(Eriksen 2022a).Reasons based on biased or inaccurate information can mislead participants and unsettle the deliberative process.Transparency is about disclosing timely and clear informa-tion about the decision to everyone affected by it.It in-volves being open about the eviden
303、ce base informing deci-sions,how the evidence has been generated,and how it will be used.Transparency is crucial to fulfilling reason-giving:information used to justify decisions must be accessible so that people can assess whether the information provided is sufficient and challenge the reasoning w
304、hen required.Moreover,the transparency of a process allows the pub-lic to judge whether procedures for decision-making are working according to stated intentions:for example,pub-lication of minutes of a discussion can show that people with a conflict of interest withdrew from participation.If person
305、s with conflicts of interest did participate,making that information accessible can enable people to object to the process.However,the positive influence of transparency on rea-son-giving depends on the decision situation,and there may be justified limits placed on transparency during a de-cision-ma
306、king process.For example,the UKs Joint Com-mittee on Vaccination and Immunisation(JCVI),an inde-pendent vaccine advisory committee that advises the UK government about the prioritization and introduction of vaccines in the immunization program,has a code of prac-Domain CriterionShort explanation Rea
307、son-giving Reason-giving involves decision-makers justifying decisions to those affected by them.It requires that disagreements be resolved by reasons being exchanged,listened to,and accepted or rejected by free and equal persons.TransparencyTransparency is about making information accessible,includ
308、ing information on 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,and discussions around these);and reasoning on the decisions taken(e.g.,why this particular budget is adopted),a
309、s well as the output of the decision itself(e.g.,a budgetary document with actual figures in it).Accuracy of informationAccuracy of information is about decisions being based on a comprehensive array of infor-mation sources,encompassing a diverse spectrum of evidence,perspectives,and views.Public pa
310、rticipation Public participation is about enabling members of the public to access information,express their opinions,and directly engage in the decision-making process.Inclusiveness Inclusiveness entails considering a broad range of views and concerns,necessitating mechanisms to involve individuals
311、 who typically do not contribute to public policy and decision-making and ensuring the inclusion of diverse perspectives and arguments,even in cases where stakeholders are unable to directly participate.RevisabilityRevisability means accepting that new reasonssuch as new evidence and new understandi
312、ngs of the issue at handcan be given greater weight in the future,and therefore justify revised decisions.Mechanisms must therefore exist for those who disagree with the decision to challenge it and for decision-makers to respond to reasons and to consider revising the original decision.EnforcementE
313、nforcement 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 the outcomes of the decision-making process and having laws,regulations,and oversight mechanisms to ensure that outcomes are implemen
314、ted.Information VoiceOversightTable 5.Criteria for fair processes 26Oversight:Securing fair process in the real worldThe third domain,comprising revisability and enforce-ment,is about oversight of the process.Revisability means that new reasons such as new evidence about the benefits and harms of a
315、policy and new understandings of the issue at hand can be given greater weight in the future and so justify revised decisions ww(Gutmann and Thompson 2004;Leventhal,Karuza,and Fry 1980).Mechanisms for revising decisions will vary depending on the decision type as well as a countrys legal and politic
316、al system.However,in all cases,mechanisms must exist for those who disagree with the decision to challenge it and bring updated evidence and reasons to bear on the issue,and for decision-makers to respond to these reasons and consider revising the original decision(Maluka,Kamuzora,San Sebastian,Bysk
317、ov,Ndawi,et al.2010;Gibson,Martin,and Singer 2004;Barasa et al.2017).Equality implies that mechanisms for challenging and revising decisions must be accessible to all.Promoting impartiality requires special attention to ensuring that mechanisms for revision are not misused to counter the public inte
318、rest.Finally,consistency prescribes that procedures for evaluating new arguments should be predictable.Finally,whether fairer processes can be achieved is determined to a large extent by enforcement with respect to processes and outcomes.Without enforcement,none of the principles and criteria can be
319、 expected to achieve their stated intentions,ultimately undermining fairness.Legislation is a key tool for securing enforcement of fair processes.For example,consistency over time can be partially enforced through primary legislation regulating a process for adopting new taxes.However,if the legisla
320、tion has many loopholes that result in frequent changes to the rules on how new taxes are adopted,then consistency over time is difficult to achieve.With respect to outcomes,the literature on deliberative democracy and partici-patory budgeting emphasizes the critical role that enforce-ment plays in
321、securing respect for the binding nature of decisions(Gutmann and Thompson 2004).For example,officials who make decisions on behalf of other people have responsibility to ensure that these decisions are implemented.3.2 Policy context Crucial to the application of the fair-process concepts is a thorou
322、gh consideration of the political culture in which they are applied and embedded(Sparkes et al.2019;Reich 2002).Critical factors to consider include the distribution and exercise of power when policies are discussed and formed(Gore and Parker 2019;Sparkes et al.2019;Voice:Mitigating power imbalances
323、 to achieve inclusionThe second domain covers participation and inclusiveness and is about creating opportunities for voice.Public participation implies creating opportunities for the pub-lic to directly participate in the decision-making process and influence the outcome(P.Smith and McDonough 2001;
324、Weale et al.2016).Meaningful engagement between decision-makers and the public requires forums that secure mutual respect and provide space for the public to express views,share evidence,and challenge official positions and for those making decisions to defend their arguments,respond to objections,a
325、nd,if necessary,revise their decisions(Eriksen 2022b).Power imbalances between participants,shaped by social,political,and economic factors in society,must be mitigated to create a supportive environment for respectful deliberation(Gutmann and Thompson 2004;Masefield,Msosa,and Grugel 2020;Razavi et
326、al.2019).For example,direct representation of community members through mechanisms such as Brazils health management councils enables citizens voice and has potential for promoting fairer decision-making processes(Barnes and Coelho 2009,230).Inclusiveness is about securing the representation,directl
327、y or indirectly,of all relevant voices and interests that are affected by the decision(Baber and Bartlett 2018;Bohman 2012).Promoting inclusiveness involves ensuring that the diversity of views expressed in the public sphere is channeled to formally organized institutions that have decision-making p
328、ower,like parliamentary assemblies and government departments(Dryzek 2009).It requires mechanismstailored to the needs of the specific decision and the affected audiencefor bringing in voices that typically would not contribute to public policy and decision-making unless barriers to their participat
329、ion are removed and their views and experiences are actively sought(Razavi et al.2020).Special attention is therefore given to securing the views and perspectives of disadvantaged populations.However,achieving this goal requires attention to financial,social,and cultural sources of power differences
330、 that constrain or prevent inclusive processes(Razavi et al.2020;World Health Organization 2019;Mulvale et al.2019).Moreover,inclusiveness goes beyond a single-minded focus on the numerical representation of different groups,i.e.,simply counting who and how many are directly present in participatory
331、 and decision-making forums.Inclusiveness requires en-suring that diverse perspectives,experiences,and under-lying discourses are reflected,even when stakeholders are unable to directly participate in the process(Milewa 2008;Dryzek and Niemeyer 2008;Rajan et al.2019).27Hayward 2021);the supportive e
332、nvironment for and the strength of civil society(Francs and Parra-Casado 2019);and the specific political regime,including the state of open political discussion and good governance in the country(N.Smith et al.2014;Herrera et al.2017).Fair process takes power relations seriouslyThe exercise of powe
333、r and the power relations that operate at different levels lie at the heart of policy making(Gore and Parker 2019;Sriram et al.2018;G.Sen et al.2020).The design of fair processes cannot be separated from the role of power within political institutions or the imbalance of power among those who participate in decision-mak-ing processes(Abelson et al.2003;Rohrer-Herold,Rajan,and Koch 2021).Financial