Making Choices on the Journey to Universal Health Care Coverage: From Advocacy to Analysis.

Universal health care coverage (UHC) is now an integral part of the global health agenda, with the adoption of a resolution of the United Nations by most country governments in 2012 that committed to attain and sustain UHC for their populations [1]. The subsequent commitment to health intervention and technology assessment at the 2014 World Assembly (the World Health Organization’s [WHO’s] decision-making body) [2] and the numerous public statements by leaders at the WHO and the World Bank to the same effect reinforced this view. At the center of UHC is “a set of services that is available when needed without causing financial hardship to the population” [3]; indeed, the UN resolution describes UHC as “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost,” and also calls for UHC to deliver equitable opportunities for the “highest attainable standard of physical and mental health.” The obvious questions remain: How best may countries determine what is truly “key”? How might that judgment change as time passes and further development happens? By what trajectory might the barriers to access be removed and full population coverage achieved—not merely in name but also in reality? For countries to deliver on their UHC aspirations, they need to be able to create fit-for-purpose institutions and processes through which either advice will be given or decisions made. Common desirable features of such processes include the use of the best possible evidence, the participation of relevant stakeholders, and sufficient transparency for decision makers to be held to account. Countries also need to decide which services and interventions are the main priorities. To do this it will be necessary to describe and justify the associated resource requirements, target budgets and payments, and the expected outcomes for the public of reforming service delivery and supply chains. Countries also need to determine the preferred mix of public and private agencies within their systems. Within global targets and metrics, it will be up to countries themselves to explicitly determine and adjust their priorities for public spending on health to achieve UHC goals, such as selecting a benefits “package,” determining social insurance entitlements and short-term co-payments, and using instruments such as the Essential Medicines List to good purpose [4–7]. In 1991, Australia announced that economic evaluations would be required from 1993 onwards by its Pharmaceutical Benefits Advisory Committee, which advises ministers on the national drug formulary of publicly subsidized medicines [8]. Since then Canada, Sweden, and England and Wales established similar procedures, which became increasingly applied to interventions beyond the realm of pharmaceuticals, and today about half of the European Union, together with Australia, Canada, and New Zealand, has similar agencies. Moves are afoot in several states in the United States and in several lowand middle-income countries also to create such prioritizing procedures and to adapt the criteria embodied in economic evaluation to their own circumstances. Thailand leads the way with its Health Intervention and Technology Assessment Program, a technical and process body responsible for advising the national health insurer on technologies and services, including prevention and health promotion, to be paid for under the country’s successful UHC [9]. More recently, the International Decision Support Initiative (iDSI) has been formed. This is an international collaborative network for providing policymakers with coordinated support in priority setting as a means to UHC. The initiative shares experiences, showcases lessons learned, and identifies practical ways to scale technical support for more systematic, fair, and evidence-informed priority-setting processes. It brings together academic, analytical, and practitioner expertise from various decision-making agencies, universities, and development think tanks, all involved in priority-setting as a means of approaching UHC in a way that maximizes the impact of limited resources on the welfare of the population. iDSI partners include NICE International (United Kingdom), the Health Intervention and Technology Assessment Program (Thailand), the Centre for Global Development (United States), PRICELESS/Wits (South Africa), as well as