Procedural fairness to recalibrate the power imbalance in health decision-making: comment on the report: ‘Open and inclusive: Fair processes for financing universal health coverage’

Abstract

The policy-making process for health financing in most places lacks equity, failing to adequately consider the voices of ordinary citizens, residents, and especially those facing significant disadvantage. Procedural fairness is about addressing this imbalance, which requires a recalibration of power dynamics, ensuring that decision-making incorporates a more diverse range of perspectives. In this comment, we highlight the important contributions made by the report ‘Open and inclusive: Fair processes for financing universal health coverage’ in furthering the understanding and importance of procedural fairness in health financing decision-making especially as it relates to the three sub-functions of financing – revenue raising, pooling, and purchasing. We also argue for the importance of conceptual clarity – especially as to the added value of procedural fairness vis-à-vis accountability – and critically review the proposed framework for procedural fairness, emphasising the role of voice as the linchpin to advancing equity in influence.

1. Introduction

Health, at its core, is inherently political (Ghebreyesus, 2019). We at international organisations like the World Health Organization (WHO) come up with a plethora of technical solutions to many health issues. However, while we provide policymakers with policy options and best practices, it is up to them to navigate the political economy of the different issues at hand to go from policy options to actual decision-making.

Among the myriad of these decisions confronting policymakers, the issue of how to finance health – how to raise and pool funds, what services to purchase and for whom¹ – is undeniably one of the most politically charged. Regardless of national context, financial considerations inevitably attract diverse interests and interest groups eager to assert their influence (Sparkes et al., 2019). The decision-making process on health financing is frequently swayed by well-organised, well-funded interest groups (e.g. professional associations, patient advocacy groups, pharmaceutical manufacturers association) advocating for their own preferences (Shiffman, 2019). While interest groups are a legitimate part of the decision-making landscape, their influence should not be disproportionate due to financial or political advantages (Berry et al., 2019). This inherent bias raises questions about fairness, as decisions made in this context are often challenging to reverse once implemented.

To address this issue of fairness in health financing decision-making processes, the World Bank, the Norwegian Institute of Public Health, and the Bergen Centre of Ethics and Priority Settings published in 2023 the ‘Open and inclusive: Fair processes for financing universal health coverage’ report (World Bank, 2023). In this special section of Health Economics, Policy and Law, the authors of the report invited different global health constituencies to share their perspective on this report.

In this comment, (1) we commend the contribution made to procedural fairness while making the case for additional conceptual clarity, especially vis-à-vis accountability; (2) we examine the principles and operational criteria put forward in this report, emphasising the role of voice to advance the procedural fairness agenda; and (3) recognise the importance of highlighting health financing decisions most likely to affect equity across the three health financing functions.

2. Procedural fairness, conceptual clarity, and rectifying the power imbalance

In our opinion, the policy-making process for health financing in most places lacks equity, failing to adequately consider the voices of ordinary citizens, residents, and especially those facing significant disadvantage. Procedural fairness is about addressing this imbalance, which requires a recalibration of power dynamics, ensuring that decision-making incorporates a more diverse range of perspectives.

In that sense, the first important contribution from this report is the strong case made as to the relevance of procedural fairness in health financing, both to lead to fairer outcomes and to increase the acceptability of decisions and people's trust in the system. Because what is considered fair outcomes would vastly differ depending on stakeholder groups and cultural context, we appreciate the choice made in this report to focus on procedural fairness. We suggest that additional conceptual clarity is needed.

Indeed, this report doesn't offer a definition or clear orientation as to what is considered a fair process beyond its constitutive elements explored in the proposed framework. More importantly, procedural fairness and accountability in this report seem intimately linked, both from the sources it draws from (more than 20 references have accountability in their title) and from the different dimensions explored in the principles and operational criteria. In fact, while most of the criteria put forward in this report would fit under the generally accepted answerability ² and enforceability ³ dimensions of accountability (Schedler, 1999; Ocampo and Gomez Arteaga, 2014), no mention of accountability is made in the body of the report, but for the title of tools that are introduced as having been used so far to assess procedural fairness (i.e. accountability for reasonableness, public expenditure and financial accountability). We argue that there is a missed opportunity here to not explore more clearly the conceptual linkages between accountability and procedural fairness to further conceptual clarity, avoid that fairness could be perceived as a new buzzword replacing accountability, and most importantly highlight the added value of focusing on procedural fairness and go beyond accountability, for which a large body of literature already exists.

From our perspective, looking at procedural fairness is fundamentally about rectifying the power imbalances that may affect decision-making, and in that sense, it goes a step beyond accountability. To the dimensions of accountability focusing on justification and possible sanctions a posteriori, procedural fairness adds the opportunity for the people to weigh in on decisions as they are considered. Central to this process is the concept of equity in influence, ensuring that all stakeholders, regardless of their socio-economic standing, have a meaningful role in shaping health financing decisions. This realignment means making purposeful space for the input of ordinary citizens and civil society (Greer and Wismar, 2017). It demands a deep understanding of the unique needs and expectations of these communities. Consequently, meaningful engagement with people, communities, and civil society becomes the linchpin of a fair financing process. Furthering our understanding of procedural fairness and how to achieve it is therefore critical in the nuanced and intricate task of striking the right balance in financing for underserved populations.

3. Comment on the principles and operational criteria for procedural fairness: a plea for a more central role of voice in health financing decision-making

This leads us to the second strong contribution from this report, which is to offer core principles guiding procedural fairness, as well as operational criteria that can serve as assessment areas to be examined when considering the fairness of a specific process (see Figure 1). Below we examine further these dimensions and how they contribute to procedural fairness.

Figure 1. Principles and operational criteria for procedural fairness (World Bank, 2023).

First, we fully endorse this report's principles of equality and impartiality as core to procedural fairness and recalibrating power influences in decision-making for health financing. Ensuring that every stakeholder or stakeholder group as an equal opportunity to express their views and that decision makers give each view equal and objective consideration is indeed the very fabric of a fair process (WHO, 2021). Consistency over time however seems less of an obvious candidate as a core principle for two reasons: (1) equality and impartiality are indeed values and therefore legitimate candidates for guiding principles, while it seems to us that consistency could be considered as more of an objective attribute of a process; and (2) while we support the rationale behind the importance of consistency, should equality and impartiality be respected, it seems likely to us that, liberated from vested interests and undue influences, changes in the rules of engagement would only happen when thoroughly justified by the country context. Additionally, we would argue that consistency should not only apply longitudinally (i.e. the rules of a specific process should be consistent over time) but also cross-sectionally (i.e. similar rules should apply to similar processes across the board). We would therefore invite a reflection on how best to reposition consistency within the procedural fairness framework to account for these specificities and ultimately link it more to the operational level.

Second, in delving into operational criteria of procedural fairness⁴, we find ourselves aligned with these foundational concepts while we would suggest emphasising a somewhat more central importance to the voice hexagon, particularly focusing on inclusiveness and participation. Accepting that procedural fairness is ultimately about equity in influence, the voice hexagon, in our view, serves as its linchpin, and the other two hexagons – information and oversight – as prerequisites to the meaningful exercise of voice, by contributing significantly to recalibrating the balance of power in decision-making processes.

In this report, the information hexagon emerges as a critical component in fostering fairness within decision-making realms. It revolves around ensuring that all stakeholders have access to, sufficient time to digest, and a shared understanding of the same information. We believe this to be absolutely vital because, in reality, key pieces of information or technical analyses often elude the general public, underserved communities, and civil society (WHO, 2021). This information asymmetry arises due to its confinement within a select group of stakeholders or the limited capacity of those not professionally engaged in such work, resulting in elite capture of participatory initiatives by organised interest groups or the more typical stakeholders involved decision-making (Lund and Saito-Jensen, 2013) – in health, such stakeholders include insurance funds, pharmaceutical companies, professional associations, etc.

In addressing this imbalance, the operational criteria linked to information – transparency, accuracy of information, and reason giving – become imperative. Transparency ensures that community groups and civil society can access the right information, accuracy of information guarantees its verification and reliability, and reason giving necessitates engagement with all stakeholders, including the public and civil society. We think the holistic approach put forward in this report enables community groups to deliberate internally, with comprehensive and correct information as a basis, on the implications for their constituencies. As the information hexagon becomes fully implemented, the balance of power should inherently tip towards a more equitable distribution, empowering communities with the tools to meaningfully participate in decision-making processes.

Moving to the oversight hexagon of the report, it introduces what we think is a crucial dimension by emphasising the follow-up of decisions once they are made. The revisability criterion inherent in oversight serves to reinforce the voice principle, allowing for mechanisms to revise decisions. However, the effectiveness of these mechanisms is contingent on their accessibility and feasibility for underserved communities and the public. Without careful consideration, well-organised and well-financed interest groups can potentially overpower these mechanisms, undermining the very essence of fairness they are meant to uphold (Rasmussen and Reher, 2023). Consequently, the oversight hexagon, while holding promise, demands a strong civil society to counterbalance the influence of already powerful groups within society.

The enforcement criterion emerges as paramount in this context. By ensuring that procedural fairness criteria are upheld and by leveraging legal frameworks to do so, the voice hexagon can provide structural, in-built protections. These legal safeguards become vital shields for the voices that would otherwise easily go unheard. In essence, the enforcement criterion serves as a bedrock for the entire framework of procedural fairness, acting as a bulwark against the undue influence of powerful interest groups and ensuring that the principles of inclusiveness and participation are not just ideals but enforceable realities.

We think that the report could benefit from a stronger emphasis could be put on the notion of continuum of the decision-making process. The actual expression of voice is but a punctual moment in this process and it is only as strong as the effective operationalisation of the information and oversight criteria before, during, and after the consultation of people's needs and expectations (Rohrer and Rajan, 2016). Special attention is needed all along the decision-making continuum, from ensuring transparent and impartial choice and framing of the policy questions, to ensure that the outcomes of participatory spaces are reflected in the directional decisions and translated appropriately at the technical level, which is less likely to involve broad participation.

The fair financing reports duly appreciate the interconnectedness of these hexagons, recognising that procedural fairness operates as a holistic framework, with each hexagon reinforcing and complementing the others. For us, the voice hexagon stands somewhat more at the core, requiring the support of the information and oversight hexagons to truly effect a rebalancing of power dynamics.

The core principles of equality and impartiality, are ultimately about power dynamics and ensuring that all stakeholders, including the public, disadvantaged communities, and civil society, are accorded the same standing, respect, influence, and rights as others in society when it comes to how money for health is raised, pooled, and spent in a health system.

4. Equitable and inclusive decision-making in the three financing sub-functions

The principles and criteria examined above can potentially apply to the review of any decision-making process in health financing. A third important contribution of this report is highlighting which type of decision-making processes to prioritise when assessing fairness, based on their potential impact on equity, in all three of the financing sub-functions. Traditionally, efforts to include people's voices in decision-making processes have predominantly focused on the purchasing sub-function of health systems (see Figure 2), that is, the way funds are allocated to ‘purchase’ health services. For example, both the design and practice of the inclusion of people's voices in areas such as health technology assessment, benefit package design discussions, and priority setting processes have been studied and practiced. However, less attention has been paid to the inclusion in the other critical functions of health financing – revenue raising and pooling of funds.

Figure 2. Financing (sub)-functions (Papanicolas et al., 2022).

The roles played by revenue raising and pooling in designing an equitable health system cannot be overstated. These sub-functions are integral to achieving major health system goals of access, quality, equity, and financial protection, thus enhancing overall system performance (Rajan et al., 2022). Therefore, a comprehensive approach to equity-oriented decision-making must extend its focus to all aspects of health financing which this report is the first to do in a systematic and well-researched way, to our knowledge.

5. Conclusion

In this comment, we make the case for additional work to further explore procedural fairness, its added value vis-à-vis accountability mechanism, and its potential to rectify power imbalances. Accepting the need for moving away from the status quo, where powerful interest groups dictate outcomes and demand concessions that may not align with the broader public interest, procedural fairness becomes the yardstick by which decisions are measured. Where decisions, once implemented, are seldom challenged or reversed; procedural fairness goes beyond a posteriori accountability mechanisms, ensuring that those historically marginalised now have a counterbalancing voice in the decision-making process.

In this recalibrated landscape, equality and impartiality become the guiding principles, ensuring that decisions are made with fairness and inclusivity at their core. We suggest highlighting the pivotal role played by the voice hexagon, based on inclusiveness and participation, where the information hexagon acts as a catalyst, ensuring equitable access to crucial information, while the oversight hexagon introduces mechanisms for revising decisions, provided they are shielded from undue external influences. By embracing these principles and operational criteria in tandem, societies can aspire to create decision-making processes that truly reflect the diverse voices and needs of their constituents, fostering a fair and just society for all.

Health policy-making is a deeply political endeavour. The decisions surrounding health financing, in particular, exemplify the intricate dance between various interest groups vying for influence. Achieving fairness is not easy – it requires a deliberate and sustained effort to amplify the voices of those traditionally marginalised in decision-making processes. By embracing a comprehensive, participatory model that encompasses all facets of health financing, societies can forge a path towards a more equitable and just healthcare system.

To that end, we believe this report to be an important piece of work that provides (1) a strong rationale for looking at procedural fairness in health financing; (2) a framework to better understand and assess procedural fairness through guiding principles and operational criteria; (3) guidance on the type of decisions across the three financing sub-functions that are most likely to affect equity; and (4) policy instruments to foster procedural fairness. We laud this effort and hope that its insights will be used by countries of all income groups when debating about money and health.