Why procedural fairness is essential to financing universal health coverage

Discussions around universal health coverage (UHC) often centre on what is fair when distributing resources for health. But fairness is not only about outcomes such as who gets what, and who pays, but also about how those decisions are made. Procedural fairness – ensuring that the processes by which decisions are reached are transparent, inclusive, and accountable – is not just a technical feature of policymaking. It is essential for legitimacy, trust, and ultimately, the success of UHC reforms.

The 2023 World Bank report ‘Open and inclusive: Fair processes for financing universal health coverage’ presents an important case for embedding procedural fairness in health financing (World Bank, 2023). However, there are questions about how far such procedural ideals can be realised. At its core, procedural fairness is about who gets to be heard, how decisions are justified, and whether all affected can see themselves reflected in the process. Decisions about health financing shape the distribution of health, which is one of the most important social goods, and these decisions often require difficult trade-offs. It is, therefore, that in such contexts, people deserve not just fair outcomes, but fair treatment in the decision-making itself.

Procedural fairness also builds legitimacy. As Alex Voorhoeve et al. (2025a) argue, fair processes help ensure that health financing decisions are not simply accepted because they are imposed, but because citizens recognise them as the result of impartial, reasonable deliberation. This kind of legitimacy is critical in a time when trust in institutions is low in many countries. Moreover, involving a broad range of voices, especially those marginalised, can lead to better, more equitable outcomes. A health financing system designed without considering the voices of poor or vulnerable groups risks reinforcing inequalities.

Despite these compelling arguments, critics of the ‘Open and Inclusive’ framework have raised important challenges published in this special section of Health Economics, Policy and Law.

First, Hausman (2024) argues that focusing on process without sufficiently addressing substantive questions like how much people should contribute, what services should be covered, and how funds should be raised is a serious limitation. Hausman is right that substantive fairness cannot be ignored. Decisions about process should not be divorced from debates about equity in outcomes. Yet, as Voorhoeve et al. (2025b) reply, procedural fairness has its own intrinsic value – respecting citizens as equal participants in shaping systems that affect them deeply.

Second, Kinuthia (2025) offers a critical perspective of public finance in low- and middle-income countries. He emphasises that information provision alone is not enough and argues that without civic education and facilitation, citizens may be overwhelmed or excluded from meaningful participation. Procedural fairness requires more than holding public meetings or publishing reports; it needs investment in equipping people to engage effectively. Kinuthia also highlights the lack of attention to how health financing decisions intersect with broader budgetary trade-offs, like funding for education, infrastructure, or agriculture. Healthcare does not exist in a silo, and fair processes must acknowledge these cross-sectoral tensions.

Third, Rajan and Rouffy-Ly (2024) emphasise the need for procedural fairness when addressing inequities in health financing decision-making. This is particularly because current processes are often dominated by powerful, well-organised interest groups, which marginalise the voices of ordinary citizens and disadvantaged communities. However, the authors call for greater conceptual clarity in distinguishing procedural fairness from accountability. They highlight how inclusive participation should be central to health financing decisions and advocate for balancing it with transparent information sharing and robust oversight. Ultimately, procedural fairness is essential for recalibrating power dynamics, improving legitimacy, and ensuring that health financing decisions reflect broader societal interests.

The fourth critique by Bennett and Merritt (2025) explores whether the principles of procedural fairness should apply to development partners, like international donors and agencies. They argue that while procedural fairness is relevant to donors, conflicting accountabilities to both taxpayers in donor countries and recipients complicate the picture. Still, as they suggest, donors should strive to embed procedural fairness in their engagement with recipient countries to avoid perpetuating inequities or undermining trust.

If procedural fairness is to move into policy mainstay, several challenges must be addressed. As Kinuthia argues, access to information does not equal understanding or empowerment. Governments and civil society need to invest in ongoing civic education, not one-off consultations. This includes training on how budget processes work, what trade-offs are at stake, and how citizens' input can influence outcomes. It also requires facilitated spaces, for example Kenya's budget cafés where citizens and officials can engage in dialogue. A challenge in participatory processes is however what to do when consensus cannot be reached. Not all voices can be fully satisfied in trade-off decisions about limited resources. Fair processes must therefore include clear principles for decision-making when agreement is impossible, which will ensure that decisions are made impartially and reflect reasonable compromises.

Health financing cannot be isolated from national budgetary debates. Trade-offs between sectors are inevitable, especially in resource-constrained settings. The ‘Open and inclusive’ framework needs to be applied across sectors, ensuring that health is not unfairly disadvantaged in competition for funds, and that health financing debates contribute to broader social priorities like equity and poverty reduction.

Finally, as Bennett and Merritt note, development partners' decisions also affect health financing fairness, but their processes often lack transparency and inclusivity. Donors should adopt the same standards they promote for national governments, including public justification of funding decisions and genuine recipient country participation. This is particularly crucial when donor funds make up a large share of health budgets.

The importance of procedural fairness is further highlighted by two additional papers published in this issue of Health Economics, Policy and Law. Levi et al. (2025) present findings on the establishment (or lack thereof) of national physician databases in Canada and Israel. The paper demonstrates that in Canada, a collaborative, trust-based relationship between the state and medical profession has enabled the creation of physician databases, which presents as an important tool for equitable workforce planning and resource allocation. This cooperation reflects key elements of procedural fairness, including voice, accountability, and transparency, allowing for better-informed, fairer decisions about physician distribution and healthcare access. Conversely, in Israel, the persistent conflict and mistrust between the Ministry of Health and the medical association have undermined efforts to build such a database, resulting in fragmented, outdated data that hampers fair and effective workforce planning. The lack of procedural fairness, as key stakeholders (in this case, the medical profession) have been excluded from meaningful engagement in shaping a shared governance solution.

The final paper by Levenets et al. (2025) explores the complex coping strategies Ukrainian patients employ to navigate barriers in accessing healthcare, particularly in a system plagued by underfunding and informality. The research took place prior to the war in Ukraine, yet the authors also reflect on current circumstances. Using nationally representative survey data, the authors demonstrate that securing quality healthcare often requires a combination of informal payments, personal connections, and insider knowledge of the healthcare system's unwritten rules. The study finds that these practices are more prevalent among individuals with higher education levels and stronger social ties to medical professionals, while older individuals, healthier patients, and those with greater trust in the state are less likely to engage in such practices. Importantly, the paper argues that informal strategies deepen inequalities in healthcare access and delivery, highlighting that overcoming systemic barriers often depends on one's social capital and resources rather than formal, equitable pathways. This analysis underscores the need for systemic reform that enhances transparency and procedural fairness, ensuring that access to healthcare is based on need rather than connections or ability to pay.

The debates around procedural fairness in health financing show that this is not only a technical issue. It determines what kind of society we want to build: one in which people have a real voice in shaping decisions that affect their lives, or one in which experts and policy makers decide for them. But importantly, procedural fairness is not a distraction from substantive fairness, but rather it is a necessary foundation for it. Without fair processes, even well-designed policies risk rejection, mistrust, and failure. Conversely, processes that give people a say can produce solutions that are both more just and more sustainable. Making procedural fairness a widely adopted decision-making approach will take time, effort, and political will. But if one is serious about UHC as a universal right, then the path to it must be open and inclusive.