We summarise key messages from the World Bank Report Open and Inclusive: Fair Processes for Financing Universal Health Coverage. A central lesson of the Report is that in decision-making on the path to Universal Health Coverage (UHC), procedural fairness matters alongside substantive fairness. Decision systems should be assessed using a complete conception of procedural fairness that embodies core commitments to impartial and equal consideration of interests and perspectives. These commitments demand that comprehensive information is gathered and disclosed and that justifications for policies are publicly debated; that participation in decision-making is enabled; and that these characteristics of the decision system are institutionalised rather than up to the good will of decision-makers. Procedural fairness can improve equity in outcomes, raise legitimacy and trust, and can help make reforms last. While improving procedural fairness can be costly and there are barriers to achieving it, the range of instruments that countries at varying levels of income and institutional capacity have used with some success shows that, in many contexts, advances in procedural fairness in health financing are possible and worthwhile.

Systems of managed competition naturally seek the middle ground between competition and regulation. This debate essay makes the case for adjusting the level of regulation according to the characteristics of the submarket in question. We first develop a theoretical framework that can be used to identify the services in which relatively free competition will be beneficial. The framework is grounded in the economic literature and consists of eight criteria. Targeted regulatory tools are then discussed that can be used to structure submarkets in which these criteria are not (fully) met. Applying this framework and targeted interventions, regulators gain the flexibility to react to potential market failures, without foregoing the benefits of managed competition where it works well. This analysis is highly relevant for countries in transition to managed competition. Regulators can identify potential failure in submarkets for medical services, and apply the necessary regulatory tools to prepare for a smooth transition.

Although the fair financing report, ‘Open and Inclusive: Fair Processes for Financing Universal Health Coverage’, has many sage things to say about democratic deliberative processes, its title belies its content: the report does not offer any assessment of processes for financing universal health coverage. What it does instead is scrutinise processes for deciding how to finance universal health coverage without any linkage to substantive questions concerning financing, and, moreover, the discussion is not narrowly focused on fairness.

This article is a critique of a report, Open and Inclusive: Fair Processes for Financing Universal Health Coverage. The report proposes a framework that is meant to improve procedural fairness and how decisions in financing of health care can be fairer. The author of this article argues that while procedural fairness and the proposed framework are an important step in improving equity in health sector financing, the report falls short on several aspects of achieving the set objectives. First, the report does not place emphasis on the role of civic education as an important component of public education building on access to information. Therefore, there should be caution in assuming that improved dissemination of information will lead to increased civic action. Secondly, the author proposes that the report include principles that should guide how decisions are made in public deliberations when consensus cannot be achieved. Lastly, the framework in the report does not speak to the complexity of the trade-offs that have to be made between health and other sectors. The author argues that a key area of deliberations in health financing is understanding how practitioners in the sector can argue for better funding against other competing sector such as education and agriculture while still finding complementarities.

Health systems’ insurance/funding can be organised in several ways. Some countries have adopted systems with a mixture of public–private involvement (e.g. Australia, Chile, Ireland, South Africa, New Zealand) which creates two-tier health systems, allowing consumers (groups) to have preferential access to the basic standard of care (e.g. skipping waiting times). The degree to which efficiency and equity are achieved in these types of systems is questioned. In this paper, we consider integration of the two tiers by means of a managed competition model, which underpins Social Health Insurance (SHI) systems. We elaborate a two-part conceptual framework, where, first, we review and update the existing pre-requisites for the model of managed competition to fit a broader definition of health systems, and second, we typologise possible roadmaps to achieve that model in terms of the insurance function, and focus on the consequences on providers and governance/stewardship.

South Africa offers universal health coverage through large public and private systems. The private system is characterised by a regulated market for health insurance, referred to domestically as medical schemes. From 2000, the private system was undergoing a reform process consistent with theoretical approaches for regulated competition for health insurance. However, from 2008, the reform process was interrupted, leaving in place a partial framework which included open enrolment, community rating and regulated minimum benefits but excluded, inter alia, risk equalisation. The incomplete reform, however, provides an opportunity to examine the system outcomes that result from a partial approach. This paper therefore reviews the system outcomes of the partial reform using a descriptive data analysis. The findings then inform an evaluation of the extent to which the preconditions for regulated competition have been met as indicated by the theory of regulated competition in healthcare. The paper therefore highlights the areas where regulatory interventions need to be prioritised in South Africa to achieve the objectives of regulatory competition that are able to achieve access, fairness and efficiency. The analysis points to significant failures at the level of health insurance competition in South Africa with resulting outcomes consistent with the theory of regulated competition.

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.

The framework presented in the World Bank report Open and Inclusive: Fair processes for Financing Universal Health Coverage effectively connects proposed decision-making principles with practical examples that country governments can use to pursue greater fairness. In this commentary, we consider the suggestion that international development partners might use the report's criteria to examine their own processes. We consider what the report's primary Fair Process principles – equality, impartiality and consistency – imply for development partners. Specifically, we address two questions in turn: (i) how relevant the Fair Processes report is to development assistance for health; (ii) if it is deemed relevant, what practical implications does the report have for how aid works? We address the second question by briefly applying the framework to a particular global health initiative, namely the United States President's Emergency Plan for AIDS Relief (PEPFAR). Our analysis suggests that development partners' additional sets of accountabilities, particularly linked to funding sources, may pose more fundamental challenges to impartiality than to equality and consistency in decision-making processes. A question inviting further examination, then, is how development partners can redesign their processes to optimise impartiality given institutional constraints that bind them independently of the populations they purport to serve.

The Australian health system is characterised by high quality care by international standards, produced by a mix of public and private provision and funding of healthcare services. Despite good overall results, three issues are of concern. The first issue relates to the public procurement of healthcare, whose flaws have impacted individuals' access to care, and the high out-of-pocket spending. The second issue concerns the sustainability of the private health insurance market, given the government's goal of relieving cost and capacity from the public scheme, incentivising participation. Third, there are existing inefficiencies and inequities related to the duplication resulting from the interaction between public and private schemes. To ensure a sustainable, efficient and equitable health system, structural reforms are necessary to achieve long-term performance improvements. Using a framework for mixed public–private health systems, we assess the extent to which the Australian healthcare system achieves preconditions for efficiency and affordability in competitive healthcare markets.

In response to our critics, we clarify and defend key ideas in the report Open and Inclusive: Fair Processes for Financing Universal Health Coverage. First, we argue that procedural fairness has greater value than Dan Hausman allows. Second, we argue that the Report aligns with John Kinuthia's view that a knowledgeable public and a capable civil society, alongside good facilitation, are important for effective public deliberation. Moreover, we agree with Kinuthia that the Report's framework for procedural fairness applies not merely within the health sector, but also to the wider budget process. Third, we argue that while Dheepa Rajan and Benjamin Rouffy-Ly are right that robust processes for equal participation are often central to a fair process, sometimes improvements in other aspects of procedural fairness, such as transparency, can take priority over strengthening participation. Fourth, while we welcome Sara Bennett and Maria Merritt's fascinating use of the Report's principles of procedural fairness to assess the US President's Emergency Plan for AIDS Relief, we argue that their application of the Report's principle of equality to development partners' decision-making requires further justification.

Managed competition frameworks aim to control healthcare costs and promote access to high-quality health insurance and services through a combination of public policies and market forces. In the United States, managed competition delivery systems are varied and diffused across a patchwork of divided markets and populations. This, coupled with extremely high national health spending per capita, makes a more unified managed competition strategy an appealing alternative to a currently struggling healthcare system. We examine the relative effectiveness of three existing programmes in the U.S. that each rely upon some principles of managed competition: health insurance exchanges instituted by the Affordable Care Act, Medicaid managed care organisations, and Medicare Advantage plans. Although each programme leverages some competitive features, each faces significant hurdles as a candidate for expansion. We highlight these challenges with a survey of academic health economists, and find that provider and insurer consolidation, highly segmented markets, and failing to incentivise competitive efficiencies all dampen the success of existing programmes. Although managed competition for all is a potentially desirable framework for future health reform in the U.S., successful expansion relies on addressing fundamental issues revealed by imperfect existing programmes.

Physician databases constitute an essential component of health workforce planning. However, while some countries have established functioning national physician databases, others have failed to do so. We compared the healthcare systems of two technologically and economically developed countries, Canada and Israel, which represent cases of respective success and failure in establishing physician databases. A comparative analysis was conducted using a historical-institutionalist approach to examine contemporary health policy outcomes. White papers, studies on healthcare human resources, and reports by professional committees were examined to explore the aims, interests, positions, and actions of stakeholders. In Canada, state–medical profession cooperation, deep-rooted in a longstanding regulatory bargain between the two parties, has facilitated the creation and management of physician databases, albeit limited and in need of urgent improvement, on national and jurisdictional levels. The lack of such regulatory arrangement coupled with enduring conflicted relations between stakeholders due to particular historical developments have hindered the development of an Israeli equivalent database so far. Finally, health policy outcomes may be explained against the backdrop of broader political, governance, and organisational contexts. How medical organisations respond to governmental healthcare initiatives is heavily influenced by their institutional position vis-à-vis the state, shaped by historical processes and regulatory arrangements.

The Colombian health system has made a deep transition into managed competition since a major reform in 1993. A market for insurers was created, the consumer has free choice of insurer and a national-level equalisation fund distributes revenues via a per-capita payment. Fully subsidised insurance for the poor and informal, and a comprehensive standardised benefit package for subsidised and contributory schemes (both schemes covering 98 per cent of the population), has led to a low level of out-of-pocket expenses and high financial protection, as well as to reduced gaps in equity in access. The preconditions for managed competition are largely met, but improving health care providers' organisation towards integrated care, to enable them to deliver more value, is a necessary step to achieve the expected results of managed competition in terms of efficiency and quality. Although the current system is likely to be reformed in the coming months, the nature and extent of those reforms are not defined yet, so our analysis is based on the current system.

Ireland has a long-standing voluntary private health insurance market (PHI) which is regulated to meet the public policy objective of achieving risk solidarity to promote affordability of PHI. Under the regulations underpinning the market, many features are common to those of universal mandatory health insurance markets, that have wider equity objectives of ensuring universal equitable access to care for everyone. The market acts a complete/partial alternative to the public health system, and has been criticised for leading to a two-tier system with consequent implications for equity. To improve equity, these criticisms led to the adoption of a new public health reform plan, called Sláintecare, which seeks to build towards equal access to services based on patient need and not their ability to pay. Given this context, this paper re-examines how might the current voluntary health insurance system be adapted to meet the central Sláintecare objective of increasing health coverage on an equitable basis. It does so by considering to what extent does Ireland meet the preconditions for equity and efficiency under the Enthoven managed competition model. It provides a roadmap for the use of health insurance as a tool for bring this equity.

In Ukraine, patients and their family members face numerous barriers to health care services. In response, they use coping strategies, that are manifold and complex activities aimed at overcoming these barriers, the financial burden of the treatment, and the poor quality of health care services. These activities include formal and informal practices. Based on representative survey data from 2015 (N = 2,022), we identify patterns in the use of coping strategies, specific coping strategies used to secure good quality consultation and treatment, and analyse opinions and actions towards coping practices. We further analyse the factors associated with the last experience of coping and look at patterns of connection building. We find that the chances of using both money and connection as a coping strategy are higher for people with incomplete higher and highest levels of education. The size of this effect increases with the level of education. Older people, people with better health, and people with a higher opinion of the state use informal practices less, while women are more active in developing connections. The closer the relationship is with a medical doctor, the higher is the chance that such connection will be used in case of health service consumption.

This paper considers whether and how managed competition arrangements could be introduced into the Aotearoa health and disability system. The paper describes the key features of the system, including new organisational arrangements established from 1 July 2022. It discusses major reforms and managed competition plans that were developed in the 1990s, with the managed competition plans abandoned fairly early on, as a result of major issues with the reforms that had been implemented and with problems in designing a fair payment system for competing health plans. The paper goes on to argue that the development of capitated, risk-bearing and competing Primary Health Organisations set up in the 2000s should be considered in terms of managed competition, and the paper points to the issues that have arisen in Aotearoa due to a lack of regulations that would have better supported the better achievement of effectiveness, efficiency, and equity goals over the past 20 years. Finally, the paper also looks ahead to whether and how managed competition might again be considered in Aotearoa and the extent to which the system currently includes key pre-conditions to support such arrangements.