Asian Bioethics Review

, Volume 11, Issue 1, pp 5–19 | Cite as

Justice and public participation in universal health coverage: when is tiered coverage unfair and who should decide?

  • Bridget PrattEmail author
Original Paper


Universal health coverage is often implemented within countries through several national insurance schemes that collectively cover their populations. Yet the extent of services and benefits available can vary substantially between different schemes. This paper argues that these variations in coverage comprise tiering and then reviews different accounts of health and social justice that consider whether and when a tiered health system is fair. Using these accounts, it shows that the fairness of tiering can be determined by assessing whether differences in coverage mean enrolees under some national insurance schemes do not achieve sufficient health or normal functioning and/or feel inferior relative to those belonging to other national insurance schemes. The paper further contends that these determinations of fairness should involve the people covered by different insurance schemes. Key universal health coverage questions to involve the public in answering are: Do the sum of differences between the schemes in your country generate feelings of unequal moral worth and/or mean enrolees struggle to achieve sufficient health or normal functioning? Which specific differences between health insurance schemes generate the greatest feelings of unequal moral worth in individuals? Which specific differences generate the greatest barriers to individuals achieving sufficient health or normal functioning? Rather than identifying which services to extend coverage to first, answering these questions will identify which disparities in services and benefits are the most morally urgent to address. Finally, some initial thoughts are offered on who from the public should be involved in making these decisions and how they might be involved as a matter of justice.


Universal health coverage Participation Ethics Justice Decision-making Tiered system 



The author would like to thank the speakers and attendees of the ABR Research Conference on the Ethics of Universal Health Coverage, held at the National University of Singapore, 5–7 February 2018. Their insightful presentations and comments informed the thinking that is reflected in this paper.

Funding information

BP is currently supported by an Australian Research Council (ARC) Discovery Early Career Researcher Award (Award No. DE170100414).

Compliance with ethical standards

Conflict of interest

BP’s participation (travel and accommodation) in the ABR Research Conference on the Ethics of Universal Health Coverage was supported by the National University of Singapore.


The contents of this article are solely the responsibility of the author and do not reflect the views of the ARC.


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Copyright information

© National University of Singapore and Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  1. 1.Nossal Institute for Global Health and Centre for Health Equity, School of Population and Global HealthUniversity of MelbourneCarltonAustralia

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