Prah Ruger, Jennifer (2014). 'Health Capability Paradigm as a Framework for Universal Health Coverage' Paper presented at the annual conference of the HDCA, 2-5 September 2014, Athens, Greece.

On 12 December 2012, the United Nations General Assembly unanimously adopted a resolution that emphasizes health as an integral component of international development. This resolution, which builds on WHO Constitution's declaration of health as a fundamental human right, urges governments to move toward providing all people with access to affordable, quality health care services. Despite the increasing global support for health to be included in the international development agenda, little agreement exists on where the bar—both practical and moral—should be set for access to and quality of health care. It seems appropriate and timely, then, to bridge these disparate perspectives by putting forth a framework for universal health coverage.


Current approaches to policymaking propose varied justifications as the basis for health care, yet none captures a fundamental reality: people seek both good health and the ability to pursue it. The account discussed here captures both these intuitions in a concept called health capability. Conceptually, health capability includes, but is broader than, health functioning (the outcome of an action to maintain or improve health) and health agency (individuals' ability to achieve health goals they value and act as agents of their own health)—it is the ability to be healthy.


According to WHO, the goal of universal health coverage is 'to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.'  The health capability paradigm can help outline the conditions necessary to allow for this goal to materialize, to serve as the moral framework for health policies, universal health coverage in particular.


In health policy, the health capability paradigm recognizes that all people should have access to the means to avoid premature death and preventable morbidity, as such, a central purpose of health care, should be to ensure the conditions in which all individuals have the capability to be healthy and achieve the highest possible level of health functioning, thus, shortfall inequalities in health capabilities must be reduced. Governments can address these limitations by applying the health capability paradigm to establish universal health coverage.


An important consideration for universal health coverage relates to limited resources—how a society would prioritize goods and services to those in need, while also setting limits so as not to jeopardize the society's overall health achievements. The health capability paradigm addresses this issue in several stages. First, by prioritizing central health capabilities (e.g., the capability of an individual to avoid premature mortality) above non-central ones (e.g., the ability of an individual to look more muscular through receiving cosmetic bicep implants) and leaving open the selection and valuation of the latter, the account explicitly prioritizes health services associated with core dimensions of health while limiting others. Second, within the medically appropriate care associated with central health capabilities, the account prioritizes those goods and services that reduce shortfall inequalities in central health capabilities over those that do not. Each society will have a slightly different set of guidelines for the distribution of resources in accordance with the overarching goal of reducing shortfall inequalities in its population's health capabilities. Nonetheless, there exists opportunities worldwide to reallocate money within existing health budgets in health policy.


Meeting the dual obligations of equality and efficiency are possible through universal health coverage that is guided by an iterative approach, first addressing equity by using clinical input to analyze deficits in individuals' ability for health functioning below a given threshold. The paradigm then addresses efficiency, using measures of medical care appropriateness, cost-minimization, and, in specific cases, cost-effectiveness analysis to achieve given health objectives with the fewest resources. The integration of clinical and economic considerations, then, allows for the determination of which goods and services should be guaranteed under a health capability-based universal health coverage plan.


While other accounts focus on guaranteeing equal access to decent minimum health care, the health capability paradigm requires the establishment of health systems that are efficient, sufficient, affordable, and accessible so that all have the ability -- to achieve health functioning and health agency.