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 fairnessensuring that the processes by which decisions are reached are transparent, inclusive, and accountableis 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 valuerespecting 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