Procedural fairness and the resilience of health financing reforms in Ukraine

In 2017, Ukraine’s Parliament passed legislation that introduced a new health financing arrangement which relied on general tax revenues to finance a set of health services for the entire population. This legislation was in line with key principles for financing universal health coverage. However, health professionals and some policymakers have been critical about elements of the reform, including its reliance on general taxes. Using qualitative methods and drawing on deliberative democratic theory and criteria for procedural fairness, the study argues that acceptance and sustainability of reforms could be strengthened through a fairer decision-making process. It suggests that three main factors limited the extent of participation and inclusiveness in the process. First, a perception among reformers that a fast15 paced reform was required because there was only a short political window in which to address long standing issues with oversized and unaffordable health care system. Second, there was lack of trust among reformers in the motives and capacity of some stakeholders due to their vested interests. Third, there was under-appreciation of the importance of engagement with the lay public in a way that would treat them as active agents with valuable insights on key reform options. These findings highlight a profound challenge for policymakers. In retrospect, some of those involved in the reform design and implementation believe that meaningful engagement with the public and those who opposed the reform might have strengthened its legitimacy and its ability to endure. At the same time, the study shows how challenging it is to have an inclusive process in settings where some actors may be driven by unconstrained self-interest or lack the capacity to be knowledgeable interlocutors. It suggests that investment in deliberative capital, defined as the attitudes and behaviors that facilitate good deliberation, and civil society capacity may help overcome this difficulty.