No health system can afford everything that may be demanded of it, making priority-setting arguably the most significant and challenging health policy issue, writes Prof Solomon Benatar of the universities of Cape Town and Toronto.
Professor Solomon Benatar, emeritus professor of medicine and a senior scholar at the University of Cape Town and adjunct professor in the Dalla Lana School of Public Health, University of Toronto, writes:
In all countries and at all times demands for health care services exceed supply strengths. The numerous and complex reasons for this will not be addressed in detail here but include the high cost of applying major advances in the science and technology of medicine to all who could benefit from these, and the structural characteristics of health care services.
No health system, whether public, private, or mixed, can afford to provide everything that may be demanded of it. Therefore, resource allocation or priority-setting choices are inevitable, and these are better made explicitly (openly) rather than implicitly (covertly).
Given the wide disparities in wealth and health within and between countries and the increasing importance of improving the health of whole populations on both strategic and humanitarian grounds, priority-setting is arguably the most significant and challenging health policy issue in most countries in the twenty-first century.
The overriding challenge is how to allocate available resources fairly. The range of health associated activities across which allocation needs to be considered include inter alia, structural components of health facilities, professional time and knowledge, beds (general and intensive) and medications. Added complexity relates to adjudication between competing aspects of medicine (prevention, acute care, chronic care, education, research).
In South Africa this challenge is even more complex, given the different relationships between demand and supply in the private and public sectors, as compared with many countries that have national health services of one kind or another. Annual per capita expenditure on health in our private sector is about ten times that in the public sector. Approximately 16% of South Africans have private health insurance that provides access to health care from the 70% of doctors who work full-time in the private sector. The public health sector, staffed by some 30% of the doctors in the country, remains the sole provider of health care for 84% of the national population.
The spectrum of the burden of diseases is also very different in these sectors. South Africa, with 0.7% of the world’s population, accounts for 17% of global human immunodeficiency virus (HIV) infections and also suffers one of the worst tuberculosis epidemics in the world. These diseases, with devastating effects on the lives of individuals, families, whole population groups and society, predominate in the public sector. Increases in non-communicable diseases such as cancer, diabetes, cardiovascular diseases, and trauma, also most heavily burdening those in the public sector, aggravate social disparities in the context of inadequate resources to sustain care for a growing population. Now the pressing COVID-19 pandemic adds to the burden of diseases and further amplifies social disparities.
Determinants of health and disease
Before making priority setting decisions, the forces determining the health of individuals and populations, and the variable extent to which they do so, need to be considered in specific countries.
In Canada, as an example, these proportions have been assessed as: 50% from social factors (maternal and child care, living conditions, access to education/jobs, community development and personal behaviour) and societal influences (the nature of the political economy and belief systems] that together form the foundations for health and longevity; 25% from access to effective health care services; 15% from individual genetic and biological make-up; and 10% through the impact of our environment – air, land and water pollution, transport and the built environment.
In low-and middle-income countries, the social, societal and environmental influences constitute a greater proportion of the causal influences on health and disease. Africa, including South Africa, are further disadvantaged by legacies of previous exploitation and corruption that continue through internal and external processes.
The power of social and societal influences on health is illustrated by historical trends in mortality from tuberculosis (TB) in the UK. In the mid eighteenth century, before the underlying cause of TB was known and there was no specific treatment, this disease killed about 500 people per 100 000 population every year. The public health measure of isolating patients in sanatoria, together with improved living conditions associated with the industrial revolution, reduced the annual death rate to 200/100 000 by 1882 (when Koch discovered the tubercle bacillus), and further to 50/100 000 by the 1940s just before the first anti-tuberculosis drugs were introduced. With the availability and application of modern treatment, mortality fell to 2 per 100,000 population.
Insight into these social influences needs to be more consciously appreciated and acted on today, especially in South Africa, where large pockets of pre-industrial revolution living conditions still exist, and HIV infection is an amplifying factor for tuberculosis, hunger and unemployment. Recognition and acknowledgement of social influences are reminders to address them and not rely exclusively on medical services. Some health disparities are narrowed through improved access to more health care, which is clearly desirable and necessary but certainly not sufficient if social forces sustaining egregious poverty are not addressed.
Debates about improving equity in access to health care and narrowing gaps in health locally and globally have been long-standing and controversial. Recently, equitable universal access to health care services has been touted widely as a high priority for reducing inequitable health status within countries. National Health Insurance in South Africa to provide universal access to high quality individual health services has increasing support, and health economists have suggested that it is feasible to raise some additional funding. Given the extent of disparities in human and material resources within the private and public sectors, it would take several decades to achieve equity in health care delivery at close to current private-sector levels. Vast numbers of additional health professionals and many more highly functional health care facilities would be required. In addition, it should be noted that the global rhetoric about universal access does not stipulate at what level this could be achieved in a world in which 70% of the population live on less than $10/day, most at the lower range – close to $5/day. Disparities in health and health status in South Africa resembling strikingly disparate health status across the globe have been seen as threats to human security in an increasingly unstable world that has reached multiple tipping points. The need for more equitable access to health care has thus been highlighted by the COVID-19 pandemic. Even many wealthy countries have fallen short – not least because of poor planning related to failure to learn from experiences with the SARS and Ebola epidemics.
How should priorities be set and resources allocated in the clinical setting of health care?
Distributive justice, a primary ethical concern, requires that the benefits and burdens of health-related services be distributed according to morally relevant criteria such as need, benefit, cost, cost-effectiveness, equity, equality, and the rule of rescue (obligation to rescue from disaster situations). However, these morally relevant criteria often conflict and there is no overarching moral theory that can resolve the conflicts
Traditional scholarly disciplinary approaches to achieving substantive justice in the allocation of resources can be helpful in clarifying values, but not in actually setting policies. Philosophical theories of justice (utilitarianism, egalitarianism, communitarianism, and capability theory) emphasise different values and lead to different outcomes, and there is no agreement about which theory is most appropriate. Economic approaches (cost-effectiveness analysis) are helpful but are practically limited, and emphasise such values as efficiency about which there is no consensus. Legal approaches can inform us on what is currently considered unacceptable (discrimination), but not about what is right. Knowing what resource allocation decisions to make would be possible if we could agree on the substantive criteria to guide allocations. In the absence of the ability to achieve substantive justice and lack of consensus on what or how allocation decisions should be made, the politics of rationing generally favours muddling through, while evading moral responsibility.
In response to such shortcomings, a method of procedural justice has been developed as a standard of fairness in allocating resources. ‘Accountability for reasonableness’ (A4R) has been offered as an option for health funders to attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that health care is delivered in a reasonable and non-discriminatory fashion. Four conditions need to be met in the A4R approach:
Relevance. Rationales for priority-setting decisions must rest on reasons (evidence and principles) that ‘fair-minded’ people can agree are relevant in the context. ‘Fair-minded’ people seek to cooperate according to terms they can justify to each other while specifying reasons relevant to the specific context to narrow the scope of controversy.
Publicity. Priority-setting decisions and their rationales must be publicly accessible – justice requires openness where people’s well-being is concerned
Revisions/Appeals. There must be a mechanism for challenge, including the opportunity for revising decisions in light of considerations that stakeholders may raise
Enforcement. There must be either voluntary or public regulation of the process to ensure that the first three conditions are met.
A4R includes ethical, economic, legal and policy considerations, that could bring health, political, economic and ethical gains, whilst allaying a social crisis by being seen to be fair. Such an evaluation framework can embrace and share lessons between contexts, and provide a common language to facilitate public learning about reasonable limit-setting that connects allocation decisions to fundamental democratic deliberative processes.
South Africa’ s Constitutional Court’s argument in approving a resource-allocation policy adopted by a hospital to limit costly, long-term dialysis to patients who meet medical criteria for a kidney transplant, resembled the A4R process. This added weight to the legitimacy of policy-makers meeting the essential A4R conditions as most likely to satisfy the requirements of South Africa’ s Constitution that ‘the government’ s health-resource allocation policies must be ‘reasonable.’
A proposal to the Western Province Health Department (WPDOH) in the early 2000s to adopt the A4R process led to workshops under the auspices of the UCT Bioethics Centre (with assistance from the Joint Centre for Bioethics University of Toronto) and the WCDOH. The outcome was a document outlining the rationale for, and features of the decision by the WPDOH to embark on an explicit and accountable priority setting process in health care and health expenditure. Initially the process would apply to setting priorities for access to renal dialysis and transplantation and admission to intensive care units. The intention was to then facilitate enhanced capacity in priority setting and dialogue amongst stakeholders and decision-makers involved in clinical governance throughout the Western Province. This would set the scene for ongoing application of A4R at higher levels of resource allocation in the health care system (hospitals, provinces and nationally) to reduce the potential of overwhelming a rapidly deteriorating public health system facing excessive demands. The ultimate goal was to improve the health of people in the Western Cape and beyond by ensuring the provision of a balanced health care system in partnership with stakeholders, within the context of optimal socio-economic development. Regrettably, this follow up was not pursued and no mention of it is made in WPDOH strategic plans.
While several publicly funded teaching and other hospitals continue to function admirably under difficult circumstances, many others are in a state of crisis. Much of the public health care infrastructure is run down and dysfunctional as a result of under-funding, mismanagement, and neglect. Taking the A4R process forward in earlier non-emergency times could have cultivated an environment of fair decision-making in which limit-setting decisions, perceived to be acceptable, would have been in place to strengthen our public health system and apply to challenges such as the COVID-19 pandemic.
This recent decision, to fund care for COVID -19 public sector patients in the private sector, by sidestepping the A4R process, both sets a precedent for other unmeetable exceptions, such as renal dialysis and transplantation, and adds to, rather than eases existing challenges to equitable health care in our fragile society. The public resources allocated to care of public sector patients in the private sector could achieve more if the A4R deliberative process had been used to identify and prioritise methods of reducing many unnecessary additional deaths, for example from tuberculosis in the public sector.
The report was carried in Daily Maverick