The World Bank published its World Development Report, Investing in Health, in 1993 (World Bank 1993). It points to a number of inequities in today's health care systems. Public money is spent on interventions of low cost-effectiveness for wealthy people in urban areas, at the same time as cost-effective interventions are not available for the rural poor. The Report instead recommends that public money should be used to deliver a package of essential public health interventions and essential clinical services. Delivering this package should be a government responsibility, and the essential package of health services should be available to everyone, independent of one's ability to pay. Additional care could be provided through the private sector and made available through private insurance schemes. This care would be provided based on an ability to pay. The essential package would include services such as chemotherapy for tuberculosis, prenatal and delivery care, school health education, tobacco and alcohol control programmes, and prevention of AIDS.
Issues of health policy in developing countries and the World Bank proposals have been discussed extensively in the recent literature. There has been a concern about issues such as whether public or private health care systems are more efficient at providing health care (Hsiao 1995; Frenk 1993; Bennet et al 1994; McPake and Banda 1994), the effect on user charges on cost-recovery and on equity (Gilson et al 1995; Shaw and Ainsworth 1995; Shaw and Griffin 1995; McPake 1993) and whether concepts developed in industrialized nations such as managed competition are applicable in developing countries (Carr-Hill 1994; Hsiao 1994). There is no agreement on any of these topics.
In many of the writings there is an explicit demand that one should pay attention to issues of equity and ethics. This is also the case in the World Bank Report. There is, however, little detail in the discussion of ethical issues raised by various health policy proposals. Instead, one is mainly concerned with empirical and technical questions, such as whether a particular proposal has or does not have the desired effects.
Many writers in the health policy literature accept health maximization as the goal of health policy reforms. This is, however, controversial. There are familiar problems with all forms of ethical theories that demand maximization of benefits. It has repeatedly been pointed out that maximization approaches to resource allocation, such as the QALY and DALY methods, cannot take into account the moral relevance of how resources are the distributed (for this criticism, see Lockwood 1988; Harris 1988; Morreim 1986; Harris 1987). Data from empirical studies also indicate that people do not accept health maximization as the only goal of health policy when there is a need to prioritize between different patients and different interventions (Nord 1993; Nord et al 1995; Ubel and Loewenstein 1996). The third difficulty with DALY and QALY methods is that it is assumed that the values assigned to a limited number of health states by a small group of experts in some way represent the values the general population will assign to all possible consequences of different disease states. In spite of this, the expert literature continue to adopt health maximization as the overriding goal of health policy. There is therefore an urgent need to develop alternative ethical frameworks for health resource allocation and health policy
There is, of course, a need for more empirical studies about what people actually want out of a health care system. The most urgent need, however, may be to establish a moral framework for health policy more in line with accepted goals of health policy than a health maximization model. There are basically three different ways to go.
The first approach is skeptical towards any scheme that distributes benefits according to some common notion of what people want. This approach would point out that people desire different things from the health care system. Some may for example put a high value on life-saving treatments, even if they have low probability of success. Others may want to use their resources for interventions that increase quality of life. Any approach that attempts to define one rational way to distribute resources would be unjust because it would violate peoples' rights to choose their own conception of the good life (see for example Brody 1983; Brody 1987). Even in this approach one would recognize that certain basic needs should be satisfied, and the provision of health services to satisfy those needs may be an obligation of the state. The inclusion of health care services in the basic package would not necessarily be based on health maximization, however, precisely because of the scepticism towards any one correct way of calculating health benefits. Instead one might include services that would insure people against catastrophic loss (for example very expensive, but effective interventions). Although some people have defended this approach, many would argue that health is more basic than other goods distributed through market mechanisms. Resource allocation should therefore be based on an egalitarian conception of justice, which gives us a second approach..
In order to capture such concerns such as these, a number of people have introduced the notion of equity (Morrow and Bryant 1994; Nolan 1996; Pereira 1993). Equity with regard to health care can be defined in a number of different ways. In the most general sense, an equitable distribution of resources simply means a just distribution of resources. What is equitable would therefore be what is just according to the theory of justice that we subscribe to. If we accept utilitarianism as an acceptable theory of justice, a distribution of resources in accordance with a utilitarian calculation would therefore be equitable, and in particular there would be no conflict between a maximizing approach and equity. Most commentators who use the term 'equity' have something more specific in mind, however. Equity in this more specific sense is closely association with egalitarianism, or with the notion that all people should be treated as equals.
Even this more specific notion, however, allows for a general interpretation. As Amartya Sen (1992) has reminded us, all theories of justice introduce some notion equality. Utilitarians argue that the utilities of each person should only be counted once; in the QALY approach each person's health benefit counts for the same and so on. Again, those who argue for equity have something different in mind.
Wagstaff (1991) has shown that there are several possible ways of capturing these intuitions: Equal treatment for equal need, equality of access and equality of health. Despite its problems, equality of health is the most useful specification of this notion of equity. The demand that resource allocations should be distributed so as to 'equalize health' cannot be taken as an absolute demand; that would mean that all resources would be spent on very sick individuals with little possible for benefit. What it plausibly means is that we should be concerned with an equal distribution of health status as an independent criterion to health maximization. Wagstaff has introduced a correction factor in the QALY formula that will give a numerical estimate of society's aversion to an inegalitarian distribution of health.
This second approach uses a correction factor to the health maximization model to take into consideration issues of equity. The third approach to resource allocation would abandon the health maximization approach altogether. It would start by identifying interventions that we agree should be provided to all people. One way of identifying these interventions would be to use Amartya Sen's capabilities approach or Martha Nussbaum's neo-Aristotelian theory (see Sen 1993; Nussbaum 1993; Nussbaum 1995). The model captures the insight that health is something all people, ideally, should have access to, and should have access to at the same level, irrespective of the level of wealth in the society that one happens to live in. The level of health care services that one thinks should be available to everyone would probably be close to what is available in publicly financed systems in Western nations. Alternatively, in a country context, one could suggest that it is close to what is provided to the urban middle class in that country (see for example Baily 1986)
Clearly these three approaches to health care resource allocation would give different answers to many of the health policy options discussed today. There is an urgent need to explore the strengths and weaknesses of these alternative frameworks for health policy reform.
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