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Accessibility, ethics and equity in health care
Sm. Sci. Med. Vol. 36, No. 12. pp. iii-vii, Printed in Great Britain
0277-9536/93 $6.00 + 0.00 Pergamon Press Ltd
1993
EDITORIAL ACCESSIBILITY,
ETHICS
AND
Over the past five decades tremendous strides have been made universally in improving health status; but while the richer western and northern countries have made immense gains, the poorer southern, developing countries, as well as pockets of population and special groups within industrialized nations, still carry lingering burdens of illness and disease. Much remains to be done in order to ameliorate this situation; but enormous difficulties seem to confront efforts to mobilize the human and material resources needed for doing so. The causes are numerous, but generally have to do with economic power. Achievements have been made in spite of, and in some cases clearly because of, different underlying philosophies and ideologies which have held sway during these decades. The horrors of World War II seem to have been followed by much social activism in an effort to bring about greater social justice. Hence policies and programmes, including a move to universal health insurance, implemented in most of the industrialized world. Now, as we near the end of the twentieth century, there is much ferment both internationally and locally within countries, old and new. The old order is everywhere being swept aside, there is increasing chaos, disappointment in the lack of accomplishment of great expectations for a new era of peace and justice. There is fear for the immediate future as well as for the welfare of the next generation. Values have changed and are changing. There has meantime seemingly been a slow swing of the pendulum of public policy away from social activism towards individualism and the sway of market forces. Private corporations, including the multinationals, now exercise increasing power, often beyond that of sovereign nations; and it is averred by some spokesmen that the integrity and the power of intervention by the nation state in its own affairs will soon disappear. As an expression of the ‘new economic facts of life’ which we supposedly have to confront, new shibboleths are appearing. Predominant among them is ‘competitiveness’, which seemingly is the lodestar for future economic relations among nations and groups. The underlying philosophy, and the manner in which it is played out, will alter profoundly the nature of the international order, if indeed such now exists; and will shape the structures and arrangements, including the health infrastructures and operations, that will need to be built or modified in
EQUITY
IN HEALTH
CARE
order to best serve societal needs, nationally and locally. This is therefore the time for critical examination of some of these basic issues. In the present state of flux, there may be opportunities for positive as well as negative change. The ACCESSIBILITY of health care to any individual or group is dependent on a multiplicity of factors existing at different levels of a society. They include the overall quantity and quality of care available, however judged-and judgment may be based among other things on the acceptability of the system or systems of medicine, depending on the extent of society or group orientation to ‘western’ or to the other systems, and the prevailing norms in the society. Other important factors include the social organization of the society-more or less individualistic as against cooperative or community oriented; the degree to which there is commitment on the part of political leaders and other influentials for the provision of health care, whether as a social good or as a commodity-in other words, the priority assigned to it; and therefore the usually closely related prevailing ideology, which may view that provision of health care either as a public responsibility or as a function of the market-place. There may indeed exist a combination of the two which, with their many nuances, could lead to many patterns of health care delivery systems. The general level of wages as compared to the cost of services may be equally important from the point of view of the consumer of services. The cost of the training and deployment of health professionals and paraprofessionals, and their relevance and appropriateness to their tasks are also obviously important, as is their demeanour in dealing with clients. Large countries may have the added complication of having to attend to the needs of different subgroups with differing ideologies and expectations. The tools of the health trade are no less important. Nowadays they include quite expensive high technology diagnostic and treatment devices and facilities, which are promoted by their manufacturers as critical and obligatory for good medical practice; which are viewed by some health practitioners as the epitome of science, and therefore are probably over-used, often supplanting good diagnostic and clinical skills; in the ownership of which the operators of care facilities perceive the highest prestige, giving rise to duplication within relatively small health jurisdiction; and which clients are driven to demand
IV
Editorial
in consultations with their health practitioners. No less important are the various pharmaceutical preparations which are available for purchase. Many are quite unnecessary, and arc often over-prescribed. In several instances. even now. their use is related more to promotion by their manufacturers than to any demonstrated effectiveness. This is particularly so in developing countries where some manufacturers tend to dump pharmaceuticals which are acceptable neither in their countries of manufacture nor in other developed countries. Because of patent laws. some are excessively highly priced, with price protection extending over long periods. ostensibly to ensure fair returns on investments in research and development. However, in the eyes of some sceptics. it is equally to ensure large profits for a relatively small number of prosperous shareholders. Ultimately. questions of cost and alfordability are the critical determinants of accessibility. The situation may be mitigated by who pays; at what stage of the health transaction; how the costs arc in the long run covered ~-by a fee for service. through personal msurance, through contributory insurance schemes. from the general tax base. or by various combinations of these. Given this multiplicity of factors operating. ol which the above are only a few, the question of EQUITY in health care then arises. It should not be surprising to find that in the real world accessibility is in most countries skewed to a greater or lesser extent: generally the richer. more influential members of society have easier access. vvhilc the poorer. less well educated tind access restricted. The matter of ETHICS is no less complicated. embracing concepts ofa duty to one’s fellow humans. of moral principles or of accepted rules of conduct one with another. which have evolved in step with society’s maturation. Much attention has been paid in recent years, particularly following some of the horrors pcrpctrated on innocent people during times of war. to ethics in relation to medical research. The Council for International Organizations of Medical Sciences (CIOMS). in cooperation with the World Health Organization. has been instrumental in elaborating and distributing guidelines in this regard, generally acceptable to the international research community. Most of us rccognise that there are sometimes circumstances in individual countries or localities. with their own cultural values and norms. which may require modifications of internationally desirable and accepted ethical standards, in order to enhance the usefulness of health research. The ultimate test is whether benefits to those studied outweigh any harm that may bc done as a result of the research itself. As expressed by the International Commission on Health Research for Development, it is becoming more and more evident that research is a necessary element in the planning and programming of health care delivery, especially in the developing countries
with limited financial resources. What IS described as ccwntial notiord lwdth researclr is viewed as imperative in trying to achieve EQUITY. The notion of EQUITY conjures up thoughts of fairness and justice. In the context of health care delivery, the essence is equal access. according to need, to all members of the society. There is thus an explicit link between essential national health research and equity; and in these circumstances a clear link between ethics as well. and not strictly as rclatcd to health research. There is constant argument as to whether good health is a human right or a privilege. In some countries it is seen as the former. in others as the latter. reflecting respective ideology. In the formet group there is obviously a greater potential for equity, at least in theory: and this could also be seen as ethical. The World Health Organization has done much to encourage equity. at both international and local levels. Its efforts led to the Alma Ata Declaration of 1978. emphasizing Pritnq\~ Hdtiz Core as the rational and practical approach for health cart delivery. This was combined with an expression on the idcal to bc achieved of Ildtlr For- ,411hr tlw Ywr 2000. That the ideal. though inherently optimistic. will not have been achieved, is perhaps less the fault of the WHO than of those who arc unable. or unwilling sometimes because of ideology. to make the nccdcd material support available. At the national Icvel. several countries have since World War II attempted, with varying degrees of fervour. and with varying success, to bring about EQUITY in access to health care. Among developed countries, the I!nited Kingdom embarked on a particularly bold attempt at this in the 1940s with a national health insurance system largely funded through contributions from the employed or from the general tax base to cover those unable to contribute. The idea was that no-one should be denied access to the best available care as a result of an inability to pay at point of service. An early problem. which has echoes today in many countries. was the practicality of a means test to determine who was or was not indeed able to pay. There has always been a preoccupation by some sectors of society with so-called cheaters, abusers and overusers of these systems. This has been the cast in the United Kingdom as in other countries: and in the context of today’s economic difficulties and prevailing ideologies. their voices are in many countries quite loud. Other probincreasing costs, administrative lems, including difficulties, and the opting out of increasing numbers of practitioners from the centralized system, based on ideological persuasion as well as on the lure of greater financial returns in private practice. have led in the IJnited Kingdom and in other countries to some degree of rationing and to queueing particularly for some specialist services. At the same time there has been a growth of private systems of health insurance
Editorial
benefiting mainly those select contributors who are already in better health or are better able to pay. Equity is at best diminished at worst abandoned. Most recently many countries have a dual system: one the national system, seen by many to be costly and inefficient, starved of funds and struggling to meet the needs of the disadvantaged in society; the other a well organized and well run private system, eminently capable of catering to the needs of the already advantaged. There are at present many examples of efforts being made to introduce better management into the systems, especially at the local level, with limits of some sort set on available funds, the justification being to improve efficiency and effectiveness, to ‘do more with less’. In the U.S.A., where private enterprise and the ascendancy of the market place are national icons, a great many systems have grown up, representing largely variations on the basic theme. Citizens employed in large companies have health insurance paid by their employers to a wide variety of third party private, profit-oriented insurance companies. Those who are unemployed, indigent or old are theoretically looked after through insurance schemes funded by government. However, for a variety of reasons-ineligibility and administrative complexity among them-30 million Americans have little or no access to decent health care. This at a time when the cost of health care is increasing exponentially. The excessive use of high technology; high administrative costs of an extremely complex and burdensome system; the high cost of litigation, a particular preoccupation-dare one suggest a foible?-of the Americans; the forced, improper use of high-cost facilities by some people who are without other access to health care in present circumstances are just some of the causes for escalating costs. Practitioners want adequate compensation for what they regard as very expensive, intensive and protracted education and preparation; they wish to ensure a decent standard of living and appropriate lifestyles befitting themselves and their families. Some are seen by sectors of the society as too rich and powerful, insistent on maintaining the status quo, answerable to no authority except their own. The system is perceived by some as one which encourages the practice of medicine more as a business than a social service. This may or may not be true; and it is moot as to whether or not it raises an ethical question. Ready litigation for actual or perceived physician incompetence is a real and present danger. Then there is the extremely high cost of prescription drugs. Over decades groups such as the American Public Health Association have been pressing for changes in the national health care systems, towards some form or forms of universal health insurance, to produce greater equity and accessibility in health care for Americans; but so far their efforts have met with little success. The influence of the over-riding national ethos which emphasizes private enterprise, the market
”
place and free choice has been too strong. Very recently, with new political developments, there appears the potential for the kind of change that has long been sought. Experiments are beginning in some states for the introduction of universality, epitomized by the standardization of services and of the fees paid for such services. In brief, there will be rationing. Exclusions include such non-life threatening conditions as the common cold. At the national level there will likely be similar attempts at universal coverage, with rationing, including the imposition of upper limits on costs, and some competition for the provision of standard services. Funding will likely come from both employer contributions and general taxes. There is likely to be increased ‘sin’ taxation: on alcohol and tobacco sales, to help pay for the services. There will almost certainly be a greater emphasis on prevention and preventive services. This will all take place in a situation in which the cost of an existing inefficient service, far from universal, is already constituting a major drain on national resources. The new president has already targeted exorbitant drug costs and the fees paid to physicians as areas for examination and reform. Some envision in due course a new system which is universal but which, in keeping with American preference, will be privately run. There is every indication that, as would be expected, there will be stiff resistance to these measures from some of the vested interests. Canada is generally accepted as having one of the more efficient universal health care insurance schemes in the developed world, based on a centralized administrative system with a single payer (for billings). Funding is provided through employer and employee contributions and from general taxes. Canadian ‘sin’ taxes which support social insurance are very high. Critics insist that there is widespread dissatisfaction with the system, though others have the impression that consumers generally do not wish to see much tampering with it. High and increasing costs are attributed to the almost indiscriminate use of high technology, often duplicated unnecessarily, promoted by manufacturers, demanded by clients and prescribed by doctors; the high fees paid to doctors for services rendered, with over-billing beyond the prescribed fees being permitted; the extremely high cost of drugs; and the abuse of the system by clients who, for example, use night emergency hospital services for non-threatening conditions, rather than daytime neighbourhood facilities and personnel. There is the inevitable accusation of cheating, including unlawful use by foreigners; and appeals are made for better methods of monitoring and scrutiny in order to obviate this particular problem. Other suggested changes include the imposition of nonrefundable or only partially refundable user fees; rationing the use of high technology; and capping or reducing the fees paid to physicians for standard services. The fact is that some physicians are already
vi
Editorial
accepting the notion of stabilized fees and are reducing the use of high technology. Most other industrialized countries have some version of a health care system based on universal insurance. In the former Soviet Union and the socialist countries of Eastern Europe, as well as in Cuba and in other Marxist-oriented countries in Africa and Asia, there was an ideological commitment to equity in accessibility, with a major emphasis on prevention. Health care was viewed as social responsibility. Certainly in Cuba this has led to quite astounding accomplishments in health status in a relatively short time. It is now doubtful whether the gains elsewhere in the socialist countries were overall as great as they were reported to bc. In any case health care has suffered as much as other areas of endeavour as a consequence of the recent economic disaster befalling these countries, the result of bad planning and management over a period of decades. In most developing countries there is a clear lack 01 universal coverage, little equity. Normally health care services of two distinct qualities co-exist: one which provides accessibility and excellence for the rich and influential; another. publicly funded, which is rudimentary, restrictive. generally inefficient and which serves the less advantaged. These realities are not always the result of national preference. Loans from the International Monetary Fund and the World Bank to these countries, supposedly to help them improve their economies. and under the rubric of structural adjustment programmes, usually come with restrictions on expenditures for social programmes, including education and health care. There is evidence that latterly some of agency personnel are discerning the injustice and the brake on development inherent in these strictures; and it is hoped that the stricutres will be removed or modified. Good health is. after all. a major element in development. If development is people-oriented. they cannot fully participate or benefit if their health status is poor. Ill or diseased people certainly cannot be efficient producers. Within the existing systems. various efforts have been made to mitigate the cost of health cart delivery. a heavy burden on the central exchequer in most developing (as well as developed) countries. The so-called Bamako initiative. implemented in parts of West and North Africa. attempts to subsidize the cost of expanding health care delivery through the sale of drugs for a profit. 11 is as yet unclear as to whether this initiative, by itself. can really lead to self-sustenance and self-sufficiency. Similarly, user fees. promoted by some outside aid agencies are helping govcrnmcnts to try to sustain and expand primary health care services. These have been assessed in Kenya and Camcroon with a degree of scepticism over their success. Perhaps some ‘foreign’ ways are not readily traditional societies; other accepted in many
approaches to development may first have to demonstrate acceptance. The above has necessarily been but a brief description of some contemporary currents in health care with implications for accessibility, ethics and equity. The intent is to raise issues, pose questions, stimulate discussion and hopefully lead to attitude changes and appropriate action. Key questions need to be addressed: Is good health really a right or a privilege? If it is a right, how to ensure that it is exercised? What of the responsibility involved in ensuring that right? Whose is it? What cost implications are there, personal or societal? Is the provision of health care a personal or social responsibility? Or both? Is it a market commodity, to be bought if affordable, or accepted as a luxury if not easily affordable. with whatever consequences? What is the role of private enterprise and of the market economy in health care? In what circumstances’? And how does that role relate to considerations of ethics. accessibility and equity’? Is it ethically acceptable to have different levels and standards of health care for different segments of the society? If so why, and on what basis? What are the appropriate roles of private industry and the market economy. in their present reality, or as conceptualized. in the provision of health care. and as related to ethics, equity and accessibility? What kinds of partnerships are possible between them and the public and voluntary sectors? What is the new economic order which is being invoked, but about which there is little information of a functional nature‘? Or what should it be? Is it to be a new attempt at shaping relations among countries with a view to more balanced power relationships‘? Or is it to be more of the same present inequity’? Will the consequence be greater independence for individual countries, in particular the developing ones? Or greater interdependence? Or more dependence of the one on the other? Will there be greater freedom. the prerogative and the ability for the developing country to institute and sustain social programmes, including health, for development with equity‘? What is the role of the multinational drug in health endeavours’! How do they companies contribute to equity, accessibility? Where is the ethics in their activities? Should the generic drug companies be encouraged and supported? In what circumstances’? How? Is the use of high technology for the benefit of the few or for the many? Who decides who should have access, on what basis, under what circumstances? In general, should access preferably be for the few or for the many? Who decides? In conditions of material constraint, should limited funds be used for providing high technology for the few. or less sophisticated technology for the many? What is the ethics of the decision?
Editorial How important is research in health care? How to ensure that needed research is undertaken, and that the results are translated into planning, programme and policy? What is the role of the health professional in relation to the guarantee of ethics, accessibility and equity in health care? What can the ordinary citizen do to ensure attention to accessibility, ethics and equity in health care by those responsible for its organization? What is the role of aid agencies in promoting and ensuring equity in health care delivery? What of the recent suggestion by Carl Taylor (in the International Journal of Epidemiology) to ensure equity through surveillance of groups at greatest risk, with attention being paid to their health needs? Is this the best approach to equity in the present economic circumstances of the developing countries? Are there other models whi& will guarantee access, ensure equity, provide a minimum of quality care and still be generally affordable? Where are they? Do they need to be researched?
vii
In what circumstances, and to what extent, is it ethical for multinational companies, official and voluntary agencies and other interests external to nations and communities to enter and to determine what is the most appropriate action for promoting greater accessibility with equity? In the final analysis, is it not economic power, combined with an ideology that promotes social responsibility, that will determine accessibility with equity? Until the circumstances are right and the action appropriate to enable decisions at the level of, and by the less developed nations or groups within countries, is it merely applying band-aids to solve intractable problems? These issues have been raised in the form of questions which are not always objective. Nor are the questions new. It is hoped nevertheless that they will be provocative. Given the immediacy and sensitivity of some of them at present, in the context of rapid change in many parts of the world, al both national and local levels, they may help to stimulate discussion and debate and lead to informed rational for action.
0277-9536/93 $6.00 + 0.00 Pergamon Press Ltd
1993
EDITORIAL ACCESSIBILITY,
ETHICS
AND
Over the past five decades tremendous strides have been made universally in improving health status; but while the richer western and northern countries have made immense gains, the poorer southern, developing countries, as well as pockets of population and special groups within industrialized nations, still carry lingering burdens of illness and disease. Much remains to be done in order to ameliorate this situation; but enormous difficulties seem to confront efforts to mobilize the human and material resources needed for doing so. The causes are numerous, but generally have to do with economic power. Achievements have been made in spite of, and in some cases clearly because of, different underlying philosophies and ideologies which have held sway during these decades. The horrors of World War II seem to have been followed by much social activism in an effort to bring about greater social justice. Hence policies and programmes, including a move to universal health insurance, implemented in most of the industrialized world. Now, as we near the end of the twentieth century, there is much ferment both internationally and locally within countries, old and new. The old order is everywhere being swept aside, there is increasing chaos, disappointment in the lack of accomplishment of great expectations for a new era of peace and justice. There is fear for the immediate future as well as for the welfare of the next generation. Values have changed and are changing. There has meantime seemingly been a slow swing of the pendulum of public policy away from social activism towards individualism and the sway of market forces. Private corporations, including the multinationals, now exercise increasing power, often beyond that of sovereign nations; and it is averred by some spokesmen that the integrity and the power of intervention by the nation state in its own affairs will soon disappear. As an expression of the ‘new economic facts of life’ which we supposedly have to confront, new shibboleths are appearing. Predominant among them is ‘competitiveness’, which seemingly is the lodestar for future economic relations among nations and groups. The underlying philosophy, and the manner in which it is played out, will alter profoundly the nature of the international order, if indeed such now exists; and will shape the structures and arrangements, including the health infrastructures and operations, that will need to be built or modified in
EQUITY
IN HEALTH
CARE
order to best serve societal needs, nationally and locally. This is therefore the time for critical examination of some of these basic issues. In the present state of flux, there may be opportunities for positive as well as negative change. The ACCESSIBILITY of health care to any individual or group is dependent on a multiplicity of factors existing at different levels of a society. They include the overall quantity and quality of care available, however judged-and judgment may be based among other things on the acceptability of the system or systems of medicine, depending on the extent of society or group orientation to ‘western’ or to the other systems, and the prevailing norms in the society. Other important factors include the social organization of the society-more or less individualistic as against cooperative or community oriented; the degree to which there is commitment on the part of political leaders and other influentials for the provision of health care, whether as a social good or as a commodity-in other words, the priority assigned to it; and therefore the usually closely related prevailing ideology, which may view that provision of health care either as a public responsibility or as a function of the market-place. There may indeed exist a combination of the two which, with their many nuances, could lead to many patterns of health care delivery systems. The general level of wages as compared to the cost of services may be equally important from the point of view of the consumer of services. The cost of the training and deployment of health professionals and paraprofessionals, and their relevance and appropriateness to their tasks are also obviously important, as is their demeanour in dealing with clients. Large countries may have the added complication of having to attend to the needs of different subgroups with differing ideologies and expectations. The tools of the health trade are no less important. Nowadays they include quite expensive high technology diagnostic and treatment devices and facilities, which are promoted by their manufacturers as critical and obligatory for good medical practice; which are viewed by some health practitioners as the epitome of science, and therefore are probably over-used, often supplanting good diagnostic and clinical skills; in the ownership of which the operators of care facilities perceive the highest prestige, giving rise to duplication within relatively small health jurisdiction; and which clients are driven to demand
IV
Editorial
in consultations with their health practitioners. No less important are the various pharmaceutical preparations which are available for purchase. Many are quite unnecessary, and arc often over-prescribed. In several instances. even now. their use is related more to promotion by their manufacturers than to any demonstrated effectiveness. This is particularly so in developing countries where some manufacturers tend to dump pharmaceuticals which are acceptable neither in their countries of manufacture nor in other developed countries. Because of patent laws. some are excessively highly priced, with price protection extending over long periods. ostensibly to ensure fair returns on investments in research and development. However, in the eyes of some sceptics. it is equally to ensure large profits for a relatively small number of prosperous shareholders. Ultimately. questions of cost and alfordability are the critical determinants of accessibility. The situation may be mitigated by who pays; at what stage of the health transaction; how the costs arc in the long run covered ~-by a fee for service. through personal msurance, through contributory insurance schemes. from the general tax base. or by various combinations of these. Given this multiplicity of factors operating. ol which the above are only a few, the question of EQUITY in health care then arises. It should not be surprising to find that in the real world accessibility is in most countries skewed to a greater or lesser extent: generally the richer. more influential members of society have easier access. vvhilc the poorer. less well educated tind access restricted. The matter of ETHICS is no less complicated. embracing concepts ofa duty to one’s fellow humans. of moral principles or of accepted rules of conduct one with another. which have evolved in step with society’s maturation. Much attention has been paid in recent years, particularly following some of the horrors pcrpctrated on innocent people during times of war. to ethics in relation to medical research. The Council for International Organizations of Medical Sciences (CIOMS). in cooperation with the World Health Organization. has been instrumental in elaborating and distributing guidelines in this regard, generally acceptable to the international research community. Most of us rccognise that there are sometimes circumstances in individual countries or localities. with their own cultural values and norms. which may require modifications of internationally desirable and accepted ethical standards, in order to enhance the usefulness of health research. The ultimate test is whether benefits to those studied outweigh any harm that may bc done as a result of the research itself. As expressed by the International Commission on Health Research for Development, it is becoming more and more evident that research is a necessary element in the planning and programming of health care delivery, especially in the developing countries
with limited financial resources. What IS described as ccwntial notiord lwdth researclr is viewed as imperative in trying to achieve EQUITY. The notion of EQUITY conjures up thoughts of fairness and justice. In the context of health care delivery, the essence is equal access. according to need, to all members of the society. There is thus an explicit link between essential national health research and equity; and in these circumstances a clear link between ethics as well. and not strictly as rclatcd to health research. There is constant argument as to whether good health is a human right or a privilege. In some countries it is seen as the former. in others as the latter. reflecting respective ideology. In the formet group there is obviously a greater potential for equity, at least in theory: and this could also be seen as ethical. The World Health Organization has done much to encourage equity. at both international and local levels. Its efforts led to the Alma Ata Declaration of 1978. emphasizing Pritnq\~ Hdtiz Core as the rational and practical approach for health cart delivery. This was combined with an expression on the idcal to bc achieved of Ildtlr For- ,411hr tlw Ywr 2000. That the ideal. though inherently optimistic. will not have been achieved, is perhaps less the fault of the WHO than of those who arc unable. or unwilling sometimes because of ideology. to make the nccdcd material support available. At the national Icvel. several countries have since World War II attempted, with varying degrees of fervour. and with varying success, to bring about EQUITY in access to health care. Among developed countries, the I!nited Kingdom embarked on a particularly bold attempt at this in the 1940s with a national health insurance system largely funded through contributions from the employed or from the general tax base to cover those unable to contribute. The idea was that no-one should be denied access to the best available care as a result of an inability to pay at point of service. An early problem. which has echoes today in many countries. was the practicality of a means test to determine who was or was not indeed able to pay. There has always been a preoccupation by some sectors of society with so-called cheaters, abusers and overusers of these systems. This has been the cast in the United Kingdom as in other countries: and in the context of today’s economic difficulties and prevailing ideologies. their voices are in many countries quite loud. Other probincreasing costs, administrative lems, including difficulties, and the opting out of increasing numbers of practitioners from the centralized system, based on ideological persuasion as well as on the lure of greater financial returns in private practice. have led in the IJnited Kingdom and in other countries to some degree of rationing and to queueing particularly for some specialist services. At the same time there has been a growth of private systems of health insurance
Editorial
benefiting mainly those select contributors who are already in better health or are better able to pay. Equity is at best diminished at worst abandoned. Most recently many countries have a dual system: one the national system, seen by many to be costly and inefficient, starved of funds and struggling to meet the needs of the disadvantaged in society; the other a well organized and well run private system, eminently capable of catering to the needs of the already advantaged. There are at present many examples of efforts being made to introduce better management into the systems, especially at the local level, with limits of some sort set on available funds, the justification being to improve efficiency and effectiveness, to ‘do more with less’. In the U.S.A., where private enterprise and the ascendancy of the market place are national icons, a great many systems have grown up, representing largely variations on the basic theme. Citizens employed in large companies have health insurance paid by their employers to a wide variety of third party private, profit-oriented insurance companies. Those who are unemployed, indigent or old are theoretically looked after through insurance schemes funded by government. However, for a variety of reasons-ineligibility and administrative complexity among them-30 million Americans have little or no access to decent health care. This at a time when the cost of health care is increasing exponentially. The excessive use of high technology; high administrative costs of an extremely complex and burdensome system; the high cost of litigation, a particular preoccupation-dare one suggest a foible?-of the Americans; the forced, improper use of high-cost facilities by some people who are without other access to health care in present circumstances are just some of the causes for escalating costs. Practitioners want adequate compensation for what they regard as very expensive, intensive and protracted education and preparation; they wish to ensure a decent standard of living and appropriate lifestyles befitting themselves and their families. Some are seen by sectors of the society as too rich and powerful, insistent on maintaining the status quo, answerable to no authority except their own. The system is perceived by some as one which encourages the practice of medicine more as a business than a social service. This may or may not be true; and it is moot as to whether or not it raises an ethical question. Ready litigation for actual or perceived physician incompetence is a real and present danger. Then there is the extremely high cost of prescription drugs. Over decades groups such as the American Public Health Association have been pressing for changes in the national health care systems, towards some form or forms of universal health insurance, to produce greater equity and accessibility in health care for Americans; but so far their efforts have met with little success. The influence of the over-riding national ethos which emphasizes private enterprise, the market
”
place and free choice has been too strong. Very recently, with new political developments, there appears the potential for the kind of change that has long been sought. Experiments are beginning in some states for the introduction of universality, epitomized by the standardization of services and of the fees paid for such services. In brief, there will be rationing. Exclusions include such non-life threatening conditions as the common cold. At the national level there will likely be similar attempts at universal coverage, with rationing, including the imposition of upper limits on costs, and some competition for the provision of standard services. Funding will likely come from both employer contributions and general taxes. There is likely to be increased ‘sin’ taxation: on alcohol and tobacco sales, to help pay for the services. There will almost certainly be a greater emphasis on prevention and preventive services. This will all take place in a situation in which the cost of an existing inefficient service, far from universal, is already constituting a major drain on national resources. The new president has already targeted exorbitant drug costs and the fees paid to physicians as areas for examination and reform. Some envision in due course a new system which is universal but which, in keeping with American preference, will be privately run. There is every indication that, as would be expected, there will be stiff resistance to these measures from some of the vested interests. Canada is generally accepted as having one of the more efficient universal health care insurance schemes in the developed world, based on a centralized administrative system with a single payer (for billings). Funding is provided through employer and employee contributions and from general taxes. Canadian ‘sin’ taxes which support social insurance are very high. Critics insist that there is widespread dissatisfaction with the system, though others have the impression that consumers generally do not wish to see much tampering with it. High and increasing costs are attributed to the almost indiscriminate use of high technology, often duplicated unnecessarily, promoted by manufacturers, demanded by clients and prescribed by doctors; the high fees paid to doctors for services rendered, with over-billing beyond the prescribed fees being permitted; the extremely high cost of drugs; and the abuse of the system by clients who, for example, use night emergency hospital services for non-threatening conditions, rather than daytime neighbourhood facilities and personnel. There is the inevitable accusation of cheating, including unlawful use by foreigners; and appeals are made for better methods of monitoring and scrutiny in order to obviate this particular problem. Other suggested changes include the imposition of nonrefundable or only partially refundable user fees; rationing the use of high technology; and capping or reducing the fees paid to physicians for standard services. The fact is that some physicians are already
vi
Editorial
accepting the notion of stabilized fees and are reducing the use of high technology. Most other industrialized countries have some version of a health care system based on universal insurance. In the former Soviet Union and the socialist countries of Eastern Europe, as well as in Cuba and in other Marxist-oriented countries in Africa and Asia, there was an ideological commitment to equity in accessibility, with a major emphasis on prevention. Health care was viewed as social responsibility. Certainly in Cuba this has led to quite astounding accomplishments in health status in a relatively short time. It is now doubtful whether the gains elsewhere in the socialist countries were overall as great as they were reported to bc. In any case health care has suffered as much as other areas of endeavour as a consequence of the recent economic disaster befalling these countries, the result of bad planning and management over a period of decades. In most developing countries there is a clear lack 01 universal coverage, little equity. Normally health care services of two distinct qualities co-exist: one which provides accessibility and excellence for the rich and influential; another. publicly funded, which is rudimentary, restrictive. generally inefficient and which serves the less advantaged. These realities are not always the result of national preference. Loans from the International Monetary Fund and the World Bank to these countries, supposedly to help them improve their economies. and under the rubric of structural adjustment programmes, usually come with restrictions on expenditures for social programmes, including education and health care. There is evidence that latterly some of agency personnel are discerning the injustice and the brake on development inherent in these strictures; and it is hoped that the stricutres will be removed or modified. Good health is. after all. a major element in development. If development is people-oriented. they cannot fully participate or benefit if their health status is poor. Ill or diseased people certainly cannot be efficient producers. Within the existing systems. various efforts have been made to mitigate the cost of health cart delivery. a heavy burden on the central exchequer in most developing (as well as developed) countries. The so-called Bamako initiative. implemented in parts of West and North Africa. attempts to subsidize the cost of expanding health care delivery through the sale of drugs for a profit. 11 is as yet unclear as to whether this initiative, by itself. can really lead to self-sustenance and self-sufficiency. Similarly, user fees. promoted by some outside aid agencies are helping govcrnmcnts to try to sustain and expand primary health care services. These have been assessed in Kenya and Camcroon with a degree of scepticism over their success. Perhaps some ‘foreign’ ways are not readily traditional societies; other accepted in many
approaches to development may first have to demonstrate acceptance. The above has necessarily been but a brief description of some contemporary currents in health care with implications for accessibility, ethics and equity. The intent is to raise issues, pose questions, stimulate discussion and hopefully lead to attitude changes and appropriate action. Key questions need to be addressed: Is good health really a right or a privilege? If it is a right, how to ensure that it is exercised? What of the responsibility involved in ensuring that right? Whose is it? What cost implications are there, personal or societal? Is the provision of health care a personal or social responsibility? Or both? Is it a market commodity, to be bought if affordable, or accepted as a luxury if not easily affordable. with whatever consequences? What is the role of private enterprise and of the market economy in health care? In what circumstances’? And how does that role relate to considerations of ethics. accessibility and equity’? Is it ethically acceptable to have different levels and standards of health care for different segments of the society? If so why, and on what basis? What are the appropriate roles of private industry and the market economy. in their present reality, or as conceptualized. in the provision of health care. and as related to ethics, equity and accessibility? What kinds of partnerships are possible between them and the public and voluntary sectors? What is the new economic order which is being invoked, but about which there is little information of a functional nature‘? Or what should it be? Is it to be a new attempt at shaping relations among countries with a view to more balanced power relationships‘? Or is it to be more of the same present inequity’? Will the consequence be greater independence for individual countries, in particular the developing ones? Or greater interdependence? Or more dependence of the one on the other? Will there be greater freedom. the prerogative and the ability for the developing country to institute and sustain social programmes, including health, for development with equity‘? What is the role of the multinational drug in health endeavours’! How do they companies contribute to equity, accessibility? Where is the ethics in their activities? Should the generic drug companies be encouraged and supported? In what circumstances’? How? Is the use of high technology for the benefit of the few or for the many? Who decides who should have access, on what basis, under what circumstances? In general, should access preferably be for the few or for the many? Who decides? In conditions of material constraint, should limited funds be used for providing high technology for the few. or less sophisticated technology for the many? What is the ethics of the decision?
Editorial How important is research in health care? How to ensure that needed research is undertaken, and that the results are translated into planning, programme and policy? What is the role of the health professional in relation to the guarantee of ethics, accessibility and equity in health care? What can the ordinary citizen do to ensure attention to accessibility, ethics and equity in health care by those responsible for its organization? What is the role of aid agencies in promoting and ensuring equity in health care delivery? What of the recent suggestion by Carl Taylor (in the International Journal of Epidemiology) to ensure equity through surveillance of groups at greatest risk, with attention being paid to their health needs? Is this the best approach to equity in the present economic circumstances of the developing countries? Are there other models whi& will guarantee access, ensure equity, provide a minimum of quality care and still be generally affordable? Where are they? Do they need to be researched?
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In what circumstances, and to what extent, is it ethical for multinational companies, official and voluntary agencies and other interests external to nations and communities to enter and to determine what is the most appropriate action for promoting greater accessibility with equity? In the final analysis, is it not economic power, combined with an ideology that promotes social responsibility, that will determine accessibility with equity? Until the circumstances are right and the action appropriate to enable decisions at the level of, and by the less developed nations or groups within countries, is it merely applying band-aids to solve intractable problems? These issues have been raised in the form of questions which are not always objective. Nor are the questions new. It is hoped nevertheless that they will be provocative. Given the immediacy and sensitivity of some of them at present, in the context of rapid change in many parts of the world, al both national and local levels, they may help to stimulate discussion and debate and lead to informed rational for action.