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What is needed to claim adequacy in health services?
Pergamon
0277~9536(94)00217-7
Sm. Sci. Med. Vol. 39, No. 9, pp. 139>1403, 1994 Elsevier Science Ltd. Printed in Great Britain
SECTION R WHAT
IS NEEDED TO CLAIM ADEQUACY HEALTH SERVICES?
HANS S. FALCK School of Social Work and School of Medicine, Virginia Commonwealth 207 North Allen Avenue, Richmond, VA 23220, U.S.A.
IN
University,
Abstract-The answer to the question in the title of this essay is fairly readily available and can be articulated by listing those attributes that spell out adequacy in health services. A series of other concepts are presented to highlight methods of analysis in judging adequacy. These fall into two categories, those value statement that give meaning to the question to begin with as well as to its answers; and those of more mechanical significance. The first appear in the form of general principles, having to do with means, ends and the maintenance of human life; the worth of human life and common ownership of resources; and overriding contradictions with health-oriented life. The second-mechanics and techniques in judging the presence or lack of health services-are addressed by the concepts of conditionality and prioritization. Examples are provided from the current health planning efforts in the United States as viewed by a professional organization, by the Clinton administration’s proposal for adequate health care, and finally, those offered by the Republican party. Key words-social
values, conditionality, prioritization, adequacy, health services
professional practitioners scientific data bearing on health practice and health policy; and (9) links health and social services in seamless continuity with each other. (10) A final requirement applicable to all aspects of health planning and health care, are outcome studies at every level which addresses the other nine requirements listed above.
INTRODUCITON The answer to the question contained in the title of this essay is that health services are adequate when a society: (1) views the health of the population as both personal and common property; (2) emphasizes primary and preventive care for all with specialist services readily available through referral from primary physicians
w1; (3) avoids a means test as a condition for obtaining health services; (4) maintains achieved life styles of actual and potential patients and their families without financial loss for reasons of poor health; (5) treats lifelong disability and/or chronic disease or injury conditions with emphasis on the strengths of patients’ and their families or family substitutes; (6) involves others-ideally family members-in planning for the patient’s future as well as respecting their wishes; (7) assures that there be adequate financing of professional education and advanced medical education consistent with population/physician and other professional caretaker ratios; (8) manifests a national commitment to research or, absent this, make available to
In order to judge the appropriateness of these somewhat programmatic sounding requirements for adequacy, they must undergo analysis for which we have chosen the two concepts of conditionality and prioritization. Omitted from the current discussion are other important considerations such as quality of training, settings such as hospitals and outpatient facilities, local conditions, geography (especially as this concerns access to health facilities), social class variables, including education, and other than a brief declarative statements about the importance of cultural variables, such major influences on health planning and management as religion and metaphysical concerns in general. Keeping in mind the global concerns about the health of the human population, the often cited World Health Organization’s aim regarding health ‘for all’ by the year 2000 appears appropriate, though admittedly utopian when viewed from the vantage of present realities [ 11.
1395
HANS S. FALCK
I396 PRIMARY
SOURCES
ON
HEALTH
PLANNING
The general literature on social planning, health planning, and policy is vast, international and multidisciplinary. The primary analytic concepts conditionality, prioritization and adequacy are all drawn from current experience in the United States, from social science writings and from the debates concerned with the impending, major overhaul in health policy and health care. We refer to three health plans. These are the National Health Care Plan, developed and published by the National Association of Social Workers (hereafter referred to as NASW), and introduced as Senate Bill 684 in the United States Senate; House Resolution 3600 The Health Security Act qf 1993 which represents the United States administration proposals to the Congress (also referred to as the Clinton Plan), and House Resolutioii 3080 The AJordable Health Care Act of 1993. which is the product, primarily of the minority in the U.S. House of Representatives, commonly referred to as the Republican party’s alternative to the Chnton bill. All of these will be further examined below. The NASW plan may be said to reflect the thinking of the moderate political left, the Clinton administration plan can be thought of as the product of the middle, while the Republican plan reflects the views of the moderate right. Attributes of left, middle and right reflect the degree of federal government involvement in what each of the three plans proposes, as well as the comprehensiveness of potential entitlements to health services guaranteed by government. LNIVERSALISM
AND
PARTICULARISM
The thesis of this essay is that it is feasible to specify universal criteria which societies may take into account in the development of national health systems. This assumes the somewhat controversial presupposition that by and large voluntary, non-governmental effort cannot assure the meeting of needs and the benefits that would accrue to populations without government assumption of the guarantees already mentioned. It is not the aim to prescribe how these might apply in any given society; but it is suggested in these pages that it is a useful exercise to suggest some essential variables which nations and peoples need to take into account on the way to universal health services and care. Values consensus Good health policy on national, regional and international levels, rests upon the achievement of a reasonable consensus about what is desirable health policy and its counterpart, health services. Whatever is considered to be needed is a matter of enormous complexity about such matters as social values, religious belief and national priorities and political ideology. Any claim of adequacy must express the
values, aspirations, and relative involved; and in ways acceptable Relatioity
of‘sociall,v-determined
priorities of those to populations [2]. needs
The newest development in the general area of health care in the late twentieth century is that technology tends to outrun the ability of countries and societies to pay for health services heretofore impossible or inefficient without harming equally needed services as literacy, public education, in some cases feeding the population a minimum survival diet and the control of urban crime. The resulting rationing of health care for those who can benefit most, would result in socially induced death sentences for populations least likely to benefit from medical intervention. This central consideration in the realm of social ethics emanates from the fact that health care when conceptualized in terms of universalism is viewed as a basic human right. This implies the inevitably difficult decisions that arise in the rationing of health care. Oppl and von Kardoff formulated the view we espouse in these words: ‘Placing the health system back into the hands of the community could also be expected to be a positive element in budgeting for health care.. There are increasing numbers of voices that call for structural changes; and this across party lines as well as within the general social services establishment. It is still an open question whether more democratic health policy is within reach, considering the fact that the product needs to be far more transparent that it is. from the treatment of disease to the financing of health care. A lot will depend upon how health concern will be viewed by the citizenry, not only in the traditional sense as a search for health of each individual, but also as the joint effort towards better ways of living (‘Lebenskultur’). A change of medical paradigms is needed-a shift from a bio-technical and behavioristic medical model to one that includes all major aspects of health and health care (‘gemeinmedizinisches Modell’). But this involves just as importantly, the citizen: learning to view health as a communal good and demand, politically speaking, the right to health (‘das Recht auf Gesundheit’)” [3]. While
the authors
refer
to the German
health
system,
in mind that as of this writing the United States, though not alone, is wrestling with the implications for the radical revision of health care for one quarter of a billion (250 million) people. The complexities that this effort involve, as might be expected, what is happening the world over. Included are those where governmentsocieties (as in Germany) sponsored health care is a matter of history reaching well back into the 19th century. R&in and Walt point to some of the complexities implicit in the WHO/UNESCO Alma-Ata statement, in this case the control of knowledge and resources in improving the world’s health and suggest that the basic choices lie between “those who see health improvements as a result of programs based on medical and technological interventions” and “those who see health as a process dependent on individual knowledge and choice, of which medical intervention is only one and often not the most important, input” [4, p. 5651. one keeps
What is needed to claim adequacy in health services? The consumer
in health policy
Most discussions of health policy and health services suffer from their non-specificity in terms of actual consumers, patients or clients. Where the consumer is considered explicitly at all, the discourse is typically case-bound to the extent that it is difficult to draw generalizations of scientific validity and which would, in turn, guide policy and programs. Rodwell, who is a social work researcher, addresses this problem from a research standpoint where she calls attention to the phenomenological and methodological research issues involved in accounting for everyday experience in the language of the consumer [5]. Physicians however, focus much more on disease conditions than on the patient’s experience of himself or herself in the everyday relationships with others, especially members of families. We have addressed this latter point in other writings and suggested that rendering professional aid in management of membership (in family and elsewhere) under conditions of sickness, disability, and injury is a central task in the entire health field [6,7]. In sum, as consumer the patient is at the end of the continuum leading from health policy to treatment and health maintenance. As an influence on policy he/she stands at the beginning. The two extremes rarely touch. It is obvious to those who have observed emerging national health systems, and given the political and ideological conthcts attending these, that ultimately the availability of health services reduces to matters of social values [8].
PRINCIPLES
FOR
JUDGING
HEALTH
ADEQUACY
OF
SERVICES
Means, ends and the maintenance
of life
The first governing principle in the present discussion has already been stated; and it is that adequacy of health sewices presupposes a workable national consensus about means, ends, and the allocation of resources in all major categories of health activity. Despite the readily acknowledged variety of possible patterns and methods of health care delivery, there must be some fundamental type of allegiance to the maintenance of human health. It follows that one measurement of adequacy is best expressed by the comparison of consensually agreed upon goals with actual, documented performance. The worthiness of human I@ und common ownership of resources The second governing principle has to do with the belief that human life is of worth and that the society in its entirety is committed to the use of commonly, rather than indiridual/_y owned, resources to make the first principle operational in legislation and in actual services rendered to populations. Viewed from this perspective health care is a social service-with varieties of applied professions to make it technically
1397
feasible. In this connection it is worthwhile to remember that it is members of society, rather than some invisible, distant agency that make available to each other the benefits of such membership in the form of adequate health care. Overriding contradictions
with health -oriented life
Both principles fly in the face of 20th century reality. This is not because of a lack of effort to discover through basic and applied data how to view life in scientific, intellectually sophisticated terms. It is because along with the explosive growth of basic research and sophistication and their utilitarian counterparts in medicine and related professions, there has occurred a degree of human slaughter-two world wars and the Holocaust plus innumerable other wars, revolutions, and mass murder-that resist and vitiate every effort to improve human life through health care. The fact is that for health care to have any meaning at all, no matter what system of financing and care delivery be employed, peace and the most basic respect for human life are the governing preconditions that give health care a chance. The WHO/UNESCO statement is to be understood in this light. The two principles, consensus on the worthwhileness of health and shared allegiance to the worthiness of human life, lead to the insight that we are called upon to balance technical and scientific achievement in health maintenance and care with the actual state of life of multiple millions of people throughout the world. The effort leads to the realization that hunger, disease, and death from war and other brutalities including the pandemic of street crime visited upon innocent citizens in the cities of this world must be given high priority, and keeping in mind current conditions throughout much of the human universe, place in question the degree to which the world’s population is prepared to make and keep itself healthy. Adequate health care is (are) the means to a globally valid end which is the affirmation of human life. CLAIMS
TO
ADEQUACY
IN HEALTH
SERVICES
In the effort to address questions about the claim to adequacy in health services we propose that the analysis of the ten criteria listed at the outset be thought about by means of a simple tripartite set of analytic concepts. These are conditionality, prioritiration and udequacy. Their function is to clarify some of the ways of understanding the circumstances attending health services. It may also be assumed that on the whole they reflect of rational health policy decision-making. An applicable caveat is that by no means are all health measures rational, that is of neutrality based on scientific data and resulting in cohesive health programs. This is true in a wide variety of cultures, where health services are often the product of religious beliefs, professional
HANS S. FALCK
1398
protectionism and practices, and of the predominance of parochial interests. In the process of explaining the content of each of the concepts it will become apparent that their definition and use heavily influences the understanding of the U.S. health plans. It should, however, be kept in mind that these examples are nothing more than that, especially since the purposes of the essay do not include explaining the United States health ‘system’. Instead, the focus is intended to be on the concepts themselves and the purpose to show how each interacts with the others and how they may be used to understand U~J health system. Conditionalit.
Perceived needs for health services, technological innovation and pressures on personnel and financial resources work together to produce services and limitations in a population’s access to health care. Conditionality in health care legislation and planning also expresses the fact that there are policies at work which when judged valid assure (I measure of human health, imprwe current health, and prevent disease and injury. Clarity about conditionality in health policy defines the pool of intellectual and financial resources available. Conditionulit~~ us u principled apprwch to heulth
cure
alone
is
occomprtnied
plunning
not
.syficient
tukrs to
h? considerations
into
crcc’oun
render
curt
of’societui
t that
demund
unless norms.
it
is
rules.
and nzwiluhle resources. Conditionality also points to the fact that members of societies. even when health policy and services are under the control of central government. will at best enjoy a measure of health services, rather than total services for all imaginable health needs. As in the dispensation of all other communally owned property. health care comes with reference to the contextual aspects of all organized society. Generally speaking, the more specialized. sophisticated and expensive health care is, the more selective the conditions under which it is available. We mention as a titting example the Clinton plan for United States health care -7%r Heulth Securit!, Act of’ 1993--House Resolution 36OOK which after it details out what is to bc expected by way of health services. severely underrates mental health services (which are to be increased incrementally after adoptlon of the basic plan). This is consistent with the fact that in most societies. including those in the industrial West. mental illness is still subject to moral approbation. Taylor and Brown point to difficulties in specifying what it is mental health practitioners diagnose and actually treat, together with the problems of the objectification of subjective experiences so common in the mental health field [9]. Two brief excerpts from recent work under the interesting title “Illusion and Well-Being: A Social Psychological Perspective of Mental Health” will demonstrate the startling differences in language and thought between physical medicine and mental health medicine. except for those psychiatrists who
policies
decided years ago that general medicine and mental health medicine need to be brought to a common denominator essentially biological in its logic, its research, and in its procedural interventions with patients. Taylor and Brown illustrate the problems currently existing and account, thereby, for at least some of the resistance to treating mental illness in the mode of traditional medicine: To summarize,
then, although it is not the only theoretical perspective on the mentally healthy person. the view that psychological health depends on accurate perceptions of reality has been widely promulgated and widely shared in the literature on mental health (p. 194).
And: ,. the overriding
implication that we draw from our analysis of this literature is that certain biases in perception that have previously been thought of as amusing peccadillos at best and serious flaws in information processing at worst may actually be highly adaptive under many circumstances. The individual who responds to negative. ambiguous, or unsupportive feedback with a positive sense of self. a belief in personal efficacy, and an optimistic sense of the future will. we maintain. be happier, more caring, and more productive than the individual who perceives information accurately and integrates it into his or her view of the self. the world. and the future” (p. 205). These excerpts are cited to demonstrate a logic in the mental health field which goes awry of much that elsewhere would depend on scientific objectivity, that is to render meaning to conditionality and prioritization in health care based on the application of scientific data. While many would object that Taylor and Brown’s views are unrcpresentativc of the majority of how mental health people think. we would hold that the authors cited shed light on an issue rarely taken seriously in health planning and financing, namely subjective experience of the part ol patients and providers of services, in this cast psychiatric and other mental health intcrvcntions. Without offering moral judgcmcnt on such reasoning as cited above. it must be obvious that it hardly corresponds with expected kinds of conceptualizations in a scientific age of primarily physical medicine. In the case of mental illness prejudice and myth combine with scientific research and continue to undergird the biases which restrict the ready availability of mental health services. Adequate financing of long-term treatment in particular is less available than it is for the fulfilment of other health needs. The subjective aspects of diagnosis and treatment of mental illness make it more rather than less difficult to convince policy makers and others that conditionality applied to psychiatric coverage needs a more flexible profile than when the attention focuses on more empirically objective diagnosis, treatment. and, therefore, policy making. The conditionality principle in the esumple given-mentul i.e.
rulidit~~
health+uses und
reliuhilit~~
on the .scientific, of mentul
heulth
.stuttJ.
intrrren
-
In Western countries there is a distinct tendency to give preference to human services that can demonstrate a scientific base for their activities. In the tion.
What
is needed to claim adequacy
present discussion this qualifies an example of the conditionality principle in action. Non-empirical medicine is by no means confined to the difficulties experienced by Western style psychiatry and related efforts. There is a vast literature available-beyond the limits of this essay-which points to the ever growing and rather promising efforts to combine traditional healing with modern medicine. The discourse is most meaningful to those investigators who view the future of deciding what health services are needed in the order of their perceived importance, neither in Western nor in non-Western terms [20,21]. They typically focus on the interactions between East and West [IO]. Weiner hints at the problems that occur when one searches for universal explandtory, yet cultures-respecting approaches such as in science and in theory building. As Weiner put it, “[Mledicine may be the only discipline that lacks a comprehensive Theory” (p. xi). In pondering Weiner’s remark one becomes aware that neither cultural variables alone, nor science alone will do. A combination of need, culture and science turn out to be the most meaningful consideration in the definition of conditionality in health.
The prioritization of health care addresses the rank order, roughly speaking, of distribution of health resources. Cost and demand outrunning supply are the main motivating factors in prioritization. This is reenforced in countries where, primarily through high levels of technification and thereby rising expectations f%r an ever longer and healthier life are involved; and in those societies in which health services are minimal. Here health maintenance takes on the characteristics of the high priority assigned the fulfilment and protection of basic human rights. To understand some of the major features of prioritization it is useful to divide the concept into two categories, internal and external. Internal prioritization refers to those situations in which two or more health services compete for resources. C)ne instance is the competition for money to study and treat AIDS compared to breast cancer, the latter far outdistancing occurrence of the former. Another well-known example from industrial societies, in particular, occurs where specialty care competes with primary care in the training of physicians, in the development of technology, and in building hospitals beyond what is needed to cover the general population with basic health care. Conflicts in internal prioritization may have consequences of considerable importance, whether resource are focused on specialty care which, while important, may do little to lift the general standard of medical and health care for the broadest groups in the population. External prioritization occurs when efforts in relation to health are judged as to their relative importance compared to non-health focused concerns. Examples are health services versus building of roads,
in health services?
1399
investment in cultural programs such as the arts, or most commonly against public education and police protection. These are also processes which tend to involve much political conflict and tend to obscure internal prioritization issues of often much greater weight and consequences than would obtain in the generalized comparison of too broadly defined health services with equally broad categories of non-health concerns. Prioritization
and demographics
In many countries of the world health planning and the availability of health services are increasingly influenced by population statistics; these form the well-known demographic concerns such as ‘the greying’ of society and with the favoring (or disfavoring) of some population groups over others [12]. While conditionality addresses the question to be answered by what rules is health care available keeping in mind resources and competing demands, in the case of prioritization the question is that given whatever resources are available, who shall receive health care, in what order! at what cost, and according to which social interests and oalues. Thus, the increase in much of the world of life span expectations and the fact that the aged, as a group, have numerically expanded faster than any other group heavily influences both demand and services. To mention briefly the complications involved in the prioritization of services, a new study conducted by Guralnik et al. finds that “[Almong older blacks and whites, the level of education, a measure of socioeconomic status, has a greater effect than race on total life expectancy and active life expectancy” [13, p. 1 IO]. Healthy living does not, in and of itself, lead to longer life. When combined with the powerful plea that child health care be given much higher priority than has been the case, and currently is the case, it is not difficult to see that other groups-especially the middle aged-will enjoy lower priority than those mentioned in having their health needs attended to as fully as others. A population category known as ‘the aged’ or ‘the aging’ and one referred to as ‘children’ are associated in the public mind of many societies with helplessness, weakness, lack of independence and other themes which stimulate the societal desire to help; while middle-aged categories of person are, by and large, considered more likely than those named to be able to take care of themselves with minimum assistance from public resources. In other words, the prioritization factor tells us that demographically speaking, at least United States society does not as yet accept universalism as the only or even central guiding motive for national health care. The same social mechanism operates in other cases as, to cite another example, where there is a demonstrable link between manpower requirements for industry and a population healthy enough to meet these. Not very remote from such considerations is the link between the quality of achieved knowledge and skills in the intellectual
I400
HANSS. FAL~K
arena and the needs of society to apply these to technical and scientific work, typically taught in the university. Thus conditionality and prioritization work together. Social values and preferred investments in rendering health care define conditionality. and the nature of populations combined with limited rcsourccs guide what governments and other decision influencing groups mean by what we call prioritization. One result of the research revolution in health care suggests the possibility of ever longer life under medically controlled conditions and as a direct consequcncc of what is technically possible cr& ~~*itlzout MYYV~~~J~ c?sihlc /ir,~its. The unspoken hope seems to be that the more research. the mot-c health. the only caveat being the ability to pay for it. Guiding this arc the technical and research achievements of the twentieth century and the open-endcdness of what once a solid kind of prediction that the reality of death could be more or less clearly expected. temporally speaking. To live has become a matter of right simply bccausc the rcalitics have changed to a point where most expectations about limitations of the life span are accompanied by cvcr growing skepticism by citizens the world over. especially in industrialized societies. Cassell [I41 addresses the conscqucnces and the nccdcd self-restraint by physicians when technology takes on a lift of its own and results in indiscriminate use of the hopeful and yet deceptive preoccupation \vith ‘the lure of the immediate’. The contradiction at MTot-k.glvcn what has been said about conditionality and prioritization. is that when health cat-c is viewed as an absolute and unconditional human right. the argument shifts to the I‘ulfilmcnt or non-fulfilment of these rights and the concern shifts 10 strategies about their recognition and I‘iilfilnicnt. with correspondingly less concern \+ith priorities. This is what happens in the case 01 AIDS where the appeal to human rights overpowers other concerns about the relative numbers, prognoses and chances for curt when compared to other discatch. Both conditionality and prioritiLatlon tend to become nearly ignored. to say nothing of careful and thoughtful planning such as would be required. cspec~ally around prioritization. In the latter caxc it is easily conceivable that some people would reccivc cart while some others would not. that some conditions would draw more by \vay of research funds than others and that there be those who are authorired to dccidc, and others who would bc bound by their decisions. While there arc a few exceptions. such as elective plastic surgery not otherwise related to injury. sickness or disability. the overall trend tilts toward Inclusiveness rather than the opposite bccausc health is increasingly valued as an untouchable human right together with a societal interest in the health of populations. As long as this reasoning prevails. other obligations of government ofwhich we spoke earlier. could easily become ignored and that with its own disastrous consequences. One answer to the dilemma cited here is to judge the entire health
services establishment, including both the services sector and the underlying basic science community. as being regulated. always in relation to other societal needs. The theme is relativism of ‘health’ in comparison to ‘education’. ‘defense’, ‘social services’, thus keeping in mind that whatever anyone may obtain by way of health scrviccs would not necessarily be available to everyone. Ultimately. the entire health sector would be assigned a priority rating in relation to those others named above. It is a cultural and political decision of enormous complexity. One would hold out little optimism that it ought to be done. The evident reason is that an amount of power over life and death would fall upon decision-makers in excess of what in democratic society citizens would tolerate. Setting priorities has. therefore, limited utility unless done incrementally and accompanied by full public debate. Social activists. being uncomlhrtably aware ol the need for prioritization. tend to ovcrcmphasize the need to intervene in the Icgislativc process and overlook the eftcctivencss of administrative decision making by civil servants. An interesting aspect ot administrative decision making m prioritizing health cart’ in non-go\-crninental institutions in the United States appears in hospitals who i15,xcsstheir pcrformance. usually through pressure from accrediting bodits. govcrnn~cntal and non-govcrniiiciit~il. Shcr-cr [IS] writes of a11cxamplc of such in ;I Ircccnt article In the trade journal ffo.vpi/rr/s. The rcpol-ted motivation \+;I:, to remain financially viable. hut most of all. to bc sure that the priorities of the hospital under discussion wcrc such that the ‘customer rcccivcd what hc or she needed rather than what the hospital thought they ought to have (p. 10).
Adequacy is detincd as those always tcmporar> solutions to dilemmas and conflicts that result in services provided (or not provided) as ;I result ol trying to rcconcilc with each other conditionality and prioritization. Adequacy. however, is not an unitary idea. A society may do well in sonic provision 01 services while doing poorly in others. Inoculation against certain diseases may cxtcnd to school aped children, while family planning asx1stancc ma) fail. Certain expensive surgical intervention may bc providcd while mammograms may bc need4 but be typically unobtainable by large numbers of Liomcn. To elaborate and clarify the concept ol‘trrlc~~~rt~~~ as product of the interaction of c,o/~~litiontr/i/~,and ,N/Nifi:ufj~j/l wc present tirst. an example of‘ a proposal introduced into the Congress of the United States (Senate Bill 684) for umvcrsal health cart covcragc under federal law. and considered an exan~plc of adequacy in health care by those who favor it. Thea will be followed by the so-called Clinton plan. Finally. the proposals for health insurance by Republican members of the Congress will bc introduced.
What is needed to claim adequacy in health services? pointing to significantly different views on health care reform when compared to the other two proposals. Absolute rights, limited rights and the defiance of nature A powerful statement by Mahler captures the essence of absolute rights, which translate into the right to human beings to exist; into limited rights, which translates into choices and the possibility that one can exist even in some compromised state; and finally it implies that health services not only help to create and prolong life, but to some degree postpone death. We first quote Mahler: It is offensive that in one country people should die young while in another they may expect to see their grandchildren grow up; that in one part of a city nutritional deficiency diseases are common, while in another, people worry about eating too much; that, despite the great advances in technology and the human sciences, there are over 500 million people in the world with incomes equivalent to $50 a year 1161. In January Workers
1991 the National published
an
Association
Executive
Summary
of Social of
the
National Health Care Proposal which, in slightly modified form, was introduced in the Senate of the United States as the bill (Senate Bill 684) already mentioned [ 171. The National Health Care Proposal is the result of a mixture of the practice experience of health social work personnel throughout the United States and of the long-standing support NASW has given national health care for the last 50 years (and under its predecessor organization the American Association of Social Workers). We quote the essence of the proposed legislation with its following principle features: Coverage and enrolment
All persons
residing in the United States are covered through the national health plan. Each person has the freedom to choose from among any of the participating public and private providers, facilities or care delivery options, including Health Service Plans (IHSPs). IHSPs are non-profit, consumer-controlled plans which provide comprehensive health care services in their own facilities to an enrolled population. Individuals will enroll in the national health plan in the state in which they reside. Coverage through employers or other privately purchased health insurance is discontinued, although private insurance plans may provide coverage for services not covered under the national health plan (p. I).
The document ties a section on benefits to the announcement that NASW favors a cradle to the grave approach with few exceptions. In order to suggest the tone of a long and detailed document we have extracted some of the major features the plan contains, without claiming anything near completeness: Benefits --Care coordination services, to be used primarily for clients who require multiple services over a period of time or where such services are potentially costly.
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-Primary prevention and health promotion services including comprehensive well-child care for everyone O-21; perinatal and infant health care; routine, age-appropriate, clinical health maintenance examinations for everyone over 21; family planning services; and school-based primary prevention programs. -Outpatient primary care services. -Mental health services. -Substance abuse treatment and rehabilitation programs. -Inpatient and outpatient hospital services, including emergency and trauma services. -Inpatient and outpatient professional services. -Laboratory and radiology services. -Long-term care, including home and community-based services. -Hospice care. -Prescription drugs, medical supplies. and durable medical equipment (pp. 1-2).
Marshall addresses primary prevention in an article in Science [22]. It is a topic gathering unto itself ever greater attention as the shortcomings of the traditional emphasis on diagnosis and treatment as nearly exclusive modes of intervention become ever clearer. NASW gives primary prevention high priority and thereby suggests what we referred to earlier as internal prioritization, i.e. the frequent need to choose among health services themselves. Until recently it was rare that the purveyors of ideals (and occasionally ideas) about universal health services, government financed and administered, would be concerned with financing. The impression prevails that matters of money, priorities, and competition with other needed government functions were of lesser importance when compared with the belief that the right to health care should be both fundamental and absolute. The underlying question was and is what a member of society may reasonably expect to be a fulfilled and complete life. On one side of these considerations are those who would view the right to living absolute and would brook no interference whatever in non-spontaneous death. There are voices on another side who argue for both financial considerations and an ethically grounded respect for a meaningful life. These take the position that monies spent on hopelessly ill people about to die or with poor quality of life if they survived, deprives those with a greater chance for meaningful survival. In addition, there are the burdens for families beset with debts, typically paid long after the death of the person whose life was to be saved through their expenditure. The position calls for a clear definition of meaningfulness, a potentially operational concept but also one extremely difficult to define in polyglot societies. The predominant message, at least in the United States late in the 20th century, still favors the view that would, in the end, save life at nearly all cost. To return to the main argument, when adequacy does not exist or is only approximated one would judge worries about conditionality barely relevant and prioritization hardly appropriate and needed. Where the opposite occurs, that is where health service availability is plentiful, conditionality is marginally significant and prioritization of health care in
HANS S. FALCK
1402
the national agenda selectively high. The interaction between conditionality, prioritization and adequacy exists in its clearest and unambiguous forms where some services are available, where there is competition between them and other needs to be addressed (prioritization), and where what is actually delivered by way of health services is the result of compromise. This latter situation, with some glaring exceptions, prevails in much of the world. IDEOLOGICAL
AND UTILITARIAN
CONSIDERATIONS
The ideological issues underlying health care planning by government on any level have to do with general attitudes in the populace toward central planning and governmental control, ideas of freedom and personal liberty, relationships between customers or clients and professionals. choice of providers-in the current case physicians, and the assurance that health services would be available as needed as in any other business or professional transaction. Health care is one example of such concerns among many, including public and/or private education, social welfare services which are by no means available without heavy dosages of conditions about eligibility and access. A fine example of the complexities involved is available in an act introduced into the United States Congress in opposition to that of the Clinton administration (Senate Bill 684) and given the title “The Affordable Health Care Act of 1993” (House Resolution 3080) [ 18, 191. As such it represents the views of the Republican minority in the United States Congress, but more relevant to this discussion, its greatest significance is that it illustrates as well as any proposal the concept of conditionality. While the Clinton proposals accept the role of private insurance companies as part of a new government-sponsored health care program-most likely for tactical reasons-the Republican version reflects the fundamental commitment of the party to free enterprise, marginality of favoring the private, government ‘interference’. profit-making insurance sector as a major player in health insurance planning, financing and ultimately in health care delivery. While the Clinton plan relies on government as both first and last resort, the Republican Party’s proposals rest on private business as the bedrock and government as the agency of last resort. Conditionality is expressed in the latter case by tying health coverage to a profit-making role which the party supports within the context of a free enterprise system and, as is traditional, with severe limits on the federal government with its appetite for taxes. At the same time it needs to be understood that both major parties in the United States Congress will compromise for utilitarian reasons once all the traditional arguments have had their day. Often this occurs in subtle changes in language as, for example. in the case of Title One of the Republican version which reads “Improved Access to Affordable Health Care” together with sub-title “A” which reads “In-
creased Availability and Continuity of Health Coverage for Employees and their Families” and sub-title “B”, “Reform of the Health Insurance Marketplace for Small Business” (p. I) The perceptive reader recognizes the implicit statements which suggest that health care is available now and needs ‘increase’; that improvement in the mechanisms of access is to be supported by future legislation, while preserving the essentially private, capitalistically motivated, business-tied, free enterprise traditions. This illustrates once more the low level of prioritizing health care in the United States, resulting in an estimated 38.5 million persons without or with inadequate health insurance out of a population of 250 million, while at the same time. especially for those who can afford it, there is little by way of conditionality at work. This same pictureperhaps even more extreme-may readily be found in many other societies, especially those with a small number of the very wealthy, together with much larger populations living in conditions of destitution. The temptation is to be resisted in the current context to explain the politico-philosophical background to health planning in the United States since it is not the primary topic under discussion. Yet, we have said enough to indicate how such themes influence conditionality, prioritization and ultimately concepts of adequacy. This is particularly the case in the third example given above, that proposed by the Republicans in the United States Congress, who are committed to the minimization of the role of government and whenever feasible and politically supported by the population, would rather stay with the private sector in meeting health (and social services) needs: but when inevitable, take the position that government should come into play at the lowest, most locally controllable level (the States) where the population through the political process would enjoy the opportunity to seek limited government intervention in health as well other sectors. Conditionality in this case works to control and limit central control, while prioritization addresses what the taxpayer can afford or is willing to pay. (‘ONCLCSIONS It is indeed possible, as we have shown, to spell out briefly and quite specifically what conditions need to obtain to call a health system adequate; but more is needed to understand what is involved both conceptually and practically. What is required is that necessary philosophical commitments be examined which we followed-up by a tripartite methodology for a closer analysis of some of the issues. These were named conditionality. prioritization, and adequacy itself. Selected examples from the views of a United States professional organization, the United States government. and a minority political party were cited to illuminate the concepts.
What
is needed to claim adequacy
REFERENCES
1 Basch P. E. Textbook of International Health, Appendix I, Declaration of Alma-Ata, 1990. Oxford University Press, New York, 1990. P. and Corsi P., (Eds.) 2 See Pellegrino E., Mazzarella Transcultural Dimensions in Medical Ethics, University Publishing Group, Frederick, MD, 1992. This is a series of essays by some of the most prominent contributors to the ongoing debates about health ethics. 3 Oppl H. and van Kardoff E. The national health care svstem in the welfare state. Sot. Sci. Med. 31, 49. 4 I&in S. B. and Walt G. Why health improves: defining the issues concerning ‘comprehensive primary health care’ and ‘selective primary health care’. Sot. Sci. Med. 23, 559, 1986. construct: posi5. Rodwell M. K. Person/environment tivist versus naturalist, dilemma or opportunity for health social work research and practice. Sot. Sci. Med. 31, 27, 1990. 6. Carhon T. 0. Clinical Social Work in Health Settings Springer Publishing Company, New York, 1984. I. Falck H. S. What is central to social work? Hlfh and Sot. Work, 7, 235, 1982. 8. The White House Domestic Policy Council. The President’s Health Security Plan-The Clinlon Blueprint, DD. 11-13. Times Books. New York. 1993. This is an authoritative summary and explanation of the President Clinton’s plan, submitted to the Congress of the United States for legislative consideration. 9. Taylor S. E. and Brown J. D. Illusion and well-being: a social psychological perspective on mental health. Psych. Bull. 103, 193, 1988. E. Prologue: intersections of Western 10. Pellegrino biomedical ethics and world culture, In Transcuhural Dimensions in Medical Ethics (Edited by Pellegrino E., Mazzarella P. and Corsi P.). Universitv Publishing Group, Frederick, MD, 1992: 11. Weiner H. Psychobiology and Human Disease, p. xi. Elsevier. New York, 1977.
in health
services?
1403
of contextual 12. For a brief and concise discussion dimensions of availability of food and water supplies, fertility rates, literacy and other health-connected issues, see Brown L. R., Kane H. and Ayres E., Vital Signs 1993. W. W. Norton, New York, 1993. J. M., Land K. C., Blazer D., Fillenbaum 13. Guralnik G. G. and Branch L. G., Educational status and active life expectancy among older blacks and whites. N. Eng. J. Med. 329, I 10, 1993. rampart 14. Cassell E. J. The sorcerer’s broom-medicine’s technology. Haslings Center Report 23, 32. 15. Sherer J. L. Strategic planning: health assessment. Hospitals and Health Networks, American Hospital Association, July 20, pp. 3640, 1993. Hospitals is a trade journal published by the American Hospital Association and which often provides insight into the practical issues business-oriented health administrators think about. 16. Mahler H. The philosophy underlying the Alma-Ata conference of 1978. Appendix 3 in B&h P. E. Texfbook of International Health. DD. 232-233. Oxford Universitv Press, New York, 1990: _ Association of Social Workers. NASW 17. National National Health Care Proposal. NASW, Silver Springs, Maryland, 1991. The Affordable Health Care Act of 1993. 18. Summary: Mimeo. Supplied by Rep. Thomas Bliley, Jr. of Virginia. 19. 103rd Congress, H.R. 3080, The Afordable Health Care Act of 1993. A. Patients and Healers in the Context of 20. Kleinman Culture-An Exploration of the Borderland between Anthropology Medicine, and Psychiatry. University of California Press, Berkeley, 1980. 21. Kleinman A. The Illness Narratives-Suffering, Healing and the Human Condition. Basic Books, Inc. Publishers. New York, 1988. 22. Marshall E. Prevention research: a new growth area for NIH? Science, 262, 1508, 3 December 1993.
0277~9536(94)00217-7
Sm. Sci. Med. Vol. 39, No. 9, pp. 139>1403, 1994 Elsevier Science Ltd. Printed in Great Britain
SECTION R WHAT
IS NEEDED TO CLAIM ADEQUACY HEALTH SERVICES?
HANS S. FALCK School of Social Work and School of Medicine, Virginia Commonwealth 207 North Allen Avenue, Richmond, VA 23220, U.S.A.
IN
University,
Abstract-The answer to the question in the title of this essay is fairly readily available and can be articulated by listing those attributes that spell out adequacy in health services. A series of other concepts are presented to highlight methods of analysis in judging adequacy. These fall into two categories, those value statement that give meaning to the question to begin with as well as to its answers; and those of more mechanical significance. The first appear in the form of general principles, having to do with means, ends and the maintenance of human life; the worth of human life and common ownership of resources; and overriding contradictions with health-oriented life. The second-mechanics and techniques in judging the presence or lack of health services-are addressed by the concepts of conditionality and prioritization. Examples are provided from the current health planning efforts in the United States as viewed by a professional organization, by the Clinton administration’s proposal for adequate health care, and finally, those offered by the Republican party. Key words-social
values, conditionality, prioritization, adequacy, health services
professional practitioners scientific data bearing on health practice and health policy; and (9) links health and social services in seamless continuity with each other. (10) A final requirement applicable to all aspects of health planning and health care, are outcome studies at every level which addresses the other nine requirements listed above.
INTRODUCITON The answer to the question contained in the title of this essay is that health services are adequate when a society: (1) views the health of the population as both personal and common property; (2) emphasizes primary and preventive care for all with specialist services readily available through referral from primary physicians
w1; (3) avoids a means test as a condition for obtaining health services; (4) maintains achieved life styles of actual and potential patients and their families without financial loss for reasons of poor health; (5) treats lifelong disability and/or chronic disease or injury conditions with emphasis on the strengths of patients’ and their families or family substitutes; (6) involves others-ideally family members-in planning for the patient’s future as well as respecting their wishes; (7) assures that there be adequate financing of professional education and advanced medical education consistent with population/physician and other professional caretaker ratios; (8) manifests a national commitment to research or, absent this, make available to
In order to judge the appropriateness of these somewhat programmatic sounding requirements for adequacy, they must undergo analysis for which we have chosen the two concepts of conditionality and prioritization. Omitted from the current discussion are other important considerations such as quality of training, settings such as hospitals and outpatient facilities, local conditions, geography (especially as this concerns access to health facilities), social class variables, including education, and other than a brief declarative statements about the importance of cultural variables, such major influences on health planning and management as religion and metaphysical concerns in general. Keeping in mind the global concerns about the health of the human population, the often cited World Health Organization’s aim regarding health ‘for all’ by the year 2000 appears appropriate, though admittedly utopian when viewed from the vantage of present realities [ 11.
1395
HANS S. FALCK
I396 PRIMARY
SOURCES
ON
HEALTH
PLANNING
The general literature on social planning, health planning, and policy is vast, international and multidisciplinary. The primary analytic concepts conditionality, prioritization and adequacy are all drawn from current experience in the United States, from social science writings and from the debates concerned with the impending, major overhaul in health policy and health care. We refer to three health plans. These are the National Health Care Plan, developed and published by the National Association of Social Workers (hereafter referred to as NASW), and introduced as Senate Bill 684 in the United States Senate; House Resolution 3600 The Health Security Act qf 1993 which represents the United States administration proposals to the Congress (also referred to as the Clinton Plan), and House Resolutioii 3080 The AJordable Health Care Act of 1993. which is the product, primarily of the minority in the U.S. House of Representatives, commonly referred to as the Republican party’s alternative to the Chnton bill. All of these will be further examined below. The NASW plan may be said to reflect the thinking of the moderate political left, the Clinton administration plan can be thought of as the product of the middle, while the Republican plan reflects the views of the moderate right. Attributes of left, middle and right reflect the degree of federal government involvement in what each of the three plans proposes, as well as the comprehensiveness of potential entitlements to health services guaranteed by government. LNIVERSALISM
AND
PARTICULARISM
The thesis of this essay is that it is feasible to specify universal criteria which societies may take into account in the development of national health systems. This assumes the somewhat controversial presupposition that by and large voluntary, non-governmental effort cannot assure the meeting of needs and the benefits that would accrue to populations without government assumption of the guarantees already mentioned. It is not the aim to prescribe how these might apply in any given society; but it is suggested in these pages that it is a useful exercise to suggest some essential variables which nations and peoples need to take into account on the way to universal health services and care. Values consensus Good health policy on national, regional and international levels, rests upon the achievement of a reasonable consensus about what is desirable health policy and its counterpart, health services. Whatever is considered to be needed is a matter of enormous complexity about such matters as social values, religious belief and national priorities and political ideology. Any claim of adequacy must express the
values, aspirations, and relative involved; and in ways acceptable Relatioity
of‘sociall,v-determined
priorities of those to populations [2]. needs
The newest development in the general area of health care in the late twentieth century is that technology tends to outrun the ability of countries and societies to pay for health services heretofore impossible or inefficient without harming equally needed services as literacy, public education, in some cases feeding the population a minimum survival diet and the control of urban crime. The resulting rationing of health care for those who can benefit most, would result in socially induced death sentences for populations least likely to benefit from medical intervention. This central consideration in the realm of social ethics emanates from the fact that health care when conceptualized in terms of universalism is viewed as a basic human right. This implies the inevitably difficult decisions that arise in the rationing of health care. Oppl and von Kardoff formulated the view we espouse in these words: ‘Placing the health system back into the hands of the community could also be expected to be a positive element in budgeting for health care.. There are increasing numbers of voices that call for structural changes; and this across party lines as well as within the general social services establishment. It is still an open question whether more democratic health policy is within reach, considering the fact that the product needs to be far more transparent that it is. from the treatment of disease to the financing of health care. A lot will depend upon how health concern will be viewed by the citizenry, not only in the traditional sense as a search for health of each individual, but also as the joint effort towards better ways of living (‘Lebenskultur’). A change of medical paradigms is needed-a shift from a bio-technical and behavioristic medical model to one that includes all major aspects of health and health care (‘gemeinmedizinisches Modell’). But this involves just as importantly, the citizen: learning to view health as a communal good and demand, politically speaking, the right to health (‘das Recht auf Gesundheit’)” [3]. While
the authors
refer
to the German
health
system,
in mind that as of this writing the United States, though not alone, is wrestling with the implications for the radical revision of health care for one quarter of a billion (250 million) people. The complexities that this effort involve, as might be expected, what is happening the world over. Included are those where governmentsocieties (as in Germany) sponsored health care is a matter of history reaching well back into the 19th century. R&in and Walt point to some of the complexities implicit in the WHO/UNESCO Alma-Ata statement, in this case the control of knowledge and resources in improving the world’s health and suggest that the basic choices lie between “those who see health improvements as a result of programs based on medical and technological interventions” and “those who see health as a process dependent on individual knowledge and choice, of which medical intervention is only one and often not the most important, input” [4, p. 5651. one keeps
What is needed to claim adequacy in health services? The consumer
in health policy
Most discussions of health policy and health services suffer from their non-specificity in terms of actual consumers, patients or clients. Where the consumer is considered explicitly at all, the discourse is typically case-bound to the extent that it is difficult to draw generalizations of scientific validity and which would, in turn, guide policy and programs. Rodwell, who is a social work researcher, addresses this problem from a research standpoint where she calls attention to the phenomenological and methodological research issues involved in accounting for everyday experience in the language of the consumer [5]. Physicians however, focus much more on disease conditions than on the patient’s experience of himself or herself in the everyday relationships with others, especially members of families. We have addressed this latter point in other writings and suggested that rendering professional aid in management of membership (in family and elsewhere) under conditions of sickness, disability, and injury is a central task in the entire health field [6,7]. In sum, as consumer the patient is at the end of the continuum leading from health policy to treatment and health maintenance. As an influence on policy he/she stands at the beginning. The two extremes rarely touch. It is obvious to those who have observed emerging national health systems, and given the political and ideological conthcts attending these, that ultimately the availability of health services reduces to matters of social values [8].
PRINCIPLES
FOR
JUDGING
HEALTH
ADEQUACY
OF
SERVICES
Means, ends and the maintenance
of life
The first governing principle in the present discussion has already been stated; and it is that adequacy of health sewices presupposes a workable national consensus about means, ends, and the allocation of resources in all major categories of health activity. Despite the readily acknowledged variety of possible patterns and methods of health care delivery, there must be some fundamental type of allegiance to the maintenance of human health. It follows that one measurement of adequacy is best expressed by the comparison of consensually agreed upon goals with actual, documented performance. The worthiness of human I@ und common ownership of resources The second governing principle has to do with the belief that human life is of worth and that the society in its entirety is committed to the use of commonly, rather than indiridual/_y owned, resources to make the first principle operational in legislation and in actual services rendered to populations. Viewed from this perspective health care is a social service-with varieties of applied professions to make it technically
1397
feasible. In this connection it is worthwhile to remember that it is members of society, rather than some invisible, distant agency that make available to each other the benefits of such membership in the form of adequate health care. Overriding contradictions
with health -oriented life
Both principles fly in the face of 20th century reality. This is not because of a lack of effort to discover through basic and applied data how to view life in scientific, intellectually sophisticated terms. It is because along with the explosive growth of basic research and sophistication and their utilitarian counterparts in medicine and related professions, there has occurred a degree of human slaughter-two world wars and the Holocaust plus innumerable other wars, revolutions, and mass murder-that resist and vitiate every effort to improve human life through health care. The fact is that for health care to have any meaning at all, no matter what system of financing and care delivery be employed, peace and the most basic respect for human life are the governing preconditions that give health care a chance. The WHO/UNESCO statement is to be understood in this light. The two principles, consensus on the worthwhileness of health and shared allegiance to the worthiness of human life, lead to the insight that we are called upon to balance technical and scientific achievement in health maintenance and care with the actual state of life of multiple millions of people throughout the world. The effort leads to the realization that hunger, disease, and death from war and other brutalities including the pandemic of street crime visited upon innocent citizens in the cities of this world must be given high priority, and keeping in mind current conditions throughout much of the human universe, place in question the degree to which the world’s population is prepared to make and keep itself healthy. Adequate health care is (are) the means to a globally valid end which is the affirmation of human life. CLAIMS
TO
ADEQUACY
IN HEALTH
SERVICES
In the effort to address questions about the claim to adequacy in health services we propose that the analysis of the ten criteria listed at the outset be thought about by means of a simple tripartite set of analytic concepts. These are conditionality, prioritiration and udequacy. Their function is to clarify some of the ways of understanding the circumstances attending health services. It may also be assumed that on the whole they reflect of rational health policy decision-making. An applicable caveat is that by no means are all health measures rational, that is of neutrality based on scientific data and resulting in cohesive health programs. This is true in a wide variety of cultures, where health services are often the product of religious beliefs, professional
HANS S. FALCK
1398
protectionism and practices, and of the predominance of parochial interests. In the process of explaining the content of each of the concepts it will become apparent that their definition and use heavily influences the understanding of the U.S. health plans. It should, however, be kept in mind that these examples are nothing more than that, especially since the purposes of the essay do not include explaining the United States health ‘system’. Instead, the focus is intended to be on the concepts themselves and the purpose to show how each interacts with the others and how they may be used to understand U~J health system. Conditionalit.
Perceived needs for health services, technological innovation and pressures on personnel and financial resources work together to produce services and limitations in a population’s access to health care. Conditionality in health care legislation and planning also expresses the fact that there are policies at work which when judged valid assure (I measure of human health, imprwe current health, and prevent disease and injury. Clarity about conditionality in health policy defines the pool of intellectual and financial resources available. Conditionulit~~ us u principled apprwch to heulth
cure
alone
is
occomprtnied
plunning
not
.syficient
tukrs to
h? considerations
into
crcc’oun
render
curt
of’societui
t that
demund
unless norms.
it
is
rules.
and nzwiluhle resources. Conditionality also points to the fact that members of societies. even when health policy and services are under the control of central government. will at best enjoy a measure of health services, rather than total services for all imaginable health needs. As in the dispensation of all other communally owned property. health care comes with reference to the contextual aspects of all organized society. Generally speaking, the more specialized. sophisticated and expensive health care is, the more selective the conditions under which it is available. We mention as a titting example the Clinton plan for United States health care -7%r Heulth Securit!, Act of’ 1993--House Resolution 36OOK which after it details out what is to bc expected by way of health services. severely underrates mental health services (which are to be increased incrementally after adoptlon of the basic plan). This is consistent with the fact that in most societies. including those in the industrial West. mental illness is still subject to moral approbation. Taylor and Brown point to difficulties in specifying what it is mental health practitioners diagnose and actually treat, together with the problems of the objectification of subjective experiences so common in the mental health field [9]. Two brief excerpts from recent work under the interesting title “Illusion and Well-Being: A Social Psychological Perspective of Mental Health” will demonstrate the startling differences in language and thought between physical medicine and mental health medicine. except for those psychiatrists who
policies
decided years ago that general medicine and mental health medicine need to be brought to a common denominator essentially biological in its logic, its research, and in its procedural interventions with patients. Taylor and Brown illustrate the problems currently existing and account, thereby, for at least some of the resistance to treating mental illness in the mode of traditional medicine: To summarize,
then, although it is not the only theoretical perspective on the mentally healthy person. the view that psychological health depends on accurate perceptions of reality has been widely promulgated and widely shared in the literature on mental health (p. 194).
And: ,. the overriding
implication that we draw from our analysis of this literature is that certain biases in perception that have previously been thought of as amusing peccadillos at best and serious flaws in information processing at worst may actually be highly adaptive under many circumstances. The individual who responds to negative. ambiguous, or unsupportive feedback with a positive sense of self. a belief in personal efficacy, and an optimistic sense of the future will. we maintain. be happier, more caring, and more productive than the individual who perceives information accurately and integrates it into his or her view of the self. the world. and the future” (p. 205). These excerpts are cited to demonstrate a logic in the mental health field which goes awry of much that elsewhere would depend on scientific objectivity, that is to render meaning to conditionality and prioritization in health care based on the application of scientific data. While many would object that Taylor and Brown’s views are unrcpresentativc of the majority of how mental health people think. we would hold that the authors cited shed light on an issue rarely taken seriously in health planning and financing, namely subjective experience of the part ol patients and providers of services, in this cast psychiatric and other mental health intcrvcntions. Without offering moral judgcmcnt on such reasoning as cited above. it must be obvious that it hardly corresponds with expected kinds of conceptualizations in a scientific age of primarily physical medicine. In the case of mental illness prejudice and myth combine with scientific research and continue to undergird the biases which restrict the ready availability of mental health services. Adequate financing of long-term treatment in particular is less available than it is for the fulfilment of other health needs. The subjective aspects of diagnosis and treatment of mental illness make it more rather than less difficult to convince policy makers and others that conditionality applied to psychiatric coverage needs a more flexible profile than when the attention focuses on more empirically objective diagnosis, treatment. and, therefore, policy making. The conditionality principle in the esumple given-mentul i.e.
rulidit~~
health+uses und
reliuhilit~~
on the .scientific, of mentul
heulth
.stuttJ.
intrrren
-
In Western countries there is a distinct tendency to give preference to human services that can demonstrate a scientific base for their activities. In the tion.
What
is needed to claim adequacy
present discussion this qualifies an example of the conditionality principle in action. Non-empirical medicine is by no means confined to the difficulties experienced by Western style psychiatry and related efforts. There is a vast literature available-beyond the limits of this essay-which points to the ever growing and rather promising efforts to combine traditional healing with modern medicine. The discourse is most meaningful to those investigators who view the future of deciding what health services are needed in the order of their perceived importance, neither in Western nor in non-Western terms [20,21]. They typically focus on the interactions between East and West [IO]. Weiner hints at the problems that occur when one searches for universal explandtory, yet cultures-respecting approaches such as in science and in theory building. As Weiner put it, “[Mledicine may be the only discipline that lacks a comprehensive Theory” (p. xi). In pondering Weiner’s remark one becomes aware that neither cultural variables alone, nor science alone will do. A combination of need, culture and science turn out to be the most meaningful consideration in the definition of conditionality in health.
The prioritization of health care addresses the rank order, roughly speaking, of distribution of health resources. Cost and demand outrunning supply are the main motivating factors in prioritization. This is reenforced in countries where, primarily through high levels of technification and thereby rising expectations f%r an ever longer and healthier life are involved; and in those societies in which health services are minimal. Here health maintenance takes on the characteristics of the high priority assigned the fulfilment and protection of basic human rights. To understand some of the major features of prioritization it is useful to divide the concept into two categories, internal and external. Internal prioritization refers to those situations in which two or more health services compete for resources. C)ne instance is the competition for money to study and treat AIDS compared to breast cancer, the latter far outdistancing occurrence of the former. Another well-known example from industrial societies, in particular, occurs where specialty care competes with primary care in the training of physicians, in the development of technology, and in building hospitals beyond what is needed to cover the general population with basic health care. Conflicts in internal prioritization may have consequences of considerable importance, whether resource are focused on specialty care which, while important, may do little to lift the general standard of medical and health care for the broadest groups in the population. External prioritization occurs when efforts in relation to health are judged as to their relative importance compared to non-health focused concerns. Examples are health services versus building of roads,
in health services?
1399
investment in cultural programs such as the arts, or most commonly against public education and police protection. These are also processes which tend to involve much political conflict and tend to obscure internal prioritization issues of often much greater weight and consequences than would obtain in the generalized comparison of too broadly defined health services with equally broad categories of non-health concerns. Prioritization
and demographics
In many countries of the world health planning and the availability of health services are increasingly influenced by population statistics; these form the well-known demographic concerns such as ‘the greying’ of society and with the favoring (or disfavoring) of some population groups over others [12]. While conditionality addresses the question to be answered by what rules is health care available keeping in mind resources and competing demands, in the case of prioritization the question is that given whatever resources are available, who shall receive health care, in what order! at what cost, and according to which social interests and oalues. Thus, the increase in much of the world of life span expectations and the fact that the aged, as a group, have numerically expanded faster than any other group heavily influences both demand and services. To mention briefly the complications involved in the prioritization of services, a new study conducted by Guralnik et al. finds that “[Almong older blacks and whites, the level of education, a measure of socioeconomic status, has a greater effect than race on total life expectancy and active life expectancy” [13, p. 1 IO]. Healthy living does not, in and of itself, lead to longer life. When combined with the powerful plea that child health care be given much higher priority than has been the case, and currently is the case, it is not difficult to see that other groups-especially the middle aged-will enjoy lower priority than those mentioned in having their health needs attended to as fully as others. A population category known as ‘the aged’ or ‘the aging’ and one referred to as ‘children’ are associated in the public mind of many societies with helplessness, weakness, lack of independence and other themes which stimulate the societal desire to help; while middle-aged categories of person are, by and large, considered more likely than those named to be able to take care of themselves with minimum assistance from public resources. In other words, the prioritization factor tells us that demographically speaking, at least United States society does not as yet accept universalism as the only or even central guiding motive for national health care. The same social mechanism operates in other cases as, to cite another example, where there is a demonstrable link between manpower requirements for industry and a population healthy enough to meet these. Not very remote from such considerations is the link between the quality of achieved knowledge and skills in the intellectual
I400
HANSS. FAL~K
arena and the needs of society to apply these to technical and scientific work, typically taught in the university. Thus conditionality and prioritization work together. Social values and preferred investments in rendering health care define conditionality. and the nature of populations combined with limited rcsourccs guide what governments and other decision influencing groups mean by what we call prioritization. One result of the research revolution in health care suggests the possibility of ever longer life under medically controlled conditions and as a direct consequcncc of what is technically possible cr& ~~*itlzout MYYV~~~J~ c?sihlc /ir,~its. The unspoken hope seems to be that the more research. the mot-c health. the only caveat being the ability to pay for it. Guiding this arc the technical and research achievements of the twentieth century and the open-endcdness of what once a solid kind of prediction that the reality of death could be more or less clearly expected. temporally speaking. To live has become a matter of right simply bccausc the rcalitics have changed to a point where most expectations about limitations of the life span are accompanied by cvcr growing skepticism by citizens the world over. especially in industrialized societies. Cassell [I41 addresses the conscqucnces and the nccdcd self-restraint by physicians when technology takes on a lift of its own and results in indiscriminate use of the hopeful and yet deceptive preoccupation \vith ‘the lure of the immediate’. The contradiction at MTot-k.glvcn what has been said about conditionality and prioritization. is that when health cat-c is viewed as an absolute and unconditional human right. the argument shifts to the I‘ulfilmcnt or non-fulfilment of these rights and the concern shifts 10 strategies about their recognition and I‘iilfilnicnt. with correspondingly less concern \+ith priorities. This is what happens in the case 01 AIDS where the appeal to human rights overpowers other concerns about the relative numbers, prognoses and chances for curt when compared to other discatch. Both conditionality and prioritiLatlon tend to become nearly ignored. to say nothing of careful and thoughtful planning such as would be required. cspec~ally around prioritization. In the latter caxc it is easily conceivable that some people would reccivc cart while some others would not. that some conditions would draw more by \vay of research funds than others and that there be those who are authorired to dccidc, and others who would bc bound by their decisions. While there arc a few exceptions. such as elective plastic surgery not otherwise related to injury. sickness or disability. the overall trend tilts toward Inclusiveness rather than the opposite bccausc health is increasingly valued as an untouchable human right together with a societal interest in the health of populations. As long as this reasoning prevails. other obligations of government ofwhich we spoke earlier. could easily become ignored and that with its own disastrous consequences. One answer to the dilemma cited here is to judge the entire health
services establishment, including both the services sector and the underlying basic science community. as being regulated. always in relation to other societal needs. The theme is relativism of ‘health’ in comparison to ‘education’. ‘defense’, ‘social services’, thus keeping in mind that whatever anyone may obtain by way of health scrviccs would not necessarily be available to everyone. Ultimately. the entire health sector would be assigned a priority rating in relation to those others named above. It is a cultural and political decision of enormous complexity. One would hold out little optimism that it ought to be done. The evident reason is that an amount of power over life and death would fall upon decision-makers in excess of what in democratic society citizens would tolerate. Setting priorities has. therefore, limited utility unless done incrementally and accompanied by full public debate. Social activists. being uncomlhrtably aware ol the need for prioritization. tend to ovcrcmphasize the need to intervene in the Icgislativc process and overlook the eftcctivencss of administrative decision making by civil servants. An interesting aspect ot administrative decision making m prioritizing health cart’ in non-go\-crninental institutions in the United States appears in hospitals who i15,xcsstheir pcrformance. usually through pressure from accrediting bodits. govcrnn~cntal and non-govcrniiiciit~il. Shcr-cr [IS] writes of a11cxamplc of such in ;I Ircccnt article In the trade journal ffo.vpi/rr/s. The rcpol-ted motivation \+;I:, to remain financially viable. hut most of all. to bc sure that the priorities of the hospital under discussion wcrc such that the ‘customer rcccivcd what hc or she needed rather than what the hospital thought they ought to have (p. 10).
Adequacy is detincd as those always tcmporar> solutions to dilemmas and conflicts that result in services provided (or not provided) as ;I result ol trying to rcconcilc with each other conditionality and prioritization. Adequacy. however, is not an unitary idea. A society may do well in sonic provision 01 services while doing poorly in others. Inoculation against certain diseases may cxtcnd to school aped children, while family planning asx1stancc ma) fail. Certain expensive surgical intervention may bc providcd while mammograms may bc need4 but be typically unobtainable by large numbers of Liomcn. To elaborate and clarify the concept ol‘trrlc~~~rt~~~ as product of the interaction of c,o/~~litiontr/i/~,and ,N/Nifi:ufj~j/l wc present tirst. an example of‘ a proposal introduced into the Congress of the United States (Senate Bill 684) for umvcrsal health cart covcragc under federal law. and considered an exan~plc of adequacy in health care by those who favor it. Thea will be followed by the so-called Clinton plan. Finally. the proposals for health insurance by Republican members of the Congress will bc introduced.
What is needed to claim adequacy in health services? pointing to significantly different views on health care reform when compared to the other two proposals. Absolute rights, limited rights and the defiance of nature A powerful statement by Mahler captures the essence of absolute rights, which translate into the right to human beings to exist; into limited rights, which translates into choices and the possibility that one can exist even in some compromised state; and finally it implies that health services not only help to create and prolong life, but to some degree postpone death. We first quote Mahler: It is offensive that in one country people should die young while in another they may expect to see their grandchildren grow up; that in one part of a city nutritional deficiency diseases are common, while in another, people worry about eating too much; that, despite the great advances in technology and the human sciences, there are over 500 million people in the world with incomes equivalent to $50 a year 1161. In January Workers
1991 the National published
an
Association
Executive
Summary
of Social of
the
National Health Care Proposal which, in slightly modified form, was introduced in the Senate of the United States as the bill (Senate Bill 684) already mentioned [ 171. The National Health Care Proposal is the result of a mixture of the practice experience of health social work personnel throughout the United States and of the long-standing support NASW has given national health care for the last 50 years (and under its predecessor organization the American Association of Social Workers). We quote the essence of the proposed legislation with its following principle features: Coverage and enrolment
All persons
residing in the United States are covered through the national health plan. Each person has the freedom to choose from among any of the participating public and private providers, facilities or care delivery options, including Health Service Plans (IHSPs). IHSPs are non-profit, consumer-controlled plans which provide comprehensive health care services in their own facilities to an enrolled population. Individuals will enroll in the national health plan in the state in which they reside. Coverage through employers or other privately purchased health insurance is discontinued, although private insurance plans may provide coverage for services not covered under the national health plan (p. I).
The document ties a section on benefits to the announcement that NASW favors a cradle to the grave approach with few exceptions. In order to suggest the tone of a long and detailed document we have extracted some of the major features the plan contains, without claiming anything near completeness: Benefits --Care coordination services, to be used primarily for clients who require multiple services over a period of time or where such services are potentially costly.
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-Primary prevention and health promotion services including comprehensive well-child care for everyone O-21; perinatal and infant health care; routine, age-appropriate, clinical health maintenance examinations for everyone over 21; family planning services; and school-based primary prevention programs. -Outpatient primary care services. -Mental health services. -Substance abuse treatment and rehabilitation programs. -Inpatient and outpatient hospital services, including emergency and trauma services. -Inpatient and outpatient professional services. -Laboratory and radiology services. -Long-term care, including home and community-based services. -Hospice care. -Prescription drugs, medical supplies. and durable medical equipment (pp. 1-2).
Marshall addresses primary prevention in an article in Science [22]. It is a topic gathering unto itself ever greater attention as the shortcomings of the traditional emphasis on diagnosis and treatment as nearly exclusive modes of intervention become ever clearer. NASW gives primary prevention high priority and thereby suggests what we referred to earlier as internal prioritization, i.e. the frequent need to choose among health services themselves. Until recently it was rare that the purveyors of ideals (and occasionally ideas) about universal health services, government financed and administered, would be concerned with financing. The impression prevails that matters of money, priorities, and competition with other needed government functions were of lesser importance when compared with the belief that the right to health care should be both fundamental and absolute. The underlying question was and is what a member of society may reasonably expect to be a fulfilled and complete life. On one side of these considerations are those who would view the right to living absolute and would brook no interference whatever in non-spontaneous death. There are voices on another side who argue for both financial considerations and an ethically grounded respect for a meaningful life. These take the position that monies spent on hopelessly ill people about to die or with poor quality of life if they survived, deprives those with a greater chance for meaningful survival. In addition, there are the burdens for families beset with debts, typically paid long after the death of the person whose life was to be saved through their expenditure. The position calls for a clear definition of meaningfulness, a potentially operational concept but also one extremely difficult to define in polyglot societies. The predominant message, at least in the United States late in the 20th century, still favors the view that would, in the end, save life at nearly all cost. To return to the main argument, when adequacy does not exist or is only approximated one would judge worries about conditionality barely relevant and prioritization hardly appropriate and needed. Where the opposite occurs, that is where health service availability is plentiful, conditionality is marginally significant and prioritization of health care in
HANS S. FALCK
1402
the national agenda selectively high. The interaction between conditionality, prioritization and adequacy exists in its clearest and unambiguous forms where some services are available, where there is competition between them and other needs to be addressed (prioritization), and where what is actually delivered by way of health services is the result of compromise. This latter situation, with some glaring exceptions, prevails in much of the world. IDEOLOGICAL
AND UTILITARIAN
CONSIDERATIONS
The ideological issues underlying health care planning by government on any level have to do with general attitudes in the populace toward central planning and governmental control, ideas of freedom and personal liberty, relationships between customers or clients and professionals. choice of providers-in the current case physicians, and the assurance that health services would be available as needed as in any other business or professional transaction. Health care is one example of such concerns among many, including public and/or private education, social welfare services which are by no means available without heavy dosages of conditions about eligibility and access. A fine example of the complexities involved is available in an act introduced into the United States Congress in opposition to that of the Clinton administration (Senate Bill 684) and given the title “The Affordable Health Care Act of 1993” (House Resolution 3080) [ 18, 191. As such it represents the views of the Republican minority in the United States Congress, but more relevant to this discussion, its greatest significance is that it illustrates as well as any proposal the concept of conditionality. While the Clinton proposals accept the role of private insurance companies as part of a new government-sponsored health care program-most likely for tactical reasons-the Republican version reflects the fundamental commitment of the party to free enterprise, marginality of favoring the private, government ‘interference’. profit-making insurance sector as a major player in health insurance planning, financing and ultimately in health care delivery. While the Clinton plan relies on government as both first and last resort, the Republican Party’s proposals rest on private business as the bedrock and government as the agency of last resort. Conditionality is expressed in the latter case by tying health coverage to a profit-making role which the party supports within the context of a free enterprise system and, as is traditional, with severe limits on the federal government with its appetite for taxes. At the same time it needs to be understood that both major parties in the United States Congress will compromise for utilitarian reasons once all the traditional arguments have had their day. Often this occurs in subtle changes in language as, for example. in the case of Title One of the Republican version which reads “Improved Access to Affordable Health Care” together with sub-title “A” which reads “In-
creased Availability and Continuity of Health Coverage for Employees and their Families” and sub-title “B”, “Reform of the Health Insurance Marketplace for Small Business” (p. I) The perceptive reader recognizes the implicit statements which suggest that health care is available now and needs ‘increase’; that improvement in the mechanisms of access is to be supported by future legislation, while preserving the essentially private, capitalistically motivated, business-tied, free enterprise traditions. This illustrates once more the low level of prioritizing health care in the United States, resulting in an estimated 38.5 million persons without or with inadequate health insurance out of a population of 250 million, while at the same time. especially for those who can afford it, there is little by way of conditionality at work. This same pictureperhaps even more extreme-may readily be found in many other societies, especially those with a small number of the very wealthy, together with much larger populations living in conditions of destitution. The temptation is to be resisted in the current context to explain the politico-philosophical background to health planning in the United States since it is not the primary topic under discussion. Yet, we have said enough to indicate how such themes influence conditionality, prioritization and ultimately concepts of adequacy. This is particularly the case in the third example given above, that proposed by the Republicans in the United States Congress, who are committed to the minimization of the role of government and whenever feasible and politically supported by the population, would rather stay with the private sector in meeting health (and social services) needs: but when inevitable, take the position that government should come into play at the lowest, most locally controllable level (the States) where the population through the political process would enjoy the opportunity to seek limited government intervention in health as well other sectors. Conditionality in this case works to control and limit central control, while prioritization addresses what the taxpayer can afford or is willing to pay. (‘ONCLCSIONS It is indeed possible, as we have shown, to spell out briefly and quite specifically what conditions need to obtain to call a health system adequate; but more is needed to understand what is involved both conceptually and practically. What is required is that necessary philosophical commitments be examined which we followed-up by a tripartite methodology for a closer analysis of some of the issues. These were named conditionality. prioritization, and adequacy itself. Selected examples from the views of a United States professional organization, the United States government. and a minority political party were cited to illuminate the concepts.
What
is needed to claim adequacy
REFERENCES
1 Basch P. E. Textbook of International Health, Appendix I, Declaration of Alma-Ata, 1990. Oxford University Press, New York, 1990. P. and Corsi P., (Eds.) 2 See Pellegrino E., Mazzarella Transcultural Dimensions in Medical Ethics, University Publishing Group, Frederick, MD, 1992. This is a series of essays by some of the most prominent contributors to the ongoing debates about health ethics. 3 Oppl H. and van Kardoff E. The national health care svstem in the welfare state. Sot. Sci. Med. 31, 49. 4 I&in S. B. and Walt G. Why health improves: defining the issues concerning ‘comprehensive primary health care’ and ‘selective primary health care’. Sot. Sci. Med. 23, 559, 1986. construct: posi5. Rodwell M. K. Person/environment tivist versus naturalist, dilemma or opportunity for health social work research and practice. Sot. Sci. Med. 31, 27, 1990. 6. Carhon T. 0. Clinical Social Work in Health Settings Springer Publishing Company, New York, 1984. I. Falck H. S. What is central to social work? Hlfh and Sot. Work, 7, 235, 1982. 8. The White House Domestic Policy Council. The President’s Health Security Plan-The Clinlon Blueprint, DD. 11-13. Times Books. New York. 1993. This is an authoritative summary and explanation of the President Clinton’s plan, submitted to the Congress of the United States for legislative consideration. 9. Taylor S. E. and Brown J. D. Illusion and well-being: a social psychological perspective on mental health. Psych. Bull. 103, 193, 1988. E. Prologue: intersections of Western 10. Pellegrino biomedical ethics and world culture, In Transcuhural Dimensions in Medical Ethics (Edited by Pellegrino E., Mazzarella P. and Corsi P.). Universitv Publishing Group, Frederick, MD, 1992: 11. Weiner H. Psychobiology and Human Disease, p. xi. Elsevier. New York, 1977.
in health
services?
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of contextual 12. For a brief and concise discussion dimensions of availability of food and water supplies, fertility rates, literacy and other health-connected issues, see Brown L. R., Kane H. and Ayres E., Vital Signs 1993. W. W. Norton, New York, 1993. J. M., Land K. C., Blazer D., Fillenbaum 13. Guralnik G. G. and Branch L. G., Educational status and active life expectancy among older blacks and whites. N. Eng. J. Med. 329, I 10, 1993. rampart 14. Cassell E. J. The sorcerer’s broom-medicine’s technology. Haslings Center Report 23, 32. 15. Sherer J. L. Strategic planning: health assessment. Hospitals and Health Networks, American Hospital Association, July 20, pp. 3640, 1993. Hospitals is a trade journal published by the American Hospital Association and which often provides insight into the practical issues business-oriented health administrators think about. 16. Mahler H. The philosophy underlying the Alma-Ata conference of 1978. Appendix 3 in B&h P. E. Texfbook of International Health. DD. 232-233. Oxford Universitv Press, New York, 1990: _ Association of Social Workers. NASW 17. National National Health Care Proposal. NASW, Silver Springs, Maryland, 1991. The Affordable Health Care Act of 1993. 18. Summary: Mimeo. Supplied by Rep. Thomas Bliley, Jr. of Virginia. 19. 103rd Congress, H.R. 3080, The Afordable Health Care Act of 1993. A. Patients and Healers in the Context of 20. Kleinman Culture-An Exploration of the Borderland between Anthropology Medicine, and Psychiatry. University of California Press, Berkeley, 1980. 21. Kleinman A. The Illness Narratives-Suffering, Healing and the Human Condition. Basic Books, Inc. Publishers. New York, 1988. 22. Marshall E. Prevention research: a new growth area for NIH? Science, 262, 1508, 3 December 1993.