Health equity is very vital particularly for those people who are involved in the decision making process
Health equity is very vital particularly for those people who are involved in the decision making process, it should be of great concern to them when setting priorities in health and health care. In health care through making just decisions one could serve the people by alleviating their health problems. In my opinion, GPS-Health checklist not only serves as a key to priority setting processes but it also provides methods for equitable priority setting of health interventions (Norheim et al., 2014). It would also enable decision makers to consider those criteria that they find pertinent to health care setting and use it in combination with the cost effectiveness analysis. The checklist would also permit equitable decisions, efficient use of resources and prevent financial losses. In addition, inclusion of equity weights allows us as decision makers to consider opportunity costs. Incorporating equity weights also helps to prioritize the worst off. One fundamental of this fair process is transparency, accountability and appeal for decisions to meet the people needs fairly assuring “accountability for reasonableness.” Thus GPS- health checklist could be considered as an integral part to facilitate legitimate decision making. Lastly, this checklist could act as a means to overcome barriers, making right and fair choices when financing target interventions. Though there is one deficiency in the criteria that is worth mentioning that it did not include any category for life threatening conditions and rare diseases which still is a challenge for priority setting. To ensure equal access to treatment for such categories of patients who are more vulnerable, sometimes neglected during the process, become a victim of unjust rationing and ultimately become more worst off.
John Rawls theory of justice which addresses that each person is entitled to; an equal and extensive set of basic liberties, political or civil rights (Liberty principle); secondly, fair distribution of primary goods i.e.; income and wealth in society and inequality is justified only if that makes the worse off better off as possible (Difference principle); thirdly, everyone is entitled to fair equality of opportunity (Fair opportunity principle). He believes that inequalities in society could be for everyone’s benefit; for instance high wages in society may be could bring out incentives to make everyone better off and only in that case inequality is justified.
Since we know that Rawls addresses the issue of fair distribution of social primary goods but still his theory of justice lacks anything related to right to health care. The theory can be applied to priority setting guidelines since it emphasizes in making the worse off better off as much as possible. It is focused on a fair distribution rather than an absolute equitable distribution. It puts forth the idea that the social institutions in the society should make decisions on the fair distribution of goods, rights and opportunities to all people based on these principles of justice to form a well administered society. Rawls principles are clearly translated in the checklist. The initial two criteria by WHO care clearly based on his fair opportunity principle where he addresses that justice can be achieved with fairness while to achieve fairness it is important that everyone has access to the services they need. Other important aspect of Rawls theory that is highlighted in the checklist is that one cannot attain justice by having absolute equity but rather we should strive for fairness. In my view, Rawls principles of justice are quite narrower when it comes to health needs and they do not give a complete view of when health inequalities are unjust.
Norman Daniels perspective
Rawls theory is further extended by Norman Daniels and the aforementioned WHO’s checklist addresses the same issue of disparities in health based on the social determinants of health as determined by Daniels.
I n view of Norman Daniels health could be introduced in Rawls theory of justice as health is closely linked to opportunities. He introduced procedural justice to make fair decisions taking solidarity and equity in to account. Many high income countries have coupled their economic growth according to a social welfare model, i.e.; providing certain social services to its citizens that guarantees access to health care facilities and education. The total governmental expenditure on health care has also grown steadily in many developed OECD countries. Moreover, a vital tool to tackle this matter resorts to an idea proposed by Norman Daniels referred to as ‘Accountability for reasonableness” (Nunes and Rego, 2014)
Daniels elaborated the Rawls theory of justice and applied it to the health system. He proposed that health care system should be designed in a way to bring everyone close to a decent minimal level of health care which he regarded as “normal species functioning” (Cookson et al., 2000). He argued Rawls by saying that inequalities are not only un just if they do not benefit the least advantaged rather the inequalities should be reduced by a just redistribution of social determinants of health. According to him priority setting in a society is a fair process if it meets following four conditions (Nunes and Rego, 2014):
Relevance; rationales for priority setting lies on evidence which is agreed upon by fair minded people to be able to make decisions that are mutual to meet the health needs under resource constraints.
Publicity; public accessibility of priority setting rationales is a must.
Appeals; There must be an opportunity to challenge and make an appeal which could be beneficial for the improvement of policies.
Enforcement; This is a voluntary process to make sure that previous conditions are met.
Hence for fair and equitable decision making in health care the following conditions should be taken in to account. This perspective is also mentioned in the second criteria of the WHO checklist. Introducing Daniels proposal of “accountability for reasonableness” have a great impact in delivering social justice and hence connects rationing to more fundamental processes (Martin and Singer, 2003) . Therefore to have a just and equitable priority process in health care there is a need to adjust the ”accountability for reasonableness” in the guidelines. His concept of equal opportunity is also infused in the WHO’s checklist with respect to disease or disability which is basically focused on prioritizing those that have least opportunities and to facilitate a just distribution of socio economic determinants of health, thus reducing the health inequalities. Daniels also claims that this measure not only make limit setting decisions in health care legitimate but also fair. However, opportunities are limited due to resource constraints but still the choices made in health care must be held responsible by democratic procedures.
Thus the viewpoint of distributive justice and democratic accountability facilitates fair limit setting decisions. Hence it could be applied to the concept of rationing in health care to have widespread implications for fair decisions under scarce resources.
Often in public health policy making decisions are analyzed and based on their resultant consequences. An action that produces net gains is considered as the right choice. For example, a major drop in the disease burden. This perspective is highly important for a public health professional too. Bentham proposed that if an idea is good we should measure the consequences that is to say we should consider the impact of that decision on the happiness, pleasure and wellbeing of all affected people, which he referred to as Utilitarianism. Prevention of pain evil or unhappiness to the party in question should also be considered. Utilitarian would probably oppose these priority setting guidelines because they believe that one should think of maximizing people’s utility by distributing resources, opportunities etc which is a moral obligation. For them compensating the worse or redistribution might be a good idea but for them at some point it becomes impractical or everybody would be worse off at the end or even access to the means of subsistence would be destroyed. For them losing something would be a form of disutility. Therefore, modern time utilitarians would argue as subjective or objective utilitarians. According to the subjective utilitarians individual’s happiness or well being is determined by their personal experiences. While other category of utilitarians believe that it is difficult to ascertain the reliability or validity of a judgment. Both groups of utilitarians will focus on the approaches of consequentialism and use the resources efficiently to make the most of it according to their preferences. For the process of prioritization subjective utilitarians would consider doing a cost benefit analysis and would go for willingness to pay estimates. Contrastingly the objective utilitarians would look for gain in QALYs or DALYs averted. Hence equity is comprised.
Hence the viewpoint of distributive justice and democratic accountability facilitates fair limit setting decisions. Hence it could be applied to the concept of rationing in health care to have widespread implications for fair decisions under scarce resources. GPS- health checklist could be considered as an integral part to facilitate legitimate decision making. Lastly, one deficiency in the c GPS- health criteria that is worth mentioning is that it did not include any category for life threatening conditions and rare diseases which still is a challenge for priority setting.
Therefore to fulfill challenging demands in the health care system there is a need to prioritize and make fair choices for the allocation of resources. Since the total governmental expenditure on health care has also grown steadily in many developed OECD countries. In fact, in 2010, the statistical figures on governmental health expenditure were found to be 9.4% of the GDP in Norway, 11.1% in Denmark and 9.6% in the United Kingdom (with an average of 9.5% in OECD countries) (Nunes and Rego, 2014). Scandinavian countries, the Netherlands, England, Canada, along with others have already implemented explicit ways to prioritize, this is to bring down and manage the high expenditures on public health. One fundamental of this fair process is transparency, accountability and appeal for decisions to meet the people needs fairly assuring “accountability for reasonableness.” Thus GPS- health checklist could be considered as an integral part to facilitate legitimate decision making.