Monday, 24 July 2017

Justice and equity in the health system

Xavier Bayona

Should we review the principle of justice from an ethical perspective? If so, we’ll notice that it’s a principle of minimums (of coexistence) faced with the principle of happiness – a principle of maximums ("individual justice") and, unfortunately, we’re often erring by thinking we speak of justice when in fact we speak of happiness (or individual convenience). Similarly, from the bioethical standpoint, justice can be defined as the fact of treating each one appropriately, in order to reduce situations of inequality (ideological, social, cultural, economic, etc.). On the other hand, equity is defined as giving each individual no more and no less of what they need. Following these definitions, when we speak of justice and equity, deep down, we are doing a reiteration, because they are synonymous.

A few months ago, an editorial was published in "Atención Primaria", reflecting on the justice and equity of copayments (Simó Miñana 2015). The author highlighted some aspects such as:
  • It’s fair to say that in a health system of universal and free access it’s necessary that its financing be made from taxes;
  • Copayments can introduce inequality in access especially among the most ill and among the poorest or socially disadvantaged population groups;
  • Health needs and health demand are virtually synonymous, so the urgent health demand is when the citizen expresses it; 
  • No expressed demand doesn’t mean that there’s no need; the most disadvantaged social sectors have a disadvantage;
  • Exaggerated health expectations generate health consumerism in an environment of limited resources and an infinitely increasing demand.
In an environment of budgetary austerity, different decisions can be made:
  • Raising taxes by insisting on the "social responsibility" of anonymous tax payers;
  • Excluding from public coverage some services that in practice are equivalent to a 100% copayment of exclusions, payments that end up exclusively  in private hands;
  • Introducing copayment of part of the benefits, with the consequent individual co-responsibility and the secondary benefit in the system’s financing. 
The challenge is to combine social and individual responsibility and solidarity. The author of the editorial ended by asking the following question: "To what extent do bad uses and their consequences have their origin in indifference at a cost that none of its actors, except the anonymous tax payer, bear?"

Although a whole book could be written on this theme, I hope the reader will forgive me for simplifying the proposed reflections on the theme of adjusting the fairness in an economic environment as adverse as ours which, as the experts say, has come to stay.

I will insist once again that it’s necessary for the different levels of care to coexist harmoniously and to strengthen cooperation and networking, while focusing on a citizen-centred approach. All levels of care are necessary, but the time has come to take action, we can not wait any longer. We need:
  1. Health policies accompanied by resources that should be more focused on the community and primary care so that the system can be more efficient and equitable;
  2. To recover resources from the existing waste, to redistribute them where they will be more necessary and cost-effective; 
  3. To evaluate the introduction of new diagnostic and therapeutic strategies; what is the added value that these contribute; we need to use tools of analysis of cost-utility as for example the QALY (years of life adjusted by quality) for the evaluation; 
  4. To promote payment for health results (not by procedures) that is obtained in the community;
  5. To raise awareness that the citizens are responsible for their health decisions are binding, therefore self-care and self-responsibility must be encouraged.

To conclude, I’ll use a quote from the General Practitioner and professor at the University of Leicester, Marshall Marinker (1930), editor of the book Constructive Conversations about Health Policy and Values ​​(2006), and many other contributions to the National Health Service. "The specialist's diagnostic task is to reduce uncertainty, to explore the possible and to marginalize the error. It contrasts openly with the general family doctor’s task, who is accepting uncertainty, exploring the probable and marginalizing the risk."

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