As the Covid-19 pandemic intensifies, the demands on the healthcare system will intensify and result in critical shortages of healthcare resources. Based on patterns seen in even the most economically developed countries, the epidemic will result in critical shortages of hospital and ICU beds, ventilators, medical workers and protective personal equipment. Given the massive socioeconomic inequality and the fragmented two-tiered system operating in the country, the situation is likely to be much worse in South Africa.
Providing services to all who need them is simply not going to be possible. This gives rise to an obligation to develop an explicit framework for the fair allocation of resources that is aligned to the Constitution and internationally accepted ethics codes. The alternative of leaving that decision to the private or public sectors, or to individual institutions, or to a clinician’s intuition in the heat of the moment, cannot be acceptable. The urgent question facing the country then is not whether to set priorities, but how to do so quickly so that there is a national framework that is applied on a nationwide basis.
Approaches to health sector priority setting
Approaches to priority setting in acute scarcity settings globally have converged around four fundamental values.
One value is to treat people equally. With this approach, people are selected for treatment on a first-come, first-served basis or through a “lottery” system where there is a random selection of people for treatment.
The second value is based on favouring the “worst off” in the prioritisation process with the sickest and/or the youngest being prioritised for treatment. The sickest are prioritised as the aim here is to assist those who are suffering the most and right now, and the youngest are prioritised as they have lived the least.
A third value is based on utilitarianism. This approach prioritises people for treatment with the aim of doing the greatest good for the greatest number of people, either by saving the most number of lives and/or saving the largest number of life-years.
The fourth value is based on promoting and rewarding social usefulness. With this approach, priority is given to those who can save others (e.g. health workers), or to those who have saved others in the past.
Daniels and Sabin’s Accountability for Reasonableness (A4R), the framework is one framework that is still considered to be a legitimate one for priority setting in a healthcare context. Central to the A4R framework is the belief that in resource allocation decisions, the actual process of reaching a decision is fundamental and open-ended. Decisions that are transparent, consistent and reasonable, and open to appeal will make priority setting more legitimate in the eyes of the public.
The framework outlines four conditions that priority setting has to meet in order to be considered fair and legitimate: (1) publicity; (2) relevance; (3) appeals; and (4) enforcement. “Publicity is about the transparency and accessibility of decisions. Under the ‘relevance condition’, reasons for decisions must be given. Under the ‘appeals condition’, processes that provide opportunities to challenge decisions must be in place. Finally, the ‘enforcement condition’ refers to mechanisms that ensure that the conditions 1–3 are upheld.”
Deciding on an approach to priority setting in the health sector
On their own, all of the values are compelling and have merit. However, experience globally suggests that no single value is sufficient on its own. For example, the application of the first-come-first-served approach would in likelihood favour the rich and well connected. On the other hand, an approach based on prioritising the sickest first ignores the needs of those who may have a better prognosis and chance of recovery.
It is now generally accepted that a multi-ethical framework, adopted and agreed to by key stakeholders, taking into account their particular context and resource constraints, is more likely to result in a fairer allocation of resources. This multi-ethical framework requires the multiple ethical values to be balanced and “weighted”. Depending on the interventions and the circumstances, very different judgements are possible on the weighting of each value.
It is therefore critical that an open, transparent and accountable priority setting process is followed, which allows for the participation of all key stakeholder groups, including healthcare workers in community settings, civil society organisations working in health and labour. In turn, the openness and transparency of this process will influence how the public broadly accepts the country’s approach to priority setting in both the public and private health sectors.
Covid-19 and the South African health system
South Africa has a two-tiered healthcare system with a relatively well-resourced private system caring for no more than 20% of the population and a less well-resourced public system providing care to about 80% of the population.
It is almost certain that the public healthcare system will be overwhelmed by increased demands related to the Covid-19 epidemic. The Competition Commission Health Market Inquiry found excess capacity of high-care and intensive care unit (ICU) beds in the private healthcare sector.
The continuation of a “business as usual” two-tiered system is not tenable in the face of the epidemic and with the publication of Covid-19 block exemption for the healthcare sector by the Competition Commission, efforts are underway to promote better coordination, sharing of information and standardisation of practice across the entire healthcare sector.
The intention of the exemption is to promote agreements between the National Department of Health and the private sector, with the sole purpose of making additional capacity that is available at private healthcare facilities available to the public sector and ensuring adequate medical supplies. The Covid-19 pandemic requires a national response and a coordinated, and integrated national approach utilising the national resources available in the public and private health systems in the national interest.
These efforts in pursuit of the national interest must be accompanied by the adoption of a uniform, standardised priority-setting framework, which applies to both the public and private healthcare systems.
There is no doubt that the impact of Covid-19 on all spheres of South African society will be devastating. However, the epidemic also brings opportunities for intersectoral action and social mobilisation across the public/private divide. Establishing a nationwide healthcare priority framework for Covid-19 presents an important opportunity to put in place a building block on the road to universal healthcare in South Africa.
First: The alternative of delegating that decision to the private or public sectors, or to individual institutions, or to a clinician’s intuition in the heat of the moment cannot be acceptable.
There is no delegating authority as far as we know. The Department of Health, can to some extent, delegate to the public system, but the private sector has been pretty sacrosanct up till now. Furthermore, it is fragmented into many unwieldy schemes, hospital groups etc. Yet it has massive human, infrastructural and material resources that have to be pooled with the public sector’s resources and then allocated through some fair process.
Is it even possible to reach a process of resource allocation in such a context?
The situation calls for both sectors to come together as one, hopefully in the spirit of solidarity. But if they dig their heels in, it should probably come to commandeering some of them, including the human resources to do “national service” as a key step towards fair resource allocation. We think we should be explicit about this.
Second: What kind of a country do we want to emerge from all of this? We think it is absolutely clear that we have not promoted fair allocation and equity in the democratic era. We speak here about both our unequal access to the Social Determinants of Health (water, sewerage, housing etc.) and our broken health system. Neoliberalism plus corruption have got us into this mess. DM
Geetesh Solanki is Specialist Scientist at the Health Systems Research Unit, SA Medical Research Council (SAMRC); Reno Morar is Chief Operating Officer, University of Cape Town; Louis Reynolds is with the People’s Health Movement; Neil Myburgh is Acting Dean of the Dental Faculty, University of Cape Town; and Leonard Gentle is a former trade unionist and former research translation consultant to the SAMRC.
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