Health Care for South Africa's Children: Constitutional Guarantees and Policy Options
Willem A. Landman, D.Phil., and Lesley D. Henley, Ph.D.
In 1994 Nelson Mandela's government came to power in South Africa, ending three centuries of racially-based minority rule which had shaped the country's institutions and social practices. A new constitution that includes a Bill of Rights provides the framework for South Africa's democratic reconstruction.
Macro-allocation of health care resources is an enormous problem facing the transformation process in South Africa. South Africa has a mixed public/private health care system in which the public sector plays an indispensable coordinating and material role. Difficult resource allocation decisions must be made as public health care delivery moves from "status quo" rationing by default to a more rational system which reflects the demands of the constitution, in a context of extreme health care need and resource scarcity.
What does this mean for South Africa's children? Any attempt to define a rational health care policy by setting priorities for macro-allocation of children's health care resources faces formidable tensions, some of which arise from the peculiar facts of the South African situation.
Crucially, public policy debate in South Africa is shaped by the new Constitution, an egalitarian document with equality as its focus and organizing principle . According to the Bill of Rights, children under 18 years are entitled to "basic health care services." Significantly, in the case of children, this socioeconomic right is not expressly subject to available resources, which suggests that the state has a duty to fulfil this obligation even if it means diverting funds from elsewhere in the national budget.
The Constitution gives no content to the term "basic health care services." Does it refer only to a fixed package of primary health care services, or does it include health care services for children with special needs requiring specialized care that is basic in the sense of being necessary for survival or adequate functioning? Providing "basic health care services" will likely require setting and implementing priorities beyond the bare minimum of essential primary health care. Arguably, a clause in the Bill of Rights forbidding unfair discrimination on grounds that include disability supports this interpretation. Additionally, on an international level, the South African government has health-related obligations as a signatory to the Convention on the Rights of the Child.
Recognizing its constitutional and international legal commitments, the South African government published a White Paper stating its moral criteria for the future health care of children, namely, equity, efficiency, cost-effectiveness, quality, public participation, and priority to the poorest and the geographically disadvantaged. Moreover, the government has taken specific practical steps, beginning with the introduction of free health care for all children under age six and pregnant women. The first stage of a national health service with universal access and a focus on primary health care was introduced in 1996. Simultaneously, health care resources are being redistributed from tertiary to primary and secondary care. In turn, ability to pay has become the sole criterion for receiving certain beneficial treatment no longer affordable in the public sector. This is problematic since it disadvantages poor children.
The combination of conflicting constitutional demands and moral commitments, great health care need, resource scarcity, and lack of a clear definition of "basic health care services," presents seemingly intractable tensions for public policy on health care for children, especially those with special needs. We mention five overlapping tensions that relate to questions such as the following: How do we value equally the lives of children with acute, preventable conditions and those with complex, long term, often costly, conditions? How do we achieve a just allocation of health care resources for children beyond the minimum of essential primary health care?
The first tension is the fundamental conflict between two basic moral values that typically characterize distributive choices, namely, equality of basic opportunities and overall well-being. If we distribute scarce resources to give each individual child, as far as reasonably possible, equal basic opportunities with all others, then we would likely fail to maximize the overall well-being those resources could generate, in the form of extension of life or improved quality of life, since some children would require much greater resources than others. Conversely, if we distribute resources to extract maximum overall benefit, then some individuals may not enjoy equal basic opportunities, because that would require a sub-optimal overall use of resources. The next three tensions illustrate this underlying philosophical conflict, as well as the need to balance and weigh them in practice.
The second tension is between providing low cost, primary health care, and providing high-cost health care for children who require more resources, for example, the chronically ill. Treatment of a relatively small number of children with chronic diseases, such as cystic fibrosis and cancer, is expensive, but may be justified when cost is weighed against other morally relevant factors.
Third, severity of disease (however conceived) presents tensions. The widespread social conviction that a worse-off individual has a moral claim to relatively more health-care resources than a better-off individual, appears to be incompatible with maximizing effective overall treatment outcomes while minimizing overall costs.
Fourth, disease prevalence varies, but do numbers count morally? If all things other than prevalence of disease were constant, giving greater numbers, in and of themselves, priority over smaller numbers would seem to contradict the requirements of equality of basic opportunities. On the other hand, if disease prevalence is the only non-constant variable, what other than numbers could be the basis for a rational or non-random decision?
In practice, all these morally relevant considerations will have to be balanced and weighed against one another since none has absolute priority .
Public policy decisions about ranking for macro-allocation need to take rational account of these four tensions. But who should make these decisions, and how? If ranking decisions follow a democratic process, other tensions are likely to arise: first, between democratic decision-making and popular prejudices against vulnerable groups of children (for example, with HIV/AIDS), and, second, between different social values that must be balanced in the rationing process (forcing tragic choices between individual human life and the overall good, or requiring that a price be put on life).
(This article is based on Landman WA, Henley LD. Tensions in Setting Health Care Priorities for South Africa's Children. "J Med Ethics" 1998;24:268-273. Lesley D. Henley is a Senior Lecturer in the Department of Paediatrics, Institute of Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.).
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