Benchmarks of Fairness for Health Care Reform: A Policy Tool for Developing Countries
Daniels, Norman, Bryant, J., Castano, R. A., Dantes, O. G., Khan, K. S., Pannarunothai, S., Bulletin of the World Health Organization
Voir page 748 le resume en francais. En la pagina 749 figura un resumen en espanol.
A new tool for policy analysis
We report here on progress towards developing the benchmarks of fairness (1) into a policy tool that will be useful in developing countries for analysing the overall fairness of health care reforms. Fairness is a many-sided concept, broader than the concept of equity (2-4). Fairness includes equity in health outcomes, in access to all forms of care and in financing. Fairness also includes efficiency in management and allocation, since when resources are constrained their inefficient use means that some needs will not be met that could have been. For the public to have influence over health care, fairness must also include accountability. Finally, fairness also includes appropriate forms of patient and provider autonomy. The benchmarks help the integrated examination of objectives that often involve tradeoffs with each other, which requires looking across disciplinary, boundaries in a systematic way.
When originally developed and presented in the United States, the benchmarks had an ethical rationale that appealed to a theory of justice and health care (1, 5). The central thought is that disease and disability reduce the opportunities open to individuals, and that the principle of equal opportunity provides a basis for regulating a health care system. The same theory can also be extended to look beyond the point of delivery of health care to the social determinants of health (6).
The objection might be raised that this liberal democratic, rights-based account is too culturally limited to provide an international framework for the benchmark approach. Nevertheless, in our work in four developing country sites, which differ considerably in their political, cultural and religious backgrounds, we found a wide agreement on the benchmarks without extensive discussion of an underlying ethical framework. Participants were introduced to the equal-opportunity theory but it played no explicit role in producing agreement on benchmarks. Because of our focus on fairness, we also avoided some culturally sensitive issues, such as abortion, euthanasia, and the use of human and fetal tissues or organs. We did discuss the fact that the weight or priority given to different benchmarks might vary in different countries depending on some cultural beliefs. In our workshops, these variations were not significant. We deliberately refrained from giving benchmarks an equal weighting in all countries.
The benchmarks are relevant, because there is rapid reform of health care systems around the world as a result of changes in economic and political systems, economic growth, or previous failures to meet population needs. External agencies have played a large role in offering incentives to privatizing and decentralizing reforms. In all these contexts, however, reforms are usually debated without a systematic evaluation of their impact on the fairness of the resulting system. Privatizing and decentralizing efforts may aim at adding new resources and circumventing inefficient bureaucracies. The private sector, however, often competes with and weakens the public sector, and it requires strong and efficient regulation if it is not to undermine equity. Promoting some kinds of efficiency without attention to other dimensions of fairness will not improve fairness and may undercut it. The benchmarks provide a framework for evaluating the effects on fairness of these and other strategies.
The aim of the benchmarks is to encourage debate on the specific, interacting effects of the reforms being compared, not simply to produce a "report card" with numerical "grades." Consequently, for the necessary objectivity it is essential that a rationale, containing reasons and evidence, be provided for the score on each relevant criterion. Rationales might not be needed if we only included criteria with measurable magnitudes, such as the proportion of the population receiving some particular service or having some particular health status. …