Gavin Mooney

Beyond health outcomes: The benefits of health care

Most of the debate surrounding standards in medical care, issues of medical audit and what constitutes benefit from health care assumes that what is obtained from health care is health and only that. This is an assumption which most health economists at least implicitly appear to endorse. This paper questions that assumption. There are various outcomes beyond health and there are various processes involved in health care about which patients are not indifferent. This paper calls for a fuller investigation as to what it is that patients want from their health services and the adoption of a more pluralistic conception of health care benefits. It is further argued that the objectives of health care systems are those in which citizensqua citizens also have interests and which may be different from those of patients. It is yet less likely that citizens’ interests in health care will be restricted to health.

Equity and efficiency in HIV-treatment in South Africa: the contribution of mathematical programming to priority setting

The HIV-epidemic is one of the greatest public health crises to face South Africa. A health care response to the treatment needs of HIV-positive people is a prime example of the desirability of an economic, rational approach to resource allocation in the face of scarcity. Despite this, almost no input based on economic analysis is currently used in national strategic planning. While cost-utility analysis is theoretically able to establish technical efficiency, in practice this is accomplished by comparing an interventions ICER to a threshold level representing societys maximum willingness to pay to avoid death and improve health-related quality of life. Such an approach has been criticised for a number of reasons, including that it is inconsistent with a fixed budget for health care and that equity is not taken into account. It is also impractical if no national policy on the threshold exists. As an alternative, this paper proposes a mathematical programming approach that is capable of highlighting technical efficiency, equity, the equity/efficiency trade-off and the affordability of alternative HIV-treatment interventions. Government could use this information to plan an HIV-treatment strategy that best meets equity and efficiency objectives within budget constraints.

Neoliberalism is Bad for Our Health

This paper examines some of the concerns that arise from the impact of neoliberalism on health and health care. It also examines the way that global institutions such as the World Health Organization and the World Trade Organization, having been captured by neoliberalism, fail to act decisively to reduce poverty and inequality and thereby do all too little to promote population health at a global level. The paper argues for a greater community focus, with health care systems being seen more as social institutions and placing more power over decision making in the hands of a critically-informed citizenry.

Claims on health care: a decision-making framework for equity, with application to treatment for HIV/AIDS in South Africa

Trying to determine how best to allocate resources in health care is especially difficult when resources are severely constrained, as is the case in all developing countries. This is particularly true in South Africa currently where the HIV epidemic adds significantly to a health service already overstretched by the demands made upon it. This paper proposes a framework for determining how best to allocate scarce health care resources in such circumstances. This is based on communitarian claims. The basis of possible claims considered include: the need for health care, specified both as illness and capacity to benefit; whether or not claimants have personal responsibility in the conditions that have generated their health care need; relative deprivation or disadvantage; and the impact of services on the health of society and on the social fabric. Ways of determining these different claims in practice and the weights to be attached to them are also discussed. The implications for the treatment of HIV/AIDS in South Africa are spelt out.

A Communitarian Approach to Public Health

This paper argues that there is a need to move yet further than has already been suggested by some from the individual to the collective as a base for public health. A communitarian approach is one way to achieve this. This has the advantage of allowing not only the community’s voice to have a say in setting the values for public health but also more formally the development of a constitution on which public health might then be built. It also sees public health as a social institution which can be valued in its own right.

Building on ‘The concept of prevention: a good idea gone astray?’

Background In the article by Starfield and colleagues, it was suggested that the concept of prevention has gone astray. This article aims to extend their ideas. Methods Our methods are to take the Starfield et al article and argue that it is possible and useful to see prevention in a wider context, going beyond prevention in healthcare and viewing prevention as a social good. Results This wider view results in some questioning of the nature of the benefits of prevention. At the same time, it suggests that the values of informed citizens might be more often elicited to help establish the principles underpinning the concept of prevention. Conclusion There is a need for further debate involving various disciplines to examine the concept of prevention in greater depth.

Africanizing the social determinants of health: embedded structural inequalities and current health outcomes in sub-Saharan Africa.

There is a growing interest in health policy in the social determinants of health. This has increased the demand for a paradigm shift within the discipline of health economics from health care economics to health economics. While the former involves what is essentially a medical model that emphasizes the maximization of individual health outcomes and considers the social organization of the health system as merely instrumental, the latter emphasizes that health and its distribution result from political, social, economic, and cultural structures. The discipline of health economics needs to refocus its energy on the social determinants of health but, in doing so, must dig deeper into the reasons for structurally embedded inequalities that give rise to inequalities in health outcomes. Especially is this the case in Africa and other low- and middle-income regions. This article seeks to provide empirical evidence from sub-Saharan Africa, including Ghana and Nigeria, on why such inequalities exist, arguing that these are in large part a product of hangovers from historically entrenched institutions. It argues that there is a need for research in health economics to embrace the social determinants of health, especially inequality, and to move away from its current mono-cultural focus.

Whither health economics

Health economics has had many successes over its nearly half century of modern life. The time has come, however, to move to new grounds and recognise that perhaps some radical re-thinking of this discipline is needed. There are a number of reasons for this. Here we concentrate on just a few. Health economists have done all too little to examine the power structures within healthcare systems, within societies and globally that influence population health. At the same time we have clung to the values of individuals as the bases of our analyses. The negative impact of neo liberalism and its concomitant power structures on population health over the past 30 years has gone largely unchallenged in health economics. We have not done enough to challenge the move to commodify healthcare and to commercialise healthcare systems. We have cried market failure in healthcare and seemingly sought to break away from market economics. Yet the individualism of the market place has been retained in our analyses. We needed to say more about what should replace the market. A switch of power in healthcare away from existing stakeholders to the community is needed, with a building of social solidarity supported by analyses of the values that the community want by way of health and healthcare. This suggests treating healthcare systems and public health as social institutions and not just producers of the ‘commodity’ health. The value base has remained, as in the neo classical economics that health economists have sought to leave behind, the aggregation of individual values. The power that the medical profession has within healthcare is not something we would want to challenge in itself. What we would challenge is the way that power is exercised and its influence on resource allocation within healthcare. This has resulted, in Australia at least, in an inefficient emphasis on resources going to the teaching hospitals at the expense of the rest of the system. The economics of the social determinants of health is largely a neglected area (but see for example Evans et al.) and with it the issues around the distribution of power within societies that so often contribute to the two major social determinants namely poverty and inequality. For example at the iHEA world conference of health economists in Copenhagen in 2007, of 840 papers there were, at most, 12 for which the title suggested a concern with income inequality and health. It is crucial to understand how power is exercised in healthcare, in other words, to grapple with the political economy of healthcare. The same is no less true with respect to power in societies more Authors rarely refer back to the limitations section in the discussion, but it should not be up to the reader to read and remember the limitations so that they can then interpret the results and discussion. This is the authors’ responsibility. What happens all too often is that the limitations are acknowledged, and then put aside. As a result, skewed and bias interpretations proliferate throughout the manuscript. Results are then cited in other publications, based on what might be erroneous conclusions. Research is developed that is not based on a sound foundation and that can, over time, lead our science down an invalid path. We aim to publish only papers with the highest standard of rigour, but public health faces a difficult terrain. We conduct studies with communities that are difficult to contact so we get smaller than ideal sample sizes. We work with hard-to-reach groups or busy professionals and get low response rates to surveys. The longitudinal work and intervention studies are affected by attrition when participants cannot be followed up. If the topic is important to public health, and under-represented in the literature, even a compromised study adds to the knowledge base and may be worth publishing. But conclusions drawn from such papers have limitations. The question is where and how to address these methodological compromises and limitations. Some journals expect limitations to be addressed at the end of a paper. However, readers who start to read a paper that has a clearly compromised method may feel so dismissive of the research that they do not read on to a limitations section at the end of the paper. We would like to recommend that the limitations be addressed in the Methods section. We need to know that researchers have done their best to meet high methodological standards, we need to know why this has not been possible, and we need to know why it is still worthwhile continuing. This disarms the reader (and the reviewers) of the paper, encouraging them to proceed through a paper that promises to be clear about the limitations of the findings when they are discussed again towards the end of the paper. As the Journal continues to address this issue, we are considering requiring authors to also state the limitations in the abstract. This will highlight to the reader from the start issues that occurred and help to frame the results of this study. It is our hope to increase the scientific validity of results reported in this Journal.

Social Health Insurance: To Each According to His Needs; From Each According to His Means—but What Might That Mean?

Despite the substantial literature on the financing and benefit incidence of social health insurance, the principles underlying such schemes are little debated. This article examines one of these key principles: to each according to his needs; from each according to his means. The authors discuss both sides of this principle at a conceptual level. On the needs side, they examine the issue of vertical equity. The approach of “communitarian claims” is proposed, both for eliciting the components of need and for determining the relative weights to be attached to the vertical dimensions of equity in health service delivery. On the means side, the authors also look to communitarian claims to assist in determining who should bear what burden in paying for social health insurance. They argue that with respect to the concept of “from each according to his means,” it is useful to incorporate an element of willingness to pay, but meaning here the communitys willingness to pay.