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.

South Africa: a 21st century apartheid in health and health care?

The current crisis in health and health care in South Africa results from a combination of factors: the legacy of apartheid; issues of poverty, income inequality and AIDS; and the more recent influence of neoliberal economic policies and globalisation. The legacy of apartheid has meant that both health and health care are skewed along racial lines, and 60% of health care expenditure goes largely to the 14% of the population who have private health insurance. A more equitable distribution of health care resources will result from the promised National Health Insurance, the details of which are still being debated. The AIDS epidemic in South Africa was exacerbated by the government not introducing antiretroviral treatment (ART) until the early 2000s. In 2005, it was estimated that more than 5.5 million South Africans were infected with HIV. Now all those with a CD4 count below 200 are eligible for ART. A better health service will not be enough to improve the health of South Africans. A whole-of-government approach is needed to address the persistent problems of poverty and inequality.

Addictions and social compassion.

Addictions are, to a considerable extent, born of disadvantage and deprivation. That is not the whole story; there are other factors in place, some of which are in individuals as individuals. In terms of the social determinants of ill-health, addiction and poverty are highly correlated. There is also a literature that investigates whether additionally inequality is bad for our health. The hypothesis put forward in this paper is that in a caring society being poor is not good for health but it is not so bad as being poor in an uncaring society. Societies that claim to be based on social solidarity, as do the Scandinavians, tend to be highly taxed with consequent large public sectors. In Australia, taxation is very low relative to most OECD countries. The idea of tax for redistributive purposes is not seen as politically palatable to the Australian electorate. There is a need to rethink the public health response to addictions. Epidemiology and biostatistics dominate too much. Public health needs to accept the depth and width of the challenge that a concern for and acceptance of the role of social capital offer. The paper discusses this in the context of community autonomy and public compassion and the need for societies to 'own' addictions and addiction policy in public discourse. More compassion will not 'solve' problems of inequalities and addictions. The point is rather that it is a good place to start.

"Mutual" obligation in Indigenous health: can shared responsibility agreements be truly mutual?

Shared responsibility agreements between the Australian Government and Indigenous communities are based on a concept of mutual obligation but have overtones of paternalism and imposition. The nature and extent of choice in any such agreements need to be established.

Whose health service is it anyway? Community values in healthcare.

There is growing interest in involving the public in decisions about healthcare provision. Citizens' juries, whose members were randomly selected from the electoral roll (rather than derived from consumer interest groups), have been trialled in Western Australia. When asked to take a community focus, presented with balanced evidence and given time to discuss and deliberate, the juries were able to identify and debate issues of broad principle, such as equity. Such issues seem to be best handled by referring to community values. Any public consultation process should provide sufficient information, opportunity for reflection and deliberation, and recognition of the scarcity of resources.