If you think medicare put an end
to inequalities in Canadian healthcare, it's time to
think again. Speakers at a pair of conferences, held
last month in Montreal, found our system woefully unfair
and at risk for greater deterioration. The notion of
distributive justice was a hot topic at both the Canadian
Health Services and Policy Research annual conference
and International Conference on the Scientific Basis
of Healthcare.
The World Bank defines equity
in healthcare as "fairness in the allocation of resources,
treatment, or outcomes among different groups." This
is exactly what Bruce Brady of the Canadian Coordinating
Office for Health Technology Assessment (CCOHTA) is
looking out for in his investigations. In particular
he's scrutinizing some of the inequalities that are
seemingly inherent in the way we evaluate drugs and
health technologies.
When looking at preventive measures
for children, for example, a low present benefit has
to be weighed against high future benefit. Crudely,
this means that today's taxpaying adults would be financing
measures that will only benefit later generations.
THE
NUMBERS
Should we prioritize products that bring a little benefit
to many, or those that deliver great benefit to just
a few? And exactly who stands to benefit from the therapy?
These are precisely the kinds of questions policymakers
should ask. Currently, assessments rarely define what
age, sex, ethnicity or socioeconomic group a therapy
targets most. "Only one-eighth of all evaluations, according
to a 2001 study by Sassi et al, reported any information
on who benefits from a technology," says Mr Brady.
Dr Wendy Ungar, from the Hospital
for Sick Children in Toronto, studied asthma control
among children with and without prescription drug insurance
coverage (either provincial or private). She found that
children in the uninsured group had more frequent exacerbations
leading to hospital visits — in other words their
asthma was more likely to be out of control. The reason
for this is disturbing. When parents arrived at the
pharmacy with prescriptions for cheap rescue meds (salbutamol)
and relatively more expensive controller meds they quite
often picked up only the salbutamol — they simply
couldn't afford the more expensive drugs for their children.
Steven Lewis, former CEO of Saskatchewan's
Health Services Utilization and Research Commission,
feels we really must look closely at distributive justice
in health status, not just healthcare. "The gradient
in health status runs parallel to socio-economic status,
and healthcare in itself cannot eliminate major health
disparities," says Mr Lewis. "But how do we actually
do it?" he asks. "It would take a major sea of change
from the origins of medicare, away from the needs-based
idea of medicare towards a population health model based
on more equal distribution of health."
THE
LEAST AMONG US
For starters, we would also need to move away from a
rights-based system that was reinforced by the Quebec
Supreme Court decision that ruled in favour of Dr Chaouilli
and Mr Zeliotis. It's believed the decision will allow
patients to skip healthcare queues if they can afford
it. Mr Lewis sees the challenge faced by governors of
the healthcare regions, and of course the governments
responsible for them, as one of taking distributive
justice issues into consideration without alienating
the middle class. "Whether or not Canada's healthcare
system is put to work to reduce health disparities will
rest on whether there is widespread public commitment
to greater equality in health status," he says.
Mr Lewis wasn't the only one scandalized
by the Supreme Court decision. Martha Jackman of the
University of Ottawa sees the ruling as a major challenge
to the goal of distributive justice in healthcare and
health. "The poor and sick cannot procure private insurance
and thus the remedy to the human rights violation found
in the case," she says.
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