Rationing of Health Services During a Pandemic

The COVID-19 pandemic has revealed a lot of health system challenges that cut across financing for the pandemic, service delivery, quality of care and continuum of care for other medical emergencies not related to the pandemic. More recently, the discussions appear to be turning to how the limited resources (human resource for health, equipment, medicines, medical consumables, etc.) can be best allocated to serve the population that needs care, as most countries continue to report increasing numbers of COVID-19 cases on a daily basis.  

This raises the interesting question of rationing during a pandemic. Is this an ethical concept given that the World Health Organization has defined health as a basic human right?

The concept of rationing in healthcare is not new. It has always been used to limit service entitlements in the benefits package in one way or another. In the private sector, this is typically done by using market prices. In that case, people would only subscribe to specific services if they can afford to pay. In the public sector though, the capacity to pay cannot be the driving force given that health is a global public good; and so the principles of need, health maximization, equity and the medical ethic of ‘doing no harm’ play major roles here.

However, in this ongoing pandemic, these core principles appear to have been ‘ignored’ given the new realities – the sheer magnitude of the cases being diagnosed on a daily basis and needing healthcare, compared with the available resources to take care of them. Initially, the population in the eye of the storm for this pandemic was elderly but with more data from other countries experiencing the pandemic, this has increasingly stretched to involve all ages and all health status, raising ethical questions about how decisions on who gets a ventilator, when and if at all, health workers should be tested, who should be prioritized for a hospital bed, etc., should be made in the midst of a massive shortage of medical consumables and equipment.

Rationing is typically evident at four levels[1] and all have been experienced in varying extents in this pandemic:

The individual level. Financial barriers posed by the cost of testing and the potential for in-patient care for COVID-19-related illnesses, can lead to individual self-rationing and cause patients to avoid occasions of care because of the associated price tag. This situation further makes a case for universal health coverage, which will prevent situations where patients avoid occasions of care or suffer financial hardship due to the costs associated with seeking care.

At the provider level, rationing is on the basis of the clinical interactions between physicians and patients and is typically implicit1 A good example is a current discourse on guidelines for determining which patients have access to a ventilator in situations where there are multiple patients needing this and very few ventilators. Most hospitals would have an ethical governance process that guides these decisions but is it feasible to follow these processes in pandemics? Can patients or their families appeal this process, providing an extra level of accountability and making the process more transparent? How should this be structured to ensure that the goal of better accountability is achieved without introducing bottlenecks? Then on the opposite end of the COVID-19 crisis, there is also the concern that COVID-19 could be crowding out other essential services. These are key questions and concerns that have to be unpacked as we ride out this COVID-19 storm to provide adequate governance for these decisions in the future.

At the managerial level (provider organizations’ leadership), difficult decisions are being made about the provision of adequate medical supplies for frontline medical staff. Questions on if and how personal protective equipment (PPE) can be re-used and/or improvised are becoming commonplace given the scarcity of these medical supplies. Concerns have been raised about the fact that rationing of these PPEs a) exposes the clinicians to the very infection that they are working to treat, b) puts other non-COVID-19 patients at risk and 3) fails the ethical dictum of ‘do no harm’. Although these concerns are germane, these decisions still have to be made. Perhaps this presents an opportunity for pooled country procurement, potentially across countries and regions, and innovation as hospitals begin to source for improvised PPEs[2] Some of these situations may be less than ideal but provide the basis for fine-tuning responses for the future.

At the policy level, decision-makers in governments and health insurance companies are making decisions about extending benefit packages to accommodate COVID-19. An example of this can be seen in the United States where the government had to make supplementary plans to cover uninsured patients and also mandate health plans to make COVID-19 screening available to all members.

Although this pandemic is showing up the ugly faces of rationing, these tough decisions need to be made as new cases increase and health facilities all over the world, struggle to keep up with the inflow of patients while keeping their clinical staff healthy.  This raises questions about how accountability can be introduced into these life and death decisions that have to be made at split-second intervals. As the pandemic reaches a peak and peters out, experience from frontline workers in different countries will help answer these questions, further define pandemic rationing criteria and the accountability mechanisms that should accompany them.

As we seek answers to these difficult questions, a case needs to be made for what can be done now. The answer lies in social distancing and hygiene measures. These measures will help flatten the curve and reduce the occasions when rationing decisions, that are probably antithetical to the whole idea of health as a fundamental human right and the medical ethic of ‘do no harm’, have to be made.

[1] Keliddar, I., Mosadeghrad, A. M., & Jafari-Sirizi, M. (2017). Rationing in health systems: A critical review. Medical journal of the Islamic Republic of Iran31, 47. https://doi.org/10.14196/mjiri.31.47

[2] Richards, P. (2020). Preparing For COVID-19 In Africa. Available online at https://africanarguments.org/2020/03/30/preparing-for-covid-19-in-africa/ (Accessed: 6th April, 2020)

Rationing of Health Services During a Pandemic

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