2 Background: philosophical and theoretical perspectives on equity

Discussions on how to define equity in health care make reference (implicitly and explicitly) to five key philosophical perspectives on equity. The main principles of these perspectives are briefly presented here to set the context for further discussion of the different conceptions of equity in health care, to demonstrate that discussions of equity in health care are complex, that different views reflect recognisable ideologies and that it is important to understand the basic features of such ideologies. Conflicts between different definitions of equity in health care are shown here to stem from conflicts between these underlying ideologies.

Libertarianism focuses on rights, claiming that if everyone is entitled to the goods they possess, a just distribution is whatever distribution results from people’s free exchanges of those goods. Utilitarianism judges actions to be right or wrong by assessing their impact on total utility. The morally correct action is the one which produces the greatest amount of happiness for society (Kymlicka, Reference Kymlicka2002).

Rawls’ theory of social justice proposes that behind a ‘veil of ignorance’ (Reference Rawls1971: 12), where no one knows his/her place in society, rational and self-interested individuals would choose the ‘difference principle’ to govern distribution in society. This principle requires all inequalities to be judged in terms of securing the benefits for the least advantaged person in society.

‘Equality of opportunity’, described as the prevailing justification for economic distribution in our society (Kymlicka, Reference Kymlicka2002), requires that people should not be “advantaged or hampered by their social background and that their prospects in life should depend entirely on their own effort and abilities” (Baker et al., Reference Baker, Lynch, Cantillon and Walsh2004: 25). Inequalities in income, power and other domains are unfair if people are disadvantaged or privileged by arbitrary and undeserved differences in their social circumstances (Kymlicka, Reference Kymlicka2002).

As proposed by Sen (Reference Sen1992) all of the above theories are egalitarian in some form (e.g. libertarians demand equality of rights, utilitarians assign equal weights to everyone’s utility and Rawls’ theory requires equal liberty and equal distribution of social primary goods). If all people were identical, equality in one space (e.g. income) would be congruent with equalities in other spaces (e.g. utility). A consequence of human diversity is that equality in one space tends to go with inequality in another. The crucial issue, as argued by Sen, is about the reasonableness of the ‘base’ space that is chosen: “ ‘Equality of what?’ is indeed a momentous – and central – question” (1992: 21). Sen’s preferred response to that ‘momentous’ question requires equality in the space of people’s capabilities to achieve valuable beings and doings, or functionings (e.g. adequate nourishment, good health, happiness, self-respect, etc.), which make up their well-being (Sen, Reference Sen1992).

The ‘equality of what?’ question provides a framework for assessing alternative conceptions on equity in health. Theoretical analysis has focused on the implications for health of securing equality in a range of alternative spaces (e.g. rights, needs, access, health status; Culyer and Wagstaff, Reference Culyer and Wagstaff1993; Culyer, Reference Culyer1995), and each of these goals have conceptual links with the above philosophical perspectives on justice and equality.

Focus on equality in rights and allowing health care to be purchased in the market according to the individuals’ willingness to pay fits with the libertarian perspective (Culyer, Reference Culyer1995). Distribution of health care according to need can be linked with the utilitarian or Rawlsian theory depending on how need is defined. A utilitarian perspective would place equal weight on the health of everyone and would seek the maximum level of health in society. Where need is defined in terms of capacity to benefit, the utilitarian might seek distribution of resources in favour of those with the greatest capacity to benefit from that care.Footnote 1 A Rawlsian perspective is assumed to be concerned with the health of the worst-off individual (Olsen, Reference Olsen1997).Footnote 2 Equality of access to health care fits with the principle of equality of opportunity. Equality of health can be linked with Sen’s theory. Where health is an important functioning in a person’s capability set, pursuit of equality in the distribution of health will be an important goal. Strictly speaking, Sen’s theory is ultimately concerned with pursuing equality in capabilities to function rather than equality in the functioning itself. However, it has been noted that applied work in the context of Sen’s theory has focused on equality in actual achievements (i.e. functionings) rather than on capabilities to function (Wagstaff and van Doorslaer, Reference Wagstaff and van Doorslaer2000).

The potential for conflicts between these different goals for equity in health is illustrated by their respective alliance with different and conflicting philosophical perspectives. Allowing health care to be distributed according to willingness to pay risks it being concentrated in the hands of those who are rich enough to pay for it, regardless of their health status. Distributing health care according to need can give rise to different distributions of health depending on how need is defined (i.e. initial health status and capacity to benefit may be distributed differently across the population) (Culyer and Wagstaff, Reference Culyer and Wagstaff1993) and will not necessarily yield equality in other spaces such as health, rights and access. Ensuring equality of access (i.e. equality of opportunity) in terms of cost of utilisation or maximum attainable consumption of health care will not automatically give rise to an equal health distribution (Culyer and Wagstaff, Reference Culyer and Wagstaff1993). For each of the distribution principles outlined, unless people have equal willingness to pay, equal health endowments and equal capacity to benefit from health care, acceptance of equality in one space (e.g. rights, needs and access) will potentially lead to inequality in other spaces.

3 Equity in health-care policies and systems

The presentation of philosophical perspectives on equity, and of the definitions of equity in health, provides the necessary background for assessing equity principles in national health policies.

Many policy statements on equity have conflicting principles with ambiguous definitions. To illustrate, the central objective of the English National Health Service (NHS) is to ensure equal access for equal need. There are other objectives to improve health outcomes, reduce inequalities in health outcomes and others, but commentators describe these as secondary to the overriding objective of securing equal access for equal need (Oliver, Reference Oliver2005). Yet the focus on access in the core objective conflicts with goals for outcomes in the secondary objectives. In the Canadian system, there is emphasis on universal access, and on ensuring distribution of care on the basis of need rather than any other factor (e.g. wealth, region, etc.; Commission on the Future of Health Care in Canada, 2002), although need itself is not defined. As outlined in theory, ensuring equal access to care can conflict with efforts to distribute care according to need.

The way in which equity is defined has implications for the structure of the health-care system. In a libertarian system, health care is distributed in the private market according to willingness to pay (i.e. using out-of-pocket or private health insurance funds). In this context, access to health care is considered to be a part of the society’s reward system and individuals can use their income/wealth to gain as much of this reward as they wish (Wagstaff and van Doorslaer, Reference Wagstaff and van Doorslaer2000). In this case, there is a direct link between payment for and consumption of services. Individuals have exclusive rights to consume the health care that they have paid for.

Alternative, non-libertarian ideologies give rise to non-market-oriented systems where consumption of health care is separated from payment for that care. In these systems, health care is publicly provided, funded to some degree from pooled revenues collected from the population. Each of the non-libertarian ideologies discussed earlier can be seen to require some degree of government intervention. Ideologies relying on public provision have been loosely labelled ‘egalitarian’ theories, with the common characteristic that there is separation between ability to pay for, and access to, health care (Williams, Reference Williams1988).

Characterisations of international health systems often take the public or private distinction as a reference point for identifying different archetypes (McPake and Normand, Reference McPake and Normand2008) implicitly adopting the same broad dichotomy between libertarian and egalitarian viewpoints (Williams, Reference Williams1988). In practice, it is difficult to identify a system that is purely private (libertarian) or purely public (egalitarian). There are various ways in which these two ideologies can be combined in a health system and Williams (Reference Williams1988) has described three archetypes.

In a single system with mixed motives, egalitarian principles direct the provision of some aspects of the system and libertarian principles direct other aspects of the system. Access to hospital treatment might be delivered on the basis of need, whereas access to primary care is determined by willingness to pay, although Williams argued that a sensible system would be difficult to achieve if each level of care were run on a different principle. Others have suggested that not all aspects of health care need to operate on an egalitarian principle. Complementary services provided by hospitals (e.g. ‘hotel’ benefits of private or semi-private rooms) could be allocated on a libertarian basis (Culyer and Wagstaff, Reference Culyer and Wagstaff1993). However, Williams noted that separating amenity aspects of care from the clinical aspects of care is complicated and concluded that trying to cope with conflicts like these “in a single organisation would seem to be rather a horrific task” (1988: 180).

An alternative system can exist with two independent systems operating alongside each other. The success of such a system will depend, to some degree, on who is required to contribute to the costs of the public system and who uses the public system. Richer people will opt out of the public system if standards in the private system are higher. Medical professionals may have an incentive to ensure that standards in the public system are kept relatively low if they can make more money in the private system. Consumers in the private system may also wish to keep standards in the public system low (in order to minimise their contributions) if they do not intend to use the public system. It is difficult to find examples of such systems. Many Latin American countries have large private sectors operating alongside public (and social insurance) systems.

Many health systems gravitate towards the third archetype, which allows one system to predominate with the other permitted a minor role (Williams, Reference Williams1988). In this case, a predominantly private system (e.g. US) will “moderate the ruthlessness of the ‘if you can’t pay, you can’t have’ rule by organising a small public system to take care of the poorer people” (Williams, Reference Williams1988: 181). A predominantly public system (e.g. UK NHS; European Observatory, 1999) may allow a small private system to function in order to allow richer people to purchase health care that is not available in the resource-constrained public system (e.g. a faster service; a non-essential procedure).

4 Equity in the Irish health-care system

5 Is Ireland different?

The challenges of aligning health-care policy, structure and implementation to a consistent definition of equity are not unique to Ireland. There is a role for similar analysis in other countries and for further comparative work in this area. However, there are specific features of the Irish experience that set it apart in an international context when examining equity in health care. As outlined earlier, the Irish system resembles the mixed motives system described by Williams (Reference Williams1988), while in most European countries the public system (e.g. tax-based financing, compulsory health insurance) takes the dominant role (Thomson et al., Reference Thomson, Foubister and Mossialos2009). Ireland is unusual in the international context with the application of libertarian principles to primary care for the majority of the population (Smith, Reference Smith2010). Many of the current complexities and structures in the Irish system have evolved from a long history of incremental policy decisions. The policy process has been influenced at different stages by economic and non-economic factors, as well as by specific institutions. Fiscal shortages in the late 1980s had a negative impact on acute hospital care in terms of long waiting lists and bed closures. Hospitals gained additional revenues by admitting private patients, and hospital bed closures were concentrated on public rather than private beds (Wren, 2003), which in turn contributed to a growing demand for private care in the system. At various junctures, proposals were made to provide free primary care to the whole population but these were repeatedly rejected, in particular by a strong alliance between the Catholic hierarchy and the medical profession (Barrington, 2000). The recent withdrawal of automatic medical card entitlement for individuals aged 70 years and above was motivated by the need to reduce costs.Footnote 5 These examples illustrate how policy decisions that have important equity implications can be taken without clear reference to the guiding equity and other principles of the system.

The problem is of course compounded by the inconsistencies in how equity is defined in the governing policy. The complexity of the equity concept makes it difficult, but not impossible, to outline a coherent statement on equity in health-care policy, and to subsequently align health-care structures with the policy objectives. The analysis here has provided a roadmap through the various different conceptions on equity. This can be used to systematically guide policymakers on the choices available between different principles to underpin the health sector.