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Equity Issues in Vertical/Horizontal Integration for Multiple Intervention Programs Print E-mail

Using Ethical Analysis to understand Policy Processes: Implications for Multiple Intervention Programs

Speaker: Colleen Varcoe

The first speaker to discuss equity issues in MIP integration, Colleen Varcoe, clarified that she was neither an ethicist nor a multiple intervention practitioner, but was bringing a different perspective and skill set to the symposium discussions. Varcoe explained that she was looking at ethical analysis and how health policies really work from the perspective of theorists from contextual, relational, and feminist ethics, not from the dominant biomedical paradigm used in health. Her interest in policy is focussed on how research and policy making related to violence against women can have a broad impact on understanding and reducing violence.

Varcoe described a qualitative study that set out to analyze priorities and the policy-making processes of senior government personnel in the BC government. The principal issue was to examine how ethical analysis could enhance socially-just policy. A key aspect of the research was to understand the relationship between evidence and policy. Although the literature confirms the non-linear nature of this relationship, it is not always well understood in practice. The study found that, while equity might be a priority for the interviewed policy makers, their role was not only to inform policy, but also importantly, to inform and manage public outcry and public understanding, and to inform how problems are framed. There are many places where evidence can be helpful and these policy makers repeatedly said that only when there is intelligent evidence out in the public realm, and when that same evidence informs policy from the researchers’ perspective, will things move forward.

Her study also found a diversity of understanding of equity in relation to health care that represented a continuum from distributive to social justice. However, the predominant emphasis on equality of access was reflective of the distributive justice perspective. Varcoe suggested that this was attributable to several factors including the Canada Health Act; the biomedical organization of government (and embedded verticality); an emphasis on economic efficiency; and the “course correction” approach to government (i.e., fix small problems that maintain the status quo but do not attend to the broader social determinants of health).

Varcoe pointed to windows of opportunity for a more equitable approach to public policy, such as whole government/full landscape approaches but emphasized that grass roots commitment is still essential. She commented that there is a recognition of the ineffectiveness of silos; a beginning recognition that inequities are not good for business; and increasing attention to the importance of participatory democracy in policy making. She recommended proactive actions such as: 1) engaging a wide spectrum of stakeholders earlier; 2) early examination of language, values and conceptual meanings; 3) early identification and analysis of policy context, relevant policies and policy questions; 4) early analysis of dominant and competing values in public discourse; and 5) creating and taking advantage of windows of opportunity.

Varcoe concluded her presentation by setting out five important questions that participants should consider:

  • How can these understandings inform strong policy interventions?
  • How can policy context be treated as enabling structures and conditions?
  • Can ethical theory be a useful adjunct to policy change theories?
  • Can sustainability anticipate short policy cycles? and
  • When does collaboration become collusion, especially as related to economic efficiency?

Economics And Integration: Is There A Choice Between Efficiency And Equity?

Speaker: Stephen Birch

Stephen Birch concluded the Symposium presentations with a discussion about the tradeoffs between efficiency and equity and how that process impacts integration in multiple interventions programs. He began with an overview of the challenges of evidence-based medical research, calling his view “evidence-based medicine unplugged” (Birch, 1997). He then provided a brief explanation of multiple intervention programs. MIPs aim to maximize wellbeing; overcome problems of the traditional medical research approach; provide customized approaches; and respond to reality. Birch went on to present an economic perspective suggesting that MIPs “reflect multiple ‘inputs’ in the production of health, illness, and recovery in populations.”

Birch introduced three economic concepts germane to his presentation – scarcity, choice, and opportunity cost, explaining how they relate to efficiency and equity. Equity is a subjective consideration about fairness, and although all studies involve equity, the equity principle is often hidden or implicit. It can be misused to meet economic, not social justice ends in systematic economic evaluations of health care programs. Birch commented that the opportunity cost of equity is often not considered, leading to the question of whether (or when) equity improvements are warranted.

With respect to equity and efficiency, it is important to identify specific social objectives (that maximize benefits to society) first and then incorporate equity into these objectives. These should be built into evaluations to ensure systematic consideration of alternative programs in terms of precise social values generated from outcomes, thereby “being efficient in producing equitable outcomes.” Birch then discussed access to care, seeing it as an ambiguous concept at best. ‘Reasonable’ access has been a principal objective of many health care systems, with the emphasis being on demand-side problems such as ability to pay and use of service. After 50 years, we still have unequal use of services and access to care, and in some countries, inequalities are increasing under this policy. For example, when national comparisons of high and low income people who needed physician or dental care but didn’t consult a provider due to cost are examined, noticeably more of the low income group do not consult providers.

Birch viewed access not as use, but as empowerment. He defined empowerment as having the freedom to use care when needed, with integration of demand and supply side factors. In addition, empowerment occurs when individual capacity to benefit from health care services is not only based on system funding and delivery capacity, but also on policy-makers’ and managers’ obligations to empower individuals and families. He presented a framework called “The Triple ‘A’ Framework” to explain the factors that access is based on: affordability, availability, and acceptability. Affordability is determined by the full cost to individuals and the ability to pay that cost. Not only the size of payment but also the form (how one pays) and expected time patterns of income impact affordability. Availability is determined by location and timing of services and need, and includes transportation infrastructure and services, health care service configurations, and provider willingness to contribute to programs. Acceptability is determined by attitudes and expectations of providers and clients. It relates to mutual respect and client autonomy and the perspectives underlying service planning and evaluation. Importantly, it represents a shift from a normative approach, based on what should be expected, to a positive one based on what can be expected.

Birch concluded with his views on single intervention failures and equitable access. He identified impediments related to the Triple A Framework and the multiple factors that make improving equitable access by public funding a challenge. These included prohibitive additional costs to the user (affordability); insufficient fee levels to attract providers (availability); and stigmatizing criteria for eligibility (acceptability). In addition, there is a failure to recognize multiple interacting determinants. What we have instead are “unprecedented public subsidies for the middle class.” Birch left participants with the message that there is no tradeoff between equity and efficiency. Effectiveness based on multiple dimensions (the Three As) means that improving access will require multiple integrated programs.