Introduction
This study will examine government policy towards the achievement of efficiency versus equity in the provisions of the countrys health service and will prevent recent discussion on the debate surrounding the trade-offs in that area. The contribution that the private sector can make to address issues of Rural Development which is resisted by the public sector wil also be examined.
Finally the contribution of applying the Radical Equality to this debate will be flagged as a possible solution to this dilemma.
Lecture notes for this module define efficiency and equity as;
“…. the term used when society has allocated a level of output and has allocated its resources accordingly….. Equity on the other hand is a system of justice based on conscience and fairness”[i]
Government policy tends to justify a trade of equity against equality on grounds of achieving efficiency in health service provision. The implications of such a policy in rural areas have meant reduced hospital care with larger and more and more hi-tech facilities. This is justified on the grounds of economies of scale with a sparser population spread over a wide area.
The lack of hospital services in rural areas has contributed to the depopulation of rural areas and vice versa as many people especially the elderly who have a greater likelihood of needing such care move to live in urban areas.
While the inefficiency of large hospitals in rural areas is obvious from the point of view of cost and staff resources this shortfall can be complemented to some extent by the provision of outreach type services such as health centres in local areas.
Trade offs of between efficiency and equity would also occur in the types of services provided. The example of free spectacles versus insulin for diabetics is one example. The prioritisation of services for self inflicted conditions such as lung cancer from smoking against other forms of cancer or heart disease in situations where resources are limited and choices have to be made has been suggested by members of the medical profession. As such a policy would increase the efficiency with which prioritised treatments were implemented this would be a classic example of a trade-off between efficiency and equity.
The private sectors have a contribution to make in this area by the provision of health services in rural areas. An initiative by a group of doctors in has been spearheaded by a group of general practitioners in the West of Ireland known as Irish Rural Doctors Ltd..
They have set up a “St. Brendans Village Project” which provides care for elderly people in a local community. Details are available on their website http://www.rural-health.net They describe themselves as addressing problems of rural depopulation not just in health care, but have engaged in other measures such as setting up advance factories.
Other initiatives where the problems arising from the trade-off of equity and efficiency are being ameliorated by private sector initiatives are the provision of nursing homes in rural areas. These measures however are expensive and benefit only a higher socio-economic group and fail to address issues of poverty reduction in rural areas.
Lecture notes for this model acknowledge;
“… Governments tend to favour the centralisation of resources, which places people living in rural areas in a difficult situation when they need health and social services. Any move away from centralism and the geographic concentration of power and control of resources will require new thinking about the trade off between efficiency and equity in resource-allocation decision making.. We also have seen that for the majority of economists efficiency is the primary criterion by which resource allocation decision is judged. An interesting question arises as to whether in some instances; concern with equity should take precedence. Trying to make a judgement on the relative weights to be assigned to efficiency and equity arguments in resource allocation decision making forces us to think about the values that underpin the choices we make about who gets what, and the subsequent implications of those choices we make for the lives of people and communities in rural areas.”[ii]
Recent efforts to create further trade-offs in efficiency against equity by the plan to close regional hospitals and exchange services from regional hospitals with general hospitals have sparked further debate in this area.
The proposals to transfer the accident and emergency service from St. Colmans Hospital Loughlinstown to St. Vincent’s Hospital in Elm Park and provide non-emergency treatment for Wicklow based patients. This was justified on efficiency versus equity logic by efficiency consultants.
The staff however made the point that the efficiency versus equity logic would be better served by retaining the accident and emergency unit in Loughlinstown, which would mean less ambulance time bringing emergency victims for treatment. The treatment of non emergency patients who would require treatment for oncology, cardiac etc in St. Vincents however which was a larger hospital with more sophisticated equipment would be a more efficient use of limited resources.
The writer is not favouring one argument over the other apart from the benefits of rural service provision of A and E of the latter argument, but illustrates both sides in order to demonstrate the debate which is associated around these issues.
It has been shown that health problems are greater in lower socio-economic groupings that comprise a larger spread of the population than higher socio-economic groupings.[iii]
This situation supports the argument proposed by proponents of the Radical Equality philosophy that a reduction of social inequality in society will reduce the cost of providing health services. This is not a equity versus efficiency trade off argument per se but introduces the concept that real efficiency will be achieved when the socio economic divide is eliminated. Real savings will be achieved in our health costs.
Conclusion
The conflict between different attitudes in the health sector in the provision of health care has been presented. The protagonists in this debate are the hospital staff on the one hand and the statutory sector on the other offers little prospect of an agreed solution.
It is suggested by this writer that the philosophy of the Radical Equality movement offers solutions which are applicable to the practical issues involved in dealing with the nations health.
[i] Lecture Notes, Module 27, p3
[ii] Lecture Notes, Module 27, p3
[iii] Lecture Notes Module 27, p5, (TCD 2001, Nolan (1990) and O’Shea (1997)
