Akshay Swaminathan

Mar 31, 2021

7 min read

Healthcare rationing around the world

Approaches to rationing in pandemic and non-pandemic scenarios

Photo by Christina Victoria Craft on Unsplash

These values are not perfect

For example:

  • No explicit considerations for bias and discrimination. Applying these values relies on objective assessment of patient prognosis, but we know that needs of Black patients are more likely to be underestimated by physicians.
  • Prioritizing younger patients ignores dependents of older patients. Although treating a younger patient may save more life-years, this approach ignores information about dependents. It’s unclear whether treating a 5-year old with no dependents or treating a 50-year old with four dependents is the best option in terms of maximizing life-years saved. The authors argue that it’s difficult to obtain information about dependents during a pandemic and that incorporating such information risks making judgments about social worth. One alternative could be to weight life-years towards middle age, when people are most likely to have dependents.
  • No considerations for distributive justice. We know that certain groups, like incarcerated individuals, have less access to medical care than the general population (can’t we at least give prisoners soap?). Should we account for these baseline inequities when deciding how to ration care?
  • Rewarding participation in clinical trials is problematic. The authors suggest that prior participation in research to prove safety and efficacy of vaccines and treatments should be used as a tiebreaker when deciding to treat two otherwise equivalent patients. Opportunities to participate in clinical trials are not equally accessible to everyone, especially minorities and patients with certain conditions (this study found that 35% of COVID-19 clinical studies excluded pregnant women, 10% excluded those with cancer, and 16% excluded women all together).

Applying these values in South Africa, Zambia, India, and the UK

Although the framework described above were intended for pandemic scenarios, it’s interesting to apply the same reasoning to diverse instances of health care rationing.

South Africa: Rationing by committee

Problem: Dialysis is expensive in South Africa ($10k per person per year), so certain health centers ration dialysis to save resources for other forms of treatment.

UK: Rationing by cost

Problem: In the UK, the government provides and pays for health care through the National Health Service (NHS). In order to control spending, the NHS only reimburses medical treatments that are deemed “cost-effective”.

Zambia: Rationing by queue

Problem: In Zambia, antiretrovirals (ARVs) to treat HIV are free, but distribution systems to ensure everyone gets the medication they need are not robust. About 300,000 people across the country take ARVs.

India: Rationing during H1N1

When deciding how to allocate ventilators during swine flu, patients with the best prognosis are given priority. At the same time, policy forbids removing patients off ventilators. Managed to create makeshift ventilators. Essentially they got lucky.