Access, equity and the role of rights in health care

Modern health care rhetoric promotes choice and individual patient rights as dominant values. Yet we also accept that in any regime constrained by finite resources, difficult choices between patients are inevitable. How can we balance rights to liberty, on the one hand, with equity in the allocation of scarce resources on the other? For example, the duty of health authorities to allocate resources is a duty owed to the community as a whole, rather than to specific individuals. Macro-duties of this nature are founded on the notion of equity and fairness amongst individuals rather than personal liberty. They presume that if hard choices have to be made, they will be resolved according to fair and consistent principles which treat equal cases equally, and unequal cases unequally. In this paper, we argue for greater clarity and candour in the health care rights debate. With this in mind, we discuss (1) private and public rights, (2) negative and positive rights, (3) procedural and substantive rights, (4) sustainable health care rights and (5) the New Zealand booking system for prioritising access to elective services. This system aims to consider: individual need and ability to benefit alongside the resources made available to elective health services in an attempt to give the principles of equity practical effect. We describe a continuum on which the merits of those, sometimes competing, values-liberty and equity-can be evaluated and assessed.

Self-exclusion from health care in women at high risk for postpartum depression

Background A significant proportion of women who are vulnerable to postnatal depression refuse to engage in treatment programmes. Little is known about them, other than some general demographic characteristics. In particular, their access to health care and their own and their infants' health outcomes are uncharted. Methods We conducted a nested cohort case-control study, using data from computerized health systems, and general practitioner (GP) and maternity records, to identify the characteristics, health service contacts, and maternal and infant health outcomes for primiparous antenatal clinic attenders at high risk for postnatal depression who either refused (self-exclusion group) or else agreed (take-up group) to receive additional Health Visiting support in pregnancy and the first 2 months postpartum. Results Women excluding themselves from Health Visitor support were younger and less highly educated than women willing to take up the support. They were less likely to attend midwifery, GP and routine Health Visitor appointments, but were more likely to book in late and to attend accident and emergency department (A&E). Their infants had poorer outcome in terms of gestation, birthweight and breastfeeding. Differences between the groups still obtained when age and education were taken into account for midwifery contacts, A&E attendance and gestation;the difference in the initiation of breast feeding was attenuated, but not wholly explained, by age and education. Conclusion A subgroup of psychologically vulnerable childbearing women are at particular risk for poor access to health care and adverse infant outcome. Barriers to take-up of services need to be understood in order better to deliver care.

Knowledge, attitudes and practices of farmers on rodent pests and their management in the lowlands of the Sierra Madre Biodiversity Corridor, Philippines

A survey of the knowledge, attitudes and practices (KAP) of 100 rice farmers and 50 coconut farmers was conducted in the coastal lowland agro-ecosystems of the Sierra Madre Biodiversity Corridor, Luzon, Philippines to identify current rodent management practices and to understand the extent of rat damage and the attitudes of farmers to community actions for rodent management. Pests were most commonly listed as one of the three most important rice and coconut production constraints. Other major crop production constraints were typhoons and insufficient water. Farmers consider rats to be the major pest of coconut and of rice during the wet season rice crop, with average yield losses of 3.0% and 13.2%, respectively. Rice and coconut farmers practised a wide range of rodent management techniques. These included scrub clearance, hunting and trapping. Of the 42 rice farmers and 3 coconut farmers that applied rodenticides to control rodents, all used the acute rodenticide, zinc phosphide. However, only ten rice farmers (23.8%) applied rodenticides prior to the booting stage and only seven farmers (15.6%) conducted pre-baiting before applying zinc phosphide. The majority of farmers belonged to farmer organisations and believed that rat control can only be done by farmers working together. However, during the last cropping season, less than a third of rice farmers (31.2%) applied rodent management as a group. In order to reduce the impact of rodents on the farmers of the coastal lowlands of the Sierra Madre Biodiversity Corridor, integrated management strategies need to be developed that specifically target the pest rodents in a sustainable manner, and community actions for rodent management should be promoted.

The 'veil' of control: exploring the attitudes and perceptions of UK design controllers

In the UK, architectural design is regulated through a system of design control for the public interest, which aims to secure and promote ‘quality’ in the built environment. Design control is primarily implemented by locally employed planning professionals with political oversight, and independent design review panels, staffed predominantly by design professionals. Design control has a lengthy and complex history, with the concept of ‘design’ offering a range of challenges for a regulatory system of governance. A simultaneously creative and emotive discipline, architectural design is a difficult issue to regulate objectively or consistently, often leading to policy that is regarded highly discretionary and flexible. This makes regulatory outcomes difficult to predict, as approaches undertaken by the ‘agents of control’ can vary according to the individual. The role of the design controller is therefore central, tasked with the responsibility of interpreting design policy and guidance, appraising design quality and passing professional judgment. However, little is really known about what influences the way design controllers approach their task, providing a ‘veil’ over design control, shrouding the basis of their decisions. This research engaged directly with the attitudes and perceptions of design controllers in the UK, lifting this ‘veil’. Using in-depth interviews and Q-Methodology, the thesis explores this hidden element of control, revealing a number of key differences in how controllers approach and implement policy and guidance, conceptualise design quality, and rationalise their evaluations and judgments. The research develops a conceptual framework for agency in design control – this consists of six variables (Regulation; Discretion; Skills; Design Quality; Aesthetics; and Evaluation) and it is suggested that this could act as a ‘heuristic’ instrument for UK controllers, prompting more reflexivity in relation to evaluating their own position, approaches, and attitudes, leading to better practice and increased transparency of control decisions.

Health care rights and NHS rationing: turning theory into practice

How should we understand the nature of patients’ right in public health care systems? Are health care rights different to rights under a private contract for car insurance? This article distinguishes between public and private rights and the relevance of community interests and notions of social solidarity. It discusses the distinction between political and civil rights, and social and economic rights and the inherently political and redistributive nature of the latter. Nevertheless, social and economic rights certainly give rise to “rights” enforceable by the courts. In the UK (as in many other jurisdictions), the courts have favoured a “procedural” approach to the question, in which the courts closely scrutinise decisions and demand high standards of rationality from decision-makers. However, although this is the general rule, the article also discusses a number of exceptional cases where “substantive” remedies are available which guarantee patients access to the care they need.