The ethical principles which guide the allocation of healthcare resources to rural children

Abstract

This thesis describes research into the way Australian government officials decide to allocate healthcare resources for children who live in rural and remote areas of the country. It is known that infant mortality and health outcomes are worse for these children than for urban children. Moreover, there is evidence that rural families are more likely to experience difficulties gaining access to healthcare for their children than urban families. Documents and guidelines published by federal and state health departments suggest that the allocation of healthcare resources should be guided by the principles of equity and of obtaining the greatest possible improvement of the health of the whole population for the money spent. Prima facie, these principles are mutually incompatible.

Aim: This investigation was designed to answer the following questions: 1. What healthcare resources are currently available for children in rural and remote areas in Australia? 2. How do the parents of children living in rural and remote areas of NSW experience the provision of healthcare resources for their children and the consequences for their child and family of that pattern of resource provision? 3. How are healthcare resources allocated to children living in rural and remote areas and what factors are taken into consideration in making this allocation? 4. What ethical framework underpins the allocation of healthcare resources for children now? 5. What ethical framework could guide healthcare resource allocation for children in a way that best fits the needs of rural children, of their families and of government health officials?

Methodology: To gain a picture of the healthcare resources available to rural children in NSW, the decision-making process which led to the current distribution of those resources and the experience of rural families in gaining access to those resources, I employed complementary qualitative and quantitative approaches. In early 2018, information on the geographic location of healthcare resources relevant to the needs of children in the Western New South Wales (NSW) Local Health District was obtained from the National Health Services Directory and compared with the location of child populations of various sizes in geographical units known as State Suburbs. To compare family experiences in gaining healthcare for their children, raw data were obtained from the NSW Health Child Population Health Survey, and the experiences of rural families in their interactions with several kinds of healthcare resource were compared with those of urban families.

Elected and non-elected officials of the Australian Government Department of Health and Ageing and the NSW Ministry of Health were interviewed, and themes identified from the transcripts. From this analysis, descriptions of the aims and process of healthcare resource allocation decision-making emerged, including description of the constraints on decision-making and the role of ethical considerations. The analysis also revealed the views of decision-makers on the nature of the ethical principles which guide resource allocations.

Findings: Comparison of geographical locations of healthcare resources with those of child populations revealed that healthcare resources needed by rural children were lacking in many localities containing substantial child populations. This evidence partly explains the findings that rural families were more likely than urban families to experience difficulty in accessing healthcare for their children, especially due to lack of resources, long delays in waiting time for scarce resources or transport difficulties in accessing them.

Interviewed officials indicated that elected officials (health ministers) and members of the National and NSW Cabinets held the ultimate power to make allocation decisions, and that those decisions had budgetary and political constraints. Ethical principles appeared to play only a minor role in allocation of healthcare resources, and while equity was the principle most often mentioned, there was no agreement on whether equity of resource allocation, equity of access to resources or equity of health was the aim.

Discussion and Implications: The investigation canvassed a range of metaethical principles which could inform resource allocation decision-making. It concluded that equity (and especially vertical equity) in access to healthcare resources for equal need was the principle most likely to be acceptable in Australian society and to Australian resource allocation decision-makers. At the same time, it appeared to be the most likely to improve the health and wellbeing of rural children, both absolutely and in relation to that of urban children.

Despite the investigation’s identification of the value of equity of healthcare access, there is a discrepancy between the published intentions of the Australian Government Department of Health and NSW Health to allocate healthcare resources according to this principle, and the minor role which ethical principles, including equity, play in actual decision-making. Further, there is lack of certainty among officials about the goal of achieving equity (that is, whether equity in resource allocation, equity in healthcare access or equity in health should be the aim).

The investigation suggests two principal reasons why the avowed aim of allocating resources to achieve equity was not, in fact, achieving equity of health or of healthcare access. One was the apparent uncertainty among officials about the aspect of health or healthcare in which equity was to be achieved. The other reason was deficiency in motivation to act on an acknowledged moral reason (to act to achieve equity). The data suggest that adoption of the motivating principles of communitarianism or compassion would be more likely to supply the motivation to act to achieve equity than the assumption that the interests of the individual should underlie all ethical principles.