Monday, November 26, 2007

Accountability for Reasonableness in Tanzania

Starting in the early 1990s, Norman Daniels and I conducted a series of studies on how U.S. health organizations made decisions about priorities and limits. On the basis of those empirical observations and normative perspectives derived from philosophy and political science, we proposed a framework – “accountability for reasonableness” – as an account of fairness in setting priorities and limits and a broad how-to-do-it approach.

The accountability for reasonableness framework identifies four conditions for seeking fairness in health priorities:

Relevance – the rationales for priority setting decisions must be based on reasons (evidence and values) that stakeholders can agree are relevant. Procedurally, having a wide range of stakeholders participate in deliberation ensures that the full range of relevant reasons will be considered.

Publicity – priority setting decisions and their rationales must be publicly accessible, not just on demand, but through various forms of active communication outreach.

Revisability – there must be processes for revising decisions and policies in response to new evidence, individual considerations, and public reactions.

Enforcement – local systems and leaders must ensure that the above three conditions are met.

The field studies that informed the accountability for reasonableness framework were done in settings responsible for individual patients who were part of a larger population for which there was a total budget for care: not-for-profit HMOs; Medicaid programs; and, the VA. In the ten years since we did the major fieldwork, however, the U.S. backlash against managed care has led to fewer budgeted care systems.

As a result, the framework has had much more application outside of the U.S. – in countries like Canada, England, New Zealand, Norway, and Sweden, where the principle of solidarity is stronger, the entire population is insured, and the health system has an overall budget.

In recent years, Doug Martin and his colleagues at the University of Toronto Center for Bioethics have asked whether accountability for reasonableness, with its emphasis on openness, democratic process, and deliberation, could be relevant in less wealthy settings with different cultural traditions.

Earlier this month, Martin and colleagues from Denmark and Africa published “What do District Health Planners in Tanzania think about improving priority setting using ‘Accountability for Reasonableness’”? They presented the framework to local stakeholders in a series of capacity building workshops. Participants liked the framework, especially the extensive participation it calls for, the strong expectation for transparency, and the potential for including a wider range of values than current approaches did. Their major concerns had to do with the learning curve required for participation in the kind of reason-based deliberation the framework envisions.

From a global perspective, the hyper-individualistic approach we in the U.S. have built into our health care system -- as in Republican dread of expanding public SCHIP coverage and politicans' knee jerk horor when the words "socialized medicine" are spoken -- is increasingly aberrant. Virtually all other societies see basic health care as a collective responsibility we owe to each other, not as an individual responsibility to shop for as solitary consumers.

It isn't surprising that Tanzanians responded to the same values and approaches that prevail in Commonwealth countries, Scandanavia, and elsewhere. Illness, disability, and mortality are part of common humanity. We know that just as well as the Tanzanians do. When we become familiar with a communitarian program like Medicare we are able to think in terms of collective concerns. But for most of the adult population, our fragmented health system and our almost theological devotion to governing health care via market competition lead us away from thinking in terms of how to care for a population.

Health care appears to be high on the agenda of concerns for the 2008 election. It will be interesting to see if we are ready for a deeper and more thoughtful national debate than we have thus far been able to muster.

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