By Dr Calvin WL Ho and Professor Vikki Entwistle
Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore

The recent Lancet Global Health Commission on High Quality Health Systems emphasised that changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems internationally.1 The Commission also stressed that in the pursuit of better health outcomes and greater social value, “quality should not be the purview of the elite or an aspiration for some distant future”.1 This reflects both a practical recognition that good quality healthcare is required to secure desired outcomes along with an ethical commitment to equity, fairness or justice.

 

In this article, we introduce some of the work that the Centre for Biomedical Ethics (CBmE) will undertake to help advance aspirations for high quality healthcare for all in the context of its role as a World Health Organisation (WHO) Collaborating Centre for Bioethics.

 

WHO’s Global Network on Bioethics

 

WHO Collaborating Centres (CCs) are key institutions sited in countries around the world that are recognised for their expertise needed to support the WHO in meeting its global health mandate. Singapore currently has 10 WHO CCs, including the Ministry of Manpower, Health Sciences Authority, Health Promotion Board, National Environment Agency and Public Utilities Board.

 

For bioethics, there are currently 11 WHO CCs, in countries from every continent except Antarctica. WHO CCs for Bioethics report primarily through the Global Health Ethics Unit of the WHO.

 

CBmE was first designated as a WHO Collaborating Centre for Bioethics in 2014, and was voted to chair the global network of WHO CCs for Bioethics in December 2018. As chair, we facilitate the development of several network activities, including the advancement of ethical guidance relating to ageing, non-communicable diseases, big data and artificial intelligence, biobanking, preparedness in disease outbreaks, and Universal Health Coverage. We focus here on Universal Health Coverage (UHC), and introduce a project that aims to illuminate and help address the bioethical concerns relating to quality of care in this context.

 

Universal Health Coverage, quality of care and concerns about ethics

 

Since its establishment in 1948, WHO has advocated for everyone to have access to all necessary health services. The universal health coverage (UHC) initiative, anchored in the WHO Constitution and Right to Health, seeks broadly to ensure the availability of good quality healthcare for all people independent of their financial status. It encompasses services pertaining to health promotion, disease prevention, treatment, rehabilitation and palliative care.

 

Policy and health system leaders around the world can interpret and enact UHC with different emphases, and efforts to provide health services to all, however well intended, can raise a number of ethical concerns. Many of these relate to questions about which people, needs or services are prioritised (or not) and/or to various shortfalls in service quality and the distribution of these across different services or population groups.

 

Good quality healthcare remains elusive for many people across the world – even in some high income countries. The effectiveness of proffered interventions and the safety of services overall continue to be a major global concern. For example, a recent WHO report indicates that approximately 1 in 10 hospitalised patients experience harm as a result of their care, with at least 50 per cent preventability,2 and concerns about safety deepen as healthcare environments become increasingly complex, pressurised and fast-moving. Shortfalls in the person-centredness of healthcare provision also continue to be reported in many services. These include instances of healthcare staff or systems treating patients with a stark lack of respect or compassion, or failing to accommodate their particular needs and values. When quality shortfalls are disproportionately experienced among those who are already disadvantaged, additional concerns about fairness arise. These are perhaps particularly troubling in the context of the pursuit of UHC.

 

It is important to recognise that efforts to regulate and improve the quality of health services can themselves raise ethical concerns, for example about how responsibilities are allocated and how healthcare employees are treated in efforts to improve patient safety, and about how drives to improve efficiency might work against efforts to improve person-centredness or fairness.



Previous WHO work done in relation to the ethical aspects of UHC


The WHO report, "Making fair choices on the path to universal health coverage (2014)", offers guidance to countries as they consider how to allocate resources across the different kinds of healthcare interventions or services they might want to fund. It recommends a three-part strategy of (1) categorising interventions or services into priority classes, (2) expanding coverage of high priority services for everyone and (3) while doing so ensuring that disadvantaged groups are not left behind. While this guidance has been welcomed and experienced as helpful in some contexts, it was, for practical reasons, quite narrowly focused and left many important issues, including some key aspects of social fairness or equity in healthcare provision, open for future deliberation and development.


The WHO policy brief Anchoring universal health coverage in the right to health: what difference would it make (2015) recognised the ambiguity that can arise from different interpretations of the concept of UHC. It considered UHC in relation to promotion of the human right to health, and drew attention on that basis to the need to attend to forms of exclusion from health care that can arise from discrimination made on grounds other than financial ones. The brief called for more attention to vulnerable and marginalized groups.


The report of a WHO meeting in Tubingen, Germany – "Developing an ethical framework for healthy ageing (2017b)" is relevant because it recognises that problems can arise when medical care is organised and assessed with a stress on diseaserelated goals and outcomes (p15-16), and when ‘coverage’ of care provision is achieved only across segregated services (p18). It also follows the WHO 2015 report in reflecting a concern for social justice that goes beyond basic distributional concerns.


The WHO report, "Universal Health Coverage: Moving Towards Better Health (2016)", provides an action framework for countries in the Western Pacific region of WHO to help accelerate progress towards access to quality health services for all. As the report explains, the quality and safety of health services delivered at individual and population levels are fundamental to improving population health. WHO member states face barriers to quality and safety, leading to overuse, underuse or misuse of services and resources. The report considers how these issues can be addressed in practical terms by strengthening regulations and the regulatory environment, developing effective and responsive individual and population-based systems and services, and engaging individuals, families and communities. It mentions a need to ensure health professionals are ethically competent but does not discuss further engage in explicit discussion of ethical issues.



Previous WHO work has made several important contributions to thinking about ethics in the provision of UHC, in particular regarding decision-making and priority setting (see Box). But some of the other ethical concerns mentioned above have not yet been adequately addressed. Dr Tedros Adhahanom Ghebreyesus, the current Director General of WHO, recently reiterated that the “key question of UHC is essentially an ethical one”, and the WHO’s current general programme of work makes clear that WHO is committed to ensure that policy makers and health implementers at both international and national levels keep ethics at the heart of their decisionmaking. The work CBmE contributes to is consistent with this commitment.

It is important to recognise that efforts to regulate and improve the quality of health services can themselves raise ethical concerns...

Towards practical guidance on quality as an ethical imperative in UHC


CBmE is leading a collaborative initiative with the Global Health Ethics Unit of the WHO and members of the global network of WHO CCs for bioethics to develop practically useful guidance to support health policy and system leaders to consider quality of care (broadly construed) as an ethical imperative as they strive for UHC and health for all. We currently anticipate that the ethical issues of interest will include values associated with person-centred care and socio-relational aspects of equity, and the initiative will focus at least to some extent on primary health care contexts.


A key early aspect of the work will bring an international expert meeting of bioethicists, relevant WHO technical specialists and regional leads, and other international, regional and local health policy/system leaders to Singapore in the last quarter of 2019. The meeting will include presentations and discussions on ethical concerns associated with the quality of healthcare, including both: (a) insights ‘from the field’ (from a diverse selection of countries), examples of problems or concerns relating to quality and ethics in the pursuit of UHC, and a sense of whether and how these are currently dealt with; and (b) conceptual/theoretical work on ethical principles and quality norms, and ideas about how these can be made practically useful for health system development.

Following the meeting, CBmE and GHEU will lead the iterative drafting, review and refinement of the guidance resource.

 

Opportunities to participate in the international expert meeting are by invitation only, to ensure diverse domain expertise and geographic representation. If you are interested to learn more, please contact the authors, Dr Calvin Ho or Professor Vikki Entwistle, co-chairs for CBmE of the WHO network of collaborating centres for bioethics.

 

References 

  1. The Lancet Global Health Commission on High Quality HealthnSystems in the SDG Era. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Global Health, 2018; 6:e1196-252.
  2. World Health Organization. Patient Safety: Making Health Care Safer. Geneva: World Health Organization, 2017.
  3. Tedros Adhanom Ghebreyesus. Universal health coverage: a political choice. Geneva: World Health Organization Director-General’s Office, 2017. 

Available at: https://www.who.int/dg/speeches/2017/universal-health-coverage/en/