Claims on health care: a decision-making framework for equity, with application to treatment for HIV/AIDS in South Africa

Trying to determine how best to allocate resources in health care is especially difficult when resources are severely constrained, as is the case in all developing countries. This is particularly true in South Africa currently where the HIV epidemic adds significantly to a health service already overstretched by the demands made upon it.

This paper proposes a framework for determining how best to allocate scarce health care resources in such circumstances. The framework assists in thinking through the various claims made on health care.

The paper identifies different ways of considering claims and exemplifies these using a continuum from ‘free choice’ to ‘no free choice’. It also gives examples of what claims might comprise and how the use of these might in turn influence policy on HIV/AIDS in South Africa.

The claims on health care considered in the framework are:

• the need for health care, specified both as illness and capacity to benefit.
• whether or not claimants have personal responsibility in the conditions that have generated their health care need.
• relative deprivation or disadvantage.
• the impact of services on the health of society and on the social fabric.

Ways of determining these different claims in practice and the weights to be attached to them are also discussed.

A key implication for the treatment of HIV/AIDS in South Africa is, in principle, accepting the need to establish a set of principles or a constitution as the value base or philosophy that will underpin decision-making. No rational decision can be made about how much of the health service budget to spend on such treatment, nor how that is to be spent, without establishing such principles. It also implies or advocates that the South African society needs to be involved in setting both these principles and the claims and weights for claims that are implied in this set of principles.