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Integrating Health Technology Assessment and the Right to Health in South Africa: A Qualitative Content Analysis of Substantive Values in Landmark Judicial Decisions

Published online by Cambridge University Press:  25 May 2023

Michael J. DiStefano ,
Safura Abdool Karim ,
Carleigh B. Krubiner  and
Karen J. Hofman
Michael J. DiStefano
Affiliation:
SKAGGS SCHOOL OF PHARMACY AND PHARMACEUTICAL SCIENCES, UNIVERSITY OF COLORADO, AURORA, CO, USA
Safura Abdool Karim
Affiliation:
SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF WESTERN CAPE, CAPE TOWN, SOUTH AFRICA
Carleigh B. Krubiner
Affiliation:
WELLCOME TRUST, LONDON, ENGLAND
Karen J. Hofman
Affiliation:
UNIVERSITY OF THE WITWATERSRAND SCHOOL OF PUBLIC HEALTH, JOHANNESBURG, SOUTH AFRICA
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Abstract

The World Health Assembly has encouraged WHO member-states to establish capacity in health technology assessment (HTA) as a support for achieving universal health coverage (UHC). Simultaneously, the WHO has stated that UHC is “a practical expression of the concern for health equity and the right to health.” This has prompted questions about potential tensions between priority-setting efforts and the right to health on the road to UHC. South Africa (SA) is an ideal setting in which to explore how the priority-setting work of an HTA body may be integrated with an existing rights framework.

Keywords

ValuesEthicsHuman RightsPriority SettingHealth CareJudicialization

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Type
Independent Articles
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Journal of Law, Medicine & Ethics , Volume 51 , Issue 1: The Evolving Fight Against Gun Violence , Spring 2023 , pp. 131 - 149
Copyright
© 2023 The Author(s)

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References

World Health Assembly resolution 67.23, Health Intervention and Technology Assessment in Support of Universal Health Coverage (24 May 2014), available at <https://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R23-en.pdf> (last visited March 1, 2023).+(last+visited+March+1,+2023).>Google Scholar
O’Rourke, B., Oortwijn, W., Schuller, T., and the International Joint Task Force, “The New Definition of Health Technology Assessment: A Milestone in International Collaboration,” International Journal of Technology Assessment in Health Care 36, no. 3 (2020): 187–190.CrossRefGoogle ScholarPubMed
World Health Organization, Positioning Health in the Post-2015 Development Agenda, WHO discussion paper (October 2012), available at <https://www.who.int/topics/millennium_development_goals/post2015/WHOdiscussionpaper_October2012.pdf> (last visited March 1, 2023).+(last+visited+March+1,+2023).>Google Scholar
The terms “right to health” and “right to health care” (and close variants) are often used synonymously in the literature. For an example, see Wang, D.W.L., “Priority-Setting and the Right to Health: Synergies and Tensions on the Path to Universal Health Coverage,” Human Rights Law Review 20, no. 4 (2020): 704–724. Moreover, Syrett has referred to the “right to health” and the “right to have access to health care services” as “cognate formulations,” (K. Syrett, “Evolving the Right to Health: Rethinking the Normative Response to Problems of Judicialization,” Health and Human Rights 20, no. 1 (2018): 121-132). We use “right to health” throughout this article as shorthand to refer to this family of “cognate formulations,” though as we note elsewhere, the South African Constitution explicitly refers to “the right to have access to health care services.”CrossRefGoogle Scholar
Rumbold, B., Baker, R., and Ferraz, O. et al., “Universal Health Coverage, Priority Setting, and the Human Right to Health,” Lancet 390, no. 10095 (2017): 712–714; See Wang, supra note 4.CrossRefGoogle ScholarPubMed
Kavanagh, M.M., “The Right to Health: Institutional Effects of Constitutional Provisions on Health Outcomes,” Studies in Comparative International Development 51, no. 3 (2016): 328–364.CrossRefGoogle Scholar
Syrett, K., “Deference or Deliberation: Rethinking the Judicial Role in the Allocation of Healthcare Resources,” Medicine and Law 24 (2005): 309–322; S. Ettelt, “Access to Treatment and the Constitutional Right to Health in Germany: A Triumph of Hope over Evidence?” Health Economics, Policy and Law 15, no. 1 (2020): 30-42; See Wang, supra note 4.Google ScholarPubMed
See Wang, supra note 4; See Syrett, supra note 4; See Rumbold, supra note 5; See Ettelt, supra note 7; Dittrich, R., Cubillos, L., Gostin, L., Chalkidou, K., and Li, R., “The International Right to Health: What Does It Mean in Legal Practice and How Can It Affect Priority Setting for Universal Health Coverage?” Health Systems and Reform 2, no. 1 (2016): 23–31; J. Biehl, M.P. Socal, and V. Guari et al., “Judicialization 2.0: Understanding Right-to-health Litigation in Real Time,” Global Public Health 14, no. 2 (2019): 190-199; S. Gloppen, “Litigation as a Strategy to Hold Governments Accountable for Implementing the Right to Health,” Health and Human Rights 10, no. 2 (2008): 21-36; O.F. Norheim and B.M. Wilson, “Health Rights Litigation and Access to Medicines: Priority Classification of Successful Cases from Costa Rica’s Constitutional Chamber of the Supreme Court,” Health and Human Rights 16, no. 2 (2014): 47-61; A.E. Yamin and O. Parra-Vera, “How do Courts Set Health Policy? The Case of the Colombian Constitutional Court,” PLoS Medicine 6, no. 2 (2009): 0147-0150; T.S. Andia and E. Lamprea, “”Is the Judicialization of Health Care Bad for Equity? A Scoping Review,” International Journal of Equity in Health 18, no. 1 (2019): 1-12; M.J. DiStefano, S. Abdool Karim, and C.B. Krubiner, “Integrating Health Technology Assessment and the Right to Health: A Qualitative Content Analysis of Procedural Values in South African Judicial Decisions,” Health Policy and Planning 37, no. 5 (2022): 644-654.CrossRefGoogle ScholarPubMed
See Biehl, supra note 8.Google Scholar
Department of Health, Republic of South Africa, National Health Insurance for South Africa: Towards Universal Health Coverage (30 June 2017), available at <https://www.gov.za/documents/national-health-act-national-health-insurance-policy-towards-universal-health-coverage-30> (last visited March 1, 2023).+(last+visited+March+1,+2023).>Google Scholar
Constitution of the Republic of South Africa. ch. 2. § 27. cl. 1.Google Scholar
Constitution of the Republic of South Africa. ch. 2. § 27. cl. 2.Google Scholar
Krubiner, C.B., Barsdorf, N.W., and Goldstein, S.J. et al., “Developing and Piloting a Context-Specified Ethics Framework for Health Technology Assessment: The South African Values and Ethics for Universal Health Coverage (SAVE-UHC) Approach,” International Journal of Technology Assessment in Health Care 38, no. 1 (2022): e26; D. Blauuw, C. Chambers, N. Duba et al., “Introducing an Ethics Framework for Health Priority-Setting in South Africa on the Path to Universal Health Coverage,” South African Medical Journal 112, no. 3 (2022): 240-244.CrossRefGoogle ScholarPubMed
Clark, S. and Weale, A., “Social Values in Health Priority Setting: A Conceptual Framework,” Journal of Health Organization and Management 26, no. 3 (2012): 293–316.CrossRefGoogle ScholarPubMed
See Krubiner, supra note 13.Google Scholar
M.J. DiStefano, S. Abdool Karim, and C.B. Krubiner, supra note 8.Google Scholar
Beauchamp, T.L. and Childress, J.F., Principles of Biomedical Ethics, Seventh Edition (New York: Oxford University Press, 2009).Google Scholar
DiStefano et al., supra note 16.Google Scholar
B. and Others v Minister of Correctional Services and Other 1997 (6) BCLR 789 (C) (s. Afr.).Google Scholar
Soobramoney v Minister of Health, KwaZulu-Natal 1997 (12) BCLR 1969 (CC) (S. Afr.).Google Scholar
Minister of Health and Others v Treatment Action Campaign and Others (1) 2002 (10) BCLR 1033 (CC) (S. Afr.).Google Scholar
Government of the Republic of South Africa and Others v Grootboom and Others 2000 (11) BCLR 1169 (C) (S. Afr.).Google Scholar
Khosa v Minister of Social Development; Mahlaule v Minister of Social Development 2004 (6) BCLR 569 (CC) (S. Afr.).Google Scholar
Du Plooy v Minister of Correctional Services and Others 2004 JOL 12850 (T) (S. Afr.).Google Scholar
Minister of Health and Another v New Clicks SA (Pty) Ltd and Others 2006 (1) BCLR 1 (CC) (S. Afr.).Google Scholar
E N and Others v Government of the Republic of South Africa and Others 2007 (1) All SA 74 (D) (S. Afr.).Google Scholar
Mazibuko v City of Johannesburg 2010 (3) BCLR 239 (CC) (S. Afr.).Google Scholar
S v Makwanyane 1995 (6) BCLR 665 (CC) (S. Afr.).Google Scholar
Radebe, S.B. and Phooko, M.R., “Ubuntu and the Law in South Africa: Exploring and Understanding the Substantive Content of Ubuntu,” South African Journal of Philosophy 36, no. 2 (2017): 239–251.CrossRefGoogle Scholar
Brock, D., “Ethical Issuess in the Use of Cost Effectiveness Analysis for the Prioritization of Health Resources,” in Khushf, G, ed., Handbook of Bioethics: Taking Stock of the Field from a Philosophical Perspective (New York: Kluwer Academic Publishers, 2004): 352–380; S.A. Schroeder, “Value Choices in Summary Measures of Population Health,” Public Health Ethics 10, no. 2 (2017): 176-187; L.Z. Rand and A.S. Kesselheim, “Controversy Over Using Quality-Adjusted Life-Years in Cost-Effectiveness Analyses: A Systematic Literature Review,” Health Affairs 40, no. 9 (2021): 1402-1410.Google Scholar
Kluger, S., Obermann, K., Tausch, V., Chadasch, C., Ditscheid, E., and Thielscher, C., “Is QALY-based Rationing Illegal in Countries With a Natural-law Constitution? A Multidisciplinary Systematic Review,” Ethics, Medicine and Public Health 14 (2020): 100484.CrossRefGoogle Scholar
Persad, G., “Justice and Public Health,” in Mastroianni, A.C., Kahn, J.P. and Kass, N.E., eds., The Oxford Handbook of Public Health Ethics (Oxford, UK: Oxford University Press: 2019): 1–15.Google Scholar
Powers, M. and Faden, R., Social Justice: The Moral Foundations of Public Health and Health Policy (Oxford, UK: Oxford University Press, 2008).Google Scholar
Instances where the courts argued for special attention to vulnerable populations could also be coded as instances of requiring equal treatment for those with equal health needs as this principle implies unequal treatment for those with unequal health needs. However, we chose to apply the code only in cases where groups that are equally situated had not been treated equally, as this is the most explicit interpretation of the consideration as stated in the SAVE framework (see www.save-uhc.org).Google Scholar
Krohmal, B.J. and Emanuel, E.J., “Access and Ability to Pay,” Archives of Internal Medicine 167 (2007): 433–437.CrossRefGoogle ScholarPubMed
Rawls, J., A Theory of Justice (Cambridge, MA: Harvard University Press, 1971).CrossRefGoogle Scholar
Baltussen, R., Marsh, K., Thokala, P. et al., “Multicriteria Decision Analysis to Support Health Technology Assessment Agencies: Benefits, Limitations, and the Way Forward,” Value in Health 22, no. 11 (2019): 1283–1288; M.J. DiStefano and C.B. Krubiner, “Beyond the Numbers: A Critique of Quantitative Multi-Criteria Decision analysis,” International Journal of Technology Assessment in Health Care 36, no. 4 (2020): 292-296.CrossRefGoogle ScholarPubMed
Beauchamp and Childress supra note 17.Google Scholar
Ewuoso, C. and Hall, S., “Core Aspects of Ubuntu: A Systematic Review,” South African Journal of Bioethics and Law 12, no. 2 (2019): 93–103.CrossRefGoogle Scholar
See Baltussen, supra note 37.Google Scholar
Mothupi, S., “The Value of Minority Judgments in the Development of Constitutional Interpretation in South Africa,” Codicillus 46, no. 2 (2005): 13–23; A. Spies, “The Importance of Minority Judgments in Judicial Decision-Making: An Analysis of Minister of Justice and Constitutional Development v Prince,” South African Journal of Human Rights 35, no. 4 (2020): 429-440.Google Scholar
See Krubiner, supra note 13.Google Scholar
Wang, D., Vasconcelos, N.P., Poirier, M.J.P. et al., “Health Technology Assessment and Judicial Deference to Priority-setting Decision in Healthcare: Quasi-experimental Analysis of Right-to-Health Litigation in Brazil,” Social Science and Medicine 265 (2020): 113401.CrossRefGoogle ScholarPubMed
Siegfried, N., Wilkinson, T., and Hofman, K., “Where From and Where To for Health Technology Assessment in South Africa? A Legal and Policy Landscape Analysis,” South African Health Review 1 (2017): 41–48.Google Scholar
Department of Health, Republic of South Africa, supra note 10.Google Scholar