Ethical Implications of Adopting Value-Based Healthcare in Africa

Abstract

Value-based healthcare (VBHC) is purported to be the solution to address the issues that are present within fee-for-service (FFS) healthcare reimbursement. As the global discourse around adopting VBHC gains momentum, the body of knowledge on the topic is growing. Conversely, the literature on VBHC's ethical implications is still sparse. Nonetheless, a few ethical issues have emerged from existing literature and will be detailed below. Civil society and the healthcare fraternity ought to be concerned about the ethical implications of the shift in reimbursement models. This is particularly important in Africa, where economic disparities are glaring and extend into the healthcare sector. Some literature highlights issues of justice, equity, and solidarity as requiring attention with adopting VBHC. They are concerned with how VBHC disproportionately benefits certain populations at the expense of vulnerable populations. Secondly, concerns about the VBHC’s impact on patient autonomy are also emphasised as posing a risk of incentivizing providers to under-treat as a means of maximising revenue. Also, the extensive IT system integration required to underpin VBHC means that patient medical records and treatment history will be stored in a centralised location, accessible to a wider team of providers to monitor population-based patient outcomes statistics. This raises a critical issue of how patient confidentiality will be preserved within VBHC. Ⅲ The concept of “value” in healthcare is unclear and thus poses the real risk of measurement metrics being skewed towards cost containment vs patient outcomes and quality. Thus, providers would potentially use patients for financial gain. Additionally, the lack of cost transparency by providers also makes it challenging for patients to understand how their treatment is priced, how their care is evaluated and how treatment decisions are being made, ultimately potentially resulting in a mistrust of the healthcare system. Finally, VBHC does not make provisions for traditional or alternative medicine providers, who are an essential component of the healthcare system in most LMIC countries (especially in Africa). The oversight of this cultural nuance risks alienating large segments of populations, thus posing a real threat to patient dignity. This paper seeks to consolidate and describe the emerging ethical issues based on globally available literature. In light of the ethical issues raised in the previous chapter, I will argue that adopting VBHC in Africa is morally justified. I hinge my thesis on the Afro-communitarian tenets of shared identity, solidarity and goodwill. However, South Africa’s NHI (which is the most explicit national VBHC in Africa) as spelt out in the National Health Insurance (NHI) Bill of 2019, omits to include Traditional African Healers as part of the care team, thus potentially alienating a significant portion of the population. Secondly, the NHI Bill of 2019 does not provide clarity on how confidentiality will be maintained under the NHI. Until these two issues have been satisfied, I argue that VBHC in Africa is conditionally morally justified. My argument is supported by the Utilitarian ideological basis that actions provide the greatest benefit ought to be pursued. Kantian ethics adds that limiting the citizen’s choices under the NHI is an assault to their autonomy and therefore also deems adopting VBHC in Africa as being conditionally morally justifiable.