In
searh of ‘just health’
Panji Hadisoemarto ;
A lecturer at Padjadjaran University’s
School of Medicine, Bandung; He is now pursuing a doctorate of science
at
the Harvard School of Public Health in Boston, Massachusetts
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JAKARTA
POST, 07 Maret 2014
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It was
my first time reading a book of this kind. Just Health is written by Harvard
School of Public Health professor and philosopher Norman Daniels. In the
book, Daniels lays out his “integrated theory of justice and population
health” that extends Rawls’ theory of justice as fairness on population
health. That is, a liberal egalitarian view of what justice requires for a
population’s health.
Daniels’
book may be relevant to Indonesia’s current health affairs.
Among
the biggest hurdles in initiating Indonesia’s national health insurance (JKN)
was getting the government to agree on the premium for the poor, the
beneficiaries of premium subsidy (PBI). The PBI premium was agreed at Rp
19,225 (just over US$1.50) per person per month, which is far below the
“economic price” of covered services.
Simply
put, the JKN may not be financially sustainable unless the government pours
more money into it to increase the PBI premium. However, sooner than later,
we will come to realize that money and other resources are limited and will
not suffice to cover all the services that need to be covered.
What
services should we prioritize then? Here is where the idea that should
prevail.
Now
imagine a box, its length, width and depth define its volume. Imagine we want
to make a box with a certain volume, say a cubic meter, how would we make it?
Would we prefer to make all the dimensions equal, such that we would have a
cube? Or would we make it so thin than we basically just have a plate? Or
would we prefer some other dimension, and for what reason?
That box
represents the idea of universal health coverage, such as our JKN. Its length
represents the number of people covered, its width the services and its depth
the payment amount for each service. The volume is the premium pool.
The
World Health Organization, by the way, uses this analogy.
Ideally,
we would have a box so big that it covers everyone for everything. But we
will never have that. The JKN box, to me, seems like a matchbox; sufficiently
long and wide, nonetheless very thin. But whether or not the JKN box has the
right dimensions is a question of justice.
Adjusting
the dimensions of the JKN box involves rationing, controlling the distribution
of resources. Because those resources, the box’s volume, are limited, we can
never increase one dimension without decreasing another.
“How can
we meet health needs fairly when we can’t meet them all?” is one of the
questions Daniels attempts to answer in his book.
Daniels
rejects utilitarian aggregation such that resources are distributed for the
greatest good for the greatest number. Assuming Rawls’ justice as fairness,
Daniels asserts that a wide array of public health and medical services are
necessary to promote equal opportunity and that such a system must prioritize
the worst-off in society. He then supplements his general theory by a fair
procedure of rationing that will lead to a fair, and thus just, outcome.
So how
are we going to decide whether the JKN distributes resources justly?
Unfortunately,
in spite of our progress of reforming healthcare financing in Indonesia, I
found little reference to our idealization of “social justice for all people
of Indonesia” has been made. For example, although Law No. 40/2004 on
national social security system (SJSN) and Law No. 24/2011 on the Social
Security Management Agency (BPJS) explicitly state the principle of social
justice, they further explain it simply as “an ideal principle”.
That is
not helpful.
Reading
Daniels, perhaps like Rawls, we as a nation have largely excluded health from
our notion of social justice. Perhaps for us a just distribution of health,
as a part of social welfare, has been taken for granted.
I think
we need to extend our idea of social justice to health. Like “demokrasi
Pancasila” or Pancasila-based democracy and “ekonomi Pancasila”, both often
juxtaposed against “liberal democracy” and “liberal economy”, we may need to
define what “kesehatan Pancasila” is. Just like Daniels extends Rawls to
health.
Having a
detailed account of a just distribution of health can help us solve some of
the rationing problems that arise with the JKN. It is not necessarily
sufficient to resolve those problems, but what is more important is that it
will make our moral, and other, choices for rationing resources for health
explicit. Surely that will help explain why some services are covered while
others are not.
And then
we may have just, morally just, health. Not just, only, health. ●
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