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date: 04 June 2020

Responsible Resource Allocation, Public Health Stewardship, and Ethics

Abstract and Keywords

This chapter discusses the terms stewardship and governance at the intersection of ethics and public health. Within the context of public health, governance broadly refers to the political processes by which decisions are reached and upheld, and stewardship refers to the technical processes that inform those decisions. The two concepts encompass a range of morally relevant considerations found in prominent public health ethics frameworks, including promoting utility, value for money, equity, accountability, and norms of distributive and procedural justice. This chapter takes a closer look at these considerations and explores how stewardship and governance enable and empower health systems to make ethical decisions. It further explores ethical challenges and negative consequences to health that arise in systems lacking good stewardship and governance.

Keywords: accountability, distributive justice, equity, governance, procedural justice, stewardship, utility, value for money, public health ethics

(p. 830) Introduction

In all public health settings, the range of expressed health needs and the costs of providing services will far outstrip available public resources (Roberts et al., 2008). Decisions will thus have to be made about how limited resources are used to promote and protect public health, and about what governance mechanisms will guide such decisions. Health policymakers and public health practitioners are entrusted with the responsibility to use limited resources wisely to improve health—to be responsible stewards of the health system. Stewardship and governance represent critical elements of an effective health system; this chapter will discuss why they are morally important, and it will raise the ethical considerations relevant to ensuring appropriate use of public resources to improve public health through good governance and stewardship.

Defining the Terms: What Are Governance and Stewardship?

In defining governance and stewardship, it is useful to examine the origins of their root words: to govern and to steward. The word govern comes from Old French and Latin (p. 831) origins, and is derived from the nautical charge “to steer, or to pilot,” as of a ship (Jessop, 1998). The word later evolved into its more contemporary definition: “to direct, rule, guide, or govern.” As its etymology suggests, governance carries connotations of leadership and path-setting, of charting a course and faithfully navigating toward a clear direction.

By contrast, the term steward comes from Proto-Germanic origins, and originally described the domestic servant (the weard) who maintained a house or hall (the stiġ). The responsibilities of the steward encompassed meeting the comprehensive needs of a household and acting as its guardian (Jeavons, 1994). Historically, the word stewardship emerged within a theological context, later being applied to environmental movements (Saltman and Ferroussier-Davis, 2000). Today, the word retains the focus from its etymology on managing resources and maintaining the standing of an organization or entity, from a single house to an entire ecosystem.

Despite their recognized importance, universal definitions of stewardship and governance in the context of health systems remain elusive, with many sources using the terms interchangeably (Saner and Wilson, 2003; Barbazza and Tello, 2014). A selection of definitions from the relevant literature is provided in Table 71.1.

Many definitions of governance in health systems emphasize the mechanisms and institutions involved in formulating and executing decisions and policies. These definitions tend to encompass the processes by which the voices and interests of citizens are incorporated in decision-making and structures of accountability. In this way, governance appears more political than technical (Saner and Wilson, 2003): definitions of governance focus on the processes by which public authorities formulate, implement, and enforce policies concerning public health (Siddiqi et al., 2009; UNDP, 2014). Central to these definitions are the institutions—from individual stakeholders to broad systems—as well as the values and rules that structure decision-making and priority-setting.

(p. 833) Table 71.1 Example Definitions of Governance and Stewardship in Health (emphases added)

Governance

Siddiqi et al., 2009

“Governance comprises the complex mechanisms, processes and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations.” (2)

UNDP, 2014

“Governance processes refer to the quality of participation necessary ‘to ensure that political, social and economic priorities are based on a broad consensus in society and that the voices of the excluded, poorest and most vulnerable are heard in decision-making.’ ”(4)

Accountability is a key theme running through and underpinning many aspects of governance—both vertically, from government to people, and horizontally between parts of the state, such as the executive and the judiciary. Sustainable development will require that public officials account for actions taken in the public’s name and with public resources.” (4)

Stewardship

WHO, 2000

“Governments should be ‘stewards’ of their national resources, maintaining and improving them for the benefit of their populations. In health, this means being ultimately responsible for the careful management of their citizens’ well-being. Stewardship in health is the very essence of good government.” (117)

Travis et al., 2002

Stewardship has similarities to the notion of public governance, but as envisaged by WHO is more specifically focused on the state’s role in taking responsibility for the health and well-being of the population, and guiding the health system as a whole. It influences the ways other health system functions are undertaken. In addition, it ‘embeds the health system in wider society.’ In characterizing stewardship, the Report identified three broad ‘tasks’ of health system stewardship: providing vision and direction for the health system, collecting and using intelligence, and exerting influence—through regulation and other means.” (1)

By comparison, definitions of stewardship in health emphasize the use of intelligence and expertise to infuse and inform decision-making processes with guidance and vision (Travis et al., 2002). Many of these definitions connote elements of caution and prudence (WHO, 2000). Responsible stewards take care of resources by ensuring their effective use through informed and carefully managed processes (Carlson et al., 2015). Although definitions of stewardship also include political considerations, they emphasize the technical aspects of intelligence gathering, efficacy, and value for money. Stewardship encompasses processes that are informed by technical expertise, responsible risk management, and evidence-informed tools for implementation; within the context of public health, these are critical considerations for ensuring that public resources are being most effectively and efficiently expended toward the public’s health (Kass, 1988).

For the purposes of this chapter, governance will refer to the political processes by which decisions are reached and upheld, and stewardship will refer to the technical processes that inform those decisions. This chapter argues that stewardship and governance are separate concepts, though they overlap and entwine substantially. Public (p. 832) trust, for example, is central to many definitions of both governance and stewardship. Good governance and stewardship are dependent on the relationships between those who govern and the public who hold these leaders accountable. Agents acting on the public’s behalf are entrusted with executing their duties responsibly and effectively under systems of good governance and stewardship, with accountability to the public (Gostin, 2010). This underscores the complementarity of stewardship and governance—health decision-makers are charged with responsible stewardship of the public’s health and the resources to support that aim, while a number of actors and institutions can ensure that decisions and actions align with public health priorities and objectives. In a well-functioning health system, stewardship and governance should be mutually self-reinforcing.

Why Responsible Stewardship and Good Governance Are Morally Relevant

Health stewardship and governance encompass a range of morally relevant considerations found in prominent public health ethics frameworks (Lee, 2012). These include moral imperatives to build and maintain public trust, use participatory approaches to decision-making, deliver on commitments and promises, promote transparency and accountability, draw upon the evidence base, and promote efficiency to improve population health with limited resources (Childress et al., 2002; Baum et al., 2007; Lee, 2012). Furthermore, notions of good governance and stewardship—including the processes, actors, and institutional arrangements for health policymaking—closely align with theories of procedural justice (Daniels, 2013). Because many societies are pluralistic and state actors are often faced with tough trade-offs in which they will be unable to meet everyone’s needs and preferences, procedural justice aims to ensure that the processes for decision-making are fair and legitimate (Daniels, 2000, 2008). One such account, Daniels’s “accountability for reasonableness,” proposes four conditions for health decision-making: (1) making decisions and their rationales public; (2) providing relevant and reasonable justifications for decisions, to be vetted by stakeholders; (3) mechanisms to challenge or dispute decisions; and (4) public regulation of the process to ensure it meets these conditions (Daniels, 2008). The second condition links closely with responsible stewardship and the need for decisions to be evidence-based and reasonable, while the entire account encompasses norms associated with good governance.

In contrast, the consequences of poorly stewarded resources and bad health governance have serious moral implications. Health carries special moral importance, because it is both intrinsically and instrumentally important for human well-being—and achieving a basic minimum of health is central to many accounts of social justice (Powers and Faden, 2006; Daniels, 2008; Venkatapuram, 2013). Poor stewardship of the health system will result in inefficient allocations and potentially serious opportunity costs, where alternative allocations could have yielded much greater health benefits to the population (Brock and Wikler, 2006; Krubiner and Hyder, 2014). Bad governance can lead to corruption, distortion of government budgets, and public distrust in social institutions, and it can exacerbate health inequities and social exclusion (UNDP, 1997).

Promoting Responsible Stewardship

Good governance and stewardship of public health resources are thus important components of an ethically sound health system and are essential for health policymakers to (p. 834) fulfill their dual remit to serve as caretaker of public resources and public health. Health policymakers must carefully consider decisions about how best to invest a limited pool of resources—financial and otherwise—to protect and promote population health.

Stewarding these resources responsibly relies on various technical inputs to realize public health objectives. An important consideration for effectively stewarding health resources is utility, or pursuing allocations that maximize health gains whenever possible (Marchand, Wikler, and Landesman, 1998). The principle of health maximization has long been promoted by various utilitarian theories of distributive justice (Lamont and Favor, 2014). These theories hold that the most moral action is the one that generates the greatest utility, or well-being (or happiness), for the greatest number of people. While maximizing health gains must be balanced with other ethical norms—chiefly, attention to equity—responsible stewardship entails careful consideration of which investments provide the best “value for money.” Value for money takes into account the expected benefit of a health intervention against its anticipated costs. This analysis often requires quantitative costing and epidemiological impact data, making the approach reliant on data collection, statistical analysis, and methodological rigor. Cost-effectiveness analysis (CEA) is an example of such an evaluative process. Within CEA, the costs and expected outcomes of two or more interventions are compared to identify the most cost-effective intervention. This type of analysis can be helpful in identifying where constrained funds can be maximally deployed to achieve—or “purchase”—the highest quantity of health possible. Value for money analysis also ensures that public health stewards are regularly comparing and contrasting policy options against each other to determine the most efficient use of public resources, fostering a more informed and evaluative approach to policymaking through the application of decision sciences.

Utilitarian approaches, however, must be balanced with other ethical considerations, particularly those around equity, or eliminating avoidable differences in the health of different groups of people. While a health system should strive to improve efficiency and impact, it must also seek to foster health equity across the spectra of social, economic, and demographic groups. The implementation of universal health coverage (UHC), for example, is well understood to be an effort to promote equity of access and ensure a minimum set of basic health services for all (Rodney and Hill, 2014). Responsible stewardship motivated by equity concerns may entail, for instance, analysis of the distribution of health outcomes and of health services across household income strata and identifying measures that can make such distribution more equal, generally by redistributing benefits from those who are better off to those who are less affluent (Gwatkin, 2007).

Approaches must also respect the autonomy of individuals and communities—a broad principle that encompasses respect for self-rule (or self-governance) and the engagement of individuals regarding decisions that will affect them. The process by with individuals are involved in health system priority-setting and decision-making is discussed at greater length in the following section.

A concept related to value for money is evidence-informed decision-making, where priorities and policies are reviewed against a methodological standard such that policies that are adopted must demonstrate effectiveness and impact through empirical data. (p. 835) Often, this requires a foundation of quantitative—and to some extent qualitative—data that indicates that the given policy is actually likely to achieve its stated objective; this data may be obtained from pilot studies that are subsequently scaled up, or from case studies in different settings, countries, or sectors. The use of evidence to support decision-making is critical to stewardship, since it ensures that decisions are informed by the latest and most accurate data available (WHO, 2000). Furthermore, evidence-informed approaches emphasize objectively demonstrated success across measurable and well-defined indicators, and the transparency of performance measurements allows for policymakers to clearly see and define the outcomes of health investments, expanding the foundation of available knowledge and evidence of impact.

Evidence-informed decision-making can promote value for money in health care and advance the implementation of best practices, another key component of stewardship. Best practices are those which have been demonstrated through successive implementation and evaluation to be the most optimal and beneficial, such that they are considered to be the standard for a given field. The dissemination of best practices supports the public health steward’s responsibility to promote efficiency, effectiveness, and equity. By establishing successful strategies as a norm, the creation of best practices promotes beneficence and reduces harm. The process by which practices become accepted as standard and “best practices” is also modulated by the stewardship role of public health professionals; effective stewards of public health establish clear and accessible guidelines by which promising practices are evaluated and validated. Registries of best practices may provide searchable inventories of validated interventions, tools, and strategies, which may promote evidence-informed practices across a health system. The Cochrane Library (https://www.cochranelibrary.com/) is a prime example of a repository of best practices as well as meta-analyses of a range of detailed studies in order to identify wider patterns of “what works” and why.

Intelligence gathering through regular monitoring and evaluation of public health interventions may serve to continually add to knowledge surrounding evidence of impact and best practices. Interventions with monitoring and evaluation components may be more responsive to needs for course correction, enabling the adaptive use of resources to serve evolving needs. In addition, the collection of real-time data provides a component of accountability and transparency, though this is limited by the extent to which data is distributed and made public. These are all consistent with recent calls for movement toward “learning health systems” as well as a proposed ethics framework by Faden et al. (2013) that prioritizes the role of evidence generation in delivering just health care (McGinnis et al., 2013).

Ultimately, these mechanisms of good stewardship require a formal process for incorporating guidance, technical expertise, vision, and evidence-informed review into public health decision-making (see also “Health Systems Stewardship, Governance, and Accountability: Issues of Public Health Ethics,” this volume). One example of these mechanisms in action is the use of national immunization technical advisory groups (NITAGs), which are independent technical committees that advise policymakers on key decisions related to immunization policies (such as whether to introduce (p. 836) new vaccines to the national immunization schedule). NITAGs and other health advisory bodies can provide guidance on the adoption of new policies and ensure that they are supported by up-to-date epidemiological, biomedical, and economic evidence (Duclos, 2010).

Without incorporating formal processes of technical review and analysis into public health governance, the impact of good stewardship may not be translated into good decision-making. Indeed, such decisions may be poorly supported by available evidence, inadvisable, unfeasible, or counterproductive to the public’s health. Such decisions, if implemented, may corrode the public’s trust that public resources are being used effectively, thus eroding the ethical values of public trust and careful management of public welfare.

It is therefore imperative that practices of good stewardship be incorporated in systems of public health decision-making, such that technical rigor informs policy and programming in a consistent and conscientious manner. Where possible, these processes should be independent and autonomous from political influence, so as to provide unbiased expertise and evaluations. These processes, moreover, should be transparent—with clarity on how priorities and programs are evaluated, and who is involved in determining these evaluations—and remain accountable to the public as a whole.

Promoting Good Governance

The processes by which public health decisions are made often involve compromises between individual and collective interests. Decisions on the prioritization of health resources engender decisions on who receives those resources and, consequently, who will benefit the most based on the prioritized services. These decisions are critically important: when resources are scarce, those who determine where they are allocated determine who benefits from them—and who does not.

The process by which these decisions are reached has substantial ethical implications. Ethicists have argued that decisions reached through systems of poor governance are less deserving of respect than those reached through processes with accountability, consensus-building, responsiveness, participation, transparency, rule of law, and equity (Siddiqi et al., 2009). Ethical governance must enshrine ethical principles of fairness, legitimacy, accountability, and beneficence; whether public health decisions honor and uphold these principles may be modulated by the processes by which these decisions are reached and implemented.

Given the diversity of governments, institutions, values, traditions, and systems that permeate the global field of public health, we do not propose a universal model of good public health governance. Instead, we consider the principles that should guide the robust implementation of good governance in a health system.

The ethical principles that determine whether a health system is achieving good governance are similar to those of responsible stewardship. Systems of good governance tend to be transparent, responsive, and accountable to the public, providing access to knowledge, (p. 837) services, and engagement in health and the health system. Good governance, however, also encompasses additional criteria that are not as closely paralleled in good stewardship: chiefly, adherence to the rule of law and the application of justice (Carlson et al., 2015).

The consistent and just application of legal frameworks is critical to establishing public trust in systems of governance. In settings where citizens hold a justiciable right to health, the enforcement of this right becomes critical in maintaining the legitimacy of the governing authority and expressing justice. More broadly, public health systems may provide strong forms of governance that ensure adequate regulation, accreditation, protection, and redress of grievances. Through these systems, citizens may engage in their health care safely, under the protection of a legal framework that will be enforced by an accountable system.

Systems of governance may also be sensitive to moral considerations of the fair distribution of benefits and burdens, or distributive justice (Childress et al., 2002). Good governance ensures that all citizens have fair access to public health benefits and an equitable distribution of burden and costs. Public health policies that stand to benefit a select few at a precipitous cost to the population as a whole are ethically troubling and may be indicative of governing systems that are not publicly accountable. As highlighted at the beginning of this chapter, public health interests are often many and conflicting; given limited resources, investments in one area may limit available resources in another. How can public health professionals ensure that such investments are made in ways that are legitimate, equitable, and accountable to the public they serve?

One way is to recognize that—given the breadth of stakeholders involved in and affected by public health decisions—unanimity without compromise will be impossible. To facilitate the balance of public needs and interests, a pluralistic and deliberative process of governance may be advisable (Daniels, 2000). One of the most salient forms of compromise and collaborative decision-making is that of a deliberative democratic process, whereby individuals or their representatives debate and decide on policies that will affect society as a whole.

The appeal of a democratic process of decision-making is its facilitation of debate in a public and transparent forum, an essential aspect to advancing policy within pluralistic contexts. A premise of democratic policy-shaping is that it fosters “buy-in” of affected parties; when individuals feel that they are represented in the decision-making process, affected parties becomes more enjoined to the ultimate outcome, even if it runs counter to their original position (Daniels, 2000). Even if the democratic system is not perfect, ethicists argue, the system provides a sense of procedural justice, or the notion that a process to allocate resources and establish priorities was executed with the participation of affected stakeholders.

Democratic decision-making for public health policy, however, is not without its challenges. A large concern is that the public may lack the expertise public health professionals possess, and thus set policies and priorities that may actually conflict with principles of stewardship, as responsibility and accountability for public health policy is shifted away from technical experts and caregivers (who may have a better sense of the needs of the health system as a whole). However, a variety of innovative ways to better (p. 838) engage lay audiences in complex health decision-making have emerged in recent years to improve public engagement as one input into the policymaking process (Abelson et al., 2013; Goold et al., 2005).

In addition, public health practitioners must be careful in assuring that principles of equity are maintained, and that the needs of minority groups are not eclipsed by the needs of those in the majority. This concern can be mitigated by ensuring adequate representation of marginalized and underrepresented communities and patient groups in health policy decisions, providing a broad and diverse inclusion of citizens in the political decision-making process.

The Absence of Stewardship and Governance

A failure to responsibly steward public resources and govern health systems effectively may lead to the misallocation and waste of limited resources. Rather than prioritize the use of resources by impact, cost-effectiveness, or need, poor custodians of public funds may set priorities to fulfill political or personal agendas, with little association to maximizing the public’s health or serving the public’s interest (Lewis, 2006). By choosing not to implement policies that demonstrate past success and/or value for money, the health sector will miss opportunities to leverage greater gains in health for greater numbers of its citizens, leading to programming that fails to target and minimize avoidable disability and death. In ethical terms, the misuse of public health resources eschews utilitarian maximization of health and happiness, prevents the minimization of harm, fails to promote public welfare, and erodes public trust in the health system at large.

One of the clearest ways that governments can fail to be responsible stewards of public resources is by ignoring scientific consensus and adopting policies that run counter to scientific evidence. A prominent example of this poor stewardship in health occurred in South Africa at the height of the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic. During the early 2000s, the government argued that HIV was not the cause of AIDS and that antiretroviral (ARV) drugs were not useful to patients. Despite widespread domestic and international outcry from the scientific and medical communities—and from civil society organizations and patients living with HIV—the government instead recommended unproven herbal remedies and declined freely donated nevirapine and grant funding from the Global Fund to treat patients with ARVs (Chigwedere et al., 2008). An estimated 330,000 lives were lost because a timely ARV treatment program was not implemented in South Africa as a result of the government’s position.

Poor systems of government may concentrate decision-making authority within a small group or within a single individual, which provides tremendous authority with limited accountability. Such systems of limited accountability and concentrated power may foster decisions influenced by personal biases or, in more extreme cases, corruption, (p. 839) whereby public business is conducted without regard for the rule of law, transparency, and equity of access. This may erode principles of distributive and procedural justice, undermining the fairness of the health system, and delegitimizing its actions. Furthermore, with poor governance there may be an increased risk of actual harm—caused by action or inaction—against the health of the public and/or individual groups therein.

Such poorly functioning systems are anathema to the principles of ethical governance and stewardship outlined in the preceding sections, and it is hard to envision an ethical health system devoid of responsible stewardship and good governance. Where systems disregard empirical knowledge and marginalize technical expertise, public resources become decoupled from their objective to maximize public health and instead may be co-opted to serve the interests of state actors. When public officials act with self-interest rather than for collective benefit, without mechanisms to detect and prevent such action, the public health system is effectively no longer operating for the benefit of the public.

This decoupling of mission and accountability can be expected to rapidly erode public trust and confidence that public systems are operating for the public’s good. This may alienate citizens from engaging in the public health system, making it increasingly difficult to implement good governance and stewardship practices in the future.

What emerges from a consideration of a public health system lacking stewardship and governance is a public health system that fails to achieve its objectives through fair processes and an adherence to core ethical principles of public health decision-making and priority-setting. Without ethical principles enshrined by good governance and good stewardship within these processes, societies endanger commitments to public accountability and responsible use of limited resources—two critical components of an ethical public health system.

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