Equity and efficiency in health and health care for HIV-positive adults in South Africa

• Main Author: Cleary, Susan
• Other Authors: McIntyre, Di
• Format: Doctoral Thesis
• Language: English
• Published: University of Cape Town 2014
• Subjects: Public Health
• Online Access: http://hdl.handle.net/11427/9325

Includes bibliographical references (leaves 238-258). === This dissertation presents a framework for assessing equity and efficiency in health and health care for HIV-positive adults in South Africa, which is tested in the extensive analysis of empirical data on the costs and consequences of alternative HIV-treatment strategies in the public health care system. The framework is built through asking three key questions. The first question -- what is the good (value or benefit) of health care -- considers what ought to be in the evaluative space of distributive justice in relation to this dissertation and in health economics more generally. The second question considers the factors that might constitute claims on this good, including personal responsibility, need, the social context as well as the impact of allocations of the good on the health of society and the social fabric. The final question -- how should the good be distributed -- examines alternative social choice rules for distributing the good and develops an approach grounded in procedural justice that legitimizes the choice of one rule over another. To apply this framework, patient and population-level costs and consequences associated with alternative HIV-treatment interventions are analysed in Markov models. These are extensively validated and uncertainty is assessed through probabilistic and multi-way sensitivity analyses. Results of these analyses are key inputs into mathematical programming algorithms that allow an assessment of the implications of choosing one social choice rule over another in terms of gains in the good and the proportion of need that can be met through one or more treatment strategy across a range of budgets. In discussing and concluding, these empirical results are reintegrated into the conceptual framework where the notion of claims on the good and a decision-making approach grounded in procedural justice is further developed. It is argued that the proper implementation of this framework will result in allocations of the good that are fair even if this is at a level of less than universal access to the most effective treatment strategy.