Ethical Dilemmas of Health Care in the Developing
Nations
By Farhat Moazam and Mumtaz Lakhani
Karachi, Pakistan l Limited resources, widespread poverty, and the absence of health insurance pose daily ethical problems for Third World physicians, who must balance their roles as individual patient advocates against a desire to provide health care to the greatest number of children. Pakistan has a per capita income of Rs. 7,220 (USS380) per year, or Rs. 800 (USS 32) per month. The annual population growth of the country is 3.1%. and approximately 380.000 infants are born each year in Karachi, the largest city in the country. The Aga Khan University Hospital. a private teaching institution, is the only hospital in Karachi with a Level Ill Neonatal Intensive Care Unit (NICU). The financial and medical data of 200 infants admitted to the NICU in 1988 were reviewed retrospectively, and compared with those of two specific subgroups. (1) Among 15 infants who underwent surgical intervention, the average total cost of hospitalization was Rs. 38,040 (US$ 1.900) per patient, with an average daily cost of Rs. 923 (USS 491. The longest hospital stay was 6 months, for a child who had total colonic aganglionosis associated with a short gut syndrome. There were two deaths in this group. (2) Of the 21 premature neonates admitted having Idiopathic Respiratory Distress Syndrome (IRDS) during this period, the total hospitalization cost per patient was Rs. 23.280 IUSS 788). with a daily cost of Rs. 1,050 (lJS$ 55). Eleven patients required ventilatory support. There were 16 survivors. Among both groups, 6% of all revenues generated in the NICU were used to help families pay for the bills under a welfare scheme. o 1990 by W.B. Saunders Company. INDEX WORDS: Ethical dilemmas of health care: neonatal intensive care; health care in developing nations.
I
N DEVELOPED NATIONS, intensive care of critically ill neonates has resulted in a dramatic improvement in their survival. However, the expense of these programs has generated many questions regarding efficient and equitable resource allocation in the face of finite funds.‘** The last decade has seen rapid transfer of modern technology and advanced health care to developing countries. The ethical dilemmas facing physicians in the Third World are magnified in the face of minimal resources and abject poverty, but no mechanism is in place to help them with these
difficult decisions. Pakistan has a per capita income of Rs. 7,220 (US$380) per year, or Rs. 800 (US$42) per month. The infant mortality rate is approximately 115 per 1,000 Iive births, and the country spent 1.1% of its GNP in 1988 on health issues.3 The Aga Khan University Hospital is a private teaching hospital in Karachi, a city with a population of 8,000,OOOpeople. The Neonatal Intensive Care Unit of the institution has eight beds, four of which are equipped to provide Level III care. This is the only facility of its kind in a city with an estimated 360,000 births per year. MATERIALS AND METHODS A retrospective review of the medical and financial data of all
patients admitted to the NICU between January 1, 1988 and December 31, 1988 was carried out, and the data of two specific groups of infants were reviewed in detail. (1) Surgical Group. This included infants admitted directly on the surgical service and those with a primary medical problem who required major surgical intervention. (2) Medical Group. This group was limited to premature infants with varying degrees of Idiopathic Respiratory Distress Syndrome (IRDS), who did not require surgical intervention. Eleven infants required ventilatory support, whereas the others were managed with oxygen and/or Continuous Positive Airway Pressure (CPAP). In all patients the average cost of hospital stay, length of stay, and the daily cost per patient were estimated. The average laboratory and radiological charges per patient were tabulated. In the surgical group, the average surgical cost per patient, inclusive of the surgeon’s and the anaesthesiologist’s fees and the theater charges, was estimated. RESULTS
During the 12-month period, 200 neonates were admitted to the NICU. The average total bill per patient was Rs. 12,668 (US$ 667), and the average hospital stay was 12.5 days. During the same time, the hospital charges were estimated for 1,364 children admitted to the pediatric ward for medical and surgical conditions. The average total charge per child was Rs. 5,592 (US$294), with an average hospital stay of 5 to 6 days. Two subgroups among the NICU admissions were studied in detail. Surgical Group
From the Department of Surgery. The Aga Khan University Hospital. Karachi, Pakistan. Presented at the 3&h Annual Congress of the British Association of Paediatric Surgeons, Nottingham, England, July 19-21,1989. Address reprint requests to Farhat Moazam. MD, Department of Surgery, The Aga Khan University Hospital. PO Box 3500. Stadium Rd. Karachi, Pakistan. Q 1990 by W.B. Saunders Company. 0022-3468/90/2504-0015$03.00/0
A total of 15 neonates were included in this group, and except for two patients, all were transfers referred from outside institutions. Two infants died, one having a congential diaphragmatic hernia and another having necrotizing enterocolitis with barium peritonitis (Table 1). The total hospital stay ranged from 5 days to 178 days, the latter in an infant with multiple ileal atresias and short gut syndrome complicated by total
430
Journal
of Pediatric Surgery, Vol 25, No 4 (April),1990:
pp
438-441
439
HEALTH CARE ETHICS IN DEVELOPING NATIONS Table 2. Financial Information of Surgioal patients
Table 1. Surgical Group Patk?llt
No.
Diagnosis
Sex
1
M
Antenatal perforation
2
M
Hirschsprung’s disease
Total Hospital Total Hospital stay stay (days1 104
es. 44,757
18
Rs. 20,038
(US$2.356) (USS 1,055) 3
M
Midgut volvulus
37
Rs. 2 1,389 (USS1.126)
4
F
Congenital adrenal hyperpla-
27
sia
(US$1,145)
M
Bochdalek hernia
30
Rs. 37,047
6
F
llaal atresia
39
Rs. 29.69 1
uJS$ 1,950) (lJS$ 1,563) M
llaal atresia, total colon agan-
178
glionosis 8
M
Necrotizing entarocolitis.
F
Dandy Walker syndrome,
10
M
Gangrene leg
11
F
12
Rs. 8.432
Operating charge (surgeon. anesthesi-
Rs. 8,670
RJS$444) ologist, theatre charges) Laboratory (145 investigations)
(US$456) Rs. 7.07 1 (US$372)
Radiology (eight procedures)
Rs. 1,640 (US$B6)
Pharmacy
Rs. 4,060
Medical surgical supplies
Rs. 4,770
(US$214) (USS 25 1)
Rs. 156,286
5
Rs. 17,777 0JS$936)
24
Rs. 28,370
20
Rs. 24.849
Bochdalak hernia
5
Rs. 23.896
F
lmperforate anus
18
Rs. 20,340
13
F
Patent ductus arteriosus
51
Rs. 55,250
14
F
Bochdalak hernia
24
Rs. 2 1,950
15
M
Hypertrophic pyloric steno-
8
Rs. 10,316
hydrocephalus
(US$ 1,493) (US$ 1,308) KlS$ 1,258) (US$ 1,070) (US$2,9071 lUS$1.155)
sis, sepsis
uJS$ 1,900) Bed charge (39 days)
(K88.225)
barium peritonitis 9
Rs. 36,040
Total charges
Rs. 2 1,756
5
7
Averageper Patient (n = 15)
require ventilation. Whereas the average professional fee per patient was Rs. 2,592 (US$ 136), the laboratory and pharmacy charges were Rs. 7,887 (US$4 15) and Rs. 1,040 (USS 55) respectively (Table 3). Although the number of patients in each group is relatively small, as expected, the highest total charges were for infants undergoing surgical intervention and premature infants with IRDS. The average daily charges for both subgroups were comparable to patients admitted to the paediatric ward, but the longer hospital stay of the former contributed to the higher costs (Table 4).
(US$543)
DISCUSSION
colonic aganglionosis. The average length of hospital stay was 39 days, with an average total charge per patient of Rs. 36,040 (US$ 1,900). The surgical charge per patient was Rs. 8,670 (USts444). The next highest expense was incurred for laboratory investigations, with an average cost per patient of Rs. 7,078l (US$ 372). The average pharmacy and radiological charges were Rs. 4,060 (US$ 214) and Rs. 1,640 (US$ 86), respectively. The cost of medical and surgical supplies used per patient was Rs. 4,770 (US$251) (Table 2).
In developed countries, intensive care of neonates is now widespread, with dramatic improvement in survival of critically ill infants. This is especially true in low-birth weight infants, with survival rates of 80% in those weighing between 1,000 g and 1,500 g.1,4s5 However, in the last decade important questions have been raised regarding cost effectiveness and cost benefit of expensive medical programs in the face of the realization that resources are finite.6-8 This problem is Table 3. Financial Information of Premature Infants With IRDS
Medical Group There were 21 premature infants with IRDS weighing between 830 g and 2.9 kg. Nine infants weighed less than 1.5 kg, and had a mortality rate of 33.3%. Among 12 infants who weighed more than 1.5 kg at the time of admission, the mortality rate was 16%. The gestational ages varied from 28 weeks to 36 weeks. Six premature infants were transferred from other institutions. The average hospital stay for this group of infants was 22 days, with a total charge per patient of Rs. 23,260 (US$ 1,224). The average daily cost of infants requiring ventilation was Rs. 1,150 (US$ 60) compared to Rs. 500 (US$ 26) for those who did not
Averageper Patient(n = 2 1 I Total charges
Rs. 23,260 (US$ 1,224)
Bed charges (15 days)
Rs. 7.500
Professional fees
Rs. 2,592
Laboratory (96 investigations)
Rs. 7.887
lUS$395) (US$ 136) (US$415) Radiology (five procedures)
Rs. 1.040
Pharmacy
Rs. 1,380
lUS$55) (USS73) Medical surgical supplies
Rs. 2,542 lUS$134)
440
MOAZAM AND LAKHANI Table 4. Average Charges for Paediatric Patients All NICU Patients hl =
1991
Total charges
Rs. 12,668 IUS$667)
Laboratory
R.S.3,703 (US$ 195)
NICU Surgical Patients In =
15)
Rs. 36,040
NICU Premature With IRDS (n =
21)
All Ward Patients In =
1.3641
Rs. 23,260
Rs. 5,592
WS$ 1,897)
WS$ 1,224)
WSS 294)
Rs. 7.07 1
Rs. 7,887
Rs. 878
WS$372)
CUSS4 15)
WS$46)
Rs. 693
Rs. 1,640
Rs. 1,040
Rs. 317
WSS36)
uJS$86)
WS$55)
uS$
Pharmacy
Rs. 1,096
Rs. 4,060
Rs. 1,380
Rs. 1.074
(US$58)
iUS$2 14)
0x$73)
WS$57)
Daily charge
Rs. 1,000
Rs. 923
Rs. 1,050
Rs. 932
(lJS$53)
WS$49)
(US.$55)
uJSS49)
12.5 days
39 days
22 davs
5.6 davs
Radiology
Hospital stay
present far more starkly in developing nations, where resources are extremely limited, populations vast, and poverty rampant. Most developing nations spend a variable portion (1% to 5%) of their GNP on health services. The problem of limited financial resources is compounded by inadequate manpower and the absence of health insurance. In addition, few developing countries have provisions for funding or assisting handicapped survivors of intensive care. The debate on correct health policies for poor countries continues, with the World Health Organization having set a goal of health for all by the year 2000. It has been noted’ that this can be accomplished through greater emphasis on preventive medicine, and by raising general standards of living via improved agriculture, education, and community development. Experience has shown that, as a rule, health services play a small role in reducing the morbidity and mortality in a country, and implementation of good health policies are more effective in this regard. The other side of the coin that cannot be ignored, is the implicit right of every individual to the best health care available in the country. The last few years have seen a rapid transfer of advanced technology and capability for tertiary care to developing countries. The populations of such countries are increasingly sophisticated, with high expectations of and information about the latest medical advances. In the face of widespread poverty and an absence of health insurance, physicians in private institutions like the Aga Khan University Hospital are faced daily with the problem of balancing their role as individual patient advocates against the desire to provide health care for the greatest number of children. Whereas a physician in a developed nation may struggle over whether to rescusitate a malformed infant or a Trisomy 13 infant in the delivery room, his counterpart in Pakistan must agonize over which, among two otherwise healthy neonates with mild IRDS, should benefit from the last bed in the NICU, and who will pay the hospital bill.
17)
Some of these vexing issues were discussed at the Geneva meeting of the Council for International Organizations for Medical Sciences (CIOMS) in 1980. Demeny,’ while discussing economics and health problems of developing nations, suggested that governments should concentrate their resources in areas where major external benefits can be provided to raise the general standard of health, eg, by providing birth control services, antimalarial programs, etc, as opposed to expensive health services. Private institutions could help to fulfill the need for tertiary health services in response to the expectations of the population. However, without health insurance and in the face of miniscule per capita incomes, institutional resources are insufficient. Choices must be made as to who should benefit from these services and how best to allocate resources to reach as many as possible, without limiting them to the small numbers who can afford them. Whereas it is naive to ignore the financial implications, it would be immoral to constitute affordability as the sole criterion for allocation of services. The cost benefit issue must be taken into consideration, as must the quality of life among those who survive. Whereas neonatal technology has grown rapidly in developing countries, means of addressing these thorny issues are in their infancy. Although the choices may be somewhat different, lessons must be learned from the experience of countries who have been struggling with like issues for several years.‘0V12 An example would be a critical look at the wisdom of spending resources on the management of extremely low birth weight infants or neonates with multiple surgical anomalies. The Aga Khan University Hospital, based on its experience over the last 2 years, is now limiting admission to NICU to premature infants who weigh 1,000 g or more. An attempt is also being made to critically assess the long-term quality-of-life in infants with extensive congenital anomalies prior to admission, eg, the neonate with a high myelomeningocele and paraplegia. Other choices are more difficult and the
441
HEALTH CARE ETHICS IN DEVELOPING NATIONS
decision-making process must involve parents and the community. A hospital ethical committee with community participation, and terms of reference relevant to the specific problems of the country, is being considered to assist health personnel in grappling with these
difficult issues. In brief, with this presentation, we wish to focus attention on a rapidly expanding problem of developing nations that has not yet received the attention it deserves.
REFERENCES I. Walker DB. Feldman A, Vohr BR, et al: Cost-benefit analysis of neonatal intensive care for infants weighing less than 1000 grams at birth. Pediatrics 74:20-25, 1984 2. McCarthy JT, Koops BL. Honeyfield PR, et al: Who pays the bill for neonatal intensive care? J Pediatr 95:755-761, 1979 3. Economic Survey 1987-88. Islamabad, Pakistan, Economic Advisor’s Wing, Finance Division, Government of Pakistan, 1988, pp 157-171 4. Knobloch H, Malone A, Ellison PH: Considerations in evaluating changes in outcome for infants weighing less than 1,501 grams. Pediatrics 69:285-295, 1982 5. Horwood SP, Boyle MH. Torrance GW, et al: Mortality and morbidity of 500 to 1,499 gram birth weight infants live born to residents of a defined geographic region before and after neonatal intensive care. Pediatrics 69:613-620, 1982 6. Sinclair JC, Torrance GW, Boyle MH, et al: Evaluation of neonatal intensive care programs. N Engl J Med 305:489-494, 198 1
7. Phibbs CS, Williams RL, Phibbs RH: Newborn risk factors and costs of neonatal intensive care. Pediatrics 68:3 13-321, 198 1 8. Boyle MH, Torrance GW, Sinclair JC, et al: Economic evaluation of neonatal intensive care of very low birth weight infants. N Engl J Med 308:1330-1337, 1983 9. Demeny P: Economics, health services organization, and finance, in Griffiths A, Bankowski Z (eds): Economics and Health Policy, Proceedings of the XIII CIOMS Round Table Conference. Geneva, Switzerland, 1980, pp 286-287 10. Avery GB: Ethical dilemmas in the treatment of the extremely low birth weight infant. Clin Perinatol 14:361-365, 1987 Il. Fleishman AR: Bioethical review committees Clin Perinatol 14:379-393, 1987 12. Kliegman RM, Mahowald interest: Experience and workings Pediatr 108:178-187, 1986
in perinatology.
MB, Youngner SJ: In our best of an ethics review committee. J
Nations
By Farhat Moazam and Mumtaz Lakhani
Karachi, Pakistan l Limited resources, widespread poverty, and the absence of health insurance pose daily ethical problems for Third World physicians, who must balance their roles as individual patient advocates against a desire to provide health care to the greatest number of children. Pakistan has a per capita income of Rs. 7,220 (USS380) per year, or Rs. 800 (USS 32) per month. The annual population growth of the country is 3.1%. and approximately 380.000 infants are born each year in Karachi, the largest city in the country. The Aga Khan University Hospital. a private teaching institution, is the only hospital in Karachi with a Level Ill Neonatal Intensive Care Unit (NICU). The financial and medical data of 200 infants admitted to the NICU in 1988 were reviewed retrospectively, and compared with those of two specific subgroups. (1) Among 15 infants who underwent surgical intervention, the average total cost of hospitalization was Rs. 38,040 (US$ 1.900) per patient, with an average daily cost of Rs. 923 (USS 491. The longest hospital stay was 6 months, for a child who had total colonic aganglionosis associated with a short gut syndrome. There were two deaths in this group. (2) Of the 21 premature neonates admitted having Idiopathic Respiratory Distress Syndrome (IRDS) during this period, the total hospitalization cost per patient was Rs. 23.280 IUSS 788). with a daily cost of Rs. 1,050 (lJS$ 55). Eleven patients required ventilatory support. There were 16 survivors. Among both groups, 6% of all revenues generated in the NICU were used to help families pay for the bills under a welfare scheme. o 1990 by W.B. Saunders Company. INDEX WORDS: Ethical dilemmas of health care: neonatal intensive care; health care in developing nations.
I
N DEVELOPED NATIONS, intensive care of critically ill neonates has resulted in a dramatic improvement in their survival. However, the expense of these programs has generated many questions regarding efficient and equitable resource allocation in the face of finite funds.‘** The last decade has seen rapid transfer of modern technology and advanced health care to developing countries. The ethical dilemmas facing physicians in the Third World are magnified in the face of minimal resources and abject poverty, but no mechanism is in place to help them with these
difficult decisions. Pakistan has a per capita income of Rs. 7,220 (US$380) per year, or Rs. 800 (US$42) per month. The infant mortality rate is approximately 115 per 1,000 Iive births, and the country spent 1.1% of its GNP in 1988 on health issues.3 The Aga Khan University Hospital is a private teaching hospital in Karachi, a city with a population of 8,000,OOOpeople. The Neonatal Intensive Care Unit of the institution has eight beds, four of which are equipped to provide Level III care. This is the only facility of its kind in a city with an estimated 360,000 births per year. MATERIALS AND METHODS A retrospective review of the medical and financial data of all
patients admitted to the NICU between January 1, 1988 and December 31, 1988 was carried out, and the data of two specific groups of infants were reviewed in detail. (1) Surgical Group. This included infants admitted directly on the surgical service and those with a primary medical problem who required major surgical intervention. (2) Medical Group. This group was limited to premature infants with varying degrees of Idiopathic Respiratory Distress Syndrome (IRDS), who did not require surgical intervention. Eleven infants required ventilatory support, whereas the others were managed with oxygen and/or Continuous Positive Airway Pressure (CPAP). In all patients the average cost of hospital stay, length of stay, and the daily cost per patient were estimated. The average laboratory and radiological charges per patient were tabulated. In the surgical group, the average surgical cost per patient, inclusive of the surgeon’s and the anaesthesiologist’s fees and the theater charges, was estimated. RESULTS
During the 12-month period, 200 neonates were admitted to the NICU. The average total bill per patient was Rs. 12,668 (US$ 667), and the average hospital stay was 12.5 days. During the same time, the hospital charges were estimated for 1,364 children admitted to the pediatric ward for medical and surgical conditions. The average total charge per child was Rs. 5,592 (US$294), with an average hospital stay of 5 to 6 days. Two subgroups among the NICU admissions were studied in detail. Surgical Group
From the Department of Surgery. The Aga Khan University Hospital. Karachi, Pakistan. Presented at the 3&h Annual Congress of the British Association of Paediatric Surgeons, Nottingham, England, July 19-21,1989. Address reprint requests to Farhat Moazam. MD, Department of Surgery, The Aga Khan University Hospital. PO Box 3500. Stadium Rd. Karachi, Pakistan. Q 1990 by W.B. Saunders Company. 0022-3468/90/2504-0015$03.00/0
A total of 15 neonates were included in this group, and except for two patients, all were transfers referred from outside institutions. Two infants died, one having a congential diaphragmatic hernia and another having necrotizing enterocolitis with barium peritonitis (Table 1). The total hospital stay ranged from 5 days to 178 days, the latter in an infant with multiple ileal atresias and short gut syndrome complicated by total
430
Journal
of Pediatric Surgery, Vol 25, No 4 (April),1990:
pp
438-441
439
HEALTH CARE ETHICS IN DEVELOPING NATIONS Table 2. Financial Information of Surgioal patients
Table 1. Surgical Group Patk?llt
No.
Diagnosis
Sex
1
M
Antenatal perforation
2
M
Hirschsprung’s disease
Total Hospital Total Hospital stay stay (days1 104
es. 44,757
18
Rs. 20,038
(US$2.356) (USS 1,055) 3
M
Midgut volvulus
37
Rs. 2 1,389 (USS1.126)
4
F
Congenital adrenal hyperpla-
27
sia
(US$1,145)
M
Bochdalek hernia
30
Rs. 37,047
6
F
llaal atresia
39
Rs. 29.69 1
uJS$ 1,950) (lJS$ 1,563) M
llaal atresia, total colon agan-
178
glionosis 8
M
Necrotizing entarocolitis.
F
Dandy Walker syndrome,
10
M
Gangrene leg
11
F
12
Rs. 8.432
Operating charge (surgeon. anesthesi-
Rs. 8,670
RJS$444) ologist, theatre charges) Laboratory (145 investigations)
(US$456) Rs. 7.07 1 (US$372)
Radiology (eight procedures)
Rs. 1,640 (US$B6)
Pharmacy
Rs. 4,060
Medical surgical supplies
Rs. 4,770
(US$214) (USS 25 1)
Rs. 156,286
5
Rs. 17,777 0JS$936)
24
Rs. 28,370
20
Rs. 24.849
Bochdalak hernia
5
Rs. 23.896
F
lmperforate anus
18
Rs. 20,340
13
F
Patent ductus arteriosus
51
Rs. 55,250
14
F
Bochdalak hernia
24
Rs. 2 1,950
15
M
Hypertrophic pyloric steno-
8
Rs. 10,316
hydrocephalus
(US$ 1,493) (US$ 1,308) KlS$ 1,258) (US$ 1,070) (US$2,9071 lUS$1.155)
sis, sepsis
uJS$ 1,900) Bed charge (39 days)
(K88.225)
barium peritonitis 9
Rs. 36,040
Total charges
Rs. 2 1,756
5
7
Averageper Patient (n = 15)
require ventilation. Whereas the average professional fee per patient was Rs. 2,592 (US$ 136), the laboratory and pharmacy charges were Rs. 7,887 (US$4 15) and Rs. 1,040 (USS 55) respectively (Table 3). Although the number of patients in each group is relatively small, as expected, the highest total charges were for infants undergoing surgical intervention and premature infants with IRDS. The average daily charges for both subgroups were comparable to patients admitted to the paediatric ward, but the longer hospital stay of the former contributed to the higher costs (Table 4).
(US$543)
DISCUSSION
colonic aganglionosis. The average length of hospital stay was 39 days, with an average total charge per patient of Rs. 36,040 (US$ 1,900). The surgical charge per patient was Rs. 8,670 (USts444). The next highest expense was incurred for laboratory investigations, with an average cost per patient of Rs. 7,078l (US$ 372). The average pharmacy and radiological charges were Rs. 4,060 (US$ 214) and Rs. 1,640 (US$ 86), respectively. The cost of medical and surgical supplies used per patient was Rs. 4,770 (US$251) (Table 2).
In developed countries, intensive care of neonates is now widespread, with dramatic improvement in survival of critically ill infants. This is especially true in low-birth weight infants, with survival rates of 80% in those weighing between 1,000 g and 1,500 g.1,4s5 However, in the last decade important questions have been raised regarding cost effectiveness and cost benefit of expensive medical programs in the face of the realization that resources are finite.6-8 This problem is Table 3. Financial Information of Premature Infants With IRDS
Medical Group There were 21 premature infants with IRDS weighing between 830 g and 2.9 kg. Nine infants weighed less than 1.5 kg, and had a mortality rate of 33.3%. Among 12 infants who weighed more than 1.5 kg at the time of admission, the mortality rate was 16%. The gestational ages varied from 28 weeks to 36 weeks. Six premature infants were transferred from other institutions. The average hospital stay for this group of infants was 22 days, with a total charge per patient of Rs. 23,260 (US$ 1,224). The average daily cost of infants requiring ventilation was Rs. 1,150 (US$ 60) compared to Rs. 500 (US$ 26) for those who did not
Averageper Patient(n = 2 1 I Total charges
Rs. 23,260 (US$ 1,224)
Bed charges (15 days)
Rs. 7.500
Professional fees
Rs. 2,592
Laboratory (96 investigations)
Rs. 7.887
lUS$395) (US$ 136) (US$415) Radiology (five procedures)
Rs. 1.040
Pharmacy
Rs. 1,380
lUS$55) (USS73) Medical surgical supplies
Rs. 2,542 lUS$134)
440
MOAZAM AND LAKHANI Table 4. Average Charges for Paediatric Patients All NICU Patients hl =
1991
Total charges
Rs. 12,668 IUS$667)
Laboratory
R.S.3,703 (US$ 195)
NICU Surgical Patients In =
15)
Rs. 36,040
NICU Premature With IRDS (n =
21)
All Ward Patients In =
1.3641
Rs. 23,260
Rs. 5,592
WS$ 1,897)
WS$ 1,224)
WSS 294)
Rs. 7.07 1
Rs. 7,887
Rs. 878
WS$372)
CUSS4 15)
WS$46)
Rs. 693
Rs. 1,640
Rs. 1,040
Rs. 317
WSS36)
uJS$86)
WS$55)
uS$
Pharmacy
Rs. 1,096
Rs. 4,060
Rs. 1,380
Rs. 1.074
(US$58)
iUS$2 14)
0x$73)
WS$57)
Daily charge
Rs. 1,000
Rs. 923
Rs. 1,050
Rs. 932
(lJS$53)
WS$49)
(US.$55)
uJSS49)
12.5 days
39 days
22 davs
5.6 davs
Radiology
Hospital stay
present far more starkly in developing nations, where resources are extremely limited, populations vast, and poverty rampant. Most developing nations spend a variable portion (1% to 5%) of their GNP on health services. The problem of limited financial resources is compounded by inadequate manpower and the absence of health insurance. In addition, few developing countries have provisions for funding or assisting handicapped survivors of intensive care. The debate on correct health policies for poor countries continues, with the World Health Organization having set a goal of health for all by the year 2000. It has been noted’ that this can be accomplished through greater emphasis on preventive medicine, and by raising general standards of living via improved agriculture, education, and community development. Experience has shown that, as a rule, health services play a small role in reducing the morbidity and mortality in a country, and implementation of good health policies are more effective in this regard. The other side of the coin that cannot be ignored, is the implicit right of every individual to the best health care available in the country. The last few years have seen a rapid transfer of advanced technology and capability for tertiary care to developing countries. The populations of such countries are increasingly sophisticated, with high expectations of and information about the latest medical advances. In the face of widespread poverty and an absence of health insurance, physicians in private institutions like the Aga Khan University Hospital are faced daily with the problem of balancing their role as individual patient advocates against the desire to provide health care for the greatest number of children. Whereas a physician in a developed nation may struggle over whether to rescusitate a malformed infant or a Trisomy 13 infant in the delivery room, his counterpart in Pakistan must agonize over which, among two otherwise healthy neonates with mild IRDS, should benefit from the last bed in the NICU, and who will pay the hospital bill.
17)
Some of these vexing issues were discussed at the Geneva meeting of the Council for International Organizations for Medical Sciences (CIOMS) in 1980. Demeny,’ while discussing economics and health problems of developing nations, suggested that governments should concentrate their resources in areas where major external benefits can be provided to raise the general standard of health, eg, by providing birth control services, antimalarial programs, etc, as opposed to expensive health services. Private institutions could help to fulfill the need for tertiary health services in response to the expectations of the population. However, without health insurance and in the face of miniscule per capita incomes, institutional resources are insufficient. Choices must be made as to who should benefit from these services and how best to allocate resources to reach as many as possible, without limiting them to the small numbers who can afford them. Whereas it is naive to ignore the financial implications, it would be immoral to constitute affordability as the sole criterion for allocation of services. The cost benefit issue must be taken into consideration, as must the quality of life among those who survive. Whereas neonatal technology has grown rapidly in developing countries, means of addressing these thorny issues are in their infancy. Although the choices may be somewhat different, lessons must be learned from the experience of countries who have been struggling with like issues for several years.‘0V12 An example would be a critical look at the wisdom of spending resources on the management of extremely low birth weight infants or neonates with multiple surgical anomalies. The Aga Khan University Hospital, based on its experience over the last 2 years, is now limiting admission to NICU to premature infants who weigh 1,000 g or more. An attempt is also being made to critically assess the long-term quality-of-life in infants with extensive congenital anomalies prior to admission, eg, the neonate with a high myelomeningocele and paraplegia. Other choices are more difficult and the
441
HEALTH CARE ETHICS IN DEVELOPING NATIONS
decision-making process must involve parents and the community. A hospital ethical committee with community participation, and terms of reference relevant to the specific problems of the country, is being considered to assist health personnel in grappling with these
difficult issues. In brief, with this presentation, we wish to focus attention on a rapidly expanding problem of developing nations that has not yet received the attention it deserves.
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7. Phibbs CS, Williams RL, Phibbs RH: Newborn risk factors and costs of neonatal intensive care. Pediatrics 68:3 13-321, 198 1 8. Boyle MH, Torrance GW, Sinclair JC, et al: Economic evaluation of neonatal intensive care of very low birth weight infants. N Engl J Med 308:1330-1337, 1983 9. Demeny P: Economics, health services organization, and finance, in Griffiths A, Bankowski Z (eds): Economics and Health Policy, Proceedings of the XIII CIOMS Round Table Conference. Geneva, Switzerland, 1980, pp 286-287 10. Avery GB: Ethical dilemmas in the treatment of the extremely low birth weight infant. Clin Perinatol 14:361-365, 1987 Il. Fleishman AR: Bioethical review committees Clin Perinatol 14:379-393, 1987 12. Kliegman RM, Mahowald interest: Experience and workings Pediatr 108:178-187, 1986
in perinatology.
MB, Youngner SJ: In our best of an ethics review committee. J
