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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.110 n.6 Pretoria Jun. 2020 



Building trust during COVID 19: Value-driven and ethical priority-setting



On 21 April 2020, President Ramaphosa announced a ZAR20 billion addition to the health budget as a result of the COVID-19 pandemic in South Africa (SA).[1] This represents an additional 10% of the current national 2019/20 budget of ZAR222 billion.[2] The specifics of this budgetary increase remain to be seen, but with the pandemic in SA straddling the financial year end when budgetary allocations are made, many important questions arise.

These questions include whether the ZAR20 billion will be included in the equitable share for provinces to utilise according to provincial priorities, or whether it will be allocated as a special conditional grant related to COVID-19 activities. Further to this would be decisions around the use of funding to ensure that health services affected by COVID prioritisation activities are supported and whether funds would be used to redirect some services - for example, shifting immunisation temporarily from a facility-based service to a community outreach programme until the health service is able to balance the influx of COVID patients with the current services it renders.

As novel as this virus and its implications are, the decisions detailed above are not - they are examples of the resource allocation and priority-setting decisions all countries have to make on an annual and ongoing basis as the burden of disease and the country's needs evolve.[3] In a resource-constrained country such as ours these decisions are even more important, as their potential opportunity costs may have dire effects on other services and government sectors. The difference, however, is that under normal circumstances, decision-makers have time to undertake a deliberate process with the benefit of data and scientifically rigorous information, even if this is not always done.

Given the changes our planet is seeing in terms of globalisation and climate change, we have every reason to believe that the COVID-19 pandemic, like natural disasters, will not be the last, or the most severe. The decision-making process for the allocation of resources during times of crisis does not have the benefit of time and perfect processes. It is therefore imperative that a reliable but rapid process for resource allocation, similar to that utilised for mass incidents, be developed for decision-making in pandemic healthcare, where the needs of the many outweigh the needs of the few.

The exact decision-making process will require the co-ordination of multiple stakeholders, with differing interests and objectives, around a particular set of actions, but through our work as a decision science unit, some lessons have emerged that may be beneficial to this process. One important element in decision-making is the oft-utilised economic evaluation. While these evaluations are sometimes underpinned by assumptions based on imperfect information, they are a quantitative, replicable method that can spell out relative costs and benefits for a given population.

As transparent as economic evaluation may be, context-specific priority-setting dictates that decisions not be made on technical grounds alone. Processes need to be deliberately informed by legitimate priorities that are ethical and reflect public values, even if they cannot be wholly determined by them. In the face of rising deaths, whether from public health emergencies or ongoing epidemics from non-communicable diseases, tuberculosis and HIV, one could argue that decisions that acknowledge social values alongside costs are more acceptable to populations, especially when people value a fair chance at benefit.[4,5]

To this end, we propose two complementary approaches to augment decisions around resource allocation during a pandemic; these are community participation and explicit ethical consideration. Many frameworks exist for the inclusion of ethical principles and values in priority setting. The World Health Organization recognises justice, utility, beneficence, liberty, reciprocity, solidarity and respect as key principles to guide decision-making in the event of an outbreak. [4,6] In a similar vein, our National Health Insurance White Paper[7] is built around the principles of right to access, solidarity, equity, affordability, appropriateness and health as a public good, a concept even more pertinent during this pandemic, where we hope to reap health benefits from social solidarity measures undertaken by others. In order to marry ethical principles and values important to a society with the dynamics and urgency associated with a public health emergency, an explicit process for the consideration of these intricacies will need to be undertaken with key stakeholders, including communities.

Community participation has long been recognised as a method to not only involve communities in the decision-making process but empower them towards active participation in and control of their health.[8] In responding to and recovering from public health emergencies, communities mobilise extensively to assist the most vulnerable, and the value of their experiences on the ground should not be dismissed when allocating resources for health interventions. To continue the example of facility- v. community-based immunisation, pure economic analyses may favour the continuation of facility-based services. However, consideration of equity and access during a public health emergency may shift decisions towards outreach services, and ensuring community participation will build social acceptance and trust in the new approach.

As SA moves into its third month of the outbreak, we recognise the need for fairly rapid, well-informed decision-making in our current context, and we appreciate that the scientifically driven public health approach to COVID-19 has bolstered public trust in some interventions while lack of transparency has hampered others. We urge our decision-makers to utilise the lessons from this experience and other issues of public health importance to move towards a process of prioritisation for future emergencies and routine healthcare that draws on a values-based, community-involved and context-specific approach.

Funding. All authors are supported through SAMRC grant #23108 to the SAMRC Centre for Health Economics and Decision Science.

Atiya Mosam, Susan Goldstein, Agnes Erzse, Aviva Tugendhaft, Karen Hofman

PRICELESS SA: SAMRC/Wits Centre for Health Economics and Decision Science, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa



1. South African Government. Statement By President Cyril Ramaphosa: Additional coronavirus COVID-19 economic and social relief measures. 21 April 2020. (accessed 24 April 2020).         [ Links ]

2. National Treasury, Republic of South Africa. RSA Budget 2019 highlights. Budget Review 2019: iii. (accessed 24 April 2020).         [ Links ]

3. Mitton C, Donaldson C. Health care priority setting: principles, practice and challenges. Cost Eff Resour Alloc 2004;2(1):3.        [ Links ]

4. World Health Organization. Guidance for managing ethical issues in infectious disease outbreaks. 2016. (accessed 25 April 2020).         [ Links ]

5. Daniels N. Resource allocation and priority setting. In: Barrett HD, Ortmann WL, Dawson A, Saenz C, Reis A, Bolan G, eds. Public Health Ethics: Cases Spanning the Globe. Public Health Ethics Analysis, vol. 3. Cham, Switzerland: Springer International Publishing, 2016:61-94.         [ Links ]

6. World Health Organisation Working Group on Ethics and COVID-19. Ethics and COVID-19: Resource Allocation and Priority-setting. Geneva: WHO, 2020:5. (accessed 25 April 2020).         [ Links ]

7. National Department of Health, South Africa. National Health Insurance for South Afria: Towards univeral health coverage. White Paper. 2017. (accessed 26 April 2020).         [ Links ]

8. Wisner B, Adams J, eds. Environmental Health in Emergencies and Disasters: A Practical Guide. World Health Organization, 2002. (accessed 26 April 2020).         [ Links ]

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