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The systems which are in place to provide healthcare face many challenges including issues of cost, quality, workforce and equity. These challenges exist both in the developed (‘Western’) world, and in the developing world. The developing world also faces challenges with poor access to basic healthcare services, particularly services for those who are less well-off; a shortage of healthcare

providers; meeting the costs of care, medication and treatment; and the availability of and access to specialised treatment centres. These challenges may also be present in the developed world, to- gether with additional challenges resulting from over servicing, undue commercial influence, an ageing workforce, and an increase in life expectancy which extends the time during which citizens can be afflicted by complex and chronic diseases. The developed world is also troubled by ‘diseases of affluence’, which are closely associated with ‘first world problems’: inactivity, poor diet, obesity, and the iatrogenic effects of overdiagnosis, overmedication and overtreatment. In the developing world these diseases of affluence also become more evident as economic progress enables citizens to move towards higher levels of income.

Health systems also face problems with organising and managing the provision of care. Issues of cost and funding; staffing; and avoiding the fragmentation of care for multiple conditions may present differently in different countries, but with no country immune from the challenges they present. The coordination of fragmented care presents a particular problem for patients. Evidence is emerging that multimorbidity – when a patient has three or more chronic conditions – can create a significant extra pressure on healthcare systems. An effective response to multimorbidity is not helped by the prevailing ‘single disease’ model of treatment, in which patients with multimorbidity receive multiple uncoordinated types of care.

In addition, the compartmentalisation of the healthcare system can be very effective at creating ad- ditional clinical work, with treatment guidelines and quality frameworks likely to recommend that a complete parcel of care be provided for each of the morbidities that comprise the multimorbidity. (Schoen et al., 2005) This approach may also increase the workload and cost for the patient, who is likely to have more medications, more visits to healthcare providers and more travel than would be the case within a well coordinated package of care. As Barnett et al note in their study of mul- timorbidity:

Existing approaches focusing on patients with only one disease dominate most medical educa- tion, clinical research, and hospital care, but increasingly need to be complemented by sup- port for the work of generalists, mainly but not exclusively in primary care, providing continu- ity, coordination, and above all a personal approach for people with multimorbidity.

(Barnett et al., 2012) Some of the solutions that have been proposed for these challenges include engaging citizens in an attempt to reduce health-damaging behaviours, the transfer of some aspects of patient care from institutions to community settings (including patient homes), to support the frail well in living longer in their own homes, and to engage patients as partners in the delivery of their own care. If ICTs are to be a part of that response, they must be accessible by citizen non-experts.

2.3.6 (Why) does equity matter for health services?

Amartya Sen gave a keynote address (later published as an editorial in Health Economics) to the Third Conference of the Health Economics Association in 2001 (Sen, 2002). He made three obser- vations about health equality. Firstly, health equity is inextricably linked to social factors: it cannot be assessed simply by examining the way in which health care is distributed. Secondly it is not equitable for any group to be discriminated against (on any basis). Finally, health equity must take account of the way in which resources are allocated, and of the social factors which link health with other aspects of life. He noted that equity issues may present themselves in the initial alloca- tion of resources to the healthcare system, as well as in the distribution of resources within health- care.

Since health equity has to be seen, as I have tried to argue, as a broad discipline, rather than as a narrow and formulaic criterion, there is room for many distinct approaches within the basic idea of health equity.

(Sen, 2002, p. 663). In a commentary included within a ‘mini-symposium’ in the Journal of Medical Ethics, Norman Daniels framed equity in healthcare service delivery and equity in health more generally as a moral and ethical issue, on the basis that good health is needed in order to ensure equitable access to the

benefits which arise from opportunity. The intricate melding of the social determinants of health, and the role of good health in helping to address socioeconomic disadvantage means that it be- comes difficult to separate the two, or to evaluate them as independent factors (Daniels, 2009).

In her Masters thesis (2011), Malinche van der Hoog from Tilburg University explored issues of equity in the provision of health services. She reached the conclusion that equity in the provision of health services requires both formal equality, treating all cases alike (horizontal equity), as well as proportional equality, treating all citizens according to their due (vertical equity). It appears that many ehealth initiatives focus on horizontal equity, providing similar opportunities for access to all potential participants, at the expense of vertical equity, focusing on the provision of enhanced ac- cess for those most in need. Because of distortions introduced as a result of the PLU problem, there may be a need to adopt a formal and deliberate focus on vertical equity, which may entail some form of ‘positive discrimination’, applying additional resources and effort to a disadvantaged subset of the population.