The pandemic is creating a crisis on three levels: health, economic, and social. None of these levels will remain the same after the pandemic ends. We must understand that there is no way back, only forward. The role of those in power is to answer the question of what kind of society this is leading to.
Three dimensions of state intervention. In the initial phase of the COVID-19 pandemic, the majority of government actions naturally focused on treating infected patients and preventing the spread of the epidemic. When the scale of measures restricting interpersonal contact, travel, and the provision of services to the public threatened the safety of businesses and entrepreneurs and created the risk of job and income loss for large numbers of people, governments began to propose appropriate protective measures. The resulting discussion about the economic impact of the pandemic gained importance as the risk of depleting the financial reserves of businesses and individuals increased. The third perspective emerged most slowly, yet very consistently. This is the social perspective. Its source lies in the daily changes in social relations, customs, and habits, as well as the fear of a potentially lethal disease. Interest in the novelty of “tele-relationships” on this scale, intended to replace physical contact and protect against infection, is slowly giving way to anxiety, loneliness, and a longing for normal life. Not everyone copes equally well. Even those segments of society that appreciate the benefits of teleworking—flexibility in time management and the ability to balance work with household responsibilities—are recognizing the drawbacks of social isolation. Concerns are arising over cases of domestic violence and the mistreatment of loved ones, especially children. Personal problems are mounting, threatening lasting trauma and the explosion of hidden dramas in the near future.
Looking at the processes described in summary, it’s worth noting that they are interdependent. This means that a change in the status of each of them individually impacts the other two. The scale of this impact depends on the nature of the given phenomenon. Thus, state intervention focused on one aspect of the pandemic—health, economic, and, in the future, social—impacts the others. This interdependence appears to have been underappreciated to date. Saving the health and lives of COVID-19 patients clashes with the future economic and social consequences of these actions. It also impacts the state’s ability to save the health and lives of other patients. Similarly, economic measures shielding businesses and workplaces exhaust the compensatory potential of economies and limit the ability to provide public services, including healthcare, to other groups in need. However, mobilizing social capital to its physical limits in the fight against the pandemic also unfortunately produces negative consequences in the health and economic spheres, which is particularly evident in the case of medical and social personnel.
Therefore, the analysis of the appropriateness, effectiveness, and proportionality of each state intervention should be conducted independently from three perspectives: health, economic, and social. In each case, it should take into account that the state’s potential is limited. The use of its resources for specific actions in one perspective limits the scale of possible actions in the remaining ones. Each intervention can be considered optimal in the interests of the patient, society, and the economy only after considering the limitations of state resources and a multidimensional analysis of its effects.
The concept of primary importance in this approach is the resilience of the healthcare system, the economic system, and social cohesion at the national, community, and individual levels. Exceeding the limits of these resilience levels, or even approaching them, raises concerns. It raises questions about the appropriateness of specific interventions and may lead to uncontrolled social reactions.
As a result, something that, within the framework of a discussion from one of the perspectives discussed, seems purposeful, sensible, not to say optimal, may in the aggregate result turn out to be an action far from broadly understood social expectations.
The value of health interventions. The concept of value in health care is a subject of widespread debate among health care scientists and practitioners worldwide. Over the past decade, a number of definitions of value have been proposed, taking into account its various aspects. Following a broad expert debate conducted under the auspices of the European Commission, the expert panel on effective ways of investing in health, initiated by the Directorate-General for Health and Food Safety, proposed that the value of health investments should be considered from four perspectives[1]:
- technical value,
- social value,
- personal value, and
- allocative value.
In the context of combating the SARS-CoV-2 coronavirus epidemic, technical value, in its simplest terms, is a measure of how many people will die, how many lives will be saved, or how many patients will be prevented from developing a severe form of viral pneumonia requiring intensive care, relative to the measures implemented. It seems that the technical value of an intervention currently has a decisive advantage, relegating other dimensions of the value of health investments to the background.
Meanwhile, the importance of other dimensions of value should not be underestimated. Recall that the social value of health investments is a measure of how specific actions impact social relations and community cohesion, both those formed in the residential and workplace environments, as well as at the local and national levels. Cohesion can be expressed through the level of social inequality among various groups, not just COVID-19 patients. This applies equally to patients treated for cancer, cardiovascular diseases, diabetes, and those suffering from rare diseases. Their situation has changed as a result of the outbreak of the pandemic and the actions taken. In this context, it is also worth asking about the economic consequences of fighting the epidemic for healthy individuals. States’ resources are limited. This is felt, for example, internationally by refugees from Africa and the Middle East located in transit camps, whose situation illustrates the importance of social inclusion for vulnerable and marginalized groups.
A change in our quality of life, assessed from an individual perspective, creates the personal value of an investment in health. A classic example of personal value is the patient’s right not to undergo persistent resuscitation, or the right to choose a medical treatment method, so important for cancer patients in advanced stages of cancer. A dramatic example of personal value is the need, as indicated by doctors in countries stricken with the epidemic, to decide which patient to allocate limited life-saving resources to. This is all the more shocking considering that it is not the patient who decides the personal value of their life, but rather medical personnel who are forced to do so for them. This aspect is particularly evident when combined with technical value, and today, it seems, determines the type and scale of remedial actions undertaken by individual countries.
Taking the three dimensions together, we can hypothesize that the allocation dimension is crucial in assessing the value of health investments. Given the limited resources of the state, the equitable distribution of these resources, ensuring the balanced satisfaction of the interests of all groups, all citizens, across all key dimensions, has a crucial impact on assessing the value chain of public interventions. Such interventions should be considered not only in the short term, when their direct effects occur, but also in the medium and long term, when their secondary effects are observed and felt.
State resources are and will remain limited. The allocative dimension of state intervention, taking into account the well-being of all social groups, cannot be overlooked in the fight against the pandemic.
A new world. Today, public debate lacks a comprehensive analysis of the value of health investments. As one might suspect from governments’ communication, it is also lacking in the closed expert debates shaping national decisions. Meanwhile, the health consequences of these decisions for other patients, the economic consequences, and their impact on social life are already visible. At the same time, economic relations are changing permanently, as are our habits and customs. A new economy and social culture are being created. The problem is that the scale and nature of these changes have not been publicly discussed. Governments made this decision on behalf of their citizens, guided largely by the technical value of health investments, neglecting, or perhaps rather underestimating, its other dimensions. Even if they did, they failed to communicate the results of their analysis to society. Only when these changes began to take shape did messages about their irreversible, or at least multi-year, nature, or their scale, sometimes compared to a global earthquake, sometimes to World War II, appear in the public sphere.
As Poland is still in the early stages of the crisis, and its global impact has not yet fully manifested, it is time to assess the public value chain of planned actions. Such an assessment should be conducted holistically across the three perspectives described above – health, economic, and social. According to Moore’s public value chain concept[2], when shaping the optimal state intervention in each perspective, not only the benefits for direct beneficiaries but also obligations to other social groups should be considered.
When choosing a specific intervention, it’s also worth considering the four dimensions of health investment value: technical, social, personal, and allocative. It’s important to remember that emerging from the crisis, we will encounter a different economy, a different society, and different social relations. It’s crucial that this change is implemented consciously, with public participation. The costs of making a mistake in this regard will be difficult to imagine.
When responding to the challenges posed by the pandemic, it’s important to remember that there’s no way back. There’s only a way forward. It’s important to know where it will lead and the cumulative consequences of the actions we take.
Robert Mołdach
[1] Defining value in “Value-based Healthcare”. Report of the Expert Panel on effective ways of investing in Health (EXPH). Brussels, 26.06.2019. https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/docsdir/024_defining-value-vbhc_en.pdf
[2] Moore, MH. Creating Public Value. Harvard University Press. Cambridge, London 1995.