Different Strokes

A couple of posts back, I described how our team is working to look at issue of premium exemptions in the national healthcare scheme -- that is, determining what sorts of people are entitled to national healthcare but exempt from paying the annual enrollment contribution. Currently, pregnant women, children, the 70+ set, and "paupers" all receive exemptions from paying.

One of the challenges we're facing is how to define "pauper" for the purposes of the national health scheme. In fact, I've spen most of this morning thinking about the problem. Under the current law, people classed as paupers must be so poor that they cannot be expected to pay the annual $5ish fee for their heathcare. Deciding who gets pauper status is important because it determines which people will receive free healthcare.

The challenge is that it's very difficult to assign pauperhood (pauperdom?) in an area like the Upper East where the vast majority of people are, by most standards, poor. There are a few different ways to do this. Many of the Ghanaian professionals we've interviewed have suggested that hospitals and government officials will intuitively "know" who is poor based on what they are wearing, who they are in the community, and what other people in the hospital say about them. A hospital director we met with explained The Ghanaian law students on our team also agree with this approach. Most of the Western people in our group have objected to the case-by-case method and instead want a clear rule (or guidelines) to determine pauper status. After all, the "I know it when I see it" system could introduce a lot of unfairness and discrimination, not to mention the possibility of corruption.

Anyone who has been to law school will recognize that this is similar to the old 'rules v. standards' debate. Rules involve mechanical applications of facts in a given case -- e.g., if you are under 14, then you cannot drive a car; if someone else forged your signature on a contract, then the contract isn't valid. Standards are a more flexible way of determining something -- e.g., if a person "acted unreasonably" and your property was damaged as a result, then they have to pay for it; if you "pre-meditated" killing someone, then you are guilty of first-degree murder. Rules are basically black-and-white tests that should be straightforward to apply but don't take into account all the facts of the situation. Standards basically allow the person deciding to use more discretion and take everything into account, but they also provide less direct guidance. In the United States, political conservatives generally favor rules (because they offer predictability) while progressives usually favor standards (because they take into account fairness and individual circumstances). There are exceptions, of course, but this is often the way it breaks down.

But the "I know it when I see it" approach recommended by the Ghanaians is not really a standard at all, but rather intuitive thinking. On the rule-standard spectrum, intuitive judgment is beyond a simple standard because it allows the decision-maker Solomonic power to decide what seems best. Westerners, especially lawyers, tend to be very skeptical of using equitable, intuitive methods to distribute very critical resources to individuals, probably because they fear bias, corruption and unfairness. I generally feel more comfortable with clear rules because it means that everyone is going to be treated equally by the law, even if it's not the best thing in every situation. But there is no reason to think that the standard-less way of assigning pauper status is necessarily worse. The communities we are working with -- Bongo and Walewale -- are relatively small, with fewer than 100,000 people living in each. Although it is unrealistic for any community member to know everyone in the town, it's easier for government and community groups to identify people who are truly impoverished based on that person's reputation. One idea we have been batting around is getting committees of community members to identify those people who are poorest and need free healthcare; that might avoid some of the fairness concerns and make the process less arbitrary. In the end, I'm come to accept that some forms of decision-making (like the intuitive method) might be appropriate for certain needs in Ghana, even though they wouldn't be appropriate back home.

Well that's a lot of lawyer-talk for one day! At this point, the debate around how to determine pauper status remains unresolved. Hopefully we'll work it out soon.