Delivering Healthcare and Education as Rightful Services not Commodities: A Noble Cause with Great Practical Implications at Children’s Cancer Hospital – 57357 Egypt

Health care and education should be delivered to everyone as rightful services with a moral motive evolving form the fact that they are basic human rights and not commodities. Services are attainable rights, while commodities are only delivered or become of better quality when someone pays for them. Being labelled as rightful services, healthcare and education cannot be owned. And that is the right policy for health and education reform, because if they were owned as commodities, it would be easy to control them and limit their delivery based on affordability. The delivery of healthcare and educational services as rightful services has humanistic, economic and developmental implications. From a humanistic standpoint, healthcare and education should be delivered as basic human rights, and not as gifts or privileges that are granted to people with terms and conditions. Also, the concept of delivering healthcare and education from an economical versus commercial point of view will lead to the delivery of more services with lower costs, thus increasing access to these services and leading to more productivity and overall economic positive output. Consequently, this would have a developmental implication, where the performance of individuals who receive their basic human rights would tremendously improve as a result of being healthy and well-educated. These concepts have actually been practically applied at the Children’s Cancer Hospital – 57357 Egypt which treats children with cancer free of charge and implements continuous learning and education for its patients and employees as rightful services. The hospital sets an example for health policy planning and implementation as a role model towards healthcare reform in low and middle income countries.


Introduction
Over the years, there has been great concern with reforming the health care system all over the globe while controlling costs [1]. Many initiatives have been implemented to restructure the health systems to improve quality and access to health care and a lot of funds have been invested and raised for this cause [1]. However, one fatal flaw exists in the health systems where the delivery of health care is more or less attributed to symptoms of one core problem; health care is dealt with as if it were a commodity like many other commodities [2]. Whereas, the basic conceptions regarding health and healthcare should be revolutionized to deal with healthcare services as a right and not a privilege [2]. "Health and health care are not commodities that exist to drive the economy. They are among the social goals which we have an economy to achieve" [3]. It has been the consensus of the world that health care is a human right, as declared by the Universal Declaration of Human Rights adopted by the UN and as stated by the International Covenant on Economic, Social and Cultural Rights which recognizes "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" [4]. The notion that health care is a basic human right is also deep-rooted in the Declaration of Independence regarding what actually defines a right to be [5]. However, this is easier said than done and these concepts have not totally been translated into health policy implementation. The U.S. Senator, Ted Kennedy expressed the feelings of many in regards to health care mentioning that health care is not a gift to be rationed based on the ability to pay, and that it should no longer be considered as a commodity nor a privilege for those who can afford it [6]. However, health care is a basic right that should be attainable to everybody through universal health insurance which is a national priority [6]. The same concept goes for education, where it should be made attainable to everybody as a basic human right regardless of people's affordability to pay for it [7]. The purpose of this concept paper is to rationalize the importance of delivering healthcare and education as rightful services not as commodities, and the implications of applying these concepts on humanistic, economic, and developmental standpoints. The paper also provides a real-life practical example as a case study where the implementation of these concepts achieved tremendous success at the Children's Cancer Hospital -57357 Egypt.

Materials and Methods
A systematic qualitative literature review was done for sources whose focus was on addressing whether healthcare and education should be delivered as basic rights or commodities. Key words included in the search were healthcare, education, service, basic right, and commodity. This was followed by qualitatively reflecting on the authors' point of views regarding these conceptual questions and analyzing the impacts of applying healthcare and education as services to come up with new concepts and implications. Full-text papers or online articles were excluded if they did not provide sufficient evidence about the data source, or they addressed an irrelevant topic. The applicability of these concepts were then evaluated at the Children's Cancer Hospital -57357

Description of included studies
Results from the qualitative literature review are presented in Figure  1. Thirty-seven papers and articles were full-text assessed for eligibility. Among these, seventeen papers and articles were excluded for the following reasons; no sufficient evidence about data source (n=11) and irrelevant topics (n=6). Twenty papers and articles were included in the qualitative review.
Based on the qualitative literature review, it was found that many people agree that health care and education should be delivered to everyone as rightful services with a moral motive evolving form the fact that they are basic human rights and not commodities. A summary of main findings from literature is shown in Table 1. Services are attainable rights, while commodities are only delivered or become of better quality when someone pays for them; the more you pay the greater quality of health care and education you receive. No one should own the services of healthcare delivery and education, because if they were owned, it would be easy to control them and limit their delivery based on affordability to pay. The concept which considers health care and education as basic human rights that should be delivered as rightful services with moral justification-and not commodities-cannot accept the fact that they would be controlled and become of limited access based on the ability to pay. The delivery of healthcare and education as services and as basic human rights, in opposition to commodities, has led to tremendous humanistic, economic and developmental implications.

Humanistic implications
The most difficult two situations where people need support the most are when they are in need of health care services or education. Therefore, from a humanistic standpoint they should not be delivered to the people in need based on their affordability profile. Healthcare and education should be driven from a service concept, not a commodity, where they are human rights not gifts or privileges that are granted to people with terms and conditions.
There should be a more convincing moral framework that does not deprive the less privileged of their basic human rights to receive dignified health care and educational services; the poor should not be punished because of their unaffordability to pay or receive these services in poor quality, while the rich will always find ways to get better care. In fact, it would be inhumane and morally offensive to make decision about life and death based on the amount of money a person has on hand [2].
Nations have to keep what they accept as true in regards to notions of people's rights and equality. But what actually constitutes a human right? Are they determined by their availability in a given economy and can they be controlled or become limited to some people based on authority's judgment? [5]. The Declaration of Independence describes rights as unalienable, meaning they cannot be surrendered or transferred, when it states that "Men…are endowed by their Creator with certain unalienable Rights" [5]. These rights are innate and inherent to humanity and come inseparably coupled with man's ability to think, to reason, and to moralize [5]. The rights are generalized as Life, Liberty, and the Pursuit of Happiness [5]. Receiving healthcare and educational services are believed to be indispensable human rights that should be equally granted to people as a key attribute of human dignity and not be dealt with as commodities such as cars, TVs and  smartphones [2]. Only the circumstances at which these services are delivered can change, but the quality of these services should not be affected based on affordability.
In 2000, the UN Economic and Social Council's Committee on Economic, Social, and Cultural Rights published a General Comment which stated that, "Health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity [6].

Economic implications
Another very important implication for considering healthcare and education as rightful services and not commodities is the economic implication they have. The concept of delivering healthcare and education from an economical -in contrast to a commercial-point of view will lead to the delivery of more services with lower costs, thus increasing the market share of these services leading to more productivity and overall economic positive output.
This concept can change the way of thinking of the pharmaceutical, medical equipment and educational industries, to follow more economic approaches to deliver the services to cover a larger portion of the population. As long as healthcare and education are delivered as services, then their costs will be affected by changes in economies of the countries. And as noted by Dr. Andrew Coates, Physicians for a National Health Program (PNHP) president-elect, "the ideology that whatever is private is good and whatever is public is bad. It is not true, and it is certainly not cheaper" [3].
Furthermore, studies suggest that providing universal health care not only improves the health of populations, but also may be cost-effective [8]. This is because being uninsured or having inadequate insurance will reflect serious negative consequences for the individuals, families, communities and countries like the United States. Statistics have shown that the uninsured are more likely to die than the insured; approximately 44,789 Americans between the ages of 25-64, die every year due to lack of health insurance [8]. However, just having insurance is not always the solution; nearly 16 million Americans, representing 12% of insured adults, are underinsured [9]. These underinsured individuals have such insufficient health insurance that they tend to delay medical care because of costs. This issue affects all income levels; "...median household income of those who were underinsured was $58,950 and 22% lived in households making more than $100,000 per year" [9].

Study/Online Article -(Year) Dimension of Implications Main Finding(s)
Orszag and Emanuel (2010) [1] Overview -Many initiatives have been implemented to reform the health care system while controlling costs.

Winters (2016) [2]
Humanistic -Healthcare is a basic human right that should be equally granted to people as a key attribute of human dignity and not be dealt with as a commodity.

Freeman (2012) [3] Economic
-Assigning the right language about how healthcare is labeled is crucial to improve the systems.
-Healthcare does not exist to drive the economy, it is the reason we have an economy to achieve health services.
Office of the High Commissioner of Human Rights (2000) [4] Humanistic -There is consensus that healthcare is a human right, as declared by the Universal Declaration of Human Rights.
Sheppard (2016) [5] Humanistic -The Declaration of Independence also indicates that healthcare should be delivered as a basic human right.

Bergen et al. (2012) [6]
Humanistic -Health care should be attainable to everybody through universal health insurance which is a national priority.
Humme (2012)  Developmental -Cancer patients can better achieve at work when they are offered healthcare services as a basic right, not compromised by the ability to pay for treatment.

Hanly and Sharp (2014) [12] Developmental
-Receiving healthcare as a rightful service improves the psychological aspects of the patients leading to higher cure rates at lower costs. -Receiving proper medical treatment for cancer increases the work hours of employees leading to increased productivity.

Ciccone et al. (2010) [13]
Developmental -Proper care management of heart failure and diabetes in primary healthcare systems leads to increased patient empowerment and self-management of the disease, which results in improved clinical outcomes.
Berger and Fisher (2013) [14] Developmental -Delivering educational services as basic human rights leads to increased number of well-educated and welltrained employees who achieve better productivity at work with lower costs.
McAllister (2013) [15] Overview -There are still ongoing discussions about whether health care is a basic right or a commodity that is suitably priced by the marketplace.

Aggarwal et al. (2010) [16]
Overview -Profit motives behind the delivery of health care undermine the physician-patient fiduciary relationship.

Heath (2002) [17]
Humanistic -Commodification of health care services is inconsistent with human dignity, and creating markets for them violates the integrity of persons.
Press (2009) [18] Overview -Citizens in European countries believe healthcare is a basic right and would revolt if their leaders privatized their health-care systems, unlike the case in the US.

Tanner (2009) [19]
Overview -Some people still believe that healthcare should be viewed as a commodity as we have limited resources and they must be wisely distributed.

Dudzic (2012) [20] Overview
The Supreme Court Ruling considers health care as a commodity. This means that healthcare will still be treated as a profit center and that millions will continue to be denied access to their basic healthcare needs. On the other hand, health inequities are widening and the cost of health care pushes millions into poverty each year [10]. Only 11 percent of global health spending ($ 2.8 trillion) goes to low-and middleincome countries [10]. High out-of-pocket spending means that nearly a third of households in Africa and Southeast Asia are forced to borrow money or sell assets to pay for health care, often falling into financial ruin [10]. It is therefore vital that the costs of health care are shared throughout a population, through pooled funding, so that everyone has access to health services without fear of financial hardship [10].

Developmental implications
Changing the culture that healthcare and education are delivered as rightful services rather than as commodities controlled by the ability to pay will lead to tremendous developmental growth and great improvements in performance of individuals and communities. The improvements in performance and development will take place on both sides; the deliverer and the receiver of the services. The first side would be the individuals who deliver the health care or educational services, who will sense a feeling of achievement from delivering the basic human rights to the people without discrimination based on ability to pay. Thus, this will enhance feelings of self-fulfillment and accomplishment for the care givers and educators who will believe they are delivering a moral message to the world and adding value, not just doing their jobs without any humanitarian considerations. This will definitely be reflected on the positive psychology of the employees, leading to better satisfaction at work, and better productivity and developmental improvements.
Also, the developmental implications will be reflected on the second side; the individuals who are receiving the health care or educational services, where being healthy or receiving medical treatment without having to worry about the healthcare expenditures would lead to better productivity at work and better developmental and economic output. One example is for cancer patients who can better achieve at work when they are offered healthcare services as a basic right, not compromised by the ability to pay for treatment [11]. Besides, receiving proper medical treatment for cancer increases the work hours of employees leading to increased productivity [12]. Receiving healthcare as a rightful service improves the psychological aspects of the patients as well leading to better response to treatment, thus reaching higher cure rates at lower costs [12]. Another key aspect that has a great developmental implication on the patients' health status is the role of care management in primary health care systems for patients with cardiovascular disease, diabetes and heart failure [13]. It was noted that the implementation of a team-based approach to disease management for these patients to increase their self-empowerment and develop the confidence to effectively self-manage their health-resulted in tangible improvement in their clinical status and achieved better control of the disease [13]. This finding proves that there is a positive correlation between providing healthcare as a basic right and the positive outcome on patients' health. The same scenario goes for those who receive educational services from the context of basic human rights regardless of ability to pay. This leads to increased number of well-educated and well-trained employees who achieve better productivity with lower costs, and contribute to developmental growth in the different industries [14]. Evidence suggests that states in the United States that increase the level of education of their workforce see greater productivity [14]. Case Study: Children's Cancer Hospital-57357 Egypt.
The concepts of delivering healthcare and education as rightful services and not commodities have actually been adopted by the Children's Cancer Hospital -57357 Egypt (CCHE). It is hard to believe that these concepts have truly been implemented in one institution which had faith in the delivery of health care and educational services as basic human rights, not as commodities based on the ability to pay. In fact, the Children's Cancer Hospital -57357 Egypt (CCHE) is a true example of the goodness of mankind and what can be achieved when people work together for a common goal to improve the health systems in developing countries. CCHE believed in the concept of providing healthcare and education as rightful services and introduced it to the Egyptian community and worldwide from day one. The hospital provided healthcare services to children with cancer free of charge regardless of their ability to pay and without any social, racial or religious discriminations.
The hospital depended on fundraising and donations to cover the expenses of the medical care of these patients, with the highest quality of healthcare services, and state-of-the-art advances in the medical diagnosis and treatment of childhood cancers. This led to great humanistic, economic and developmental implications where all the patients were treated equally free of charge, receiving the highest standards of health care services, and achieving better cure rates at lower costs. Improved patient outcomes were attributed to improved psychological status from being granted all their basic human rights of receiving high-quality healthcare services in a dignified manner, without suffering of the patients or their families from the overwhelming costs of treatment. The delivery of the best possible health care services to children with cancer at CCHE free of charge, is a wise investment in healthcare resources to better treat the children and achieve higher cure rates, with less complications and side-effects of treatment and less possibility for disease recurrence, at relatively lower costs than the delivery of poor healthcare services to this group of patients.
One main strategic objective of CCHE was to be a learning organization striving to put knowledge into action while constantly improving its learning and training capacities. The hospital believed in the importance of continuous learning and education for its patients and employees as a basic rightful service. The hospital did not limit itself to providing quality care and cure for all patients for free, but it was also committed to cater in a comprehensive manner to the needs of the sick children so as to restore their hope in a better future through focusing on education. As part of its management of childhood cancers initiative, the hospital cooperated with the Ministry of Education to provide in-hospital education for children who stay long away from their schools. Also, the education of patients about their health, chemotherapy treatment and all aspects of the disease is a major ongoing initiative at the hospital. Regarding the learning and education of the employees, the hospital provided continuous learning and development programs for the different sectors and departments in the hospital (medical and non-medical) to improve the technical and managerial skills of the hospital staff to deliver better health care services to the patients. CCHE believed that well-educated and welltrained employees would lead to better delivery of health care services and contribute to healthier patient experiences with the belief of "we learn…we cure".

Discussion
Priced by the marketplace [15]. The Patient Protection and Affordable Care Act, signed into law by President Obama in March 2010, contains apparently two contradictory issues: healthcare as a commodity and as a right. The commodity argument suggests that the marketplace should govern demand, supply, and costs of care.
The argument that health care is a right suggests that it is a need, not a choice, and that profit motives undermine the physician-patient fiduciary relationship [16].
Assigning the right language about how healthcare and education are labeled is crucial to identifying potential solutions and improving these systems [3]. From an economic standpoint, providing a core set of social service, including health care Until now, there are still ongoing discussions about whether health care is a basic right or a commodity that is suitably, education, housing, food and employment opportunities, increases the ability to be a strong society. This is opposing to the evil myth propagated by many in the U.S. which suggests that supporting the core needs of the most vulnerable weakens the economy. In fact, it goes the opposite way; the concentration of all wealth with a few people jeopardizes the future of nations [3]. While, other countries like Canada appeal to the idea that medical care should not be treated as a "commodity", and that it is not a business venture, but a moral service [17]. The different beliefs of how health care is labeled would be greatly reflected on the expenditures and the patients' outcomes. The U.S. spends $8,230 per capita on health care, of which $5,290 are public dollars, while in Canada, total expenditures are $4,440 per capita. Thus the U.S. public fund expenditures per capita exceed Canada's total expenditure [3]. Hospital billing administrative costs in the U.S. is $570 per capita and total administrative costs are $2,685 in Canada, the numbers are $182 and $809, respectively [3].
Besides, the gap in life expectancy between the highest and lowest quintiles of income was 1.5 years in 1972 and it reached around 6 years in 2011. Furthermore, life expectancy is lower in the U.S., as well as life years adjusted for disability, infant mortality, and other health indicator. This should indicate that spending more money does not necessarily buy value, it can just be accruing wealth to a few [3]. In Europe, citizens in most countries would revolt if their leaders dared to privatize their health-care systems [18]. In fact, it's because citizens in countries such as France, Germany, Finland and the United Kingdom -all of which boast lower infant-mortality and higher life-expectancy rates than the United States -don't think of health-care as a commodity. They think of it as a public good and a basic right [18]. These are all good principles that reject the idea that the health of individuals, their families and friends and the entire society, would be a vehicle for profit [3]. Broadbased differences in health status between populations based on class, race, and other characteristics are not just disparities, they result from deeply seated societal and social problems that go against the basic human rights for health [3]. On the other hand, others still defend the fact that healthcare should be viewed and considered as a commodity, a finite one, where every dollar spent on healthcare is one not spent on education, infrastructure, or defense [19]. This is justified by the fact that our resources are not unlimited and one day will come to an end, therefore, choices will have to be made [19]. Also, the Supreme Court Ruling means health care remains a commodity [20]. This means that healthcare will still be treated as a commodity and a profit center rather than as a human right and that millions will continue to be denied access to basic healthcare needs. This also means that costs will continue to rise two, three, even four times faster than people's wages while quality deteriorates [20].
The first argument against commodification involves the observation that certain types of goods or services are so closely connected to the integrity of persons that the buying and selling of them is inconsistent with human dignity. Goods of this sort are by their very nature unsuited for purchase and sale [17]. Furthermore, the creation of markets for them generates perverse incentives to violate the integrity of persons. This is why we do not buy and sell transplant organs [17]. Healthcare and educational services should be dealt with the same way; where any means to purchase and sale these services would be against the basic human rights and dignity. Great belief in these concepts would be the foundation for any true reform in healthcare and education, especially in the low-and middle-income countries. The Children's Cancer Hospital -57357 Egypt (CCHE) is taking serious steps towards health care reform in Egypt, which is currently undergoing a transitionary phase in the design and implementation of health and education policies. In fact, the hospital is setting an example for health policy planning and implementation as a role model towards healthcare reform in developing countries.

Conclusion
The delivery of health care and education as basic human rights and not as commodities based on affordability would reshape the design of health systems and policy around the globe, and especially for the low-and middle-income countries. These concepts put an end for the international debate about whether healthcare and education should be delivered as service versus commodity, supported by evidence regarding the humanistic, economic and developmental implications they reflect Application of these concepts at the Children's Cancer Hospital Egypt -57357 (CCHE) has achieved tremendous success regarding patient health outcomes and economic impacts and productivity. Future efforts are encouraged to translate these health care and education polices into practice to be part of the international health policy.