Health Care Analysis

, Volume 16, Issue 2, pp 145–160 | Cite as

An Ethical Analysis of International Health Priority-Setting

Original Article


Health care systems throughout the developed world face ‘crises’ of quality, financing and sustainability. These pressures have led governments to look for more efficient and equitable ways to allocate public resources. Prioritisation of health care services for public funding has been one of the strategies used by decision makers to reconcile growing health care demands with limited resources. Priority setting at the macro level has yet to demonstrate real successes. This paper describes international approaches to explicit prioritisation at the macro-governmental level in the six experiences most published in the English literature; analyzes the ways in which values, principles and other normative concepts were presented in these international priority setting experiences; and identifies key elements of a more robust framework for ethical analysis which could promote meaningful and effective health priority setting.


Prioritisation Priority setting Health care services Health care values Ethical analysis Normative frameworks 


  1. 1.
    Arnesen, T. M., & Norheim, O. F. (2003). Quantifying quality of life for economic analysis: Time out for time trade-off. Medical Humanities, 29(2), 81–86.PubMedCrossRefGoogle Scholar
  2. 2.
    Bäckman, K., Anderson, A., & Carlsson, P. (2004). Open priorities in Östergötland, part I. The political decision making process (Vol. 4). National centre for priority setting in health care. English Version of 2004.Google Scholar
  3. 3.
    Bernfort, L. (2003). Decisions on inclusion in the Swedish basic health care package-roles of cost-effectiveness and need. Health Care Analysis, 11(4), 301–308.Google Scholar
  4. 4.
    Biller-Andorno, N., Lie, R. K., & ter Meulen, R. (2002). Evidence-based medicine as an instrument for rational health policy. Health Care Analysis, 10(3), 261–275.PubMedCrossRefGoogle Scholar
  5. 5.
    Brown, L. D. (1991). The national politics of Oregon’s rationing plan. Health Affairs, 10(2), 28–51.PubMedCrossRefGoogle Scholar
  6. 6.
    Calltorp, J. (1999). Priority-setting in health policy in Sweden and a comparison with Norway. Health Policy, 50(1–2), 1–22.PubMedCrossRefGoogle Scholar
  7. 7.
    Coast, J. (1996). The Oregon Plan: Technical priority setting in the USA. In Priority setting; The health care debate, ed John Wiley & Sons, (pp. 113–139). Chichester, UK: Wiley.Google Scholar
  8. 8.
    Coast, J., Donovan, J., & Frankel, S. (1996). Priority setting: The health care debate. New York: John Wiley & Sons.Google Scholar
  9. 9.
    Coulter, A., & Ham, C. (2000). The global challenge of health care rationing. Philadelphia: Open University Press.Google Scholar
  10. 10.
    Cumming, J. (1997). Defining core services: New Zealand experiences. Journal of Health Services Research & Policy, 2(1), 31–37.Google Scholar
  11. 11.
    Daniels, N. (2000). Accountability for reasonableness. British Medical Journal, 321(7272), 1300–1302.PubMedCrossRefGoogle Scholar
  12. 12.
    Daniels, N., & Sabin, J. E. (2002). Setting limits fairly: Can we learn to share medical resources. New York: Oxford University Press.Google Scholar
  13. 13.
    Danis, M., Clancy, C., & Churchill, L. R. (2002). Ethical dimensions of health policy. New York: Oxford University Press.Google Scholar
  14. 14.
    Danish Council of Ethics. (1997). Priority-setting in the health service (Vol. 5). Danish Council of Ethics.Google Scholar
  15. 15.
    Dictionary. (2007). Priority. http://dictionary.reference.comGoogle Scholar
  16. 16.
    Dobrow, M. J., Goel, V., & Upshur, R. E. G. (2004). Evidence-based health policy: Context and utilisation. Social Science & Medicine, 58(1), 207–217.CrossRefGoogle Scholar
  17. 17.
    Edgar, W. (2000). Rationing health care in New Zealand–how the public has a say. In C. Ham & A. Coulter (Eds.), The global challenge of health care rationing (pp. 175–191). Buckingham: Open University Press.Google Scholar
  18. 18.
    Ellis, R. D. (1998). Why there is no “Incommensurable Pluralism” of value systems. In Just Results: Ethical Foundations for Policy Analysis, (pp. 33–56). Washington DC: Georgetown University Press.Google Scholar
  19. 19.
    Giacomini Mita, K. (1999). The Which-hunt: Assembling health technologies for assessment and rationing. Journal of Health Politics, 24(4), 715–758.Google Scholar
  20. 20.
    Hadorn, D. (1996). The Oregon priority-setting exercise: Cost-effectiveness and the rule of rescue, revisited. Medical Decision Making, 16(2), 117–119.PubMedCrossRefGoogle Scholar
  21. 21.
    Ham, C. (1997). Priority setting in health care: Learning from international experience. Health Policy, 42(1), 49–66.PubMedCrossRefGoogle Scholar
  22. 22.
    Ham, C., & Coulter, A. (2001). Explicit and implicit rationing: Taking responsibility and avoiding blame for health care choices. Journal of Health Services Research and Policy, 6, 163–169.PubMedCrossRefGoogle Scholar
  23. 23.
    Hanson, M. J., & Callahan, D. (1999). The goals of medicine: The forgotten issues in health care reform. Georgetown: Georgetown University Press.Google Scholar
  24. 24.
    Hayry, M. (2003). European values in bioethics: Why, what, and how to be used? Theoretical Medicine, 24, 199–214.CrossRefGoogle Scholar
  25. 25.
    Hermans, H., & den Exter, A. (1998). Priorities and priority-setting in health care. Croatian Medical Journal, 39(3), 346–355.PubMedGoogle Scholar
  26. 26.
    Hoedemaekers, R. (2003). Introduction: Towards better integration of normative judgements in health care package decisions. Health Care Analysis, 11(4), 275–278.PubMedCrossRefGoogle Scholar
  27. 27.
    Hoedemaekers, R., & Dekkers, W. (2003a). Justice and solidarity in priority setting in health care. Health Care Analysis, 11(4), 325–343.PubMedCrossRefGoogle Scholar
  28. 28.
    Hoedemaekers, R., & Dekkers, W. (2003b). Key concepts in health care priority setting. Health Care Analysis, 11(4), 309–323.PubMedCrossRefGoogle Scholar
  29. 29.
    Hoedemaekers, R., & Oortwijn, W. (2003). Problematic notions in Dutch health care package decisions. Health Care Analysis, 11(4), 287–294.PubMedCrossRefGoogle Scholar
  30. 30.
    Honigsbaum, F., Calltorp, J., Ham, C., & Holmstrom, S. (1995). Priority setting processes for health care in Oregon, USA; New Zealand; The Netherlands; Sweden; and the United Kingdom. New York: Radcliffe Medical Press.Google Scholar
  31. 31.
    Houtepen, R., & ter Meulen, R. T. (2000a). The expectation(s) of solidarity: Matters of justice, responsibility and identity in the reconstruction of the health care system. Health Care Analysis, 8(4), 355–376.PubMedCrossRefGoogle Scholar
  32. 32.
    Houtepen, R., & ter Meulen, R. T. (2000b). New types of solidarity in the European welfare state. Health Care Analysis , 8(4), 329–340.PubMedCrossRefGoogle Scholar
  33. 33.
    Hunter, D. J. (1997). Measuring the appropriateness of hospital use. Canadian Medical Association Journal, 157(7), 901–902.PubMedGoogle Scholar
  34. 34.
    Hurley, J., Crosby, J. L., Giacomimi, M., & Hutchson, B. (2000). Making resource allocation decisions in the health care sector: A review of some recent proposals. Saskatoon, Saskachewan: Regionalization Research Centre, Ooccasional Paper.Google Scholar
  35. 35.
    Kapiriri, L., & Martin, D. K. (2007). Bedside rationing by health practitioners: A case study in a Ugandan hospital. Medical Decision Making, 27(1), 44–52.PubMedCrossRefGoogle Scholar
  36. 36.
    Kenny, N. P., & Giacomini, M. (2005). Wanted: A new ethics field for health policy analysis. Health Care Analysis, 13(4), 247–260.PubMedCrossRefGoogle Scholar
  37. 37.
    Kluge, E. H., & Tomasson, K. (2002). Health care resource allocation: Complicating ethical factors at the macro-allocation level. Health Care Analysis, 10(2), 209–220.PubMedCrossRefGoogle Scholar
  38. 38.
    Liss, P. E. (2003). The significance of the goal of health care for the setting of priorities. Health Care Analysis, 11(2), 161–169.PubMedCrossRefGoogle Scholar
  39. 39.
    Litva, A., Coast, J., Donovan, J., Eyles, J., Shepherd, M., Tacchi, J., Abelson, J., & Morgan, K. (2002). The public is too subjective: Public involvement at different levels of health-care decision making. Social Science & Medicine, 54(12), 1825–1837.CrossRefGoogle Scholar
  40. 40.
    Martin, D., & Singer, P. (2003). A strategy to improve priority setting in health care institutions. Health Care Analysis, 11(1), 59–68.PubMedCrossRefGoogle Scholar
  41. 41.
    Mechanic, D. (1997). Muddling through elegantly: Finding the proper balance in rationing–explicit rationing at the clinical level is likely to cause more harm than good. Health Affairs, 16(5), 83–92.PubMedCrossRefGoogle Scholar
  42. 42.
    Ministry of Health. (1991). Your health and the public health; A statement of government health policy. (Vol. 3). Wellington, N.Z: Ministry of Health.Google Scholar
  43. 43.
    Ministry of Welfare HaCA. (1992). Choices in health care. ed The Government committee on choices in health care. (Vol. 45). The Netherlands.Google Scholar
  44. 44.
    Mullen, P. M. (2000). Public involvement in health care priority setting: Are the methods appropriate and valid? In A. Coulter & C. Ham (Eds.), The global challenge of health care rationing (pp. 163–174). Buckingham: Open Universuty Press.Google Scholar
  45. 45.
    Nordenfelt, L. (2001). On the goals of medicine, health enhancement and social welfare. Health Care Analysis, 9(1), 15–23.PubMedCrossRefGoogle Scholar
  46. 46.
    Norheim, O. F. (2002a). The role of evidence in health policy making: A normative perspective. Health Care Analysis, 10(3), 309–317.PubMedCrossRefGoogle Scholar
  47. 47.
    Norheim, O. (2002b). Role of evidence in health policy making: A normative perspective. Health Care Analysis, 10, 309–317.PubMedCrossRefGoogle Scholar
  48. 48.
    Norheim, O. F. (2005). Rights to specialized care in Norway: A normative perspective. Journal of Law, Medicine and Ethics, 2(winter), 10.Google Scholar
  49. 49.
    Norheim, O. F., Ekeberg, O., Evensen, S. A., Halvorsen, M., & Kvernebo, K. (2001). Adoption of new health care services in Norway (1993–1997): Specialists’ self-assessment according to national criteria for priority setting. Health Policy, 56(1), 65–79.PubMedCrossRefGoogle Scholar
  50. 50.
    Reeleder, D., Goel, V., Singer, P. A., & Martin, D. K. (2006). Leadership and priority setting: The perspective of hospital CEOs. Health Policy, 79(1), 24–34.PubMedCrossRefGoogle Scholar
  51. 51.
    Robinson, R. (1999). Limits to rationality: Economics, economists and priority setting. Health Policy, 49(1–2), 13–26.PubMedCrossRefGoogle Scholar
  52. 52.
    Sulmasy, D. P. (1992). Physicians, cost control, and ethics. Annals of Internal Medicine, 116(11), 920–926.PubMedGoogle Scholar
  53. 53.
    Tenbensel, T. (2004). Does more evidence lead to better policy? The implications of explicit priority setting in New Zealand’s Health Policy for evidence-based policy, (pp. 189–207). Carfax publishing.Google Scholar
  54. 54.
    Tengs, T. O., Meyer, G., Siegel, J. E., Pliskin, J. S., Graham, J. D., & Weinstein, M. C. (1996). Oregon’s medicaid ranking and cost-effectiveness: Is there any relationship? Medical Decision Making, 16(2), 99–107.PubMedCrossRefGoogle Scholar
  55. 55.
    The Health Care, & Medical Priorities Commission. (1993). No easy choices: The difficult pririties of health care. Stockholm: The Ministry of Health & Social Care.Google Scholar
  56. 56.
    The Swedish Parliamentary Priorities Commission. (1995). Priorities in health care: Ethics, economy, implementation. (Vol. 26). Stockholm: The Ministry of Health and Social Affairs.Google Scholar
  57. 57.
    Tymstra, T., & Andela, M. (1993). Opinions of Dutch physicians, nurses, and citizens on health-care policy, rationing, and technology. Jama-Journal of the American Medical Association, 270(24), 2995–2999.CrossRefGoogle Scholar
  58. 58.
    van der Grinten, T. E., & Kasdorp, J. P. (1999). Choices in Dutch health care: Mixing strategies and responsibilities. Health Policy, 50(1–2), 105–122.PubMedCrossRefGoogle Scholar
  59. 59.
    van Willigenburg, T. (1993). Communitarian illusions: Or why the Dutch proposal for setting priorities in health care must fail. Health Care Analysis, 1(1), 49–52.PubMedCrossRefGoogle Scholar
  60. 60.
    Walton, N. A., Martin, D. K., Peter, E. H., Pringle, D. M., & Singer, P. A. (2007). Priority setting and cardiac surgery: A qualitative case study. Health Policy, 80(3), 444–458.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  1. 1.Department of BioethicsDalhousie UniversityHalifaxCanada
  2. 2.Faculty of Health SciencesSimon Fraser UniversityBurnabyCanada

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