Health system choice

A pilot discrete-choice experiment eliciting the preferences of British and Australian citizens


Citizen preferences surrounding desirable health system characteristics should be considered when undertaking health system reform. The objective of this study was to pilot test a discrete-choice instrument designed to elicit preference weights surrounding health system attributes.

A discrete-choice experiment was designed and administered to two convenience samples (n=50 each) recruited from the UK and Australia. The impact of eight health system attributes representing level of health, equity, responsiveness and healthcare financing on the choice between hypothetical health systems was analysed utilizing mixed logit analysis.

All characteristics affected the likelihood a health system would be preferred, with the exception of the additional tax contribution levels required to finance the system. There were very few missing or inconsistent responses. The direction of preferences was consistent with expectations for both samples; that is, an improvement in attributes describing level of health, equity or responsiveness increased the likelihood that a health system would be preferred.

A number of potential improvements to the preference instrument are suggested. The discrete-choice technique used in this study offers a feasible method for eliciting health system preferences, and its use in a larger-scale study to elicit and compare the preferences of representative population samples is supported.

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  1. 1

    WHO. The World Health Report 2000. Health systems: improving performance. Geneva: WHO, 2000

    Google Scholar 

  2. 2

    Palmer GR. Evidence-based health policy-making, hospital funding and health insurance. Med J Aust 2000 Feb 7; 172(3): 130–3

    PubMed  CAS  Google Scholar 

  3. 3

    Docteur E, Oxley H. Health-care systems: lessons from the reform experience [OECD health working papers]. Paris: Organization for Economic Co-operation and Development (OECD), 2003

    Google Scholar 

  4. 4

    Ham C. Priority setting in health care: learning from international experience. Health Policy 1997 Oct; 42(1): 49–66

    PubMed  Article  CAS  Google Scholar 

  5. 5

    National Health and Hospitals Reform Commission. A healthier future for all Australians: final report. Canberra (ACT): Australian Government, 2009 Jun

    Google Scholar 

  6. 6

    National Institute for Health and Clinical Excellence. Patient and public involvement policy, 2007 [online]. Available from URL: [Accessed 2007 Dec 12]

    Google Scholar 

  7. 7

    Health Canada. Health Canada policy toolkit for public involvement in decision making. Ottawa (ON): Health Canada, 2000

  8. 8

    Akkazieva B, Gulacsi L, Brandtmuller A, et al. Patients’ preferences for healthcare system reforms in Hungary: a conjoint analysis. Appl Health Econ Health Policy 2006; 5(3): 189–98

    PubMed  Article  Google Scholar 

  9. 9

    Viney R, Lancsar E, Louviere J. Discrete choice experiments to measure consumer preferences for health and healthcare. Expert Rev Pharmacoecon Outcomes Res 2002; 2(4): 319–26

    PubMed  Article  Google Scholar 

  10. 10

    Lancaster K. A new approach to consumer theory. J Polit Econ 1966; 74(2): 132–57

    Article  Google Scholar 

  11. 11

    Bryan S, Dolan P. Discrete choice experiments in health economics: for better or for worse? Eur J Health Econ 2004 Oct; 5(3): 199–202

    PubMed  Article  Google Scholar 

  12. 12

    Lancsar E, Louviere J. Conducting discrete choice experiments to inform healthcare decision making: a user’s guide. Pharmacoeconomics 2008; 26(8): 661–77

    PubMed  Article  Google Scholar 

  13. 13

    Fiebig D, Louviere J, Walsman D. Contemporary issues in modelling discrete choice experimental data in health economics [working paper]. Sydney (NSW): University of New South Wales, 2005

    Google Scholar 

  14. 14

    Ryan M, Gerard K. Using discrete choice experiments to value health care programmes: current practice and future research reflections. Appl Health Econ Health Policy 2003; 2(1): 55–64

    PubMed  Google Scholar 

  15. 15

    Whitty JA, Rundle-Thiele SR, Scuffham PA. Insights into public preferences for pharmaceutical funding. Int J Pharma Health Care Mark 2008; 2(3): 216–34

    Article  Google Scholar 

  16. 16

    Green C, Gerard K. Exploring the social value of health-care interventions: a stated preference discrete choice experiment. Health Econ 2009; 18(8): 951–76

    PubMed  Article  Google Scholar 

  17. 17

    Gyrd-Hansen D, Slothuus U. The citizen’s preferences for financing public health care: a Danish survey. Int J Health Care Finance Econ 2002 Mar; 2(1): 25–36

    PubMed  Article  Google Scholar 

  18. 18

    Hjelmgren J, Anell A. Population preferences and choice of primary care models: a discrete choice experiment in Sweden. Health Policy 2007 Oct; 83(2–3): 314–22

    PubMed  Article  Google Scholar 

  19. 19

    Lancsar E, Louviere J. Deleting ‘irrational’ responses from discrete choice experiments: a case of investigating or imposing preferences? Health Econ 2006 Aug; 15(8): 797–811

    PubMed  Article  Google Scholar 

  20. 20

    Ryan M, Bate A. Testing the assumptions of rationality, continuity and symmetry when applying discrete choice experiments in health care. Appl Econ Lett 2001; 8: 59–63

    Article  Google Scholar 

  21. 21

    Howard K, Salkeld G. Does attribute framing in discrete choice experiments influence willingness to pay? Results from a discrete choice experiment in screening for colorectal cancer. Value Health 2009; 12(2): 354–63

    PubMed  Article  Google Scholar 

  22. 22

    Hall J, Fiebig DG, King MT, et al. What influences participation in genetic carrier testing? Results from a discrete choice experiment. J Health Econ 2006 May; 25(3): 520–37

    PubMed  Article  Google Scholar 

  23. 23

    Hensher DA, Rose JM, Greene WH. Applied choice analysis: a primer. New York: Cambridge University Press, 2005

    Google Scholar 

  24. 24

    Greene WH. NLOGIT version 4.0: reference guide. Plainview (NY): Econometric Software, Inc., 2007

    Google Scholar 

  25. 25

    King MT, Hall J, Lancsar E, et al. Patient preferences for managing asthma: results from a discrete choice experiment. Health Econ 2007 Jul; 16(7): 703–17

    PubMed  Article  Google Scholar 

  26. 26

    Lancsar EJ, Hall JP, King M, et al. Using discrete choice experiments to investigate subject preferences for preventive asthma medication. Respirology 2007 Jan; 12(1): 127–36

    PubMed  Article  Google Scholar 

  27. 27

    Johnson FR, Banzhaf MR, Desvousges WH. Willingness to pay for improved respiratory and cardiovascular health: a multiple-format, stated-preference approach. Health Econ 2000 Jun; 9(4): 295–317

    PubMed  Article  CAS  Google Scholar 

  28. 28

    Kjaer T, Gyrd-Hansen D. Preference heterogeneity and choice of cardiac rehabilitation program: results from a discrete choice experiment. Health Policy 2008 Jan; 85(1): 124–32

    PubMed  Article  Google Scholar 

  29. 29

    Bech M, Gyrd-Hansen D. Effects coding in discrete choice experiments. Health Econ 2005 Oct; 14(10): 1079–83

    PubMed  Article  Google Scholar 

  30. 30

    Greene W. NLOGIT [computer program]. Version 4.0.1. Plainview (NY): Econometric Software, Inc., 2007

    Google Scholar 

  31. 31

    Train K. Halton sequences for mixed logit [report no. E00278]. Berkley (CA): University of California, 2000

    Google Scholar 

  32. 32

    Bryan S, Roberts T, Heginbotham C, et al. QALY-maximisation and public preferences: results from a general population survey. Health Econ 2002 Dec; 11(8): 679–93

    PubMed  Article  Google Scholar 

  33. 33

    Ryan M, Scott DA, Reeves C, et al. Eliciting public preferences for healthcare: a systematic review of techniques. Health Technol Assess 2001 Mar; 5(5): 1–186

    PubMed  CAS  Google Scholar 

  34. 34

    Ryan M, Gerard K, Currie G. Using discrete choice experiments in health economics. In: Jones AM, editor. The Elgar companion to health economics. Cheltenham: Edward Elgar Publishing Ltd, 2006: 405–14

    Google Scholar 

  35. 35

    Kontoleon A, Yabe M. Assessing the impacts of alternative ‘opt-out’ formats in choice experiment studies: consumer preferences for genetically modified content and production information in food. J Agric Policy Res 2003; 5: 1–43

    Google Scholar 

  36. 36

    Ryan M, Skatun D. Modelling non-demanders in choice experiments. Health Econ 2004 Apr; 13(4): 397–402

    PubMed  Article  Google Scholar 

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Griffith University staff research funds provided the incentive payments for the Australian participants. Funds for the UK arm of the study were provided by York Health Economics Consortium Ltd, a research and consulting company owned by the University of York.

The authors thank Sidi Cisse for his role in conducting the UK interviews and preliminary analysis of that data, and Kent Sweeting for his role in conducting the Australian interviews. The thoughtful comments from the anonymous reviewers of this manuscript played a pivotal role in the final shaping of this article. Thank you for your assistance.

The authors have no conflicts of interest that are directly relevant to the content of this article.

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Correspondence to Dr Jennifer A. Whitty.

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Scuffham, P.A., Whitty, J.A., Taylor, M. et al. Health system choice. Appl Health Econ Health Policy 8, 89–97 (2010).

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  • Health System
  • Categorical Attribute
  • Patient Choice
  • Preference Weight
  • Mixed Logit