Resource Allocation in Health Care

In many European countries where reforms of the welfare system are underway, reference is often made to the need to ‘rationalise’ the provision of health care. This term is generally used to refer to the need to organise healthcare effectively by reducing waste, containing costs, and ensuring that budgets are adhered to. Actions taken to achieve this are varied: some relate to the provision of services (for example, concentrating the provision of goods and services, redistributing health care workers); others require redefinition of the level of service provision (for example, avoiding hospital admission for conditions that can be treated in the clinic, or in day care); others rely on the application of the tools provided by evidence based medicine and evidence based healthcare to define the most effective medical care and interventions (for example, eliminating those procedures whose effectiveness is not supported by firm scientific evidence). All this is aimed at making healthcare provision more efficient and effective. Nevertheless, despite the efforts being made in this direction, it is becoming evident that rationalisation of healthcare provision is not sufficient in itself. The ageing population, the development of new and expensive technologies, the emergence of new diseases such as AIDS, Bovine Spongiform Encephalopathy (BSE), Severe Acute Respiratory Syndrome (SARS), and above all the rising expectations of healthcare users, are all leading to an unsustainable tension between demand and healthcare resources available. Because it is not possible to provide everything to everyone, even by putting unacceptable pressure on present finances and by threatening provision for future generations, and since it is arguably socially unacceptable to leave the provision of healthcare to the free market, it is inevitable that certain choices be made. This implies a process of ‘rationing’, rather than ‘rationalisation’, that can be defined as ‘the distribution of resources between programmes and persons in competition’. In the process of rationing, a series of crucial questions must be posed: What treatments or healthcare services should be provided to citizens? How should these services be distributed between members of a society amidst budgetary constraints? Who decides? How? On the basis of which criteria? The problem of rationing (also referred to as ‘priority setting’, or ‘resource allocation’) in healthcare is therefore a problem of the moral legitimacy of such choices; this chapter illustrates this. As challenges of rationing are not expected to change in the foreseeable future, at least not in principle, we will address future and present rationing challenges in health care similarly.