Resource allocation in healthcare: an overview

Tapping a variety of data sources, in our recent study we empirically tested the impact of the institutional context and social values on the use of economic evaluations in healthcare. Our aim was to explore if and how the use of these data in the healthcare field is influenced by these two factors as they relate to a given country. The study sample in our research was made up of 36 OCSE countries. To operationalize the concept of “institutional context,” we used two variables: the type of welfare system adopted in the country (i.e., coverage and financing for healthcare costs), and the administrative tradition (i.e., the relationship of the public administration with society, with political institutions, and with the legal culture). To empirically investigate the use of EE as the basis for decision making in healthcare, our analysis focused on a more measurable context, that is, the process involving a specific decision (drug reimbursement).

To conduct our study, we divided the 36 countries into two groups: 20 were classed as “high EE use systems” and the remaining 16 as “low EE use systems.” This classification is based on the only complete evaluation that is available for all the countries in our sample, i.e. the extent to which reimbursement decisions regarding prescription drugs are informed by data on their cost-effectiveness. In the first group, with the countries that require the best cost-effectiveness ratio, we find most of North Europe, Australia, Canada and New Zealand. Members of the second group are the nations of Southern Europe (Italy, Greece and Spain), France Germany, the US and Japan.

Most countries in the sample (15 out of 36) have adopted a national health system; 12 countries utilize an insurance-based system, and 3 have a hybrid system. Although our study is based on descriptive statistics, there seems to be somewhat of a gap between the two groups with regard to a number of features that typify their institutional contexts, confirming that countries cluster differently depending on their welfare system.

The two groups also differ significantly in the distribution of administrative traditions: the first consists primarily of Anglo-Saxon countries while the second is mainly Germanic countries. The study of the correlation between social values and the institutional context shows a strong positive relationship between the Anglo-American tradition and the propensity to respect the principle of efficiency, while Scandinavian countries appear to have a negative attitude toward efficiency as a criterion to adopt in healthcare. Lastly, Napoleonic countries apparently reject the concept of personal responsibility in healthcare, while Germanic countries show a strong preference for embracing this idea.

To our knowledge, this is the first study to empirically investigate how social values and the institutional context influence use of economic evaluations in making healthcare decisions in the countries in our sample. Specifically, we tested our hypothesis that social values (efficiency, equity and personal responsibility for health and healthcare) could have a direct or indirect influence. We found no evidence of a direct link. In fact, while social values have some effect on the use of EE, this is an indirect phenomenon that occurs through their influence on the institutional context. This could be due to the fact that people are more interested in defining which social values should inform and shape the healthcare system of their country, and less interested in expressing their opinion on which technicalities are needed to achieve institutional objectives. What’s more, there may be certain social values that predominate over any economic evaluation, such as personal responsibility. For an example, we can consider diseases “linked to lifestyle” (obesity, lung cancer, cirrhosis from alcohol consumption). If people think that these ailments do not warrant the same right as other diseases to be cured through the public healthcare system, a study that says the opposite won’t be likely to convince them otherwise. In addition, people who prioritize the principles of efficiency when the stakes are public funding for healthcare may not be very interested in understanding the decision-making process, as long as it achieves the desired objective. So to sum up, there is an indirect relationship between social values and economic evaluation, a relationship which is mediated by the institutional context.

Although ours is an exploratory analysis, we do reach some interesting conclusions. First of all, it’s highly unlikely that we can expect a single, standard approach to the use of EE in healthcare decisions in across countries. This is due to marked differences in institutional contexts. In addition, a country that intends to expand the role of EE in similar decisions should study the correlation that exists between its institutional context and its social values and those of countries that already make substantial use of EE. The reasoning here is that a better understanding of contextual factors could facilitate the implementation of healthcare policies.