Academic journal article Applied Health Economics and Health Policy

Aversion to Geographic Inequality and Geographic Variation in Preferences in the Context of Healthcare

Academic journal article Applied Health Economics and Health Policy

Aversion to Geographic Inequality and Geographic Variation in Preferences in the Context of Healthcare

Article excerpt

Background

Priority setting and rationing decisions are ubiquitous features of healthcare policy making around the world. The allocation of scarce resources has increasingly led to situations in which decision makers have to make explicit choices between providing healthcare to one group of patients at the cost of care to a different group of patients. Which group is given priority might, however, depend on the criteria used to support such decisions. This has motivated a more open and wider debate about the diverse criteria that may guide healthcare resource allocation. At the same time, there is a growing recognition that these decisions are as much about social value judgements as they are about understanding the medical information.[1] Thus, it is now widely accepted that preferences held by the general public have a role to play in terms of resource allocation decisions. One of the conclusions of a recent report about the use of health technology assessment in the EU[2] is precisely that the views and preferences of the ultimate end-users of a given technology should be taken into account more often.

The debate about the principles guiding resource allocation is very broad, and there is an immense amount of literature about social justice already applied in the context of health and healthcare (for reviews see, for example, Williams and Cookson[3] and Cookson and Dolan[4]). A possible distinction is that between principles of substantive justice (which are about determining who should get what healthcare and when) and procedural justice (which are about what decision-making process should be followed). In the case of substantive justice, the three principles most relevant to the context of healthcare are (i) maximizing principles (in this case, healthcare should be distributed in order to achieve the maximum 'benefit'); (ii) egalitarian principles (healthcare should be distributed with the aim of reducing 'inequality'); and (iii) need principles (the distribution of healthcare should be proportional to 'need'). Depending on how 'benefit', 'inequality' and 'need' are defined, further variants of principles might be identified.

Trade-offs among different principles have also been explored. Cookson and Dolan,[4] for example, said that most authors who defend egalitarian principles would not in fact pursue equality as a sole objective, but would rather combine equality with other goals. In this respect, health maximization and equality of health is probably the most popular pair of objectives, and the trade-off between them has been discussed[1,3,5] since the seminal paper by Adam Wagstaff.[6]

Empirical studies reporting on preferences, in the context of healthcare, have sought to determine if and to what extent people support the above principles. Several issues have so far been addressed by these studies, including aversion to inequalities. Aversion to health inequality per se might be studied on its own,[7] but inequalities have also been defined by reference to, for example, socioeconomic groups[1,5,8,9] and sex.[7] However, aversion to geographic inequalities has been given little attention in the empirical health economics literature. This is somewhat surprising considering that in many countries, at some point, resources are distributed among geographic areas and that there has been some public discontent over geographic disparities, such as the phenomenon that became known in England as the 'postcode lottery'.1

This paper thus aims to contribute to the empirical literature about preferences by reporting on a pilot study designed to explore some tools and methods to elicit the preferences of the general public regarding the criteria of health gain maximization versus geographic equality in the distribution of health gain, while providing some indicative results.

The second issue addressed in this paper is related to variation in preferences across geographic areas. This is particularly pertinent in contexts of decentralization. …

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