Explanations of the state of ‘crisis’ in the English National Health Service (NHS) generally focus on the overall level of health care funding rather than the way in which funding is distributed. Describing systematic patterns in the way different areas are experiencing crisis, this paper suggests that NHS organisations in older, rural and particularly coastal areas are more likely to be ‘failing’ and that this is due to the historic underfunding of such areas. This partly reflects methodological and technical shortcomings in NHS resource allocation formulae. It is also the outcome of a philosophical shift from horizontal (equal access for equal needs) to vertical (unequal access to equalise health outcomes) principles of equity. Insofar as health inequalities are determined by factors well beyond health care, we argue that this is an ineffective approach to addressing health inequalities. Moreover, it sacrifices equity in access to health care by failing to adequately fund the health care needs of older populations. The prioritisation of vertical over horizontal equity also conflicts with public perspectives on the NHS. Against this background, we ask whether the time has come to reassert the moral and philosophical case for the principle of equal access for equal health care need.

Using dual-entitlement theory as the guide, we conducted a survey of economists from the National Bureau of Economic Research asking them a series of questions about the fairness of drug prices in the United States. Public opinion surveys have repeatedly shown that the public perceives drug prices to be unfair, but economists trained in laws of supply and demand may have different perceptions. Three hundred and ten senior economists responded to our survey. Forty-five percent agreed that drug prices were unfair when people, specifically low-income individuals, could not afford their prescription medications. Sixty-five percent oppose a dollar threshold, or upper limit, on drug prices. The economists recommend the most promising policy change would be to provide the government additional negotiating power and price controls would moderately impact investment in pharmaceutical research and development.

Health technology assessment is frequently credited with making difficult resource allocation decisions in health care fairer, more rational and more transparent. In Germany, a constitutional ‘right to health’ allows patients to challenge decisions by sickness funds to withhold reimbursement of treatment excluded from public funding because of insufficient evidence of effectiveness. The ability to litigate was qualified by the Constitutional Court in its 2005 ‘Nikolaus decision’ that sets out criteria to be applied to these cases. Treatment must be made available if (1) the condition is life-threatening, (2) no alternative treatment is available and (3) there is an indication that the treatment could benefit the patient. This paper examines how courts struggled to apply these criteria based on an analysis of cases of patients who sought treatment for cancer between 2005 and 2015, and explores the implications of applying a constitutional ‘right to health’ to treatment decisions.

We use a reliable, intuitive and simple set of indicators to capture three dimensions of access – availability, affordability and acceptability. Data are from South Africa’s 2009 and 2010 General Household Surveys (n=190,164). Affordability constraints were faced by 23% and are more concentrated amongst the poorest. However, 73% of affordability constraints are due to travel costs which are aligned with findings of the availability constraints dimension. Availability constraints, involving distances and transport costs, particularly in underdeveloped rural areas, and inconvenient opening times, were faced by 27%. Acceptability constraints were noted by only 10%. We approximate acceptability with an indicator measuring the share of community members bypassing the closest health care facility, as we argue that reported health care provider choice is more reliable than stated preferences. However, the indicator assumes a choice of available and affordable providers, which may often not be an accurate assumption in rural areas. We recommend further work on the measurement of acceptability in household surveys, especially considering this dimension’s importance for health reform.

China has achieved nearly universal social health insurance (SHI) coverage by implementing three statutory schemes, but gaps and differences in benefit levels are apparent. There is wide agreement that China should merge the three schemes into a universal and uniform SHI. However, data on the medical expenses of all inpatients in 2014 at a public Tier-three hospital suggests that supply-induced demand (SID) is a serious concern and that, under the design of the current schemes, a higher benefit level has a greater impact on the total expenses of insured patients. Thus, if SID is not effectively controlled, a universal and uniform SHI may be more harmful than beneficial in China. Finally, we suggest that China should substitute the existing fee-for-service design with a suite of bundled provider payment methods; furthermore, China should replace its current system of pricing drugs that encourages hospitals and doctors to use costlier medications.

The bulk of health care service provision in Saudi Arabia is undertaken by the public health care sector through the Ministry of Health, which is funded annually by the total government budget, which, in turn, is derived primarily from oil revenue. Public health care services in Saudi Arabia are characterised by an overload, overuse, and shortage of medical personnel, which can result in dissatisfaction with the quality of the current public health care services. This study uses a contingent valuation method to investigate the willingness of Saudi people to pay for improvements to the quality of public health care services. This study also determines the association between the willingness to pay for quality improvements and respondents’ demographic and socioeconomic characteristics. A pre-tested interviewer-administered questionnaire was used to collect data from 1187 heads of household in Jeddah Province over a five-month period. Multi-stage sampling was employed to recruit participants. Partial Tobit regression and corresponding marginal effects analyses were used to analyse the data. These empirical analyses show that the majority of the sample was willing to pay for quality improvements in the public health care services. The results of this study might be of use to policymakers to help with both priority setting and fund allocation.

Worldwide, policymakers and purchasers are exploring innovative provider payment strategies promoting value in health care, known as value-based payments (VBP). What is meant by ‘value’, however, is often unclear and the relationship between value and the payment design is not explicated. This paper aims at: (1) identifying value dimensions that are ideally stimulated by VBP and (2) constructing a framework of a theoretically preferred VBP design. Based on a synthesis of both theoretical and empirical studies on payment incentives, we conclude that VBP should consist of two components: a relatively large base payment that implicitly stimulates value and a relatively small payment that explicitly rewards measurable aspects of value (pay-for-performance). Being the largest component, the base payment design is essential, but often neglected when it comes to VBP reform. We explain that this base payment ideally (1) is paid to a multidisciplinary provider group (2) for a cohesive set of care activities for a predefined population, (3) is fixed, (4) is adjusted for the population’s risk profile and (5) includes risk-mitigating measures. Finally, some important trade-offs in the practical operationalisation of VBP are discussed.

This paper tests the factorial structure of a questionnaire comprising seven health care rationing criteria (waiting time, ‘rule of rescue’, parenthood of minors, health maximization, youngest first, positive and negative version of social merit) and explores the adherence to them of 254 Portuguese health care professionals, when considered individually and when confronted with two-in-two combinations. Data were collected through a self-administered questionnaire where respondents faced hypothetical rationing dilemmas comprising one rationing criterion and dichotomous options pairs with two rationing criteria. Confirmatory factor analysis and multinomial logistic regressions were used to validate the structure of the questionnaire and the data. The findings suggest that: (i) the hepta-factorial structure of the questionnaire presented a good fit of the data; and (ii) support for rationing criterion depends on whether they are individually considered or confronted in dichotomous options pairs. When only one criterion distinguishes the patients, healthcare professionals support six criteria (by descending order): waiting time, rule of rescue, health maximization, penalization of patients’ risky behaviors, youngest first and being parent of a young child. When two criteria were confronted, immediate threat of life/health and large expected benefits were the most preferred. Conversely, the positive version of social merit was an unappreciated rationing criterion.

Local authorities in England have responsibility for public health, however, in recent years, budgets have been drastically reduced placing decision makers under unprecedented financial pressure. Although health economics can offer support for decision making, there is limited evidence of it being used in practice. The aim of this study was to undertake in-depth qualitative research within one local authority to better understand the context for public health decision making; what, and how economics evidence is being used; and invite suggestions for how methods could be improved to better support local public health decision making. The study included both observational methods and in-depth interviews. Key meetings were observed and semi-structured interviews conducted with participants who had a decision-making role to explore views on economics, to understand the barriers to using evidence and to invite suggestions for improvements to methods. Despite all informants valuing the use of health economics, many barriers were cited: including a perception of a narrow focus on the health sector; lack of consideration of population impact; and problems with translating long timescales to short term impact. Methodological suggestions included the broadening of frameworks; increased use of natural experiments; and capturing wider non-health outcomes that resonate with the priorities of multiple stakeholders.