DECIDING HOW TO DECIDE: THE CASE OF HEALTH CARE RATIONING

One of the challenges awaiting health care systems around the world is the containment of expenses in the face of exploding costs for new drugs and treatments. In most countries, the allocation of health care has not been politicized so far and the problem is still treated as a purely regulative one. However, there is increasing interest in the procedures used for priority-setting. The paper argues that while normative standards for their evaluation are desirable, more attention should be paid to institutional factors and their effects. I identify two demands on decision-making—discursiveness and coordinativeness—from which I derive four ideal-typical procedures. By way of international comparison, corresponding empirical cases are analysed. I conclude with considerations on whether efficient and publicly accepted decisions over the allocation of health care are possible and, if yes, by means of what type of procedures and in what forum(s) they can be taken.