Delegation and Institutional Design in Health‐Care Rationing

Abstract

The delegation of decision-making powers to nonmajoritarian, independent agencies has become a significant phenomenon in more and more policy areas. One of these is the health-care sector, where decisions on the range of services covered within public systems have, in most developed countries, been delegated to specialized bodies. This article offers an analytical framework that seeks to grasp the empirical variety and complexity of delegative processes and appointed institutions. The framework is used to describe decision-making processes and institutions in six countries: Austria, Germany, Norway, Sweden, New Zealand, and the United Kingdom. We find that, although constrained by preexisting institutional structures and traditions, delegators enjoy a considerable degree of discretion in their institutional design choices and engage in strategic design and redesign of appointed bodies.

Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden

“…that the rankings must be perceived to be fair by most of the population to maintain confidence and the will to publically finance healthcare -a condition, that the government believes will facilitate understanding of the need to set priorities in healthcare. From an institutional design perspective, the delegation of institutional powers may be viewed as one among several tactics for politicians seeking to remove the challenge of setting limits to public services from the political agenda (21,22). The delegators often enjoy a considerable degree of discretion.…”

Does the approach to economic evaluation in health care depend on culture, values, and institutional context?

“…NICE is a statutory independent agency that has considerable control over its own organization and rules of procedure. It has been depicted as the typical example of "regulation by delegation", which is a particular characteristic of the British public service tradition [11].…”

“…In Germany, rationing and priority-setting are not generally accepted topics, which is demonstrated by the fact that Germany is a rare example of an OECD country without a positive list for drugs [11]. This is also why in Germany the level of delegation is very high.…”

“…IQWiG is a statutory independent body with its own budget and secretariat, but the degree of independence is less strong than NICE in UK. For example, its recommendations regarding new technologies are not binding on the health care system [11]. While the main focus is on clinical benefit assessment, Germany apparently uses the efficiency principle (but not economic evaluation) to guide the rationing process.…”

Demokratisches Institutionendesign in der Priorisierung und Rationierung von Gesundheitsleistungen

“…Auf der Grundlage eines Vergleichs von Gremien, die in den OECD-Staaten mit der Definition von Leistungskatalogen öffentlicher Gesundheitsversorgung, und somit der Priorisierung und Rationierung von Gesundheitsleistungen befasst sind, habe ich gemeinsam mit Katharina Böhm folgende Kriterien zum Vergleich dieser Institutionen vorgeschlagen (siehe [7]):…”