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The increasing demand for healthcare and the resulting pressure on available budgets render priority setting inevitable. If societies aim to improve health and distribute health(care) fairly, equity-efficiency trade-offs are necessary. In the Netherlands, proportional shortfall (PS) was introduced to quantify necessity of care, allowing a direct equity-efficiency trade-off. This study describes the history and application of PS in the Netherlands and examines the theoretical and empirical support for PS as well as its current role in healthcare decision making. We reviewed the international literature on PS from 2001 onwards, along with publicly accessible meeting reports from the Dutch appraisal committee, Adviescommissie Pakket (ACP), from 2013 to 2016. Our results indicate that there is support for the decision model in which necessity is quantified and incremental cost-effectiveness ratios are evaluated against associated monetary reference values. The model enables a uniform framework for priority setting across all healthcare sectors. Although consensus about the application of PS has not yet been reached and alternative ways to quantify necessity were found in ACP reports, PS has increasingly been applied in decision making since 2015. However, empirical support for PS is limited and it may insufficiently reflect societal preferences regarding age and reducing lifetime-health inequalities. Hence, further investigation into refining PS-or exploration of another approach-appears warranted for operationalising the equity-efficiency trade-off.

Background/objective Because informal health care is now recognized to be indispensable to health care systems, different forms of respite care have been developed and publicly funded that supposedly alleviate caregivers’ perceived burdens and help prolong the care giving task. Nonetheless, the use of respite care services is low even among substantially strained caregivers. To throw light on this low usage, this paper explores the associations between attitudes towards respite care, characteristics of the care giving situation, and the need and use of respite care. Method The survey, administered to a sample of 273 informal caregivers, addressed caregiver, care recipient, and care giving situation characteristics, as well as the familiarity and use of respite care services. It also included a sub-set of 12 statements eliciting attitudes towards respite care from an earlier study [Van Exel NJA, De Graaf G, Brouwer WBF. Care for a break? An investigation of informal caregivers’ attitudes toward respite care using Q-methodology. Health Policy 2007;83(2/3):332–42]. Associations between variables were measured using univariate statistics and multinomial logistic regression. Results We found three caregiver attitudes, distributed fairly equally in the sample, that are apparently associated with caregiver educational level, employment status, health and happiness, as well as care recipient gender, duration and intensity of care giving, relationship, co-residence, need for surveillance, and subjective burden and process utility of care giving. However, the relation between attitude and familiarity with and use of respite care services is ambiguous. Conclusions Although further exploration is needed of the mix of Q-methodology and survey analysis, the overall results indicate that a considerable portion of the caregiver population needs but does not readily ask for support or respite care. This finding has important policy implications in the context of an ageing population.

Discounting is one of the prominent topics of debate in health economics. While the standard practice in economic evaluation is to discount costs and effects alike with a 3–5% discount rate, many have raised questions about this practice. The debate sometimes seems trapped in Weinstein and Stason’s consistency argument. In this paper, we use a set of health care programs—resembling Weinstein and Stason’s hypothetical programs—to test whether appointed societal decision makers are consistent in their preferences over present and future costs and health effects, and whether they discount costs and effects at the same rate. Our results demonstrate these appointed decision makers to be fairly inconsistent on both issues, susceptible to the framing of problems and in part myopic. In other words, our respondents appear to be incapable of providing reasonable and consistent preferences between present and future costs, and health effects for use in economic evaluations. There is some support for the idea that rather than using constant and identical rates for costs and effects, real differences in health endowment over time (the growth rate for health) could serve as a basis for discount rates. Our respondents seem to relate their discount rate for health to their expectations about future life expectancy, but this also is dependent on the elicitation method.

The recent ruling of the European Court of Justice in the case Smits-Peerbooms explicitly mentions undue delay as a legitimisation for cross-border care within the EU. In the Netherlands, waiting times are well above the norm set by several health care parties as well as maximally acceptable waiting times elicited in patients. This might indicate that Dutch patients are often entitled to care in other Member States, in the sense that insurers cannot withhold reimbursement of cross-border care in the present situation. However, experiments clearly demonstrate that few Dutch patients are willing to travel abroad. Patients seem to prefer longer waiting in the Netherlands over shorter waiting by going abroad, even those living in border regions. In addition, mobility of patients within the Netherlands is very modest. Given this inertia in patient mobility, in the short run, cross-border care will probably remain an insignificant phenomenon in terms of quantities of patients travelling abroad and therefore the impact of the Smits-Peerbooms rulings is limited.

Although the cost-effectiveness of Viagra for the treatment of patients with erectile dysfunction is favourable, both public and political opinions seem to be inclined not to fund, or merely to partially fund (i.e. by reimbursing only specific patient groups) this medicine. This shows that in funding discussions, cost-effectiveness information is not solely decisive. In a theoretical framework for choices in health care that was developed in The Netherlands (the Dunning report, 1991), two other criteria besides cost-effectiveness were put forward as being important for rationing decisions: "necessary care" and "individual responsibility". Overlooking the Viagra discussion, many of the arguments put forward seemed to be related to these two criteria. However, a clear operationalisation of the criteria necessary care and individual responsibility is lacking, which makes it difficult to use the arguments in funding decisions. In this paper, we try to demonstrate how these criteria were presented in the Viagra discussion and we will indicate how these criteria can be operationalised in relation to the outcomes of a cost-effectiveness analysis.

Private clinics for employees have emerged on a small scale during the last few years in Dutch health care. They represent new possibilities for ill employees who have to wait for medical treatments on waiting lists. Earlier proposals to allow employers in close co-operation with health insurers to start initiatives for special clinics for employees have been confronted with all kind of arguments which were considered to form serious obstacles, from theoretical, legal and economic perspectives. The European Court of Justice plays a decisive role in deciding whether free establishment and access is approved according to the rules of the EC Treaty. Private clinics can be legally allowed in the interests of the common good. However, priority treatment of a person can only be justified if the intended purpose is justified and if the priority treatment is suited as a means to (partly) realise this purpose. Furthermore, possible negative consequences may not be unreasonable in the light of the intended consequences. In this article it will be argued that both from an economic and from a legal perspective, based on national and European law, the introduction of special clinics for employees could be allowed. The main argument is that they could be introduced on a just and equitable basis.

The author's regret that in the original printing of the above mentioned paper, the acknowledgement section was not included. It is now cited in full, below. Acknowledgement This study was funded through MW-NWO grant 945-10-029. We thank the four interviewees for their co-operation.

a b s t r a c t The issue of affordability of health care services remains high on the (health) policy agenda. Determining whether health care services are affordable is complex, however, as the concept ‘affordability’ is inherently normative. With a focus on measuring affordability in lowand middle-income countries, we discuss different methods used to operationalize this concept. Using the example of medicine purchases in Indonesia, we show the choice of method and threshold to have a significant impact on outcomes. We argue it is important to further standardize methods and appropriate threshold use in applied research to increase comparability of results and to facilitate sound assessments of affordability.

Highlights • Citizens were overall satisfied with their government's response to the COVID-19 outbreak. • A north-south pattern in public opinion was observed across the European states. • Pandemic acted as a stressor, causing health and economic anxieties. • Considerable differences in levels of trust were observed between and within countries. • Containment policies offered lessons for the design of lockdown exit strategies., To understand the public sentiment toward the measures used by policymakers for COVID-19 containment, a survey among representative samples of the population in seven European countries was carried out in the first two weeks of April 2020. The study addressed people’s support for containment policies, worries about COVID-19 consequences, and trust in sources of information. Citizens were overall satisfied with their government’s response to the pandemic; however, the extent of approval differed across countries and policy measures. A north-south divide in public opinion was noticeable across the European states. It was particularly pronounced for intrusive policy measures, such as mobile data use for movement tracking, economic concerns, and trust in the information from the national government. Considerable differences in people’s attitudes were noticed within countries, especially across individual regions and age groups. The findings suggest that the epidemic acts as a stressor, causing health and economic anxieties even in households that were not directly affected by the virus. At the same time, the burden of stress was unequally distributed across regions and age groups. Based on the data collected, we draw lessons from the containment stage and identify several insights that can facilitate the design of lockdown exit strategies and future containment policies so that a high level of compliance can be expected.