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Background: Implementation of a more restrictive reimbursement policy in Norway (in June 2003) has led to an increased use of individual reimbursement (patient application ) rather than general reimbursement (based on a positive list) of important pharmaceuticals. This study investigates physicians' attitudes to and experience with increased use of individual reimbursement one year after implementation of the new directive., Material and Methods: Questions concerning individual reimbursement were included in a questionnaire to the Research Institute of the Norwegian Medical Association's reference panel in November 2004., Results: 993 (71 %) of 1399 physicians responded to the questionnaire and 605 (61 %) of these reported that they had referred patients to a specialist or applied for individual reimbursement within the last year. About half (48 %) reported that the scheme contributes to rational use of pharmaceuticals, but more than 70 % were dissatisfied with the scheme and 87 % reported the scheme to be complicated and resource demanding. Only 37 % reported that all individual reimbursement applications were granted approval. 57 % reported that the scheme prevented them from prescribing the pharmaceutical they considered best for a patient, and 52 % reported that patients rather choose to pay for a pharmaceutical so treatment could start immediately. Administrative time for individual reimbursement applications was estimated to an average of 2.6 hours per month per physician., Interpretation: The results indicate that physicians are considerably dissatisfied with the practical implications of this scheme. Comprehensive analyses of the total health consequences, costs and distributional effects of the increased use of individual reimbursement for important pharmaceuticals are needed.

Modern vaccines may be very costly, and society needs to consider vaccination against other preventive and curative interventions. An economic assessment of health care programmes implies to quantify costs and assess health consequences in order to set better priorities. The main challenge lies in obtaining valid estimates of health effects and side effects and the consequences of herd immunity and serotype shift. This article discusses the methods and challenges of economic evaluation of vaccination programs, with vaccination against whooping cough and pneumococcal disease as examples.

Number needed to treat (NNT) is one of several effect measures that does not capture the time dimension because it is based on observations at a given, random point in time. This aspect makes NNT a problematical measure of the effect of interventions against chronic disease processes in which time to event is an essential issue. Additionally, the statistical properties of NNT are not favorable. It may leave the impression that adverse disease events are completely avoided by intervention when in fact they are postponed. We suggest that NNT should be used and interpreted with caution.