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Two principles form the basis for much priority setting in health. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. Jointly, these principles accord with so-called prioritarianism. Crucial for its operationalisation is the specification of the worse off. In this paper, we examine how the worse off can be defined as those with the fewer lifetime Quality-Adjusted Life Years (QALYs). We contrast this proposal with several alternative specifications.

The public discussion on the future of the healthcare system has recognized that the gap between needs and financial possibilities for coverage is becoming increasingly larger due to increasing needs and reduced financial support. It can be assumed that due to reduced financial means and increasing demands on provision of service in healthcare and nursing, the time will come when prioritization will be necessary. The medical profession should prepare itself for this situation because prioritization is a long process.

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase "quality of care" is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, hinges on its ability to improve quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of "quality of care" are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, "quality of care," in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that "quality of care" operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system.

The requirements of the UK Equality Act 2010 and some high profile criticism for using a potentially ageist methodology have prompted the National Institute for Health and Clinical Excellence (NICE) to assess the processes and methodology it uses to make appraisal decisions. This paper argues that NICE has established rigorous systems to protect against ageist decisions, has no track record of ageism and is well placed to meet the requirements of new UK equality legislation.

In France, foreign patients, whether resident or not in France, can register on the national waiting list under administrative and financial conditions. We performed a retrospective analysis to evaluate the access to kidney transplantation on a cohort 2004-2008, using the national registry. Among the 14,732 patients registered during this period, 15.3% are of non-French nationality (3.4% other European, 5.9% North African, 3.9% sub-Saharan African, 2.9% other). Among the 84.6% of French nationality, 3.3% are living in French overseas territories. Compared to the 17.6-month median waiting time of the cohort, median waiting time differs significantly between groups, from 15.7 months for mainland French patients to 36 months for sub-Saharan African patients. Despite the regular development of the allocation rules, these disparities in access to transplantation are mainly, but not completely, explained by blood group or HLA matching difficulties. After adjustment for the other factors known to be significantly linked to a difficult access to transplantation, North and sub-Saharan African patients have the worst difficulties. Future research should consider nonmedical factors, such as socio-economic or socio-cultural factors, potentially relevant to avoid disparities in access to transplantation and should aim at developing specific interventions.

Germany's Central Ethics Committee of the Federal Chamber of Physicians (FCP) and other relevant national actors called for a public discourse on priority setting in health care. Politicians, members of a Federal Joint Committee and health insurance representatives, however, refused to promote or participate in the establishment of a public discussion. A change to that attitude only became apparent after former FCP President Hoppe's opening speech at the annual FCP assembly in Mainz in 2009. The present paper applies the Sociology of Knowledge Approach to Discourse, implemented through Qualitative Content Analysis and elements of Grounded Theory, to examine the development of the national public discourse in leading German print media. It creates a matrix that represents the discourse development between May 2009 and May 2010 and reflects central actors, their "communicative phenomena" and their interactions. Additionally, the matrix has been extended to cover the period until December 2011. Hoppe's arguments for priority setting in health care are faced with a wide opposition assuming opposing prerequisites and thus demanding alternative remedies. The lack of interaction between the different parties prevents any development of the speakers' positions. Incorrect accounts, reductions and left-outs in the media representation add to this effect. Consequently, the public discussion on priority setting is far from being an evolving rational discourse. Instead, it constitutes an exchange of preformed opposing positions., (Copyright © 2012. Published by Elsevier GmbH.)

Act CXXXII of the year 2006 - amended several times - on the development of the health care system requires that health insurance authorities should regularly review utilization of the contracted capacity of professional medical care providers, and the need for change of capacities. The first such analysis should be carried out in 2013, according to the current laws in Hungary. The law lists 16 items, which are the basis for evaluation of the performance of providers. Among them some items are difficult to analyse specifically even for health insurance specialists. This study aims to review aspects of the reevaluation process and their associated concepts. Author wants to provide help for setting up the analysis in practice by going through and analysing the requirements of the law in detail.

An ideal resource allocation in health care should ensure most people to access equal health care services while needed. Not only social welfare economists but also health policy makers concern with rational distribution of health care resources. Taiwan implemented a National Health Insurance (NHI) program in 1995, to reduce financial barriers for all residents with a universal health care system. Horizontal equity, an explicit goal of the NHI system, is to guarantee equal opportunity of access to health care. Accordingly, this study, utilizing cross-sectional data, proposes a multi-criteria decision-making approach with grey incidence analysis to measure horizontal equity of health care resource allocation of the NHI in Taiwan. From the findings of this empirical study, most resources are allocated in North Taiwan resulting in geographical disparity due to unbalanced health care resource allocation. And the large-scale hospitals are mostly congregated only at metropolitan regions; therefore, the access to health care services for patients in rural areas is still limited. Finally, the NHI in Taiwan is a single-payer for all hospitals, in which payment for health care suppliers can be adopted as an efficient strategy to induce the disparity of resource allocation and to redistribute national health care resource., (Crown Copyright © 2010. Published by Elsevier Ireland Ltd. All rights reserved.)

Liver transplantation represents a successful and well-established therapeutic concept for patients with advanced liver diseases. Organ donor shortage continues to pose a significant problem. To ensure fair and transparent allocation of too few post-mortem grafts, the model of end-stage liver disease (MELD)-based allocation was implemented in December 2006. This has decreased waiting list mortality from 20 to 10 % but at the same time has reduced post OLT survival (1-year survival from almost 90% to below 80%), which is largely due to patients with a labMELD score > 30. Following MELD introduction the regular allocation threshold has increased from a matchMELD of initially 25 to meanwhile 34. At the same time the quality of donor organs has seen a continuous deterioration over the last 10 - 15 years: 63% of organs are "suboptimal" with a donor risk index of > 1.5. Moreover, the numbers of living-related liver transplantations have decreased. In Germany incentives for transplant centres are inappropriate: patients with decompensated cirrhosis, high MELD scores and high post-transplant mortality as well as marginal liver grafts are accepted for transplantation without the necessary consideration of outcomes, and against a background of the still absent publication and transparency of outcome results. The outlined development calls for measures for improvement: (i) the increase of donor grafts (e. g., living donation, opt-out solutions, non-heart beating donors), (ii) the elimination of inappropriate incentives for transplant centres, (iii) changes of allocation guidelines, that take the current situation and suboptimal donor grafts into account, and (iv) the systematic and complete collection of transplant-related data in order to allow for the development of improved prognostic scores., (© Georg Thieme Verlag KG Stuttgart · New York.)

Hypertension is emerging in many developing nations as a leading cause of cardiovascular mortality, morbidity and disability in adults. In sub-Saharan African (SSA) countries it has specificities such as occurring in young and active adults, resulting in severe complications dominated by heart failure and taking place in limited-resource settings in which an individual's access to treatment (affordability) is very limited. Within this context of restrained economic conditions, the greatest gains for SSA in controlling the hypertension epidemic lie in its prevention. Attempts should be made to detect hypertensive patients early before irreversible organ damage becomes apparent, and to provide them with the best possible and affordable non-pharmacological and pharmacological treatment. Therefore, efforts should be made for detection and early management at the community level. In this context, a standardized algorithm of management can help in the rational use of available resources. Although many international and regional guidelines have been published, they cannot apply to SSA settings because the economy of the countries and affordability of the patients do not allow access to advocated treatment. In addition, none of them suggest a clear algorithm of management for limited-resource settings at the community level. In line with available data and analysing existing guidelines, a practical algorithm for management of hypertension at the community level, including treatment affordability, has been suggested in the present work.

Background: A programmatic research effort investigated how lay people weigh information on hypothetical patients when making decisions regarding the allocation of scarce medical resources. This study is partly replicative and partly innovative, and looks particularly at whether overweight patients would be discriminated against in allocating resources., Aims: This study aims to determine the importance given to specific patient characteristics when lay participants are asked to allocate scarce medical resources., Sample: In all, 156 British adults (82 males, 73 females), aged 19 to 84 years, took part. There were few students., Method: Participants completed a questionnaire requiring them to rank 16 hypothetical patients for access to a kidney dialysis machine.The demographic information presented regarding each hypothetical patient differed on four dimensions: gender, weight, mental health, and religiousness., Results: There were significant main effects for gender, weight, and mental health; females, patients of normal weight, and the mentally well were ranked the highest priority for access to a kidney dialysis machine. Participants discriminated most regarding the weight of hypothetical patients., Conclusion: Different patient characteristics, unrelated to medical prognoses, particularly being overweight, may have an impact on decisions regarding the use of scarce medical resources.

Objectives: In a region of Schleswig-Holstein, a regional budget was used to investigate which structural changes would be brought about by a financial plan which enables (clinical) treatment that defies rigid financial limits and makes flexible treatment in various settings possible., Results: In 5 years, the number of inpatient treatment places in the care region was reduced considerably. The length of stay per patient and year decreased by 25 %. Day care and outpatient treatment offers were expanded substantially and new treatment concepts were established. The quality of treatment remained safeguarded., Conclusions: A regional budget is suitable for bringing about fundamental changes in terms of content and structure in psychiatric care. The result is clearly improved flexibility as compared to previous care structures; incentives for disorders are reduced. The principle "outpatient before inpatient" is strengthened. The financial plan can be transposed onto other regions, whereby modifications according to the structure of the care region seem necessary., (© Georg Thieme Verlag KG Stuttgart · New York.)

While setting priorities in healthcare has been discussed internationally for about 25 years, attempts to even start a discussion in Germany have failed for more than a decade. On the contrary, the topic was and still is actively suppressed. In this respect, one helpful mechanism is to deliberately or carelessly confuse prioritization with rationing, a German taboo-word. The national healthcare debate again and again neglects the question on what to spend Germany's still very considerable resources. This helps our health politicians to continue to live the postulate that everybody should have immediate, unrestricted access to all medically indicated healthcare. Attempts to distinguish between priority setting and rationing as two entirely distinct programs based on prioritization models from Sweden, England, and Oregon/USA are presented. While discussing possible objects, levels, criteria, ethics, and normative implications of priority setting in healthcare, recent recommendations of a permanent vaccination committee (STIKO) are used as an example.

With a global commitment to scaling up AIDS care and treatment in resource-poor settings for some of the most HIV-affected countries in Africa, availability of antiretroviral treatment is no longer the principal obstacle to expanding access to treatment. A shortage of trained healthcare personnel to initiate treatment and manage patients represents a more challenging barrier to offering life-saving treatment to all patients in need. Physician-centered treatment policies accentuate this challenge. Despite evidence that task shifting for nurse-centered AIDS patient care is effective and can alleviate severe physician shortages that currently obstruct treatment scale-up, political commitment and policy action to support task shifting models of care has been slow to absent. In this paper we review the evidence in support of task shifting for AIDS treatment in Africa and argue that continued policy inaction amounts to unwarranted healthcare rationing and as such is ethically untenable.

The German health care system will face major challenges in the near future. Progress in medicine as well as demographic change will combine to drastically exacerbate the scarcity of resources in the health care system. The word scarcity in this case not only refers to the availability of funds. Other resources, e.g., staff, attention, time, and organs for transplantation, are also becoming scarce. It is conceivable that, in the future, it will no longer be possible to provide medical services for all patients to the same extent as in the past. If the necessary resources are not available in the health care system, if the potential for saving resources has been more or less exhausted, and if rationing shall not be an option, the only option to resort to will be prioritization. Prioritization in the health care sector denotes a supply of services according to specific, predetermined criteria. A broad and open public debate, which would have to be accompanied as well as moderated by the Health Council ("Gesundheitsrat"), is essential for determining such criteria.