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- Gustavsson, Erik, 1982-
(författare)
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Characterising Needs in Health Care Priority Setting
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The focus of this thesis is needs in the context of health care priority setting. The notion of needs has a strong standing in health care policy; however, how the idea should be understood more specifically and how it should guide decisions about priority setting remain contentious issues. The aim of this thesis is to explore how needs should be characterised in health care priority setting. This matter is approached by, first, exploring and developing the conceptual structure of health care needs, and second, discussing and suggesting solutions to normative questions that arise when needs are characterised as a distributive principle.In the first article, the conceptual structure of needs in general and health care needs in particular is explored, and it is argued that a specific characterisation of health care needs is required.In the second article, the notion of health care needs is explored in relation to preferences for health care within the context of shared decision-making. The paper further discusses a number of queries that arise in the intersection between what the patient needs and what the patient wants.The third article discusses how a principle of need should handle questions about interpersonal aggregation. The paper characterises a principle of need which strikes a reasonable balance between giving priority to the worst off and the distribution of benefits with regard to interpersonal aggregation.The fourth article discusses how a principle of need should account for the fact that patients often are badly off due to several conditions rather than one single condition. It is argued that how badly off patients are should be understood as a function of how badly off these patients are when all of their conditions (for which they need health care) are considered.The frame story provides the terminological, theoretical, contextual, and methodological background for the discussion undertaken in this thesis. The conclusions of the articles are brought together and the discussion extended in the concluding discussion by sketching a number of conditions of adequacy for the concept and principle of need relevant for health care priority setting.
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| 2. |
- Broqvist, Mari, 1958-
(författare)
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Asking the public : Citizens´ views on priority setting and resource allocation in democratically governed healthcare
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Resource allocation in publicly funded healthcare systems is inevitably linked with priority setting between different patient groups and between different service areas, so-called meso level priorities. Behind every priority-setting decision (investments, reallocating or rationing), are values affecting both the content of the decisions and how the decisions are made. The importance for priority-setting to reflect social values, has been emphasised for the legitimacy of the healthcare systems and the decision makers. Also important, if supposed to provide enough guidance in practice, is that content values, expressed in ethical principles and criteria, are further operationalised. Few studies exist where Swedish citizens have been asked about priority setting and rationing at meso level, and findings from other countries cannot automatically be transferred to the Swedish context.The overall aim of this thesis is to extend and deepen the knowledge of the Swedish citizens´ views on acceptance of rationing in healthcare, on appropriate decision makers for rationing, and on the severity criterion for priority setting. Two qualitative and one mixmethod study were conducted, where citizens were interviewed. Citizens´ views on severity were also compared, both with a Severity Framework, derived from parliamentary-decided ethical principles and used for resource allocation, and with health professionals´ and politicians´ ranking of different aspects of severity in a quantitative, survey study.Study I shows that citizen participants perceived that acceptance of rationing at meso level is built on the awareness of priority-setting dilemmas between patient groups. No such spontaneous awareness was found. Depending on reactions of self-interest or solidarity, acceptance was also perceived to be built on acceptable principles for rationing and/or access to alternatives to public care. Study II shows that awareness of the meso level forms the basis for awareness of different risks of unfairness, linked with potential decision makers (even health professionals). Collaborative arrangements were promoted in order to control for such risks, especially the risk of self-interest. Politicians, in contrast to previous studies, were favoured as final decision makers for rationing healthcare. In study III, citizen participants identified the same severity aspects as health professionals and experts had done in the Severity Framework. They contributed with some possible refinements, but also promoted aspects not in line with established ethical criteria for priority setting in Sweden. Study IV shows that citizen respondents differ to a larger proportion compared to politicians´ ranking of severity aspects, than with that of health professionals´. The greatest number of significant differences was found between politicians and health professionals.This thesis has several implications. Politicians ought to strive for greater public awareness of the priority-setting dilemma at the meso level in healthcare, both according to the process and the content values behind the decisions. Social values not in accordance to the parliamentary decision indicate a need to facilitate an ongoing dialogue, reason-giving activities and promotion of content values of solidarity. To capture social values on priority setting and rationing, ambitious public deliberation is not the only way. Methodologically stringent research, with a variety of study designs, could contribute in many important ways.
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