Governments around the globe are struggling with post-pandemic health systems, raising the key question of how they can make their health system sustainable. Decision-makers seek to anticipate new and yet unforeseen challenges, while trying to move forward ‘old’ complex issues like developing legitimate systems for value assessment and decision-making about the allocation of scarce resources. In this issue of Health Economics, Policy and Law, we bring together seven articles that address these issues in different European countries and Australia. The authors share an interest in the development and use of economic valuation methods and technical tools against the background of institutionalised health systems that impact how these methods and tools play out in national and local practices.
The paper of Charlton et al., co-authored by 23 (!) scholars in the field of Health Technology Assessment (HTA), introduces a new framework enabling HTA as a decision-making method to be more transparent and morally justified. This is important given that current HTA methods have limitations in their language to articulate normative reasoning and, consequently, are likely to undermine legitimacy and fairness of allocation decision-making. The proposed framework more clearly articulates the rationale on which priority-setting decisions should be based. The technical requirements of ‘good’ economic evaluation are further explored by Andrea Gabrio, who compares the practice of conducting economic evaluation in the Netherlands before and after the introduction of new guidelines to strengthen cost-effectiveness by the National Healthcare Institute. Zooming in on the aspects of statistical methodology and missing data handling, the research shows that many components of economic evaluations have changed in accordance with the new recommendations towards more transparent and advanced analytic approaches. Yet, there remain potential limitations to the new evaluation method, including the use of less advanced statistical software together with rarely satisfactory information to support the choice of missing data methods.
The article of Best and Tuncay brings us to Australia, with research on the impact of ‘wealth’ on health expenditure. They find that ‘wealth’ is more influential than ‘income’ in explaining a range of health expenditure variables. This finding provides motivation for a greater focus on asset testing rather than income testing for decisions on welfare payments.
Kleining et al. shift the focus to drugs pricing, with a price analysis for drugs with unproven additional benefit in Germany. They show that the flexibility provided by national law to negotiate on the price for drugs is successful and cost-effective, and they argue that current regulation fulfils the objective of keeping drugs without proven additional benefits out of the German health system. The topic of pricing is further explored by Sirur and Pillai who have conducted a thematic synthesis of the literature to explore practices of hospital pricing. The research underlines the complexity of these practices, showing that hospital pricing is bound up with institutional arrangements like the presence of third-party payers, insurer involvement, the (in)completeness of information, and the existence of adequate cost measurement processes. The impact of institutions and the institutional context is elaborated on in the final two articles of this HEPL issue.
Kieslich et al. studied local health policy making in London, zooming in on how the complexities of the local policy context influences how the fair allocation of resources is achieved. The authors suggest a set of political and contextual considerations to supplement exiting priority setting frameworks, which ultimately would make them more applicable to the local specificities of health resource allocation. The article of Tugce Schmitt takes us back to Germany, with a study on the corporatist system, which hampers the introduction of new technologies like the electronic health record. Comparing Germany to other European countries, Schmitt suggests that the fragmented nature of the German health system is barrier to the aim of integrated care. Yet, so it is argued, the proposed electronic health record (elektronische Patientenakte, ePA) could be a way to overcome the fragmented system, acting as an institutional tool for healthcare reform.
Together, the seven articles in this issue nicely reflect the aim of studying complexities and policies in contemporary health systems and connecting economic instruments and insights to policy making. The articles provide a theoretical lens to studying health system development and the aim to foster sustainability – as well as the ongoing difficulties in achieving this aim; both in practice and theory.
