Decision-Making Processes and Distributive Effects

The Allocation of Health Care in OECD countries

Which health care services should be provided by a public health care system that is based on the principle of solidarity? How can a just distribution of services be ensured when health expenditure has to be limited? Who can and should take complex decisions on what services have to be included in public health baskets? These issues constitute enormous challenges for developed democracies. In the last decade, nearly all OECD countries have started to constrict the range of services covered or at least to avoid further expansion of health baskets. Health services are thus rationed, which requires a comparative assessment and prioritisation of different services on the basis of a discursive assessment of principles and criteria of distributive justice.

Prioritisation and rationing of medical services

Decision-making processes in health care rationing and priority setting require considerable expert information and resources, given the complexity as well as the sheer number of single decisions required. As majoritarian democratic institutions such as the parliament and government seem to be overtaxed by these tasks, they have started to establish new decision-making processes and have delegated the comparative assessment of services to more or less independent bodies. We assume that the institutional design of decision-making processes and independent bodies (concerning the degree of independence and delegation, the composition of members, decision rules applied or publicity and transparency of forums) influences resulting decisions and thus the distribution of health care: Procedures are never completely neutral, but embody specific conceptions of justice and promote certain interests more than others.

Quantitative and qualitative analysis

The analysis of the relationship between procedural and institutional characteristics on the one hand and the distributive effects of these decision-making processes on the other hand will be carried out in two steps. The first step consists in a quantitative test of hypotheses on the basis of data collected for the OECD countries. The second step consists in an in-depth analysis of decision-making processes in four countries and aims to reconstruct the causal relationship between procedural factors and distributive effects qualitatively. To conclude the project we intend to organize a citizen conference on priority-setting in health care which we hope to yield insights on the question of whether and in what regards participative and deliberative procedures produce different distributive decisions than experts or democratic representatives.

Informing the political design of institutions

With this exploration of relationships between decision-making processes and distributive effects the project aims to make a contribution to both institutional and governance theories and to theories of justice and democracy. Results of our research can potentially provide important information for the choice of decision-making procedures and the design of institutions to which decisions are delegated: If a society seeks to achieve particular distributive results, it needs to know which decision-making process will serve to promote these.