Increased drug expenses have created challenges for drug reimbursement systems in many industrialised countries, including Finland. Prioritization of drugs could be one solution to this problem. This paper examines stakeholders' perspectives on the prioritization decisions made in the Finnish drug reimbursement system, particularly concerning drugs in the higher reimbursement categories. The analysis was based on 18 interviews with key stakeholders. The results revealed that authorities directly influencing the decisions tried to keep them as technical and non-political as possible. However, doing so was not easy, and there appeared to be hidden non-technical rationales behind many decisions. Stakeholders outside public administration had few opportunities to openly participate in decision-making because of the lack of transparency of the process. Despite this, they tried to influence decisions concerning their interests by using several means, such as lobbying the media, Parliament or other stakeholders. Transparent decision-making and better methods of open discussion on competing interests could promote democracy in the prioritization of drugs and perhaps reduce the harmful effects of indirect and unequal participation by different stakeholders.
The aims of this study were, within three Canadian health regions, to identify existing resource management techniques, to elicit ways in which the current process of setting priorities could be improved and to determine if an economic framework, used internationally, would have merit in Canada.
Structured, face-to-face interviews were conducted with 62 of 73 key decision makers. This sample included all senior executives and medical directors involved in setting priorities. Descriptive statistics and content analysis were utilised.
Key decision makers reported that a clear process of setting priorities does not exist. Allocation of resources generally occurs on the basis of historical trends; only 22% of participants stated that the process works well. Respondents were critical of the lack of transparency and a lack of meaningful inclusion of physicians in the priority setting process. Overall, 92% of respondents indicated that program budgeting and marginal analysis (PBMA) would be an appropriate and useful priority setting framework.
Given the political and historical influence in the process of priority setting and resource allocation, an evidence-based approach, like PBMA which explicitly attempts to identify ways of maximising health benefit within a limited budget, should have merit in the new regional structure in Canada.
Three groups of judges representing clinical, political, and laypersons' perspectives were given the task of prioritizing patients for subsidized psychotherapy within the Swedish health care system. The authors documented the judges' decision-making processes in think-aloud protocols and analyzed them qualitatively, focusing on the conflict between the urgency of a case and its suitability for treatment. In an earlier statistical analysis of the same material, clinicians had seemed to pay more attention to suitability criteria, whereas health care officials and laypersons prioritized based on urgency. The qualitative findings confirmed the centrality of this conflict and contributed to a deeper understanding of decision makers' ways of coping with it. Their conceptions of suitability and urgency were also elucidated by analysis of the think-aloud protocols.