Priority setting in public and private health care: a guide through the ideological jungle

Priority setting reflects ideology, and so, more surprisingly, does the quest for “efficiency”. A great deal of the current debate about alternative methods of finance and about reform of management structures, in health services all over the world, purports to be about some notion of efficiency which it is believed we all seek. But efficiency depends on objectives. How important is freedom of choice, what weight is to be given to “need”, how much innovative diversity is compatible with equality of access? This paper presents two polar ideological positions, and outlines the kind of health services each holds up as “ideal”. It is argued that neither ideal is seen in practice, but our views as to what would make a real-world health service more “efficient! Will depend on which ideal we wish it to move towards. But is there any ideologically coherent middle ground which would justify a mixed system? A mixed system is a middle, but it is a muddle we have chosen (and can therefore justify), or is it the unintended by-product of intellectual confusion? This discussion paper is intended to help its readers identify, and come to terms with the consequences of, their own ideology, so that the debate about the merits of rival systems is not conducted on a false appreciation of which issues are “factual” and which are “ideological”.