Who should participate in health care priority setting and how should priorities be set? : evidence from a Portuguese survey

w w w . e l s e v i e r . p t / r p s p

Original

Article

Who

should

participate

in

health

care

priority

setting

and

how

should

priorities

be

set?

Evidence

from

a

Portuguese

survey

Anabela

Botelho

Veloso

_,

_Michaela

_Moreira

_Pinho

_,

Paula

Alexandra

Correia

Veloso

Veiga

a_{UniversidadedoMinho,Portugal&AppliedMicroeconomicsResearchUnit(NIMA),Portugal}

b_{UniversidadeLusíadaPortoandUniversidadePortucalense,Portugal&AppliedMicroeconomicsResearchUnit(NIMA),}

RuaDr.LopodeCarvalho,4369-006Porto,Portugal

a

r

t

i

c

l

e

i

n

f

o

Received11August2011 Accepted20June2013

Availableonline13November2013

Keywords: Prioritiessetting Publicinvolvement Explicitrationing Health-care

a

b

s

t

r

a

c

t

Introduction:Thisarticleprovideshighlightsoftheevolutionofthehealthcarerationing debatetowardsamoreexplicitandopenapproachinvolvingpublicparticipation. Discre-tionarymodelsthathavedominatedthehealthsectordecision-makingarebeingquestioned bydifferentsectorsofsociety.

Methods:Usingdatafrom442collegestudents,weexplorepublicviewsonpublic involve-mentinhealthcarerationingdecisions.

Results:Findingssuggestthatalthoughcitizenswishtobeconsulted,theybelievedoctors shouldplaythemostimportantroleonrationingdecisions.

Discussion:Confidenceindoctorsis,nonetheless,notindependentfromthecriteriausedto supporttheirdecisions.

©2011EscolaNacionaldeSaúdePública.PublishedbyElsevierEspaña,S.L.Allrights reserved.

Quem

deveria

participar

na

definic¸ão

das

prioridades

em

saúde

e

como

deveriam

essas

prioridades

ser

estabelecidas?

Resultados

de

um

inquérito

em

Portugal

r

e

s

u

m

o

Introduc¸ão:Esteartigodestacaaevoluc¸ãododebatesobreoracionamentodoscuidadosde saúdecomvistaaumaaproximac¸ãomaisexplícitaemaisabertaqueenvolvaaparticipac¸ão pública.Osmodelosarbitráriosquedominaramatomadadedecisãonosetordasaúdeestão aserquestionadospordiferentessetoresdasociedade.

Métodos:Partindodedadosrecolhidoscom442estudantesuniversitário,foramexploradas asopiniõessobreaparticipac¸ãopúblicanoqueserefereàtomadadedecisãoquantoao racionamentodoscuidadosdesaúde.

∗ _{Correspondingauthor.}

E-mailaddress:[email protected](M.M.Pinho).

0870-9025/$–seefrontmatter©2011EscolaNacionaldeSaúdePública.PublishedbyElsevierEspaña,S.L.Allrightsreserved.

Resultados: Os resultados sugeremque emboraos cidadãos desejem serconsultados, acreditamquecabeaosmédicosdesempenharopapelmaisimportantenasdecisõesde racionamento.

Discussão: Aconfianc¸anosmédicosnãoé,todavia,independentedoscritériosusadospara apoiarassuasdecisões.

©2011EscolaNacionaldeSaúdePública.PublicadoporElsevierEspaña,S.L.Todosos direitosreservados.

Introduction

Healthcarecosts havegrownfasterthan overalleconomic growthindevelopedcountries,makingitnecessaryforexplicit measuresdealingwiththedistributionofhealthresourcesto beincludedonthesecountries’ politicalagendas.Although the strength of recent political and academic debate may suggestotherwise,therationingofhealthcareisnotanew process.Whatisnewisthedebatesurroundingtheneedto conciliatemethodsofprioritysettingandpublicinvolvement indecisionmaking.

Theeconomicevaluationapproaches topriority setting, groundedinthe principle ofmaximisationofhealth bene-fits byunit ofcost, despitehaving the merit ofadvancing thetheoreticaldebate,seemtohavehadlittleeffectin prac-tical terms.The greatest objection to economic evaluation techniquesistheinherentdifficultyofconciliatingefficiency principles with social values. In this context, one possi-blehypothesis wouldbetosubstitutethetechnicalcriteria for a political process of priority setting, which would be opened up toincludethe participation ofall socialactors, particularly the population. The idea that society should participateinprioritisationdecisionshasbeenwidely prop-agated, but has not yet advanced to the stage of actual implementation. Although researchers seem to agree that obtainingthepreferencesofthe populationinhealth mat-tersisacomplexprocess,thereisamplesupportforpublic involvement.1–4_{Thecontroversysurroundingpublic}

involve-mentinprioritisationdecisionsinvolvesnotonlyanethical debate about the relevance of this involvement but also a methodological debate about the weight that should be given to their statements, or rather, the degree of par-ticipation the public should be granted (advisory-based or directintervention).Somefearthatpublicunderstandingof rationing could undermine the population’s confidence in healthprofessionals,5,6_{intheNationalHealthSystem(NHS),}

andsocialcohesion.7

Activepublicparticipationinprioritysettingrequiressome transference of power and authority to this group, which couldconflictwiththeinterestsofothergroups,namelythe doctors.8,9 _{JacobsonandBowling}10_{pointoutthatthepublic}

debateonrationingiscomplicatedbytheinherentconflicts betweentheopinionsofthegeneralpopulationandthoseof thehealthprofessionalsorgroupsofpatients.Afurthercause forworryinthequestion ofpublicinvolvementin prioriti-sationdecisionsisthegeneralpopulation’slackoftechnical knowledge.11,12_{Someauthorspointoutthatthereistherisk}

ofthisprocessbeingdominatedbyuninformedpeople.9,13,14

These aspects raise doubts about the value or the weight thatshouldbeattributedtotheopinionsofthepopulation.15

AccordingtoMullen12 _{thelackofdefinitionconcerningthe}

population’sroleintheprioritisationprocessnegatively con-ditionstheresultsoftheirinvolvement.

Paradoxically,publicinvolvementintherationingdebate encountersresistanceinthepopulationitself.Studieshave shownthatdespitethecitizens’wishtobeconsultedabout healthresourcesplanning,theydonotwanttomakedirect rationingdecisionsthemselves.16–21_{Thepopulationseemsto}

experiencedisutilitywhenitfindsoutabout,oriscalledupon to makedecisionsabout the denialoftreatments toother membersofsociety21_{duetoafearofmakingawrong}

deci-sion,whichtheymaylatercometoregret.22_Itwouldseem

that regret is animportantelement in individual valorisa-tionandinmakingdecisionsabouthealthcare.19 _Thisidea

isreinforcedbyevidencethatthecitizensderiveutilityfrom ignoringhowthehealthresourcesareeffectivelyrationalised– the“utilityofignorance”argument.5,23_{Inaddition,individuals}

tendtoseedoctorsasthebestgrouptomakethedecisionsfor society.20,24,25_{Thiswouldseemtosuggestthatintheinterests}

of“peaceofmind”,therationingdecisionsshouldbelefttothe doctors,whatevertheydecide.26

The paper presents the results of asurvey questioning citizens (college students) in Portugal about their opinion towardsthepublic’sinvolvementintheplanningforlimited healthresources,theirdesignateddecision-makingauthority forrationing,andtheirlevelofconsentfortheadoptionof efficiencycriteriaintheallocationofresources

Rationing

of

health

care

in

Portugal

RationinginPortugalisnotexplicitlyaddressedinthe polit-icalagenda. Asishappeninginother developedcountries, theshortageofresourcesinthePortugueseNHShasbecome increasingly serious in recent years, especially with the increaseinhealthcosts.Thereformsthathavebeencarried outsincethemid1990s,withthemainpurposeofimproving efficiencyandcontrollingtheincreasesinhealthcosts,adopt atypologyofrationingwhichisamixtureofexplicitmeasures takenatthemacrolevelandimplicitpracticesremainingthe responsibility of the health care providers. In this sense, therationingpracticedinPortugalhasnotinvolvedthe popu-lationinanyway,notevenatthebasiclevelofpublicdebate. Onlysporadiccases,suchastheclosureofparticularsupport servicesormaternityunitswhichweregivenfullmedia cov-erage,haverecentlysparkedsomeresistanceonthepartof publicopinion.

There is verylittle information availableabout the pre-ferences of the Portuguese population on matters relating tohealthservices.Forarevision,seeMossialos,27_Pintoand

explicit rationing isnot approached inthese studies, with theexceptionoftheworkdonebyPintoandAragão28_under

anEuropeanproject,whereasurveywascarriedoutwitha representative sampleofthe population on issuessuch as transparencyandtheframeworkforprioritisationdecisions. Regardingtransparency,thecitizens werequestionedabout theusefulness ofapublicdebate onhealth carerationing. Themajority(71.6%)ofintervieweesrespondedaffirmatively. Concerningtheframeworkthatshouldupholdtherationing, theintervieweesweregiventhreeoptionstochoosefrom.The mostpopularoptionwasthepersonaldecisionofthedoctors (34.1%),followedbythepoliticaldecision(29.5%)and,finally, the relationbetween the costofthe care and the medical benefits(29.3%).IncomparisontoPintoandAragão’ssurvey, our study introduces a wider scope in terms of decision-makingauthoritiesandthelevelofsocialactors’intervention and, furthermore, tests for coherence in the respondents’ choices.

Methodology

Thisstudywasorganisedaccordingtofourmainobjectives: firstly,tocollectevidenceoncitizen’sdesiretohaveamore active role in questions relating to rationing; secondly, to examinewhethercitizensinPortugalconformwithfindings ininternationalstudiesreportingdoctorstobethebestagents formakingprioritisationdecisions;thirdly,tounderstandthe determinantsofthis choice;andfinally,tocollect evidence onpopularacceptanceofeconomicevaluationcriteriaasa frameworkforprioritysetting.

Aquestionnairewasconductedina controlled environ-mentwithasampleof442collegestudents(arguably,future opinionleaders)frompublicandprivateinstitutionslocated in the north and the centre of the country. The sample includedstudentsfrom differentprogrammes,namely Eco-nomics,Management,Psychology,Law,MedicineandNursing. AlthoughthisisnotarepresentativesampleofthePortuguese population in general, we believe that students’ attitudes canbecautiously(becausetheylackprofessionalexperience) takenasanindicatoroftheattitudes ofthecorresponding professionals.Thisstudyhastheadvantageofallowingthe comparisonofgroupsthat,althoughofthesameageandwith thesamelevelofeducation,fallintodifferentscientificfields. Todatenootherstudyhascomparedtheopinionofsomany differentgroups.Thestudieshavelimitedtheirscopeto com-paringtheopinionsofdoctorsandthepopulation,30 _orthe

attitudesofdifferentgroupsofpoliticians.31

Thequestionnaire was designed toinclude three ques-tions which have been properly justified in international studies.14,32_{AnandandWailoo}32_{testedtherobustnessofthe}

theoryofnon-consequentialsocialchoice,asanalternative approachtoeconomicefficiency,usinganon-representative sampleofthepopulationinLeicester(UnitedKingdom).There aretwoquestionsinthisquestionnairethatdeserveparticular attentionhere.Inoneofthequestions,theauthors’purpose wastoevaluatetherelevanceofhealthauthoritiesadoptinga processofpublicconsultationtodeterminehealthcare plan-ning.Theanswersobtainedsuggestageneralsupportforthis consultancyprocess.Intheotherquestion,theauthorsaimed

tofindoutwhichopinionshouldprevailinthecaseof dis-agreementbetweenthedoctorsand thegeneralpopulation about thefinancing ofacertain healthprogramme/service. Theauthorsrecreatedascenarioinwhichthepublic finan-cingofaspecifictreatmenthadbeenapprovedbyreferendum. Thedoctors,however,foundthatthelimitedhealthgains (effi-ciency)didnotjustifythechannellingofresourcesinto the provisionofthisparticularservice.Theresultscorroborated the authors’hypothesis byindicatingthat the population’s opinionispreferredby48%oftheintervieweesagainstonly 33%whopreferthecriteriaofmaximisationofhealthgains.

MossialosandKing14_{discussthequestionsraisedin}

rela-tion to public involvement in prioritisation decisions, and analyse data collected about the attitude of the citizens towardsrationingusingtheEurobarometern◦49.33The Euro-barometer questionnaire included specific questions about rationing,andwas conductedusingrepresentativesamples fromsixEUcountries(Germany,France,Italy,Holland,Great BritainandSweden).Theauthorsusedthedatatocomparethe attitudesofthecitizensfromthesesixcountries.Thequestion inthisEurobarometerquestionnairethatisofinteresttothe purposesofourstudyaimedtofindoutwhichagentthe soci-etieswouldnominatetomakeprioritisationdecisions.Froma listoffivepotentialactors(doctors,population,nurses, hospi-talmanagersandpoliticians),thedoctorsweretheconsistent choiceinthesecountries.

Inourstudy,thesethreequestionsareusedtogetherinone questionnaire.Thesimultaneoususeofthesethreequestions allows anidentification of the respondents’ understanding ofwhatconstitutesanadequatelevelofpublicinvolvement aswellastheirsupportfortheresultsofaneconomic eval-uation. Our first question aims to find out if the students thinkthatthepopulationshouldbeinvolvedintheprocess ofhealth carerationing.The answer tothis question does notallowanassessmentoftheextentofpublicinvolvement. Thus,oursecondquestionaimstodeterminetherespondents’ opiniononwhoshouldbethedecision-makingauthorityin healthcareprioritisation.Givenalistofpotentialsocialactors (people ingeneral, doctors,nurses, hospitalmanagers and politicians),therespondentsarequestionedaboutwhothey think should beresponsibleforfixing limitsinhealthcare provision.ContrarytotheEurobarometerquestionnaire,33_we

deliberatelyoptedtodenytherespondentsthepossibilityof giving multiple responses, forcing them to state the actor theyconsideredthemostimportantfromamongthedifferent groups.

The responses obtained to these two questions do not allowtheidentificationoftheprinciplesguidingthe respon-dents’ choices. That is, their opinions about whether or not the public should be involved in priority setting, and who should be the actual decision makers, do not allow the identification of whether respondents’ are indifferent tothe criteriausedbythe chosendecision makertomake prioritisation decisions. The addition of a third question in this questionnaireexploring thepotential conflictbetween popularopinionanddoctors’opinionbasedontheprinciple ofhealthgainmaximisationallowssuchidentification, shed-dinglightonwhetherthepreferencesfordoctorsasdecision makersreportedinpreviousstudiesismaintainedevenwhen doctorsadopteconomiccriteria.

Table1–Surveyquestionsandresultsbycollegedegree.

Questions Econo(%) Manag(%) Law(%) Psycol(%) Medic(%) Nurse(%) Total

Q1.Somepeoplearguethathealthauthoritiesshouldconductconsultationexercises(publicmeetings,askinggroupsmadeupfromthepublic) todeterminewhathealthcaretreatmentsareprovided.Doyouagree?

•Agree 74.29 78.64 82.50 92.73 68.00 96.83 80.50

•Disagree 22.86 16.50 15.00 1.82 30.67 3.17 16.55

•Neutral 2.86 4.85 2.50 5.45 1.33 0.00 2.95

Q2.Iflimitsneedtobeset,whoshoulddecidewhichtypesoftreatmentaregivenahigherpriority?

•Generalpublic 14.29 18.45 17.50 30.91 6.67 17.46 16.78

•Doctors 63.81 51.46 67.50 65.45 72.00 23.81 57.14

•Nurses 0.00 0.00 0.00 0.00 0.00 0.00 0.00

•Managersofhealthservices 20.95 16.50 10.00 1.82 1.33 3.17 10.66

•Politicians 0.95 3.88 2.50 1.82 0.00 3.17 2.04

•Spontaneousresponse–“multidisciplinary” 0.00 0.00 0.00 0.00 20.00 52.38 10.88

•Don’tknow 0.00 9.71 2.50 0.00 0.00 0.00 2.49

Q3.Ifahealthauthorityconductsapoll,whichshowsthat,themajorityofpeoplethinkthataparticulartreatmentshouldbeprovided,butdoctorsargue thatitisrarelysuccessfulandshouldnotbeprovided,whattoyouthingshouldhappen?

•Thetreatmentshouldbeprovided 18.10 38.83 35.00 45.45 6.67 25.81 27.05 •Thetreatmentshouldnotbeprovided 72.38 52.43 57.50 34.55 89.33 58.06 62.50

•Don’tknow 9.52 8.74 7.50 20.00 4.00 16.13 10.45

N 105 103 40 55 75 63 441

Results

Ouranalysisofthedatafocuses ontheeffects ofdifferent academictrainingonrespondents’attitudes,andisorganised byexamininginorder:(A)opinionsconcerningpublic involve-mentintheprocessofprioritysetting,(B)opinionsconcerning theprioritisation decision-making agents,and (C)opinions concerningthedecision-criteriaormodeofprioritysetting.

Publicinvolvement

Table1presents the questions posedinthe questionnaire, andthemainresults.Irrespectiveoftheiracademictraining, themajorityoftherespondentsarefavourabletotheideaof publicinvolvementintheprocessofprioritysetting. Nonethe-less,thefuturenursesshowedthemselvestobethestrongest defendersofpublicparticipation,whilethemedicalstudents werethestrongestopponents(30.7%).

TheapplicationofthePearson’s2_{testshowsthatthereis}

asignificant statisticalassociation betweenthedistribution ofanswers tothe first question and students’ college pro-gramme(2

(10)=37.554;p-value<0.001;allthePearson’s2test

resultsarecorroboratedbyFisher’sexacttest).Thiseffectis supportedbytheestimationresultsofabinarylogitmodel, inwhichthedependentvariabletakesthevalueofoneifthe respondentagreeswithpublicconsultationandthevalueof zerootherwise.Becausecollegestudentsaredifferent(despite, ingeneral,notbeingverydifferentintermsofage,income brackets,orlifeexperiences),inadditiontodummyvariables identifyingstudents’academictraining (ourfocusvariables) weincludeinthemodelascontrolvariablessocio-demographic characteristics,healthconditionsand habits,politicalparty andreligiousaffiliation,allofwhichmayalsoimpactstudents’ opinionsand,therefore,confoundtheeffectsofthe respon-dents’collegeprogramme.Table2showsthedefinitionand thedescriptivestatisticsofthevariablesusedintheanalysis.

Table3showsthemarginaleffectsoftheselectedvariables ontheprobabilityofagreementwithpublicconsultationinthe processofprioritysetting.Theresultsindicatethatstudents of Economics and Management donot differentiate them-selvesfromLawstudents(theomittedgroup).Thestudents ofPsychologyandNursinghaveahigherandstatistically sig-nificantprobabilityofagreeingwithpublicconsultationthan thestudentsofLaw,ataround12and10percentagepoints, respectively.Aspreviouslysuggested,Medicinestudentsshow alowerprobabilityofagreementthanLawstudents,byabout 14 percentagepoints (unilateral p-value isabout 5%).This resistancetothepublicinvolvementintheprocessofpriority settingonthepartofthemedicalstudentsseemsto corrobo-ratethosewhodefendthatthereisaconflictbetweenmedical paternalismandsocialparticipation.9

Decision-makers

Concerning the second question in the questionnaire, the majority of respondents (57%) believe that doctors should be the main agents for healthcareprioritisation decisions (Table 1). The results also seem to indicate that society doesnottrustpoliticianstomakethosedecisions.Afterthe doctors,therespondentselectedthegeneralpublic(17%)as thedecision-makingagent,albeitatasignificantlydistance fromthe doctors(thetestforequalityofproportionsyields astatisticz=−12.416withap-value<0.001).Thepreferences revealedbyoursampleare,ingeneral,consistentwiththose obtained byMossialosand King14 _{and Pinto and Aragão.}28

Althoughmultipleanswerswerenotpermittedinourstudy, 10.9%ofourintervieweesrespondedspontaneouslythatthe prioritisationdecisionsshouldbemadebyamultidisciplinary team.Thenursingstudents(52.4%)andthemedicalstudents (20%)werealoneinoptingtogivethisspontaneousanswer.

Table4presentsthe marginaleffectsofthe explanatory variables on the probability of selecting each one of the alternatives considered.As would be expected, the results

Table2–Definitionofvariablesanddescriptivestatisticsforthesample.

Variables Description Mean(sd)

Law Dummyvariableequalto1iflawstudent,0otherwise 0.09 Economics Dummyvariableequalto1ifeconomicsstudent,0otherwise 0.24 Management Dummyvariableequalto1ifmanagementstudent,0otherwise 0.24 Psychology Dummyvariableequalto1ifpsychologystudent,0otherwise 0.12 Medicine Dummyvariableequalto1ifmedicinestudent,0otherwise 0.17 Nursing Dummyvariableequalto1ifnursingstudent,0otherwise 0.14 Male Dummyvariableequalto1ifmale,0otherwise 0.43

Age Ageinyears 24.30(7.26)

Single Dummyvariableequalto1ifsingle,0otherwise 0.85 Nfamily Numberofpeopleintheindividual’shousehold 3.58(1.05) Inc1 Dummyvariableequalto1ifhouseholdincomegroupoftheindividualisbelowthesampleaverage,0otherwise 0.50 Inc2 Dummyvariableequalto1ifhouseholdincomegroupoftheindividualisequaltothesampleaverage,

0otherwise

0.13 Inc3 Dummyvariableequalto1ifhouseholdincomegroupoftheindividualisabovethesampleaverage,0otherwise 0.37 Insurance Dummyvariableequalto1iftheindividualhasprivatehealthinsurance,0otherwise 0.37 Smoker Dummyvariableequalto1iftheindividualcurrentlysmokes,0otherwise 0.33 Ncigs Typicalnumberofcigarettestheindividualsmokesperday 2.96(6.06) Drinker Dummyvariableequalto1iftheindividualcurrentlydrinksalcoholicbeverages,0otherwise 0.70 Chronic Dummyvariableequalto1iftheindividualreportssufferingfromachronicdisease,0otherwise 0.10 Severe Dummyvariableequalto1iftheindividualreportshavingsuffered(oranyoneinhis/herhousehold)froma

severedisease,0otherwise

0.35 Religion Dummyvariableequalto1iftheindividualholdsreligiousviews,0otherwise 0.78 CP Dummyvariableequalto1iftheindividualfavoursthecommunistparty,0otherwise 0.02 LB Dummyvariableequalto1iftheindividualfavourstheleft-blocparty,0otherwise 0.05 PP Dummyvariableequalto1iftheindividualfavoursthepeople’sparty,0otherwise 0.03 SDP Dummyvariableequalto1iftheindividualfavoursthesocial-democraticparty,0otherwise 0.24 SP Dummyvariableequalto1iftheindividualfavoursthesocialistparty,0otherwise 0.24 OtherP Dummyvariableequalto1iftheindividualfavoursotherparty,0otherwise 0.03 NoP Dummyvariableequalto1iftheindividualdoesnotfavouranypoliticalparty,0otherwise 0.39

Table3–Binomiallogitestimatesofprobabilityofagreeingwithpublicconsultation.

Variable Estimate SE p-value 95%confidenceintervals

Focusvariables: Economics −0.032 0.060 0.589 −0.150 0.085 Management 0.012 0.055 0.827 −0.095 0.119 Psychology 0.121 0.031 0.000 0.061 0.181 Medicine −0.139 0.084 0.099 −0.305 0.026 Nursing 0.097 0.038 0.011 0.022 0.173 Controlvariables: Male −0.114 0.034 0.001 −0.181 −0.047 Age 0.003 0.004 0.403 −0.004 0.011 Single 0.281 0.163 0.086 −0.040 0.601 Nfamily 0.014 0.015 0.359 −0.016 0.043 Inc2 −0.046 0.059 0.429 −0.161 0.068 Inc3 −0.081 0.039 0.038 −0.158 −0.004 Insurance 0.057 0.029 0.044 0.002 0.113 Smoker −0.059 0.047 0.211 −0.151 0.033 Ncigs 0.003 0.003 0.431 −0.004 0.009 Drinker 0.055 0.036 0.135 −0.017 0.126 Chronic 0.041 0.041 0.323 −0.040 0.122 Severe −0.033 0.031 0.277 −0.094 0.027 Religion 0.039 0.038 0.307 −0.036 0.114 LB −0.940 0.009 0.000 −0.958 −0.922 PP −0.920 0.012 0.000 −0.943 −0.896 SDP −0.994 0.001 0.000 −0.996 −0.991 SP −0.993 0.001 0.000 −0.996 −0.991 OtherP −0.912 0.013 0.000 −0.937 −0.888 NoP −0.995 0.002 0.000 −0.999 −0.991

Note:N=433responses;Log-pseudolikelihoodvalueis−173.82;Waldtestforthenullhypothesisthatallcoefficientsarezerohasa2_valueof

Table4–Multinomiallogitestimates–Q2.

Variable Generalpublic Doctors Others/don’tknow

Estimate SE Estimate SE Estimate SE

Focusvariables: Q1-Disagree −0.207** _{0.032 0.016 0.242 0.191 0.246} Q1-Agree −0.002 0.016 −0.159 0.135 0.161 0.136 Economics −0.004 0.010 −0.081 0.117 0.084 0.117 Management 0.003 0.011 −0.280** _{0.129 0.277}** _0.131 Psychology 0.020 0.020 0.174** _{0.089 −0.194}** _0.087 Medicine −0.014** _{0.007 −0.066 0.121 0.080 0.122} Nursing −0.003 0.010 −0.541** _{0.110 0.544}** _0.113 Controlvariables: Male 0.005 0.007 0.046 0.057 −0.051 0.056 Age 0.001 0.001 −0.004 0.006 0.004 0.006 Single 0.011 0.008 −0.230** _{0.075 0.219}** _0.074 Nfamily 0.003 0.003 −0.025 0.026 0.022 0.026 Inc2 −0.007 0.008 0.215** _{0.048 −0.208}** _0.047 Inc3 0.004 0.007 0.004 0.061 −0.008 0.060 Insurance −0.012** _{0.006 −0.035 0.058 0.047 0.058} Smoker 0.008 0.010 −0.150* _{0.084 0.142}* _0.084 Ncigs −0.001 0.001 −0.004 0.007 0.005 0.007 Drinker 0.002 0.006 −0.085 0.055 0.083 0.054 Chronic 0.001 0.010 −0.043 0.085 0.042 0.085 Severe 0.002 0.006 0.062 0.052 −0.064 0.051 Religion 0.006 0.006 0.004 0.067 −0.010 0.067 LB 0.023 0.044 0.091 0.179 −0.113 0.169 PP 0.024 0.051 0.206** _{0.089 −0.230}** _0.061 SDP 0.008 0.024 0.095 0.195 −0.103 0.191 SP 0.023 0.032 0.023 0.216 −0.047 0.210 OtherP 0.040 0.066 −0.162 0.311 0.122 0.316 NoP 0.013 0.022 0.098 0.211 −0.111 0.207

Note:N=432responses;Log-pseudolikelihoodvalueis−343.38;Waldtestforthenullhypothesisthatallcoefficientsarezerohasa2_valueof

6126.83with52df,implyingap-valuelessthan0.001.HausmanspecificationtestfortheIIAassumptionhas2_{valueof1.14with17df,yielding}

noevidencethattheIIAassumptionhasbeenviolated.

∗ _{p-value≤.10(two-tailedtest).} ∗∗ _{p-value≤.05(two-tailedtest).}

showthattheindividualswhodisagreewithpublic consul-tations (Q1-Disagree) are less likely to select the public as thedecision-makerinprioritysettingthanthoseindividuals who remain neutralconcerning publicconsultations. Like-wise,Medicalstudentsarelesslikelytoselectthepublicas thedecision-makerinprioritysettingthanLawstudents.The results concerning the choice ofdoctors reveal that Man-agementandNursingstudentsexhibitalowerprobabilityof choosingthedoctorsasthedecision-makersthan Law stu-dents.Inbothcases,however,thechoicedoesnotfallonthe publicasthedecision-makerbutonotherprofessionals. Inter-estingly,Psychologystudentshave,ceterisparibus,ahigher probabilityofchoosingthedoctorsasthedecision-makersin prioritysetting.Thus,althoughthisgroupistheonethatmost favoursthepublicconsultation,theydonotselectthepublic, butthedoctors,asthedecision-makers,revealingthatastrong preferenceforthepublicinvolvementinthepriorityprocess doesnottranslateintoapreferenceforitsactualparticipative roleintheprocess.

Modeofprioritisation

Ananalysisoftheresponsestothethirdquestionallowsusto concludethat,inthecaseofconflict,therespondentsselect

theopinionofthedoctors,reinforcingtheprevious conclu-sions.TheseresultscontrastwiththefindingsofAnandand Wailoo.32_{Intheirwork,respondentsrevealamuchhigher}

ten-dencytodisagreewiththehealthmaximisationprincipleas defendedbydoctors.Table5presentsthemarginaleffectsof theselectedvariablesontheprobabilityoffavouringthe opin-ionofthedoctors.Theresultsindicatethat,comparedtothe individualswhoselected‘OtherProfessionals’inQuestion2or declaredthemselvesneutral,thoseindividualswhoselected the generalpublicasthedecision-maker inprioritysetting (Q2-Public)are33.5percentagepointslesslikelytofavourthe opinionofthedoctorsinthecaseofconflictwithpublic opin-ion. Ceterisparibus,the Psychologystudentsalsoexhibita 27percentagepoint’slowerprobabilityofagreeingwiththe opinionofthedoctorsthantheLawstudents,whileMedicine studentsexhibita29.5percentagepoint’shigherprobability ofagreeingwiththeopinionofthedoctorsthantheLaw stu-dents.

Oneimportantresultfromthisanalysisisthelackofa sta-tistically significanteffect ofthevariable Q2-Doctorson the probability of agreeing with the opinion of the doctors. It would beexpectedthat,irrespective ofthe academic back-ground,thoseindividualswhoselectthedoctors(public)as thedecision-makerinprioritysettingwouldalsofavourthe

Table5–Binomiallogitestimatesofprobabilityoffavouringthedoctors’opinion.

Variable Estimate SE p-value 95%confidenceintervals

Focusvariables: Q2-Public −0.335 0.088 0.000 −0.508 −0.162 Q2-Doctors 4×10−4 0.065 0.995 −0.127 0.128 Economics 0.124 0.087 0.152 −0.046 0.293 Management −0.105 0.104 0.310 −0.309 0.098 Psychology −0.267 0.135 0.048 −0.531 −0.003 Medicine 0.295 0.065 0.000 0.168 0.422 Nursing 0.058 0.099 0.562 −0.137 0.252 Controlvariables: Male 0.069 0.060 0.255 −0.050 0.187 Age 0.002 0.006 0.728 −0.010 0.014 Single 0.193 0.120 0.107 −0.042 0.428 Nfamily −0.045 0.027 0.088 −0.098 0.007 Inc2 0.187 0.061 0.002 0.067 0.306 Inc3 0.102 0.062 0.101 −0.020 0.223 Insurance −0.080 0.061 0.187 −0.199 0.039 Smoker −0.032 0.085 0.704 −0.199 0.134 Ncigs 0.012 0.006 0.044 0.000 0.024 Drinker 0.115 0.060 0.057 −0.003 0.233 Chronic 0.190 0.065 0.004 0.062 0.319 Severe −0.019 0.056 0.737 −0.129 0.092 Religion 0.014 0.064 0.831 −0.112 0.140 LB −0.514 0.138 0.000 −0.784 −0.244 PP −0.347 0.222 0.117 −0.781 0.087 SDP −0.478 0.175 0.006 −0.821 −0.135 SP −0.480 0.173 0.005 −0.819 −0.142 NoP −0.466 0.170 0.006 −0.799 −0.132

Note:N=420responses;Log-pseudolikelihoodvalueis−228.07;Waldtestforthenullhypothesisthatallcoefficientsarezerohasa2_value

of73.76with25df,implyingap-valuelessthan0.001.ExplanatoryvariableOtherPwasdroppedduetoperfectpredictionofthedependent variable.

Table6–Binomiallogitestimatesofprobabilityofdisagreeingwithadoptedcriteria.

Variable Model1 Model2

Disagreewithdoctors Disagreewithpublic

Estimate SE p-value 95%CI Estimate SE p-value 95%CI

Focusvariables: Economics −0.081 0.082 0.326 −0.242 0.080 −0.638 0.161 0.000 −0.953 −0.323 Management 0.043 0.102 0.673 −0.157 0.243 −0.606 0.187 0.001 −0.973 −0.239 Psychology 0.359 0.163 0.028 0.040 0.679 −0.493 0.231 0.033 −0.945 −0.040 Medicine −0.263 0.061 0.000 −0.382 −0.144 −0.267 0.305 0.381 −0.864 0.330 Nursing −0.125 0.087 0.150 −0.294 0.045 −0.369 0.257 0.151 −0.873 0.135 Controlvariables: Male −0.041 0.068 0.546 −0.174 0.092 0.162 0.235 0.491 −0.299 0.622 Age −0.004 0.007 0.574 −0.017 0.009 −0.056 0.019 0.003 −0.092 −0.019 Single −0.182 0.148 0.218 −0.472 0.107 0.303 0.303 0.316 −0.290 0.897 Nfamily 0.052 0.032 0.108 −0.011 0.114 −0.272 0.100 0.007 −0.469 −0.076 Inc2 −0.114 0.064 0.072 −0.239 0.010 0.454 0.131 0.001 0.198 0.710 Inc3 0.007 0.072 0.924 −0.134 0.148 0.427 0.184 0.020 0.067 0.786 Insurance 0.071 0.067 0.289 −0.060 0.203 −0.332 0.203 0.102 −0.730 0.066 Smoker 0.039 0.100 0.693 −0.157 0.236 0.215 0.291 0.460 −0.355 0.785 Ncigs −0.012 0.008 0.117 −0.028 0.003 0.063 0.022 0.004 0.021 0.106 Drinker −0.087 0.075 0.250 −0.235 0.061 0.670 0.114 0.000 0.447 0.894 Chronic −0.197 0.057 0.001 −0.309 −0.084 −0.469 0.152 0.002 −0.767 −0.171 Severe −0.028 0.065 0.666 −0.154 0.099 0.189 0.217 0.382 −0.235 0.614 Religion 0.042 0.068 0.536 −0.091 0.176 0.005 0.265 0.984 −0.515 0.525 LB 0.882 0.021 0.000 0.840 0.923 0.695 0.079 0.000 0.541 0.850 PP 0.843 0.027 0.000 0.791 0.896 0.570 0.098 0.000 0.377 0.762 SDP 0.995 0.002 0.000 0.992 0.998 0.873 0.051 0.000 0.773 0.972 SP 0.987 0.003 0.000 0.982 0.993 0.965 0.022 0.000 0.922 1.007 NoP 0.999 0.000 0.000 0.998 1.000 0.983 0.013 0.000 0.957 1.008

Note:N=240(70)responsesformodel1(model2);Log-pseudolikelihoodvalueis−120.22(−28.50)formodel1(model2);Waldtestforthenull hypothesisthatallcoefficientsarezerohasa2_{valueof582.70(225.44)with23df,implyingap-valuelessthan0.001formodel1(model2).}

opinionofthedoctors(public)inthecaseofconflictinthe adoptedprioritisation criteria. Wedid notexplorethe rea-sonsbehindthisapparent contradiction.Onehypothesis is thatindividualsmayfearthatinthefuturesometreatments maybedeniedonthebasisofeconomiccriteria,butan inves-tigationofthesereasonsmustbeleftforfuturework.Atany rate,thisresultsuggeststhatthedominantchoicefordoctors asthemaindecision-makersinprioritysettingobservedin internationalsamplesmaynotbeindependentofthedecision criteriaadoptedbythemintheallocationofresources.

Asanattempttobetteridentifythegroupsthatexhibitthis behaviour,Table6showsthefactorsthatinfluencethe proba-bilityofdisagreeingwiththecriteriaadoptedbytheselected actorsforprioritysetting.Model1isestimatedusingthe sub-sampleofindividualsthatselectedthedoctorsasthemain decision-makersinprioritysettingandModel2isestimated usingthesubsampleofindividualsthatselectedthegeneral publicasthemaindecision-maker.Concerningthe individ-ualswhoselectedthegeneralpublicasthedecision-makers inprioritysetting,itisfoundthatthestudentsofEconomics, ManagementandPsychologyhavealowerprobabilityof dis-agreeingwithpublicopinioninthecaseofconflictwiththe “maximizing”criteriaadoptedbythedoctors.Importantly,the resultsofmodel1indicatethatitisthePsychologystudents (Medicine)who,havingselectedthedoctorsasthe decision-makers,haveahigher(lower)probabilityofdisagreeingwith thecriteriaadoptedbythedoctorsinthesedecisions.Taken together,theseresults,particularlyinthecaseofthe Psychol-ogystudents, revealthatastrongpreferencefordoctorsas theprioritisationdecision-makersisnotameretranslationof a“peaceofmind”argument.

Conclusion

Healthcarerationingisacomplex andcontroversialissue. Recentdiscussionsonthethemehavefocusedonwhether rationing,whichoccursinvirtuallyallpublichealthsystems, shouldassumeanexplicitcharacterandwhatlevelofpublic involvementtheprocessshouldhave.

Thisstudyattemptstocontributetothedebateonpublic participationintheallocationoflimitedhealthcareresources inPortugal, wherethere is anincreasingly urgent need to establish limits on what is publicly financed. The results obtainedinthisstudy indicatethatthe Portuguese respon-dents are calling for public involvement in the process of priority setting. However, and in accordance with various internationalstudies,theresultsalsosuggestthatthe domi-nantpreferenceistogivethepublicanadvisoryroleandnota participativerole,withprioritisationdecisionsbeing primar-ilyconferredonthedoctors.Oneimportantresultinourstudy isthefindingthatthePortuguesedoctors(takingmedical stu-dents’opinionasindicators)donotrejecttheresponsibilityof prioritysettingdecisions.UsingthetaxonomyofObermann andBuck,26 _{the overall resultssuggestthat the Portuguese}

wouldoptforan“open”processofprioritysetting inwhat concernspublicinvolvement.

Inrelationtothesecondaspectofthistaxonomy,i.e.the

modeofprioritisation, contrary to whathas been observed invariousinternationalstudies,thePortugueserespondents

inourstudyrevealedaclearpreferenceforthehealthgains criteria adopted by the doctors over the criteria defended bythepublic.TheresultsthereforesuggestthatPortuguese choosea“systematic”processforthemodeofprioritysetting. Therobustnessofthisresultismeasuredinourstudybya comparisonbetweenthestatedpreferencesforthe decision-makerand the stated preferencesforthe decision criteria. Ifthechoicefordoctors(orotherprofessionals)as decision-makers is a mere translation of the “utility of ignorance” argument,aconcurrencebetweenthechoiceofthe decision-makerandthecriteria–whatevertheymaybeadoptedbythe decision-maker–shouldbeobserved.Thisconcurrencewas nottotallyobservedinourstudy.Only44%oftherespondents whoselectedthegeneralpublicasthedecision-maker explic-itlyagreedwithitscriteriafortheallocationofresources,and about 70% ofthose who selected the professionals agreed withthecost-effectivenesscriteriaadoptedbythedoctorsin thegivenscenario.Itwasfurtherverifiedthatitisthefuture doctorswhoshowedahigherprobabilityofagreeingwiththe cost-effectiveness criteria. These respondents also showed a lower probability of disagreeing with these criteria than all the other respondentswho selected the doctorsas the prioritisationdecision-makingagents.

Thus, although a total adherence to cost-effectiveness criteriaisnotobserved,theresultsobtainedinthis question-naire indicate that,incomplete opposition tothe “stateof theart”inPortugalinmattersofhealthcarerationing (char-acterisedas“hiddenandnon-systematic”),theprocessthat emergesasthe“bestsolution”forthecountryisthe“openand systematic”rationingcharacterisedbyObermannandBuck26

as:(a)thepubliccallsfor“open”rationing,and(b)requires rigour inits formulation,compriseseconomic criteria,it is acceptedbythedoctors,andconformswiththepreferences ofthemajorityofthepopulation.Naturally,thisresultmust bereadwithinthecontextofthelimitationsofthesample used,butitstillconstitutesanindicationofanexisting con-tradiction inPortugalbetweenthe politicaloption thathas beenadoptedinrationingandtheaspirationsofthe popula-tion,suggestinganurgentneedforanopendebateandalarge andrepresentativeconsultationofthePortuguesepopulation onthesematters.

Funding

ThisresearchwaspartiallyfundedbyFundac¸ãoparaa Ciên-ciaeTecnologia(FCT) throughthe AppliedMicroeconomics ResearchUnit (NIMA)strategic projectwithreference PEst-OE/EGE/UI3181/2011.

Conflicts

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

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