Decision-making procedures and distributive effects. The allocation of health care in OECD-countries

Funded by the VolkswagenStiftung through of a Schumpeter-Fellowship for Claudia Landwehr

• Funding period: 2008-2014
• Principal investigator: Univ.-Prof. Dr. Claudia Landwehr
• Team members: Katharina Böhm (2009-2014), Matthis Mohs (2013), Dorothea Klinnert (2014)


Which medical services should a health care system that is based on collective solidarity provide? How can health expenditure be limited equitably and reasonably? Who can and who should take complex decisions on whether or not to cover specific medical services? These questions challenge developed democracies. In recent years, almost all OECD-countries have begun to limit the scope of services or at least have tried to prevent the expansion of lists of services covered. A comparative evaluation and prioritization of different services is necessary for this form of rationing of health services, which requires communication about the principles and criteria of just distribution.

Prioritization and rationing of medical service
Prioritization and rationing of medical services involve difficult decisions which require extensive expert knowledge, touch on morally thorny issues and put a strain on decision-makers due to the sheer number of decisions over individual services that is necessary. Since the majoritarian democratic institutions of parliament and government seem to be overstrained with the number and complexity of the necessary decisions, new decision-making procedures have been created, and in most cases, the comparative evaluation of medical services was delegated to more or less independent bodies. The assumption behind the research project was that the institutional design of these bodies – their specific arrangement concerning members, competences, rules of decision-making, publicity and other characteristics – co-determines the resulting decisions on financing and distribution: Procedures are never completely neutral, they always institutionalize and embody specific notions of  distributive justice and advance some interests more than others.

The project thus focussed on the connections between the institutional design and characteristics of decision-making procedures of appointed bodies, the application of descributive principles in decision-making and the resulting allocation decisions. Methodologically, both quantitative and qualitative analyses were carried out and systematically combined. The project was concluded with the organization of a citizen conference on institutional design in health care priority-setting.

By exploring the relationship between decision-making procedures and distributive decisions, the project has made contributions to theories of democracy and institutional design. Its findings also deliver important information for political decisions on institutional design: A society wanting to achieve certain distributive results must know which decision-making procedures will promote them.

By way of a quantitative analysis of decisions in 25 countries, we could show that the institutional design of the health care system, but also of specific decision-making procedures, affects distributive decisions (Böhm, Landwehr and Steiner 2014). Moreover, we demonstrated that governments delegating competences for allocation decisions are aware of these effects and engage in strategic institutional design (Landwehr and Böhm 2015). On the basis of these results, normative arguments on democratic institutional design and the legitimacy of non-majoritarian agencies were developed (Landwehr 2013, 2015), showing in particular that institutional design and distributive decisions must be coherent with societal norms and values (Landwehr & Klinnert 2015). Further findings concern the Europeanziation of health care coverage decisions (Böhm & Landwehr 2014) and the development of a new typology of health care systems (Böhm, Schmidt, Götze, Landwehr & Rothgang 2013).

More information can be found on the project homepage
Database on health systems and procedures of decision-making in OECD-countries