520355
research-article2014
SJP0010.1177/1403494813520355Priority setting in Swedish health careP. Rosén et al.
Scandinavian Journal of Public Health, 2014; 42: 227–234
Original Article
Priority setting in Swedish health care: Are the politicians ready?
Per Rosén1, Jenny De Fine Licht2 & Henrik Ohlsson3 1Nordic
School of Public Health NHV, Gothenburg, Sweden, 2Department of Political Science, University of Gothenburg, Sweden, and 3Center for Primary Health Care, Lund University, Clinical Research Centre (CRC) Malmö, Sweden
Abstract Background: Resource allocation in public health care principally involves politicians, administrators, and physicians. They all have their different roles, agendas and ambitions when it comes to how public health care resources should be spent. Previous studies on attitudes among health-care stakeholders have mainly focused on views and preferences among clinical decision-makers, while less attention has been paid to the views of health care politicians. Aim: The study aimed to investigate if the health care politicians’ views on priority setting and decision-making in health care differed from other stakeholder groups. Method: The study was based on a questionnaire conducted among health care politicians, administrators, and physicians in four county councils in Southern Sweden. Results: The findings show significant differences between the politicians and the other two groups in their views on health-care resources, financing, priority setting and decision-making. Conclusions: The findings could, at least partly, be explained by the special situation it means for the politicians to be forced to be re-elected every fourth year to stay in power. Key Words: Accountability, decision-making, governance, health-care politicians, priority setting, resource allocation
Introduction In most countries, people are living longer than ever before, the general health of the population is strong, and public health care is being offered to more people. Expectations on health care are growing, mainly because new medical advances offer improved therapeutic and diagnostic options, but also due to the ageing of the population [1]. As public health-care resources are limited, the pressure on the health-care system has led to a growing welfare dilemma. Attempts have been made to implement more explicit priorities and to make reasonable choices among different needs/treatment alternatives [2]. Some attention has been paid to the Swedish experiences because of the marked attempts to facilitate transparent resource allocation decisions at both the clinical and political levels; that is, vertical and horizontal prioritizations, respectively. The Swedish health care system is mainly steered by 21 county councils, which are political bodies with their own
taxation levies. Some of these county councils have had experience with explicit priority setting in recent years [3]. At the national level, the Parliament has appointed one commission (1995) and one delegation (2000) for priority setting; there are also a number of public boards and agencies handling matters of priority setting and a special National Centre for Priority Setting in Health Care. The Swedish Parliament has established an ethical platform comprised of three basic priority-setting principles in order to set guidelines for resource allocation: Human dignity, need and solidarity, and costeffectiveness. The principle of “human dignity” means that all human beings have equal rights regardless of their social status. The principle of “need and solidarity” means that those in greatest need have precedence for medical care. Finally, the principle of “cost-effectiveness” means that when a choice has to be made between different health care options, there should be a reasonable relationship
Correspondence: Per Rosén, Nordic School of Public Health NHV, Box 121 33, Göteborg, SE-402 42, Sweden. E-mail: [email protected] (Accepted 17 December 2013) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494813520355
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228 P. Rosén et al. between the costs and the effects measured in terms of improved health and improved quality of life [4]. However, this ethical platform has proven to be too general as a practical guideline, and priority setting has continued to be a somewhat less systematic approach to distributing the available resources between the competing demands in order to fashion an optimal health care system [5].These allocation decisions could be explicit (that is, politically sanctioned) or implicit (that is, hidden in the garden of medical praxis). When medical services are restricted or excluded from the public financing as a consequence of priority setting, it is often called rationing. This could, for example, be based on judgments of health care needs or different treatments’ cost-effectiveness. Fair allocation of care can never imply that everyone is given an equal amount of care, and it is not suffice to say that resources should be allocated according to need, since the needs that must be balanced are often very different. Someone must, in some way, decide which methods and treatments should be publicly available and under what conditions. How should resources be allocated between the medical disciplines? Is it possible to rank different needs in relation to each other? These questions confront members of all the three stakeholder groups and a certain level of “maturity” regarding these issues among the respondents could be expected. Previous studies on attitudes among health care stakeholders have mainly focused on views and preferences among clinical decision-makers, while less attention has been paid to the views of health care politicians. As the politicians are elected by the people, their formal authority legitimizes the decisionmaking process. They also play an important role in representing society’s view in determining choices for the provision of treatment and care. There is a limit to the finances that people are prepared to designate for health care provision if other important needs, such as education, housing, elderly care, etc., also need to be met. It is not only desirable that the politicians articulate and determine what treatments and care should be available; rather, it is necessary because it is, in a way, what people elect them to do [6]. It has been argued that most politicians are in large part motivated by their desire to maximize their prospects for re-election [7], and therefore they want to satisfy the presumed preferences of their voters [8]. Because of the popularity of the welfare state among large segments of the population, caution is advised and the most common strategy is what Kent Weaver characterizes as “The Politics of Blame Avoidance” [7]. In an analysis of cutbacks in thirteen Swedish transfer programs, it was concluded that welfare programs relatively susceptible to opaque
reforms suffered larger cutbacks than other, more transparent, programs [9]. Politicians also tend to avoid alternatives with observable short-term “costs” even if the long-term effects would be more favourable to the voters. When losses are unavoidable, it is also better to offer small losses to everybody, like higher taxes or patient fees, than strongly negative effects to an identifiable group who could have protection from special interest groups and form an attractive target for media exploitation [10]. This is a strong reason for politicians not to engage in open rationing and “retrenchment has become an exercise in blame avoidance rather than credit claiming” [9]. Politicians in general have an intuitive understanding of the fact that people’s attitudes to a certain issue can influence both their disposition toward communicators expressing opinions on that issue and also to other unrelated issues on which these communicators take stands [11]. The political strategy is, therefore, a) to be associated with popular ideas, b) to be detached from unpopular policies, and c) remain mute on issues on which voter opinion is divided [11]. The most common strategy for blame avoidance is to delegate the responsibility to lower organizational levels [12]. The aim of the politicians might not be to control the resource allocation at all, but to simply appear as if they did and thereby gain legitimacy in the eyes of the electors [13]. Methods Our hypothesis was that the politicians try to satisfy the electorates by using a strategy referred to by Weaver as “blame avoidance” [7]. This strategy includes elements of a) avoiding issues of blame-generating potential like priority setting or rationing, b) softening (or obfuscating) their position on these controversial issues, c) delegating hard decisions to someone else, and d) depicting themselves as rather powerless. A questionnaire was constructed to investigate whether answers from the politicians differ from other health care stakeholders in questions on resource allocation and financing from four different aspects: - views on today’s needs and resources - preferences on financing - attitudes on rationing - views on decision-making and power-sharing in setting priorities. If the answers of the politicians differ systematically from those of the physicians and the administrators, the difference could be explained by the “blame-avoidance theory”. The matter is complex,
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Priority setting in Swedish health care 229 though, and many explanations are thinkable. Also the other stakeholders have their different roles and special agendas that might further increase some of the observed differences.
Table I. Study population and response rates.
Politicians Administrators Physicians
n (N)
Response frequency (%)
161 (260) 220 (366) 1,222 (2073)
62 60 59
Sample The analysis is based on the questionnaire conducted among different types of stakeholders in four county councils in southern Sweden. The stakeholders included in the survey were health care politicians, administrators (including senior administrators, primary care managers, and heads of clinics), and physicians (general practitioners and hospital specialists). The physicians were randomly selected from registers containing all primary care physicians and hospital specialists within the four areas. All health-care politicians in the southern region were included. The total sample of administrators within the four geographic areas consisted of individuals who were administrators in the sense that they had budgetary responsibilities. The different administrator categories also shared the following characteristics: They worked closely with practical matters of health care and they were not, like the politicians, at risk of losing their mandate every fourth year. The administrators were in many cases, but not always, physicians themselves. Among the primary care managers, about 50% were nurses and 50% were physicians. As the group of administrators consisted of a mix of clinically- or politically-oriented people, statistically, they constituted a middle group in between the political and the medical fields. The results on a subgroup level are not shown here; they do not contradict the main conclusions but rather underline the main comparison and they are available upon request from the authors. The survey was carried out and coordinated by the authors in 2009. Data from the completed questionnaires were de-identified and controlled for errors, inconsistencies, and internal missing data. The total study population was comprised of 1603 individuals. The overall response rate was 59% (Table I). Heads of clinics at the hospitals had the highest response rate, 72%. The questionnaire only included questions concerning attitudes toward health care financing, rationing and decision-making, and in order to increase the response rate, no background variables such as age or gender were used. The respondents answered anonymously, and two reminders were sent out. Themes Attitudes toward health care priority setting and rationing within different groups of stakeholders were explored by analyzing 11 different questions.
The questions were divided into four subsections in accordance with our defined research questions. The first group of questions dealt with views on the current state of affairs; for example, “Are health care resources sufficient and how efficient could the health care organization become?” The second group of questions concerned issues of financing such as raising taxes or increasing patient fees. The third group of questions focused on supply restrictions and rationings, such as, “Should cost be an issue when choosing between treatment alternatives and are some health care needs too marginal to be covered by public funding?” In the final section of the questionnaire, decisionmaking was addressed, namely, “How big of an influence do different stakeholder groups have today and how big of an influence should different stakeholder groups have on health care resource allocation at a comprehensive level?” Other questions offered choices between political decisions on excluding therapies/diagnoses or physicians practicing stricter inclusion criteria. The last question concerned preferences for explicit priority setting. Most of the questions have been used and validated in earlier studies conducted by the authors as well as other researchers. Analysis Descriptive statistics for the 11 questions, separated according to the different stakeholders, are presented. Chi-square tests (Q1 to Q8) were performed in order to compare the groups of stakeholders within each question. For this test, a significance level of 5% was chosen. Results Healthcare needs and resources Only 10% to 15% of the respondents thought that today’s health care resources were sufficient to meet all health-care needs (Q1). The exceptions were the politicians, among whom almost 25% found that resources were sufficient (p < 0.0001). The politicians also differed in their views on whether public health care could become so efficient that economy measures would not be needed (Q2). Approximately 45% of the politicians agreed to the
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230 P. Rosén et al. statement, in comparison to 28% of the physicians (p < 0.0001). Financing alternatives Respondents also differed in their views on tax increases and additional patient fees. Approximately 50% to 60% of all respondents estimated that public health care requires increased resources (Q3). Some (40%) chose the alternative of keeping taxes at the current level. Only a small percentage of the respondents chose the alternative that health care resources should be decreased. There are significant differences between the answers from the politicians and the other stakeholders (p < 0.0104), and especially between politicians and physicians (p < 0.0001). While 45% to 55% of the administrators and physicians were positive towards increased co-payment in public health care (Q4), only 27% of the politicians sympathized with this measure (p < 0.0001). A high share of respondents answered “Don’t know” to the question. Supply restrictions and rationing In response to whether public health care should always offer the best possible care irrespective of costs (Q5), 54% of the politicians answered “Yes”, compared to only about 20% to 30% of respondents from the other stakeholder groups (p < 0.0001). While 36% of the politicians meant that the general public should always have a right to public health care irrespective of how modest their needs are (Q6), only approximately 20% of the respondents from the other groups answered “Yes” to this question (p < 0.0001).
health care supply or to increase the patient costs of some treatments (p < 0.0001). They would much prefer that the doctors were more rigorous about determining the inclusion criteria for certain treatments. There was also a difference between how the different respondent groups view their own and other stakeholders’ influence on health care resource allocation on a comprehensive level today. The answers were given on a 5-point scale from 1 (No influence at all) to 5 (Very much influence). We report the balance; that is, the percentage of respondents who answered 4 or 5 minus the percentage of respondents who answered 1 or 2. A plus thus indicates that the influence is considered to be larger than the neutral middle point (Table III). The politicians underplayed their own influence, especially compared to how the physicians experienced it, and the physicians seemed dissatisfied with their own roles in the power play (Q9). In response to how big of an influence different stakeholder groups should have on health care resource allocation on a comprehensive level (Q10), as expected, the physicians advocated more influence on their own behalf, as did the politicians, but to a somewhat more modest degree. The last question investigated whether respondents think that citizens’ confidence in health care can be affected if priority setting is open and public (Q11). There seemed to be a clear agreement among all respondents that public legitimacy would benefit from transparent priority-setting decisions. The majority of the respondents (75% to 80%) placed themselves on the positive side of the scale (4 to 5), indicating that open and official reporting of prioritysetting decisions would lead to higher public trust in the health care system.
Decision-making and influence The groups differed in their responses to whether a) politicians make comprehensive decisions to exclude certain therapies or diagnoses from public financing, or b) it is mainly physicians who make rigorous decisions on which medical conditions should give entitlement to public health care, or c) these kinds of measures do not exist (Q7). The politicians were more inclined than the others to think that it is the physicians who make the hard decisions (p < 0.0001). Among the administrators and physicians, 48% and 44%, respectively, chose the third alternative; “None of these decisions are practiced”. When being asked how these decisions should be made (Q8), the politicians were more reluctant than the other stakeholders to the idea that the politicians should take decisions to restrict the publicly financed
Discussion In a previous study, a hypothesis was developed suggesting that important stakeholders in the health care system do not share the same views on resource allocation and financing within the third part financed health care system and that politicians differ the most from the other groups [8]. In this present report, we used a postal questionnaire to examine whether the answers from the health care politicians could be said to illustrate a blame avoidance strategy [14]. Differences in answers between the subgroups could mean that respondents interpret or associate differently, or it could mean that they actually hold different attitudes towards the same attitude object. This validity problem is more or less adhered to all surveys as people never have exactly the same associations
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Priority setting in Swedish health care 231 Table II. Descriptive statistics and Chi-square statistics. Percentages in bold and numbers of responses within brackets. Question
Answer
Politicians
Administrators
Physicians
Chi-square
QI Q2 Q3 Q4 Q5 Q6
Yes No Don’t know Yes No Other Increase Decrease As today Yes No Other Yes No Other Yes No Other
23 (36) 74 (119) 3 (5) 45 (70) 42 (67) 13 (21) 51 (81) 8 (12) 41 (66) 27 (43) 60 (96) 13 (21) 54 (85) 30 (48) 16 (26) 36 (57) 54 (86) 10 (16)
12 (26) 81 (174) 7 (15) 37 (80) 44 (94) 19 (41) 53 (114) 7 (16) 40 (87) 54 (117) 33 (71) 13 (28) 17 (36) 71 (152) 12 (27) 20 (43) 77 (165) 3 (7)
10 (119) 86 (1,039) 4 (53) 28 (330) 51 (601) 21 (246) 62 (731) 4 (52) 34 (407) 44 (523) 41 (496) 15 (178) 30 (357) 54 (652) 16 (195) 23 (276) 71 (854) 6 (79)
26.0 P: < 0.0001 22.8 P: < 0.0001 13.2 P: < 0.0104 33.2 P: < 0.0001 70.7 P: < 0.0001 25.4 P: < 0.0001
(Q1) Do you think today’s health care resources are sufficient to meet all the health care needs? (Q2) Could the public health care become so efficient that economy measures will not be needed? (Q3) Do you think the public health care expenditures should increase, stay at today’s level or decrease? (Q4) Should patients pay higher co-payment in the public health care? (Q5) Should public health care always offer the best possible care, irrespectively of costs? (Q6) Should the general public always have a right to public health care, irrespective of how modest their needs are?
when they hear or read a certain expression. A choice was therefore made to ask questions used in earlier studies and thereby obtain as many options to comparisons as possible. Consistent with the view of the general public [15], most of the different stakeholders raised doubts whether available health care resources were sufficient to meet existing health care needs. The results indicate an general awareness of the conflict between limited resources and an endless growth of medical demand. The politicians, though, were significantly less inclined to raise doubts on supply of resources. They might have been more optimistic about the state of affairs as more of them were convinced that public health care could be delivered in more efficient ways. It could also be a way to deny the significance of an unrewarding issue. Yet another explanation could lie in the role of the health care politician as a financer, negotiating party, and a trustee to defend the functionality of the public health care system. The other stakeholders might answer from another rationality in which it is in their interest to emphasize a lack of resources. More politicians compared to the other stakeholders were reluctant to raise health care taxes, and they differed to an even larger extent from the other stakeholders in their views on increased patient fees, and this is in line with the view of the general public (25%) [15].
Also consistent with prior data [14,16], a larger share of the politicians demonstrated a permissible attitude toward individuals’ right to health care irrespective of how modest patients’ needs are or irrespective of cost, which is in line with the opinion of the general public, but not at all concordant with the views of the other stakeholders. It could be argued that politicians often develop their rationale based on values where equity and general access to health care are goals of specific interest [12]. Administrators are often said to represent an “efficiency perspective”, where special emphasis is placed on cost-effectiveness and budget planning, while the health care personnel are focused on the medical needs of the individual patient [17]. Compared to the answers from other respondents, politicians found their own influence on decisionmaking in the health care sector to be rather weak. Both the administrators and the physicians were regarded as more influential. Almost half of all the respondents thought that neither do the politicians make any “comprehensive decisions to exclude certain therapies or diagnoses from public financing” nor do the physicians make “rigorous decisions on which medical conditions should give entitlement to public health care”. Restrictions seem not to be an issue at all. At the same time, the annual deficits in the region are growing, expressed in one of the
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232 P. Rosén et al. Table III. Descriptive statistics. Percentages in bold and numbers of responses within brackets. Question
Answer
Politicians
Administrators
Physicians
Chi-square
Q7 Q8 Q9 Q10 Q11
a) Politicians b) Physician c) None Don’t know a) Politicians b) Physician c) None Don’t know a) Politicians b) Administrators c) Physicians a) Politicians b) Administrators c) Physicians
13 (20) 45 (70) 26 (41) 16 (26) 27 (41) 49 (75) 15 (23) 9 (14) 44 50 55 46 −41 7 67
14 (30) 32 (68) 48 (101) 6 (13) 52 (107) 35 (74) 9 (18) 4 (8) 64 37 −13 7 −10 38 77
18 (209) 29 (340) 44 (520) 9 (112) 38 (430) 46 (528) 11 (130) 5 (54) 75 57 −52 −22 −65 82 74
36.6 P: < 0.0001
28.9 P: < 0.0001
(Q7) In rationing, which of the following two alternatives is mainly used today: a) Politicians take comprehensive decisions to exclude certain therapies or diagnoses from public financing. b) Physicians make rigorous decisions on which medical conditions should give entitlement to public health care. c) None of these two alternatives. (Q8) In rationing, which of the following two alternatives should mainly be used: a) Politicians take comprehensive decisions to exclude certain therapies or diagnoses from public financing. b) Physicians make rigorous decisions on which medical conditions should give entitlement to public health care. c) None of these two alternatives. (Q9) How big influence do different stakeholders have on health care resource allocation on a comprehensive level today? (Q10) How big influence should different stakeholders have on health care resource allocation on a comprehensive level? (Q11) How would the citizens’ confidence in health care be affected if priority setting was open and public? For the questions Q9, Q10, and Q11, the answers were given on a 5-point scale from 1 (No influence at all) to 5 (Very much influence) (Q9 and Q10) and from 1 (Public confidence in the health care system diminishes) to 5 (Public confidence in the health care system increases) (Q11). We report the percentage of respondents who answered 4 or 5 minus the percentage of respondents who answered 1 or 2. Hence, a positive (negative) value indicates that the influence is considered to be larger (smaller) than the neutral middle.
included county councils as unfinanced pension guarantees to a sum of 27 billion SEK [18]. Health care deficits of this size could be regarded as loans from the future, from the coming generations. Both politicians and physicians advocated an enhanced impact on resource allocations for their own groups but were more hesitant in their answers when some concrete distributive action lines were suggested. In all respondent groups, the politicians were called upon to relegate certain therapies or diagnoses to public fund limitations. The politicians themselves were the most reluctant regarding this idea of horizontal (political) priority setting. Almost twice as many of them suggested instead that the physicians should handle the matter on a clinical level, and many of the physicians seemed prepared to carry out the task (presumably, though, with some sort of political sanction). If prioritization assignments are delegated to the clinical level, it means that legitimacy now depends on the expertise and the content of the clinical decisions [19]. In some sense, it also means that the public perspective is changed into a patient perspective
and the moral authority is replaced with a scientific one. There was also a general view among respondents that explicit priority-setting processes contribute to increased legitimacy for the public health care. This is in line with the official policy in Sweden that the priority-setting decisions should be more transparent [20]. It is a matter of discussion whether the county council politicians could be said to make prioritizations among different health care services or if their decisions just lead to continual inclusions of services, rather than exclusions. At least, choices are not expressed in an explicit way but give the impression of being taken ad hoc. Tim Tenbensel has noted that “Health policy has traditionally been an arena of little joy for policy rationalists” [21]. Many politicians might lack the knowledge needed to evaluate medical needs/treatments, but these kinds of facts are often ambiguous. They are interpreted by some interested party and they are rarely sufficient to base undisputable choices on. Nor can health-care priority-setting be based on technical grounds alone. The valuequestions are in the forefront.
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Priority setting in Swedish health care 233 It has been argued that legitimacy is more important than rationality or that “institutions matter more than information” [22]. This democratic approach often calls for fair, deliberative processes for setting limits to health care, such as accountability for reasonableness [23]. So, instead of the politicians gathering information on medical efficiency and cost utility – knowledge that will never be sufficient – they could establish transparent priority-setting processes that would bring legitimacy to the decisions. This seems to be the most feasible way to put on the uncomfortable task of priority setting. In sum, the results suggest that the politicians are more permissible and optimistic about resources than the other stakeholders within the health care sector, for which there could be several possible explanations. One, which our study results give some support to, suggests that politicians are unwilling to participate in a discussion on priority setting because they prefer to propagate the idea that all demands for health care could be met if only efficiency could be increased. Naturally, managers and physicians are less attracted by such views [24]. The politicians find their own influence on decision-making in the health care sector to be weaker compared to the other stakeholders. One reason could be based on their experience of their decisions not being implemented in the health care sector [25,26]. Another explanation could be that they expect the physicians to act independently and flexibly and to make all necessary decisions [27]. However, this is not always the case as political reforms often aim at cost restrictions and limitation of clinical freedom [28]. Another reason why politicians experience a lack of influence might be that they feel restricted in their exercise of power because other stakeholder groups have a greater knowledge of economy, medicine, organizational structures, etc. [5]. The politicians are most often laymen. Furthermore, in the eyes of the public, the physicians are more legitimate as decision-makers than the politicians [29]. This could be a good reason for the politicians to choose blame avoidance strategies and to stay away from the critical task of explicit priority-setting. Interestingly, physicians also view their own group as being relatively powerless. One explanation as to why all groups “understate” their own influence in comparison to the other groups’ influence could be that Sweden is what has been described as a “lowpower distance index country” [30], where power is often something that causes power holders to feel uncomfortable and that they try to underplay. However, this could also be explained by the organizational structure of the Swedish health care system,
with its regulative national-level and independent county councils with their own taxation power and where it is not always clear who bears the responsibility in different contexts. Conclusion The results strengthens the hypothesis that politicians as a group differ from the other stakeholder groups in that they seemingly demonstrate a higher grade of confidence in the publicly funded health care, both in their views on the present resource situation and in their willingness to take measures. In addition, the majority of the politicians want more influence on these issues and want to advocate for explicit priority-setting processes. Whether they realize what this means in terms of negative exposure to voters is not clear. When the questions try to concretize the measures that are at stake, the politicians tend to “pass the bucket” to the physicians [7]. Some of the results could be explained by the specific role of the politicians, and the necessity for them to defend the prevailing system and its ethical principles. On the other hand, their answers differ too much from the other stakeholders’ and the over-all picture shows a blame-avoidance structure. It seems that influence on resource allocation is regarded as more important than responsibility for the “hands-on” tasks of deciding on treatment criteria and valuating opportunity costs. Combined with the context of low legitimacy and the overriding ambition to be re-elected, it seems like the politicians are not quite ready to address the increasing gap between health care demands and resources. This suggest that they might be faced with a dilemma if they opt to satisfy potential voters’ expectations while simultaneously trying to provide publicly funded health care within a limited budget. The results from this study indicate that more politicians focus on the former. The goal of politics cannot solely be to win the elections, but the final aim must be to exercise the political power. A strategy to avoid unpopular decisions might in the long run come at the expense of vulnerable groups who depend on a solid and well-functioning public health care system. Even if individual politicians are prepared to address the long-term financing problems, the task has to be handled with care. Facts do not speak for themselves and the politicians cannot aspire on being knowledgeable enough to take the right decisions on their own. But they can build up fair processes for setting limits to health care and they can get the issue of priority-setting onto the public agenda to encourage greater willingness for citizens to accept the unavoidable decisions.
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234 P. Rosén et al. Conflict of interest None declared. Funding The research was made possible through funding from Region Skåne. References [1] Carpenter D. Is health politics different? Annu Rev Polit Sci 2012;15:287–311 [2] Donaldson C, Blate A, Brambleby P, et al. Moving forward on rationing: an economic view. BMJ 2008; 337:a1872. [3] Waldau S, Lindholm L andWiechel AH. Priority setting in practice: participation opinions on vertical and horizontal priority setting for reallocation. Health Policy 2010;96:245–54. [4] Anell A, Glenngård A and Merkur S. Health systems in transition – Sweden. Copenhagen: WHO, 2012. [5] Smith P, Anell A, Busse R, et al. Leadership and governance in seven developed health systems. Health Policy 2012;106:37–49 [6] Chantler C. Health-care technology assessment: a clinical perspective. Int J Tech Assess Health Care 2004;20: 87–91. [7] Weaver K. The politics of blame avoidance. J Publ Pol 1986; 6:371–98. [8] Pitkin H. The concept of representation. Berkeley, CA: University of California Press, 1967. [9] Lindbom A. Obfuscating retrenchment: The Swedish welfare policy in the1990s. J Publ Pol 2007;27:129–50. [10] Fiorina M. Congress: Keystone of the Washington establishment. New Haven, CT: Yale University Press. 1977. [11] Eagly A and Chaiken S. The psychology of attitudes. Fort Worth, TX: Harcourt Brace Jovanovich College Publishers, 1993. [12] Pierson P. Dismantling the welfare state? Cambridge, UK: Cambridge University Press, 1994. [13] Czarniawska-Joerges B. Ideological control in non-ideological organizations. New York, NY: Praeger, 1988. [14] Rosén P and Karlberg I. Opinions of Swedish citizens, healthcare politicians, administrators and doctors on rationing and health-care financing. Health Expectations 2002;5:148–55. [15] Rosén P. Public dialogue on health care prioritization. Health Policy 2006;79:107–16.
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research-article2014
SJP0010.1177/1403494813520355Priority setting in Swedish health careP. Rosén et al.
Scandinavian Journal of Public Health, 2014; 42: 227–234
Original Article
Priority setting in Swedish health care: Are the politicians ready?
Per Rosén1, Jenny De Fine Licht2 & Henrik Ohlsson3 1Nordic
School of Public Health NHV, Gothenburg, Sweden, 2Department of Political Science, University of Gothenburg, Sweden, and 3Center for Primary Health Care, Lund University, Clinical Research Centre (CRC) Malmö, Sweden
Abstract Background: Resource allocation in public health care principally involves politicians, administrators, and physicians. They all have their different roles, agendas and ambitions when it comes to how public health care resources should be spent. Previous studies on attitudes among health-care stakeholders have mainly focused on views and preferences among clinical decision-makers, while less attention has been paid to the views of health care politicians. Aim: The study aimed to investigate if the health care politicians’ views on priority setting and decision-making in health care differed from other stakeholder groups. Method: The study was based on a questionnaire conducted among health care politicians, administrators, and physicians in four county councils in Southern Sweden. Results: The findings show significant differences between the politicians and the other two groups in their views on health-care resources, financing, priority setting and decision-making. Conclusions: The findings could, at least partly, be explained by the special situation it means for the politicians to be forced to be re-elected every fourth year to stay in power. Key Words: Accountability, decision-making, governance, health-care politicians, priority setting, resource allocation
Introduction In most countries, people are living longer than ever before, the general health of the population is strong, and public health care is being offered to more people. Expectations on health care are growing, mainly because new medical advances offer improved therapeutic and diagnostic options, but also due to the ageing of the population [1]. As public health-care resources are limited, the pressure on the health-care system has led to a growing welfare dilemma. Attempts have been made to implement more explicit priorities and to make reasonable choices among different needs/treatment alternatives [2]. Some attention has been paid to the Swedish experiences because of the marked attempts to facilitate transparent resource allocation decisions at both the clinical and political levels; that is, vertical and horizontal prioritizations, respectively. The Swedish health care system is mainly steered by 21 county councils, which are political bodies with their own
taxation levies. Some of these county councils have had experience with explicit priority setting in recent years [3]. At the national level, the Parliament has appointed one commission (1995) and one delegation (2000) for priority setting; there are also a number of public boards and agencies handling matters of priority setting and a special National Centre for Priority Setting in Health Care. The Swedish Parliament has established an ethical platform comprised of three basic priority-setting principles in order to set guidelines for resource allocation: Human dignity, need and solidarity, and costeffectiveness. The principle of “human dignity” means that all human beings have equal rights regardless of their social status. The principle of “need and solidarity” means that those in greatest need have precedence for medical care. Finally, the principle of “cost-effectiveness” means that when a choice has to be made between different health care options, there should be a reasonable relationship
Correspondence: Per Rosén, Nordic School of Public Health NHV, Box 121 33, Göteborg, SE-402 42, Sweden. E-mail: [email protected] (Accepted 17 December 2013) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494813520355
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228 P. Rosén et al. between the costs and the effects measured in terms of improved health and improved quality of life [4]. However, this ethical platform has proven to be too general as a practical guideline, and priority setting has continued to be a somewhat less systematic approach to distributing the available resources between the competing demands in order to fashion an optimal health care system [5].These allocation decisions could be explicit (that is, politically sanctioned) or implicit (that is, hidden in the garden of medical praxis). When medical services are restricted or excluded from the public financing as a consequence of priority setting, it is often called rationing. This could, for example, be based on judgments of health care needs or different treatments’ cost-effectiveness. Fair allocation of care can never imply that everyone is given an equal amount of care, and it is not suffice to say that resources should be allocated according to need, since the needs that must be balanced are often very different. Someone must, in some way, decide which methods and treatments should be publicly available and under what conditions. How should resources be allocated between the medical disciplines? Is it possible to rank different needs in relation to each other? These questions confront members of all the three stakeholder groups and a certain level of “maturity” regarding these issues among the respondents could be expected. Previous studies on attitudes among health care stakeholders have mainly focused on views and preferences among clinical decision-makers, while less attention has been paid to the views of health care politicians. As the politicians are elected by the people, their formal authority legitimizes the decisionmaking process. They also play an important role in representing society’s view in determining choices for the provision of treatment and care. There is a limit to the finances that people are prepared to designate for health care provision if other important needs, such as education, housing, elderly care, etc., also need to be met. It is not only desirable that the politicians articulate and determine what treatments and care should be available; rather, it is necessary because it is, in a way, what people elect them to do [6]. It has been argued that most politicians are in large part motivated by their desire to maximize their prospects for re-election [7], and therefore they want to satisfy the presumed preferences of their voters [8]. Because of the popularity of the welfare state among large segments of the population, caution is advised and the most common strategy is what Kent Weaver characterizes as “The Politics of Blame Avoidance” [7]. In an analysis of cutbacks in thirteen Swedish transfer programs, it was concluded that welfare programs relatively susceptible to opaque
reforms suffered larger cutbacks than other, more transparent, programs [9]. Politicians also tend to avoid alternatives with observable short-term “costs” even if the long-term effects would be more favourable to the voters. When losses are unavoidable, it is also better to offer small losses to everybody, like higher taxes or patient fees, than strongly negative effects to an identifiable group who could have protection from special interest groups and form an attractive target for media exploitation [10]. This is a strong reason for politicians not to engage in open rationing and “retrenchment has become an exercise in blame avoidance rather than credit claiming” [9]. Politicians in general have an intuitive understanding of the fact that people’s attitudes to a certain issue can influence both their disposition toward communicators expressing opinions on that issue and also to other unrelated issues on which these communicators take stands [11]. The political strategy is, therefore, a) to be associated with popular ideas, b) to be detached from unpopular policies, and c) remain mute on issues on which voter opinion is divided [11]. The most common strategy for blame avoidance is to delegate the responsibility to lower organizational levels [12]. The aim of the politicians might not be to control the resource allocation at all, but to simply appear as if they did and thereby gain legitimacy in the eyes of the electors [13]. Methods Our hypothesis was that the politicians try to satisfy the electorates by using a strategy referred to by Weaver as “blame avoidance” [7]. This strategy includes elements of a) avoiding issues of blame-generating potential like priority setting or rationing, b) softening (or obfuscating) their position on these controversial issues, c) delegating hard decisions to someone else, and d) depicting themselves as rather powerless. A questionnaire was constructed to investigate whether answers from the politicians differ from other health care stakeholders in questions on resource allocation and financing from four different aspects: - views on today’s needs and resources - preferences on financing - attitudes on rationing - views on decision-making and power-sharing in setting priorities. If the answers of the politicians differ systematically from those of the physicians and the administrators, the difference could be explained by the “blame-avoidance theory”. The matter is complex,
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Priority setting in Swedish health care 229 though, and many explanations are thinkable. Also the other stakeholders have their different roles and special agendas that might further increase some of the observed differences.
Table I. Study population and response rates.
Politicians Administrators Physicians
n (N)
Response frequency (%)
161 (260) 220 (366) 1,222 (2073)
62 60 59
Sample The analysis is based on the questionnaire conducted among different types of stakeholders in four county councils in southern Sweden. The stakeholders included in the survey were health care politicians, administrators (including senior administrators, primary care managers, and heads of clinics), and physicians (general practitioners and hospital specialists). The physicians were randomly selected from registers containing all primary care physicians and hospital specialists within the four areas. All health-care politicians in the southern region were included. The total sample of administrators within the four geographic areas consisted of individuals who were administrators in the sense that they had budgetary responsibilities. The different administrator categories also shared the following characteristics: They worked closely with practical matters of health care and they were not, like the politicians, at risk of losing their mandate every fourth year. The administrators were in many cases, but not always, physicians themselves. Among the primary care managers, about 50% were nurses and 50% were physicians. As the group of administrators consisted of a mix of clinically- or politically-oriented people, statistically, they constituted a middle group in between the political and the medical fields. The results on a subgroup level are not shown here; they do not contradict the main conclusions but rather underline the main comparison and they are available upon request from the authors. The survey was carried out and coordinated by the authors in 2009. Data from the completed questionnaires were de-identified and controlled for errors, inconsistencies, and internal missing data. The total study population was comprised of 1603 individuals. The overall response rate was 59% (Table I). Heads of clinics at the hospitals had the highest response rate, 72%. The questionnaire only included questions concerning attitudes toward health care financing, rationing and decision-making, and in order to increase the response rate, no background variables such as age or gender were used. The respondents answered anonymously, and two reminders were sent out. Themes Attitudes toward health care priority setting and rationing within different groups of stakeholders were explored by analyzing 11 different questions.
The questions were divided into four subsections in accordance with our defined research questions. The first group of questions dealt with views on the current state of affairs; for example, “Are health care resources sufficient and how efficient could the health care organization become?” The second group of questions concerned issues of financing such as raising taxes or increasing patient fees. The third group of questions focused on supply restrictions and rationings, such as, “Should cost be an issue when choosing between treatment alternatives and are some health care needs too marginal to be covered by public funding?” In the final section of the questionnaire, decisionmaking was addressed, namely, “How big of an influence do different stakeholder groups have today and how big of an influence should different stakeholder groups have on health care resource allocation at a comprehensive level?” Other questions offered choices between political decisions on excluding therapies/diagnoses or physicians practicing stricter inclusion criteria. The last question concerned preferences for explicit priority setting. Most of the questions have been used and validated in earlier studies conducted by the authors as well as other researchers. Analysis Descriptive statistics for the 11 questions, separated according to the different stakeholders, are presented. Chi-square tests (Q1 to Q8) were performed in order to compare the groups of stakeholders within each question. For this test, a significance level of 5% was chosen. Results Healthcare needs and resources Only 10% to 15% of the respondents thought that today’s health care resources were sufficient to meet all health-care needs (Q1). The exceptions were the politicians, among whom almost 25% found that resources were sufficient (p < 0.0001). The politicians also differed in their views on whether public health care could become so efficient that economy measures would not be needed (Q2). Approximately 45% of the politicians agreed to the
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230 P. Rosén et al. statement, in comparison to 28% of the physicians (p < 0.0001). Financing alternatives Respondents also differed in their views on tax increases and additional patient fees. Approximately 50% to 60% of all respondents estimated that public health care requires increased resources (Q3). Some (40%) chose the alternative of keeping taxes at the current level. Only a small percentage of the respondents chose the alternative that health care resources should be decreased. There are significant differences between the answers from the politicians and the other stakeholders (p < 0.0104), and especially between politicians and physicians (p < 0.0001). While 45% to 55% of the administrators and physicians were positive towards increased co-payment in public health care (Q4), only 27% of the politicians sympathized with this measure (p < 0.0001). A high share of respondents answered “Don’t know” to the question. Supply restrictions and rationing In response to whether public health care should always offer the best possible care irrespective of costs (Q5), 54% of the politicians answered “Yes”, compared to only about 20% to 30% of respondents from the other stakeholder groups (p < 0.0001). While 36% of the politicians meant that the general public should always have a right to public health care irrespective of how modest their needs are (Q6), only approximately 20% of the respondents from the other groups answered “Yes” to this question (p < 0.0001).
health care supply or to increase the patient costs of some treatments (p < 0.0001). They would much prefer that the doctors were more rigorous about determining the inclusion criteria for certain treatments. There was also a difference between how the different respondent groups view their own and other stakeholders’ influence on health care resource allocation on a comprehensive level today. The answers were given on a 5-point scale from 1 (No influence at all) to 5 (Very much influence). We report the balance; that is, the percentage of respondents who answered 4 or 5 minus the percentage of respondents who answered 1 or 2. A plus thus indicates that the influence is considered to be larger than the neutral middle point (Table III). The politicians underplayed their own influence, especially compared to how the physicians experienced it, and the physicians seemed dissatisfied with their own roles in the power play (Q9). In response to how big of an influence different stakeholder groups should have on health care resource allocation on a comprehensive level (Q10), as expected, the physicians advocated more influence on their own behalf, as did the politicians, but to a somewhat more modest degree. The last question investigated whether respondents think that citizens’ confidence in health care can be affected if priority setting is open and public (Q11). There seemed to be a clear agreement among all respondents that public legitimacy would benefit from transparent priority-setting decisions. The majority of the respondents (75% to 80%) placed themselves on the positive side of the scale (4 to 5), indicating that open and official reporting of prioritysetting decisions would lead to higher public trust in the health care system.
Decision-making and influence The groups differed in their responses to whether a) politicians make comprehensive decisions to exclude certain therapies or diagnoses from public financing, or b) it is mainly physicians who make rigorous decisions on which medical conditions should give entitlement to public health care, or c) these kinds of measures do not exist (Q7). The politicians were more inclined than the others to think that it is the physicians who make the hard decisions (p < 0.0001). Among the administrators and physicians, 48% and 44%, respectively, chose the third alternative; “None of these decisions are practiced”. When being asked how these decisions should be made (Q8), the politicians were more reluctant than the other stakeholders to the idea that the politicians should take decisions to restrict the publicly financed
Discussion In a previous study, a hypothesis was developed suggesting that important stakeholders in the health care system do not share the same views on resource allocation and financing within the third part financed health care system and that politicians differ the most from the other groups [8]. In this present report, we used a postal questionnaire to examine whether the answers from the health care politicians could be said to illustrate a blame avoidance strategy [14]. Differences in answers between the subgroups could mean that respondents interpret or associate differently, or it could mean that they actually hold different attitudes towards the same attitude object. This validity problem is more or less adhered to all surveys as people never have exactly the same associations
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Priority setting in Swedish health care 231 Table II. Descriptive statistics and Chi-square statistics. Percentages in bold and numbers of responses within brackets. Question
Answer
Politicians
Administrators
Physicians
Chi-square
QI Q2 Q3 Q4 Q5 Q6
Yes No Don’t know Yes No Other Increase Decrease As today Yes No Other Yes No Other Yes No Other
23 (36) 74 (119) 3 (5) 45 (70) 42 (67) 13 (21) 51 (81) 8 (12) 41 (66) 27 (43) 60 (96) 13 (21) 54 (85) 30 (48) 16 (26) 36 (57) 54 (86) 10 (16)
12 (26) 81 (174) 7 (15) 37 (80) 44 (94) 19 (41) 53 (114) 7 (16) 40 (87) 54 (117) 33 (71) 13 (28) 17 (36) 71 (152) 12 (27) 20 (43) 77 (165) 3 (7)
10 (119) 86 (1,039) 4 (53) 28 (330) 51 (601) 21 (246) 62 (731) 4 (52) 34 (407) 44 (523) 41 (496) 15 (178) 30 (357) 54 (652) 16 (195) 23 (276) 71 (854) 6 (79)
26.0 P: < 0.0001 22.8 P: < 0.0001 13.2 P: < 0.0104 33.2 P: < 0.0001 70.7 P: < 0.0001 25.4 P: < 0.0001
(Q1) Do you think today’s health care resources are sufficient to meet all the health care needs? (Q2) Could the public health care become so efficient that economy measures will not be needed? (Q3) Do you think the public health care expenditures should increase, stay at today’s level or decrease? (Q4) Should patients pay higher co-payment in the public health care? (Q5) Should public health care always offer the best possible care, irrespectively of costs? (Q6) Should the general public always have a right to public health care, irrespective of how modest their needs are?
when they hear or read a certain expression. A choice was therefore made to ask questions used in earlier studies and thereby obtain as many options to comparisons as possible. Consistent with the view of the general public [15], most of the different stakeholders raised doubts whether available health care resources were sufficient to meet existing health care needs. The results indicate an general awareness of the conflict between limited resources and an endless growth of medical demand. The politicians, though, were significantly less inclined to raise doubts on supply of resources. They might have been more optimistic about the state of affairs as more of them were convinced that public health care could be delivered in more efficient ways. It could also be a way to deny the significance of an unrewarding issue. Yet another explanation could lie in the role of the health care politician as a financer, negotiating party, and a trustee to defend the functionality of the public health care system. The other stakeholders might answer from another rationality in which it is in their interest to emphasize a lack of resources. More politicians compared to the other stakeholders were reluctant to raise health care taxes, and they differed to an even larger extent from the other stakeholders in their views on increased patient fees, and this is in line with the view of the general public (25%) [15].
Also consistent with prior data [14,16], a larger share of the politicians demonstrated a permissible attitude toward individuals’ right to health care irrespective of how modest patients’ needs are or irrespective of cost, which is in line with the opinion of the general public, but not at all concordant with the views of the other stakeholders. It could be argued that politicians often develop their rationale based on values where equity and general access to health care are goals of specific interest [12]. Administrators are often said to represent an “efficiency perspective”, where special emphasis is placed on cost-effectiveness and budget planning, while the health care personnel are focused on the medical needs of the individual patient [17]. Compared to the answers from other respondents, politicians found their own influence on decisionmaking in the health care sector to be rather weak. Both the administrators and the physicians were regarded as more influential. Almost half of all the respondents thought that neither do the politicians make any “comprehensive decisions to exclude certain therapies or diagnoses from public financing” nor do the physicians make “rigorous decisions on which medical conditions should give entitlement to public health care”. Restrictions seem not to be an issue at all. At the same time, the annual deficits in the region are growing, expressed in one of the
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232 P. Rosén et al. Table III. Descriptive statistics. Percentages in bold and numbers of responses within brackets. Question
Answer
Politicians
Administrators
Physicians
Chi-square
Q7 Q8 Q9 Q10 Q11
a) Politicians b) Physician c) None Don’t know a) Politicians b) Physician c) None Don’t know a) Politicians b) Administrators c) Physicians a) Politicians b) Administrators c) Physicians
13 (20) 45 (70) 26 (41) 16 (26) 27 (41) 49 (75) 15 (23) 9 (14) 44 50 55 46 −41 7 67
14 (30) 32 (68) 48 (101) 6 (13) 52 (107) 35 (74) 9 (18) 4 (8) 64 37 −13 7 −10 38 77
18 (209) 29 (340) 44 (520) 9 (112) 38 (430) 46 (528) 11 (130) 5 (54) 75 57 −52 −22 −65 82 74
36.6 P: < 0.0001
28.9 P: < 0.0001
(Q7) In rationing, which of the following two alternatives is mainly used today: a) Politicians take comprehensive decisions to exclude certain therapies or diagnoses from public financing. b) Physicians make rigorous decisions on which medical conditions should give entitlement to public health care. c) None of these two alternatives. (Q8) In rationing, which of the following two alternatives should mainly be used: a) Politicians take comprehensive decisions to exclude certain therapies or diagnoses from public financing. b) Physicians make rigorous decisions on which medical conditions should give entitlement to public health care. c) None of these two alternatives. (Q9) How big influence do different stakeholders have on health care resource allocation on a comprehensive level today? (Q10) How big influence should different stakeholders have on health care resource allocation on a comprehensive level? (Q11) How would the citizens’ confidence in health care be affected if priority setting was open and public? For the questions Q9, Q10, and Q11, the answers were given on a 5-point scale from 1 (No influence at all) to 5 (Very much influence) (Q9 and Q10) and from 1 (Public confidence in the health care system diminishes) to 5 (Public confidence in the health care system increases) (Q11). We report the percentage of respondents who answered 4 or 5 minus the percentage of respondents who answered 1 or 2. Hence, a positive (negative) value indicates that the influence is considered to be larger (smaller) than the neutral middle.
included county councils as unfinanced pension guarantees to a sum of 27 billion SEK [18]. Health care deficits of this size could be regarded as loans from the future, from the coming generations. Both politicians and physicians advocated an enhanced impact on resource allocations for their own groups but were more hesitant in their answers when some concrete distributive action lines were suggested. In all respondent groups, the politicians were called upon to relegate certain therapies or diagnoses to public fund limitations. The politicians themselves were the most reluctant regarding this idea of horizontal (political) priority setting. Almost twice as many of them suggested instead that the physicians should handle the matter on a clinical level, and many of the physicians seemed prepared to carry out the task (presumably, though, with some sort of political sanction). If prioritization assignments are delegated to the clinical level, it means that legitimacy now depends on the expertise and the content of the clinical decisions [19]. In some sense, it also means that the public perspective is changed into a patient perspective
and the moral authority is replaced with a scientific one. There was also a general view among respondents that explicit priority-setting processes contribute to increased legitimacy for the public health care. This is in line with the official policy in Sweden that the priority-setting decisions should be more transparent [20]. It is a matter of discussion whether the county council politicians could be said to make prioritizations among different health care services or if their decisions just lead to continual inclusions of services, rather than exclusions. At least, choices are not expressed in an explicit way but give the impression of being taken ad hoc. Tim Tenbensel has noted that “Health policy has traditionally been an arena of little joy for policy rationalists” [21]. Many politicians might lack the knowledge needed to evaluate medical needs/treatments, but these kinds of facts are often ambiguous. They are interpreted by some interested party and they are rarely sufficient to base undisputable choices on. Nor can health-care priority-setting be based on technical grounds alone. The valuequestions are in the forefront.
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Priority setting in Swedish health care 233 It has been argued that legitimacy is more important than rationality or that “institutions matter more than information” [22]. This democratic approach often calls for fair, deliberative processes for setting limits to health care, such as accountability for reasonableness [23]. So, instead of the politicians gathering information on medical efficiency and cost utility – knowledge that will never be sufficient – they could establish transparent priority-setting processes that would bring legitimacy to the decisions. This seems to be the most feasible way to put on the uncomfortable task of priority setting. In sum, the results suggest that the politicians are more permissible and optimistic about resources than the other stakeholders within the health care sector, for which there could be several possible explanations. One, which our study results give some support to, suggests that politicians are unwilling to participate in a discussion on priority setting because they prefer to propagate the idea that all demands for health care could be met if only efficiency could be increased. Naturally, managers and physicians are less attracted by such views [24]. The politicians find their own influence on decision-making in the health care sector to be weaker compared to the other stakeholders. One reason could be based on their experience of their decisions not being implemented in the health care sector [25,26]. Another explanation could be that they expect the physicians to act independently and flexibly and to make all necessary decisions [27]. However, this is not always the case as political reforms often aim at cost restrictions and limitation of clinical freedom [28]. Another reason why politicians experience a lack of influence might be that they feel restricted in their exercise of power because other stakeholder groups have a greater knowledge of economy, medicine, organizational structures, etc. [5]. The politicians are most often laymen. Furthermore, in the eyes of the public, the physicians are more legitimate as decision-makers than the politicians [29]. This could be a good reason for the politicians to choose blame avoidance strategies and to stay away from the critical task of explicit priority-setting. Interestingly, physicians also view their own group as being relatively powerless. One explanation as to why all groups “understate” their own influence in comparison to the other groups’ influence could be that Sweden is what has been described as a “lowpower distance index country” [30], where power is often something that causes power holders to feel uncomfortable and that they try to underplay. However, this could also be explained by the organizational structure of the Swedish health care system,
with its regulative national-level and independent county councils with their own taxation power and where it is not always clear who bears the responsibility in different contexts. Conclusion The results strengthens the hypothesis that politicians as a group differ from the other stakeholder groups in that they seemingly demonstrate a higher grade of confidence in the publicly funded health care, both in their views on the present resource situation and in their willingness to take measures. In addition, the majority of the politicians want more influence on these issues and want to advocate for explicit priority-setting processes. Whether they realize what this means in terms of negative exposure to voters is not clear. When the questions try to concretize the measures that are at stake, the politicians tend to “pass the bucket” to the physicians [7]. Some of the results could be explained by the specific role of the politicians, and the necessity for them to defend the prevailing system and its ethical principles. On the other hand, their answers differ too much from the other stakeholders’ and the over-all picture shows a blame-avoidance structure. It seems that influence on resource allocation is regarded as more important than responsibility for the “hands-on” tasks of deciding on treatment criteria and valuating opportunity costs. Combined with the context of low legitimacy and the overriding ambition to be re-elected, it seems like the politicians are not quite ready to address the increasing gap between health care demands and resources. This suggest that they might be faced with a dilemma if they opt to satisfy potential voters’ expectations while simultaneously trying to provide publicly funded health care within a limited budget. The results from this study indicate that more politicians focus on the former. The goal of politics cannot solely be to win the elections, but the final aim must be to exercise the political power. A strategy to avoid unpopular decisions might in the long run come at the expense of vulnerable groups who depend on a solid and well-functioning public health care system. Even if individual politicians are prepared to address the long-term financing problems, the task has to be handled with care. Facts do not speak for themselves and the politicians cannot aspire on being knowledgeable enough to take the right decisions on their own. But they can build up fair processes for setting limits to health care and they can get the issue of priority-setting onto the public agenda to encourage greater willingness for citizens to accept the unavoidable decisions.
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