Managing the gap between demand and publicly affordable health care in an ethical way

A major health policy challenge of the 1990s is to manage thegap between the demand for health care and our ability to payfor care and to do so in an ethical way. This paper describesEuropean responses to the gap, which have been to do nothing,to do more with the same or less resources, to do more withmore resources, to change behaviour and attitudes and to definehealth needs more narrowly. These responses have not reducedthe gap and cannot prevent it from widening in the future. Rationingand prioritizing are other responses, which will have an increasinglyimportant role. This paper proposes that the survival of publichealth care systems depends on recognizing and ‘managing’the gaps and doing so in an ethical way. Conventional responseshave ethical problems equal to or more serious than those involvedin rationing and prioritizing. The paper proposes that rationingand prioritizing must become more central methods for managingthe gap between resources and demand in the future, but thatsuch approaches will need to be more explicit and ethical ifthey are to gain public support.