Intended for healthcare professionals


Moving forward on rationing: an economic view

BMJ 2008; 337 doi: (Published 09 October 2008) Cite this as: BMJ 2008;337:a1872
  1. Cam Donaldson, health foundation chair in health economics12,
  2. Angela Bate, lecturer in health economics1,
  3. Peter Brambleby, director of public health3,
  4. Howard Waldner, chief executive officer45
  1. 1Institute of Health and Society, Newcastle University, Newcastle upon Tyne NE2 4AA
  2. 2University of Calgary, Calgary, Canada
  3. 3North Yorkshire and York Primary Care Trust, Harrogate HG2 8RE
  4. 4Vancouver Island Health Authority, Victoria, British Columbia, Canada
  5. 5Faculty of Medicine, University of British Columbia, Canada
  1. Correspondence to: C Donaldson cam.donaldson{at}

    Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician (doi:10.1136/bmj.a1846), two ethicists (doi:10.1136/bmj.a1850), and four health economists discuss how their ideas have developed—and been put into practice—since then

    Economists normally propose markets for rationing of goods. However, we know markets do not work well for health care.1 2 But the creation of publicly funded healthcare systems, in recognition of such market failure, does not get rid of scarcity. To sustain publicly funded health care and prevent moves back towards more market based systems, societies need to wake up and tackle rationing through explicit recognition and management of scarcity.

    Management of scarcity requires two things. The first is to eliminate waste (where opportunities exist to meet a need at less cost, or meet more need at no extra cost, we should take them). Beyond this, we need to consider relative value (disinvesting from interventions providing little benefit to fund those providing greater benefit). Box 1 outlines a framework for doing this.3 It can be applied wherever scarcity of resources is a problem. This framework tends to be known as programme budgeting and marginal analysis, but it is based on recognition of scarcity and the need, ultimately, to make trade-offs between interventions and, thus, patients.

    Box 1 Five questions and seven steps of programme budgeting and marginal analysis4

    Five questions
    • What is the total amount of resources available for a given programme or health organisation?

    • How are these resources currently spent?

    • What services are on the wish list for receiving more resources (and what are the costs and benefits of these expansions)?

    • Can any existing services be provided as effectively but with fewer resources, allowing some of the items on the wish list to be implemented?

    • If further resources are still required to …

    View Full Text

    Log in

    Log in through your institution


    * For online subscription