Rationing: how and who?

Rationing health services, in the sense of denying care deemed of positive benefit by at least some health system actors, is a problem that politicians would like to avoid. Health policy analysis has offered a number of approaches, such as global budgeting, technology assessment, managed competition, legal recourse and public participation as palliatives for this difficult problem. Each of these approaches on its own falls short, but no country has yet designed a process for explicit rationing. Israel, in the context of its recent health reform, has gone as far as any country in this direction. However, significant political leadership will be required to frame the public discussion of these difficult issues.