Synthesis: what can we learn from international experience?

International experience shows that rationing can occur through exclusions or through the use of guidelines. Oregon has chosen to ration by excluding certain services in order to move towards universal population coverage. New Zealand has avoided exclusions and has chosen to ration through the use of guidelines. The Netherlands is pursuing both approaches. The experience of these and other countries demonstrates that rationing is inherently difficult. Choices in health care can be informed by techniques drawn from economics and other disciplines but these techniques need to be used as part of debate and discussion in the process of arriving at decisions. Experts and the public can contribute to this process and strenuous efforts need to be made to ensure participation by a representative cross-section of the population. At its root priority setting is a political process shaped by beliefs and values. Increased transparency in decision making should promote greater accountability and increased public awareness of the nature of rationing.