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 the gap between the demand for health care and our ability to pay for care and to do so in an ethical way. This paper describes European responses to the gap, which have been to do nothing, to do more with the same or less resources, to do more with more resources, to change behaviour and attitudes and to define health needs more narrowly. These responses have not reduced the gap and cannot prevent it from widening in the future. Rationing and prioritizing are other responses, which will have an increasingly important role. This paper proposes that the survival of public health care systems depends on recognizing and 'managing' the gaps and doing so in an ethical way. Conventional responses have ethical problems equal to or more serious than those involved in rationing and prioritizing. The paper proposes that rationing and prioritizing must become more central methods for managing the gap between resources and demand in the future, but that such approaches will need to be more explicit and ethical if they are to gain public support.