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The focus of this thesis is needs in the context of health care priority setting. The notion of needs has a strong standing in health care policy; however, how the idea should be understood more specifically and how it should guide decisions about priority setting remain contentious issues. The aim of this thesis is to explore how needs should be characterised in health care priority setting. This matter is approached by, first, exploring and developing the conceptual structure of health care needs, and second, discussing and suggesting solutions to normative questions that arise when needs are characterised as a distributive principle. In the first article, the conceptual structure of needs in general and health care needs in particular is explored, and it is argued that a specific characterisation of health care needs is required. In the second article, the notion of health care needs is explored in relation to preferences for health care within the context of shared decision-making. The paper further discusses a number of queries that arise in the intersection between what the patient needs and what the patient wants. The third article discusses how a principle of need should handle questions about interpersonal aggregation. The paper characterises a principle of need which strikes a reasonable balance between giving priority to the worst off and the distribution of benefits with regard to interpersonal aggregation. The fourth article discusses how a principle of need should account for the fact that patients often are badly off due to several conditions rather than one single condition. It is argued that how badly off patients are should be understood as a function of how badly off these patients are when all of their conditions (for which they need health care) are considered. The frame story provides the terminological, theoretical, contextual, and methodological background for the discussion undertaken in this thesis. The conclusions of the articles are brought together and the discussion extended in the concluding discussion by sketching a number of conditions of adequacy for the concept and principle of need relevant for health care priority setting. ; Den här avhandlingen fokuserar på behov och behovsprinciper inom hälso- och sjukvården. Behov har länge haft en stark ställning inom hälso- och sjukvården men det är omdiskuterat hur begreppet ska förstås mer specifikt och framförallt hur det ska vara vägledande för prioriteringar inom hälso- och sjukvården. Syftet med den här avhandlingen är att karakterisera behov för sådana prioriteringar. Avhandlingen tar sig an detta syfte utifrån två ansatser. För det första, genom att undersöka och utveckla den begreppsliga strukturen hos vårdbehov och, för det andra, genom att diskutera samt ge förslag på lösningar på ett antal normativa frågor som uppstår när vårdbehov skall karakteriseras som en fördelningsprincip. I den första artikeln undersöks begreppen behov och vårdbehov utifrån den allmänfilosofiska diskussionen om behov. I artikeln karakteriseras begreppet vårdbehov på ett sätt som gör det lämpligt för prioriteringar inom hälsooch sjukvården. I den andra artikeln utforskas begreppet vårdbehov i relation till önskemål om vård inom ramen för delat beslutsfattande. I artikeln diskuteras också ett antal frågeställningar som aktualiseras i relation till den spänning som kan uppstå mellan patientens behov å ena sidan och patientens önskemål å andra sidan. I den tredje artikeln behandlas frågan om hur en behovsprincip bör hantera frågor som rör sammanvägning av olika personers behov. I artikeln karakteriseras och försvaras en behovsprincip som balanserar prioritet till de sämst ställda och hur hälsovinster bör fördelas. I den fjärde artikeln förs en diskussion om hur en behovsprincip bör göra reda för det faktum att patienter ofta lider av samsjuklighet snarare än av ett enskilt tillstånd. I artikeln drivs tesen att hur dåligt ställt en patient har det bör förstås som en funktion av hur dåligt ställt patienten har det när alla patientens tillstånd (för vilka patienten behöver vård) har tagits i beaktande, snarare än hur dåligt ställt patienten har det med avseende på det specifika tillstånd för vilket patienten skall behandlas. I kappan ges den terminologiska, kontextuella, teoretiska och metodologiska bakgrunden för diskussionen i avhandlingen. I en avslutande diskussion förs slutsatserna från artiklarna samman och diskussionen utvidgas genom att skissera ett antal adekvansvillkor för begreppet vårdbehov och behovsprinciper i vården. ; I den tryckta versionen är det ena serienamnet felaktigt. I den elektroniska versionen är detta ändrat till korrekt "Linköping Dissertations on Health and Society"

AbstractHow to balance the maximization of health and concerns for the worse off remains a challenge for health care decision makers when setting priorities. In regulatory guidelines these concerns are typically specified in terms of priority setting according to needs and priority setting according to cost-effectiveness. Still, it is often unclear when and why needs and cost-effectiveness diverge or overlap as guiding priority setting principles in practice. We conduct a comparative analysis of need and cost-effectiveness in the context of health care priority setting. Based on theories of distributive justice we specify three normative interpretations of need and explicate how these relate to the normative basis for cost-effectiveness analysis. Using priority-setting dilemmas we then move on to explicate when and why need and cost-effectiveness diverge as priority-setting principles. We find that: (i) although principles of need and cost-effectiveness may recommend the same allocation of resources the underlying reason for an allocation is different; (ii) while they both may give weight to patients who are worse off they do so in different ways and to different degree; and (iii) whereas cost-effectiveness clearly implies the aggregation of benefits across individuals principles of needs give no guidance with regard to if, and if so, how needs should be aggregated. Priority setting according to needs or cost-effectiveness does not necessarily recommend different allocations of resources. Thus, the normative conflict between them, often highlighted in practice, seems exaggerated. For health policy this is important knowledge because unclear conceptions may obstruct an informed public discussion. Moreover, if decision-makers are to properly account for both principles they need to recognize the inconsistencies as well as similarities between the two.

How to handle orphan drugs for rare diseases is a pressing problem in current health-care. Due to the group size of patients affecting the cost of treatment, they risk being disadvantaged in relation to existing cost-effectiveness thresholds. In an article by Niklas Juth it has been argued that it is irrelevant to take indirectly operative factors like group size into account since such a compensation would risk discounting the use of cost, a relevant factor, altogether. In this article we analyze Juths argument and observe that we already do compensate for indirectly operative factors, both outside and within cost-effectiveness evaluations, for formal equality reasons. Based on this we argue that we have reason to set cost-effectiveness thresholds to integrate equity concerns also including formal equality considerations. We find no reason not to compensate for group size to the extent we already compensate for other factors. Moreover, groups size implying a systematic disadvantage also on a global scale, i.e. taking different aspects of the health condition of patients suffering from rare diseases into account, will provide strong reason for why group size is indeed relevant to compensate for (if anything).