Elsevier

Health Policy

Volume 59, Issue 1, January 2002, Pages 53-63
Health Policy

Rationalising rationing: economic and other considerations in the debate about funding of Viagra

https://doi.org/10.1016/S0168-8510(01)00162-2Get rights and content

Abstract

Although the cost-effectiveness of Viagra for the treatment of patients with erectile dysfunction is favourable, both public and political opinions seem to be inclined not to fund, or merely to partially fund (i.e. by reimbursing only specific patient groups) this medicine. This shows that in funding discussions, cost-effectiveness information is not solely decisive. In a theoretical framework for choices in health care that was developed in The Netherlands (the Dunning report, 1991), two other criteria besides cost-effectiveness were put forward as being important for rationing decisions: ‘necessary care’ and ‘individual responsibility’. Overlooking the Viagra discussion, many of the arguments put forward seemed to be related to these two criteria. However, a clear operationalisation of the criteria necessary care and individual responsibility is lacking, which makes it difficult to use the arguments in funding decisions. In this paper, we try to demonstrate how these criteria were presented in the Viagra discussion and we will indicate how these criteria can be operationalised in relation to the outcomes of a cost-effectiveness analysis.

Section snippets

Viagra: an exceptional case in debates on rationing

In September 1998, Viagra was introduced on the European market, where it was an immediate success: the sales figures in the first months after introduction were extraordinarily high, especially given the fact that Viagra was a new, non-funded medicine. The question then became whether or not governments should fund Viagra in a public health care system. After all, the budgetary impact of funding of Viagra could be substantial, given this high demand.

In such funding decisions, economic

Main arguments against funding Viagra

In the Viagra discussion, two main arguments are put forward, both in the political and in the public discussion, that object to funding the new drug [7], [8], [9]. First, erectile dysfunction is often accepted as normal part of ageing. Consequentially, treatment can be viewed as an unnecessary luxury, which should not interfere with providing necessary medical interventions (e.g. lifesaving interventions). Second, it is argued that funding of treatment of erectile dysfunction may be denied on

Operationalisation of other arguments

In spite of their poor current operationalisation, the here discussed arguments of necessity and individual responsibility have intuitive appeal and seem to be based on widely shared underlying moral principles.

Implications for decision making

The arguments regarding necessary care and individual responsibility, in combination with information about cost-effectiveness, seem to outline a decision-making framework in which QALY maximisation is not the only goal. Necessity and individual responsibility also play a role. Below we explore how these findings can change the Dutch model for choices in health care.

The criteria necessary care and individual responsibility have been discussed before. For example, they were put forward, together

Conclusions

It becomes apparent from the Viagra funding discussion, that cost-effectiveness information alone cannot provide sufficient information to guide reimbursement decisions. Economic considerations need to be supplemented with the criteria necessary care and individual responsibility. The way these criteria are used in the Viagra debate may suggest that QALY gains are valued differently, depending on the place on the QALY scale where they occur compared to some societal reference point for health.

Acknowledgements

We would like to thank an anonymous referee for his valuable comments on an earlier version of this paper.

References (27)

  • P. Ramsey-Baggs et al.

    Rationing

    British Medical Journal

    (1998)
  • Letters to the editor. Rationing of sildenafil. British Medical Journal...
  • M. Jønler et al.

    The effect of age, ethnicity and geographical location on impotence and quality of life

    British Journal of Urology

    (1995)
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