Necessity under construction – societal weighing rationality in the appraisal of health care technologies

TH (Tineke) Vliek, AA (Antoinette) de Bont, A (Bert) Boer

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7 Citations (Scopus)


Health care coverage decisions may employ many different considerations, which are brought together across two phases. The assessment phase examines the available scientific evidence, such as the cost-effectiveness, of the technology. The appraisal then contextualises this evidence to arrive at an (advised) coverage decision, but little is known about how this is done.

In the Netherlands, the appraisal is set up to achieve a societal weighing and is the primary place where need- and solidarity-related (‘necessity’) argumentations are used. To elucidate how the Dutch appraisal committee ‘constructs necessity’, we analysed observations and recordings of two appraisal committee meetings at the National Health Care Institute, the corresponding documents (five), and interviews with committee members and policy makers (13 interviewees in 12 interviews), with attention to specific necessity argumentations.

The Dutch appraisal committee constructs necessity in four phases: (1) allowing explicit criteria to steer the process; (2) allowing patient (representative) contributions to challenge the process; (3) bringing new argumentations in from outside and weaving them together; and (4) formulating recommendations to societal stakeholders. We argue that in these ways, the appraisal committee achieves societal weighing rationality, as the committee actively uses argumentations from society and embeds the decision outcome in society.
Original languageEnglish
Pages (from-to)1-16
Number of pages16
JournalHealth Economics, Policy and Law
Publication statusPublished - 21 Oct 2020

Bibliographical note

Acknowledgements. We are first and foremost indebted to all our interviewees. Second, we wish to acknowledge our colleagues at the European Association of Medical Ethics for the opportunity to present this paper at their 2017 annual conference in Barcelona, Spain, and our colleagues at the Health Care Governance group at the Erasmus School of Health
Policy & Management for providing generous feedback on an early draft.


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