Priority setting and rationing
- Topic
No system pays for everything; setting priorities with explicit criteria and a fair process is more ethical than hidden rationing.
What it is
Rationing means not giving someone a service that would help them because resources run short. It always happens, either explicitly (lists, published criteria) or implicitly (delays, paperwork, lack of supply). Priority setting means deciding by rules what is funded first. WHO proposes three criteria: cost-effectiveness, priority to the worse off and protection against impoverishing spending. Because theories disagree, a fair process is added: Daniels and Sabin's «accountability for reasonableness». This page expands «Allocation of scarce resources and triage», which covers acute scarcity and triage.
Key facts
- Levels: macro (national budget), meso (institution) and micro (patient). The doctor should not ration at the bedside on their own.
- QALYs and DALYs (disability-adjusted life-years) measure health benefit; the cost per QALY ranks interventions.
- Criticisms of QALYs: they value a life with disability less, ignore who receives the benefit and add up small benefits for many against large benefits for few.
- Rule of rescue: the urge to save an identifiable person at any cost; understandable, but it can divert resources from many unseen people.
- «Fair innings»: giving some priority to those who have lived fewer years; a contested criterion.
- Unacceptable trade-offs according to WHO: expanding low-priority services before nearly everyone has high-priority ones, or first covering only those able to pay.
Accountability for reasonableness (Daniels and Sabin)
| Condition | What it requires |
|---|---|
| Publicity | Decisions and their reasons are public |
| Relevance | The reasons are acceptable to fair-minded people and rest on evidence |
| Revision and appeals | There is a way to challenge, and the decision changes with new evidence |
| Enforcement | An authority ensures the other three are respected |
In clinical practice
- The doctor advocates for the patient and does not hide options for cost reasons; limits are set by public rules, not by private judgement.
- If a necessary service is denied, the patient is told how to challenge it (complaint, medical board, tutela).
- Avoiding futile spending is also justice: what gives no benefit is taken from another patient.
- On a priority-setting committee, declaring conflicts of interest and hearing affected patients is part of a fair process.
Legal framework in Colombia
- Statutory Law 1751 of 2015, art. 15: public funds do not pay for cosmetic or luxury services, services without evidence of safety, efficacy or effectiveness, unauthorised or experimental services, or services that must be provided abroad.
- Art. 15: exclusion is decided by the Ministry of Health through a technical-scientific, public, collective, participatory and transparent procedure, with independent experts, specialty associations and patients; it may not fragment a service already covered or affect people with orphan diseases (paragraph 3).
- Art. 12, literals d and e: people may take part in decisions on including or excluding services and in setting health priorities.
- Art. 6, paragraph: the principles are read together, without privileging one (for example, sustainability) over the others; art. 17: professional autonomy.
- Official text checked on 2026-11-13 at funcionpublica.gov.co.
Test yourself
Think of the answer, then tap the question to see it.
What is the difference between explicit and implicit rationing?
Explicit rationing uses public rules and criteria; implicit rationing limits access through delays, paperwork or lack of supply, without saying so.
What are the four conditions of accountability for reasonableness?
Publicity, relevance, revision and appeals, and enforcement (an authority checks that they are respected).
What three criteria does WHO propose for setting priorities on the path to universal coverage?
Cost-effectiveness, priority to the worse off and protection against impoverishing spending.
Why are QALYs criticised?
Because they can value the lives of people with disabilities or older people less and do not consider who receives the benefit.
What right does article 12 of Law 1751 recognise regarding priority setting?
The right to take part in decisions on including or excluding services and in setting health priorities (literals d and e).
Connections
Educational content on ethics and health law; not legal advice. Laws and case law change: each page links the official text and says when it was last checked. For a real case, read the text in force and ask a lawyer or the medical ethics tribunal.
Sources: Making fair choices on the path to universal health coverage (World Health Organization, 2014); Justice and Access to Health Care (Stanford Encyclopedia of Philosophy, 2017); Ley Estatutaria 1751 de 2015, arts. 6, 12, 15 y 17 (Función Pública, Gestor Normativo, 2015).
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Representative model, for educational purposes only.