Health Policy 114 (2014) 226–235
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Review
Priority setting in health care as portrayed in South Korean and Israeli newspapers Roni Factor a , Minah Kang b,∗ a b
School of Criminology, University of Haifa, Mount Carmel, Haifa 31905, Israel Department of Public Administration, Ewha Womans University, Seoul, South Korea
a r t i c l e
i n f o
Article history: Received 13 April 2013 Received in revised form 6 August 2013 Accepted 6 December 2013 Keywords: Priority setting Health care allocation governance Content analysis Basket of services Newspaper reports
a b s t r a c t Studies have reported differences in the public’s understanding of, trust in, and satisfaction with its priority-setting processes and outcomes across countries. How the media frames and reports decision making processes and outcomes may both reflect and affect the public’s knowledge of and attitudes toward them. Nevertheless, no studies have analyzed how priority-setting decision making processes are portrayed in the media. We analyzed 202 newspaper articles published over a decade, from January 2000 through December 2009, in leading newspapers of Israel and South Korea. The findings reveal intriguing differences between the countries in both the number and content of the reports. The issue of priority setting is much less salient in Korean than in Israeli society. While the complexity of the task was the most prevalent theme in the Israeli reports sampled, benefits package expansion decisions were most common in the Korean reports. Similarly, the Israeli reports emphasized the qualifications and backgrounds of individual members of the decision making committee, but the equivalent Korean committee was not portrayed as a major actor, and so received less attention. The least reported theme in both countries was prioritysetting procedures and principles. These findings, along with results from previous studies which indicate that public satisfaction with the two systems differs between the countries, provoke several interesting future research questions. © 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The limited resources of nations and health care providers, along with the rapid development of expensive new health care technologies, make priority setting in health care systems unavoidable [1–3]. Priority setting is a complex task involving difficult, value-laden choices and painful decisions affecting various stakeholders, including the public and health care professionals [4]. Finding ways to
∗ Corresponding author at: Department of Public Administration, Ewha Womans University, 314 Posco-Bd, 11-1, Daehyun-dong, Seodaemu-gu, Seoul 120-750, South Korea. Tel.: +82 2 3277 4100; fax: +82 2 3277 4100. E-mail addresses: [email protected] (R. Factor), [email protected] (M. Kang). 0168-8510/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.healthpol.2013.12.003
ration and set priorities for limited public resources while making the process more systematic and transparent has thus become a critical policy agenda in many countries [5–7]. Across countries there seem to be differences in the public’s understanding of, trust in, and satisfaction with its priority-setting processes. For example, studies from Israel have found high trust in the country’s priority-setting procedures, with over two-thirds of the general public said to have trust or some trust in the system, and even greater levels of support among physicians [8]. On the whole, Israelis do not feel the public should have more say about the inclusion of new technologies in the health services basket offered citizens under the country’s national health insurance system, and they are comfortable not having a larger voice in the relevant ethical issues. In South Korea,
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however, the public are more likely to report a desire to participate in health care resource allocation. In one Korean survey conducted in 2005, 62.1% of the respondents said that such decisions should be made in consultation with the public or patient representatives [9]. The media are a mirror of public opinion on the one hand, and an instrument of social influence on the other [10,11]. Thus, how decision making processes and outcomes are reported in the media may both reflect and affect the public’s knowledge of and attitudes toward them. Nevertheless, although priority setting in health care systems has been extensively discussed in the literature [6,12–16], and a number of studies have surveyed or interviewed members of the public or patients in various countries [17–20], to the best of our knowledge, no studies have analyzed how these priority-setting decision making processes or outcomes in health care systems are portrayed in the media. To help fill this gap, the current study aims to explore the ways through which priority-setting mechanisms are presented to the public via the media in Israel and South Korea. Israel and South Korea have been in recent years the subject of several comparative studies in different fields [21]. Indeed, the two make good subjects for comparison, because while differing in important respects, including historical development and culture, they have a great deal in common. South Korea and Israel were both established in 1948, and both have democratic regimes (a parliamentary democracy in Israel, a presidential republic in South Korea). Both societies have been involved in continuous political and military conflicts, giving security issues an important role in policy making. The two countries had similar GDPs per capita (PPP) in 2011 ($28,809 in Israel and $29,786 in South Korea), and have similar levels of literacy [21–23]. Notably, for the purposes of the present study, both countries respect press freedom, which is protected by law or court rulings, and both have a thriving privately owned printed media: in 2010 Israel had nine dailies and South Korea had 11 [21–26]. And finally, both countries have publicly funded social insurance systems that have relatively short histories. The two systems provide mandatory and universal health insurance coverage to all citizens with a uniform benefits package. Despite these similarities, and particularly the similar histories of their health insurance systems, South Korea and Israel differ in key aspects of their priority-setting procedures, as well as levels of public satisfaction with health care decision making [3,25,27]. While to some degree these differences can doubtless be traced to aspects of the two society’s cultures and historical development, such an investigation is beyond the scope of the current study. Indeed, our concern here is less with the deeper origins of these differences than with the current role of the media in reflecting and propagating them. Specifically, using a comparative content analysis of news reports published in leading newspapers in South Korea and Israel, we aim to understand how the work of resource allocation decision makers is presented in the media of each country, and the implications of these media portrayals for both policy making and future studies on priority-setting processes.
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2. Background 2.1. The health care systems in Israel and South Korea The Israeli health care system is a mixed system with public and private components. The publicly funded social insurance system provides mandatory and universal health insurance coverage to its citizens. As stipulated by the Health Services Basket of the National Health Insurance (NHI) Law of 1995, basic services are funded through a tax paid by each adult citizen (currently 4.8% of the individual’s income) through Israel’s National Insurance Institute, and by direct government contributions. The law specifies a uniform benefits package – the National List of Health Services or Health Services Basket (HSB) – which provides coverage for basic care, delivered through four not-for-profit sick funds. The sick funds deliver services to their members through contracted providers or their own facilities based on a model similar to health maintenance organizations in the USA. In addition, the four sick funds are allowed to sell members supplemental coverage for services not included in the basic basket, and private insurance firms can offer insurance that covers both basic and additional services [1,2,5,28–31]. Like Israel, Korea has a compulsory social insurance system that provides universal health insurance coverage to its citizens, who pay a mandatory contribution. The scheme is financed by contributions from employers, employees, the self-employed, and from government subsidies. As of 2012, employees contribute 5.80% of their wages or salary, the same amount contributed by the employer. For the selfemployed, contributions are calculated based on various factors, including the householder’s income, assets, age, and gender. One of the distinct features of the Korean health care system that may be relevant to priority-setting decisions is the dominance of the private sector in the delivery of health care services. In the event of sickness or injury, the insured and their dependents are entitled to health insurance benefits, which consist of benefits in kind and in cash. The benefits package is the same for all population groups [27]. 2.2. Priority setting in Israel and South Korea 2.2.1. Israel Israel’s National Health Insurance law provides two mechanisms for adjustment of the health services basket. The first is an automatic annual update of the total cost of the HSB based on several economic and social indices, including a health costs index, population growth figures, and aging rates. The second gives parliament the right to add items to the HSB on condition that the government makes a sufficient budget available. The process of updating the HSB began toward the end of 1998, with the creation of a National Advisory Committee charged with considering the addition of new services [1–3,5,8,30]. The committee has about 20 members (the exact number varies from year to year) who are appointed by the Ministers of Health and Finance; they include Health and Finance Ministry representatives; medical doctors from the four sick funds and public hospitals;
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other members of the Israeli Medical Association; health economists; and professionals from the areas of medicine, ethics, and the social sciences. The choice of committee members is designed to ensure that different stakeholders’ opinions will be heard and considered [1,3,30]. When the time comes to update the HSB, each potential new drug or technology is assessed from many perspectives: clinical, epidemiological, economic, social, legal, and ethical. The initial stages of evaluation entail several layers of analysis by the Ministry of Health; the Ministry’s findings are then turned over to the committee for review and decision making. The stages in the process are as follows: (1) Proposed technologies are submitted to the Ministry of Health by various stakeholders such as the public, physicians, medical staff, administrators, professional associations, and companies. (2) A list of new proposed technologies is created. (3) This list undergoes initial screening by the Medical Technologies Administration, a unit of the Ministry of Health. (4) The technologies that passed the initial screening undergo comprehensive assessment (clinical, epidemiological, and economic). This stage includes extensive data collection and consultation with the Israeli Medical Association. (5) The Medical Technologies Forum, chaired by the head of the Medical Technologies Administration, prepares a list of recommended technologies, divided into three main categories. These recommendations are submitted to the National Advisory Committee to be used as background material for its discussions. (6) The committee makes its decisions. Finally, (7) the decisions are submitted to the government for approval [2,3,7,29]. The vast majority of the committee’s decisions are reached using a consensus process, so most decisions are made unanimously. Only once have the committee’s members been asked to vote. The public committee meets several times a year and, though its meetings are closed to the public, in 2005 deliberations were opened to representative of the media, and the committee’s activities are now covered by the press on a regular basis [8]. While in the first few years following its inception the committee was treated by the press and the public with great respect, in recent years, its procedures and members have been the object of criticism and various allegations of misconduct [2]. 2.2.2. South Korea Under the National Health Insurance Act of 1997, health care benefits are set by the Health Insurance Policy Deliberation Committee (hereinafter “Deliberation Committee”). The Deliberation Committee consists of 24 members, plus the Vice Minister of Health and Welfare, who serves as committee chair. The 24 committee members are selected to balance the interests of major stakeholders and are divided equally among three categories: purchasers and beneficiaries (e.g., employees, employers, farmers, and consumers); the medical and pharmaceutical sectors; and public bodies (the Ministry of Health and Welfare [MOHW], the Ministry of Strategy and Finance, the National Health Insurance Corporation [NHIC], and the Health Insurance Review and Assessment Service [HIRA]), along with academic experts. Representatives are selected by the relevant consumer, professional, or trade association or Ministry and appointed
by the MOHW for a term of three years. The committee meets when major agenda items come up, rather than on a regular basis. The meetings are not open to the public. Notably, the stages for making benefit coverage decisions differ from those in Israel in that the Deliberation Committee is in practice normally limited to approving decisions made by the MOHW. The typical stages are as follows: (1) companies submit new drugs or technologies to the HIRA for inclusion in the benefits package; (2) the application is reviewed by in-house staff and outside experts; (3) the Drug Reimbursement Evaluation Committee (DREC) makes a recommendation; (4) the NHIC negotiates the price of the recommended drugs or technologies; (5) the Deliberation Committee confirms the recommendation; and (6) the MOHW announces the decision. (For a comparison of the schematic stages of the priority-setting process in Israel and South Korea, see Table 1.) 3. Materials and methods 3.1. Data The data for the current research were based on articles reporting on resource allocation decision making in health care – i.e., priority setting in the health services basket – published in major South Korean and Israeli newspapers from January 2000 through December 2009. Since our main interest was news reports, and in order to reduce biases in the data due to newspapers’ political color, we did not include in our dataset articles published as editorials or commentary. We obtained the Israeli articles by searching the online archive of Haaretz. Haaretz is among the top three daily newspapers sold in Israel. We used the keywords “National Advisory Committee AND health basket” or “National Advisory Committee AND drug basket”. The search yielded 131 articles, which were then accessed manually from the library’s microfilm collection. For the South Korean articles, we initially searched the online archive of Dong-Ah Ilbo, which is the largest newspaper in the online database. We used similar keywords as in the Israeli search: “NIH coverage AND Health Insurance Deliberation Committee,” “Health Insurance Policy Deliberation Committee,” “benefit decision criteria AND KNHI,” and “Ministry of Health AND benefits coverage”. As the search yielded only 44 articles (only about a third of the number found in the Israeli paper), we conducted an additional search in a second newspaper, Hankyoreh Shinmun, which is among the top six sellers in Korea. This search yielded 71 articles. Because the Israeli data came from one newspaper and the Korean data from two, we handled the qualitative and quantitative analyses in different ways. First, for the qualitative analysis, we read and analyzed the articles from the two Korean papers separately. Despite their differing political colors – Dong-A Ilbo is rather conservative while Hankyoreh Shinmun is left-of-center – we could not find content-wise differences between them, and they produced the same order of subthemes. In the quantitative analyses, to ensure consistency between the Israeli and Korean datasets, we drew on the data only from Hankyoreh
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Table 1 A comparison of the schematic stages of the priority setting process in Israel and South Korea. Israel
South Korea
Submission of proposed technologies Application review in-house by the Medical Technologies Administration in Ministry of Health and through outside experts Recommendation of priority setting by the Medical Technology Forum in the Ministry of Health
Submission of proposed technologies Application review in-house by the Ministry of Health and Welfare and through outside experts Recommendation of priority setting by the Drug Reimbursement Evaluation Committee Negotiation of the price of the technologies by the National Health Insurance Corporation Confirmation of the recommendations by the Deliberation Committee Announcement of the decisions by the Ministry of Health and Welfare
Decision making by the committee Approval of the recommendation by the government and official announcement to the public
Shinmun, which had the higher number of articles. The final sample of Korean articles used in the quantitative analysis was thus 71.
and most of the themes were discussed in a similar manner over the years. In South Korea, we did observe some changes over time, which will be described below.
3.2. Method of analysis
4.1. Israel
The articles were analyzed qualitatively following Strauss and Corbin’s [32] and Mason’s [33] guidelines for qualitative research using a two-stage process. First, the articles were screened by the researchers and were read literally and interpretively in order to identify broad themes. These were indexed into analytical categories which represent key substantive topics. Then, the articles were read again and their content analyzed to identify more specific themes and categories. At this point, we counted the number of articles dealing with each of these themes and categories to produce a quantitative analysis. Finally, we compared the Korean and Israeli articles in terms of these themes and categories. Throughout the process, the articles were read in their original language by one of the researchers.
Table 2 shows the four main themes and 14 subthemes appearing in the Israeli articles in order of prevalence.
4. Results Tables 2 and 3 summarize the results of the review of the Israeli and South Korean articles respectively. The righthand column in each table shows the number of articles that cover a given subtheme or category. Since many articles discuss more than one category, the total number in this column exceeds the total number of articles that were analyzed. Four broad themes were identified for both countries: (1) the complexity of the task (due to ethical, budgetary and political considerations); (2) benefits package decisions arrived at (including decisions on the contents of the HSB and fees or premiums charged); (3) the composition of the committee, or formal actions by or involving it (e.g., appointment of members; announcements of decisions); and (4) priority-setting procedures and principles (including both broad ethical issues and the committee’s specific working procedures). Within these four broad groups, the researchers identified 11 (Korea) or 14 (Israel) more specific categories. The themes and categories are discussed in greater detail in the following sections. In addition, we conducted a longitudinal analysis of the reports in both sets of newspapers over the research period. In Israel, we observed no conspicuous changes over time,
4.1.1. Reports on the complexity of the task The most prevalent theme in the Israeli newspaper, appearing in over a third of the articles (94, or 39%), centers on the difficulty of the task facing the committee. The most prevalent key topic within this theme is the pressure of budget constraints. Many articles point out that the government’s allocated budget for the HSB is extremely small relative to the cost of new medical technologies that could be added to the basket, and consequently the committee faced the difficult, even impossible, task of selecting the most important among them. Typical citations include: “The committee was forced to make decisions subject to impossible priority-setting constraints. Ultimately only a sixth of the medicines and technologies brought before the Ministry of Health were added to the HSB.” (Haaretz, 01/06/2000) Indeed, some articles report that the government had not only failed to allocate a sufficient budget to the HSB, but was threatening to cut funding. The articles report the potentially negative consequences of this situation for patients: “[Some sick persons] will be doomed to die, and others will be sentenced to imperfect treatment instead of the best possible treatment that medicine can offer. This is because Ministry of Finance officials, with the backing of the Minister of Finance, are asking to cut the HSB, or in less severe cases not to add anything to it” (Haaretz, 12/30/2003). The second most prevalent topic, the physical and psychological burden of the task on the committee’s members, was reported in twenty-eight articles. This can be seen, for instance, in the following typical citations: “. . .impossible mission. . . some people must determine the destiny of the sick in Israel, who will leave orphans after him and who will see her grandchildren” (Haaretz, 03/19/2006)
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Table 2 Main themes and categories, Israel, 2000–2009. Theme
Category
Typical content
No. (%)
Complexity of the task (94, 39%)
Budget constraints
The budget is too small relative to the cost of drugs/technologies that should be included in the basket; description of the gap between the allocated budget and the needed drugs/technologies; the difficult task of the committee in setting priorities in light of the restricted budget; the consequences of the small budget The committee’s deliberations very difficult; long discussions; moral decisions; hard questions; meticulous screening work; the committee members are forced to determine destinies; life and death decisions; resignation of committee members; By the Health Minister, Ministry of Health, Israel Medical Association, members of parliament, the committee; description of the negotiations; announcements of budget increase Pressure from the public, pharmaceutical companies, senior physicians, Medical Association, etc. Disagreements regarding mental health drugs, the use of the drugs, what to exclude from the recommended list; protests of some members against the committee on government decisions
34 (14%)
Descriptions of the committee’s difficult task
Attempts to increase the allocated budget
Attempts to influence or change decisions Disagreements among committee members
Decisions on benefits package (61, 25%)
Drugs, treatments, and services recommended by the committee
Type and cost of drugs, treatments, and services brought before the committee Drugs, treatments, and services not included in the basket The committee (47, 19%)
Committee appointments
Formal announcements Submission and confirmation of recommendations by the government
Priority setting procedures and principles (41, 17%)
Principles for inclusion of drugs, treatments, and services
Procedures of the committee
Committee deliberations Total
“. . .the last battle of the HSB. . .the crucial deliberation over the HSB started at 4:00 am. . .after long hours of arguments and struggles. . .after all, the committee’s members are those who will have to look straight in the eyes of the patients who do not get required medicines and explain the considerations to them” (Haaretz, 12/24/2008) In this vein, there are several descriptions of the adverse physical environment where the committee’s discussions
28 (12%)
16 (7%)
9 (4%) 7 (3%)
Type, quantity, conditions covered (cancer, rape, pregnancy termination, Parkinsons, blood pressure, heart failure, depression, AIDS, asthma); type of patients who will benefit; expanding the treatment and groups covered; costs; recommendation of drugs/technologies that do not require extra budget Type and purpose of drugs/technologies; costs; how funded
15 (6%)
Types; reasons (economic and medical)
14 (6%)
Signing the letter of appointment for the committee’s members; composition and members of the committee – number, affiliation, current and past positions; members given prestige and recognition; number of meetings End of the committee’s work; committee’s decisions; press conference presenting the decisions Submission of recommendation to: the Health Council, Health Minister, government; by the committee’s chairman/Ministry of Health General Manager; confirmation of the committee’s recommendations by the government
21 (9%)
Will drugs/technologies save lives, extend lives, or improve the quality of life; will they help large/small population; are drugs/technologies essential, very high priority, high priority; the availability of generic drugs; options that will not increase expenses; the committee’s job is to weigh all considerations including ethical and social factors; groups with special needs (vulnerable populations, elderly, infants, etc.) Get initial list from the Ministry of Health; ranking of drugs/technologies; consultations with specialists; procedures not officially set; decisions by consensus/voting Deliberations are closed to the public; cancelation of protocol writings; opening deliberations to the press
32 (13%)
19 (8%) 7 (3%)
25 (10%)
9 (4%)
7 (3%) 243 (100%)
took place: “The deliberations took place in a small, packed, and choking room; the refreshments were poor” (Haaretz, 12/24/2008). The next three categories deal with pressure from various stakeholders, including the Minister of Health, the Israeli Medical Association, members of parliament, and the chair and members of the committee, to influence or change the committee’s decisions and the budget allocated to the HSB. There were several reports about disagreements among the committee’s members about the inclusion and
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Table 3 Main themes and categories, South Korea, 2000–2009. Theme
Category
Typical content
No. (%)
Decisions on benefits package (75, 39%)
Drugs, treatments, and services included by the committee Decisions to raise the insurance premium Decisions to change the fee schedule
Type, quantity, conditions covered; type of patients who will benefit (children, elderly, etc.); expected total cost Decision to raise premiums, decision not to raise premiums Decision to increase/reduce payments to providers, decision to lower drug prices Type, quantity, conditions covered; type of patients who would have benefited
32 (17%)
Drugs, treatments, and services not included in the basket The committee (59, 31%)
Formal announcements
Committee appointments
Complexity of the task (43, 22%)
Response from society
Disagreements among committee members
Budget constraints/surplus Priority setting procedures and principles (15, 8%)
Principles for inclusion of drugs, treatments, and services Decision-making procedures
The Ministry of Health and Welfare announced the committee’s priority-setting decisions, the Ministry announced the committee’s decisions to raise premiums, the Ministry announced the committee’s decision to change the fee schedule The committee made priority-setting decisions, the committee confirmed the government’s plan for priorities; The committee made insurance premium decisions, the committee made fee schedule changes Committee members and composition – number, affiliation, current and past positions, prestige and recognition Patients and citizen group resistance to insurance premium rise, provider group resistance to reduction in fees; patient/citizen group and business group resistance to increased fees Conflict among committee members about the fee schedule, protests of some members against the committee on government decisions Conflict among committee members about raising insurance premiums; protests of some members against the committee on government decisions Conflict among committee members about priority setting Deficit is expected to increase; huge deficit is expected Huge budget surplus, where to spend the budget surplus Catastrophic disease; groups with special needs (elderly, children, pregnant women); patient burdens, universality, effectiveness, etc. Decisions by consensus/voting within the committee; public hearings will be held, public opinion surveys will be conducted
21 (11%) 18 (9%) 4 (2%) 42 (22%)
14 (7%)
3 (2%)
17 (9%)
7 (4%)
5 (3%)
1 (1%) 8 (4%) 5 (3%) 10 (5%)
5 (3%)
192 (100%)
Total Note: In order to avoid bias due to duplicate reporting, only the articles in Hankyoreh Shinmun were counted to prepare this table.
use of different drugs, or individual members’ protests against decisions. 4.1.2. Reports on the benefits package The second most prevalent theme, appearing in about a quarter of the articles (61, 25%), is straightforward reporting about the drugs and technologies brought before the committee. Articles in this group report on drugs and technologies at all key stages in the deliberative process: those brought before the committee; those recommended (or not recommended) by the committee; and those ultimately included or not included in the HSB, following the final government-approval stage. These reports typically include the name of the medicine or procedure, the disease they treat, the cost, and the type of patients who will benefit. 4.1.3. Reports on the committee As can be seen from Table 2, 47 articles (about 19%) report on the committee itself – its composition, or formal actions by or involving it, such as appointments
and announcements. In most of the studied years the same ritual of appointing the committee was reported: e.g., “The Minister of Health, Nissim Dahan, yesterday signed the letter of appointment for the HSB committee’s members. . .Like last year, the head of the committee will be Professor Avi Israeli, former manager of Hadassah hospital” (Haaretz, 10/29/2001). As that quotation suggests, strong emphasis is placed on the qualifications of both the committee as a whole and its individual members. This classification also includes formal announcements made by the committee. These might be, for example, the committee’s recommendations – “The HSB committee recommended yesterday adding eight medicines and medical technologies” (Haaretz, 7/16/2003) – or confirmation of the committee’s recommendations by the government’s Health Council: “The Health Council yesterday approved the HSB committee recommendations” (Haaretz, 02/29/2008). Committee appointments or decisions are presented to the public through a press conference with the participation of the Minister of Health, the Ministry of Health General Manager, and the committee chair.
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4.1.4. Reports on priority-setting procedures and principles The last of the four broad themes centers on the procedures and principles that guide the committee in its deliberations on policy decisions. These issues appear in 41 articles (about 17%), and can be further divided into three subthemes. The first of these involves the thorny social and ethical considerations by which all new drugs and technologies must be judged: for instance, whether they are designed to save life, extend life, or improve the quality of life; the size and nature of the populations likely to benefit from them; and the availability of alternatives. The second involves descriptions of the committee’s operating procedures: not formal announcements, as described above, but reports on the committee’s day-today working procedures – its deliberations, consultations, and votes. The third comprises discussions of issues related to these working procedures, such as the fact that the deliberations are closed to the public. 4.2. South Korea As noted above, the same four broad themes emerged from the Korean articles as from the Israeli sample. However, the prevalence among the four broad themes differs between the two countries. Reports on the benefits package were most frequent, followed by reports on the committee. The complexity of the procedure was emphasized less in the Korean than in the Israeli media. Similarly to the Israeli case, reports on priority setting procedures and principles ranked last. The subthemes and categories emerging from the Korean articles also differed from those in Israel. The quantitative analysis of some of the subthemes revealed interesting patterns. For this reason, the major subthemes shown in Table 3 differ from those in Table 2. The four themes are discussed here in their order of prevalence in Hankyoreh Shinmun. 4.2.1. Reports on the benefits package Unlike in Israel, the largest group of articles in Korea (75, or 39%) deal with decisions made by the Deliberation Committee. Many of these deal with expansion of the benefits package or reduction of fees, so they appear to present mainly “good” news. For instance, 32 articles (about 17% of the total) describe the addition of new services, treatments, or drugs to the KNHI, compared with only four articles (about 2% of the total) dealing with decisions to exclude such drugs or treatments. The following is a typical report: “The Ministry of Health and Welfare today announced that the Insurance Policy Deliberation Committee has decided to include Enbrel injections for treatment of ankylosing spondylitis in the Korean NHI benefit package. Due to this decision, patients’ out-of-pocket cost for the medicine over nine months will decrease from 13,000,000 Korean won to 2,600,000 Korean won.” (Hankyoreh 04/28/2005) Interestingly, while many articles report on policy decisions vis-à-vis the benefits package, there are very few reports on why those decisions were made. Indeed, of the
32 articles discussing expansion of the HSB, only 2 discuss the rationales for those decisions. 4.2.2. Reports on the committee Reports on the Deliberation Committee made up the second-largest group in our quantitative analysis (59, or 31%). But this finding requires some explanation. In contrast to what we observed in Haaretz vis-à-vis the Israeli public committee, in the Korean newspapers the Deliberation Committee is not presented as a major actor in the story during the study period. In fact, the largest group of articles that we have classified under the rubric “formal actions by or involving the committee” actually refer, in the Korean case, to announcements by the Ministry of Health and Welfare. The committee appears to be regarded as a secondary body that approves and confirms decisions by the MOHW. For example, in 2005, after his visit to a children’s ward at a tertiary hospital in Seoul, Hankyoreh reported Minister Kim Guen-Tae’s promise that “the government will develop a policy to cover children’s health care expenditures this year. The plan will be instituted and implemented after it is discussed in the Committee meeting and confirmed” (Hankyoreh, 09/20/2005). Along with the limited reporting on the committee as a whole, news reports on the individual members of the committee were also uncommon. Unlike in the case of Israel, we found no reports on the composition of the committee or the names and qualifications of particular members during the study period. Only in a few instances did reports mention the chair of the committee, who is the Vice Minister of Health and Welfare. 4.2.3. Reports on the complexity of the task During much of the period of the study, from 2001 through 2005, budget constraints were mentioned in the Korean publications relatively infrequently, in contrast to the case in the Israeli newspaper. During this period, KNHI enjoyed a budget surplus. Accordingly, news reports from that period cover discussions on the need to expand the benefits package and where to spend the surplus (e.g., Dong-A, 12/03/2004; Hankyoreh, 11/28/2003). This may in part explain why relative to Israel, there were few reports on the complexity of priority setting in Hankyoreh during the study period – only 43, or 22%. Beginning in 2006, the implementation of the expansion produced unexpected expenditures, and the number of reports on concerns about potential budget constraints increased sharply. Still, even at that time, the Korean news reporting focused chiefly on rising insurance premiums rather than the effects of priority-setting decisions on the benefits package. For example, the government’s announcement to increase the insurance premium by 6.5 percentage points to address the potential budget constraints and harsh criticism by citizens’ groups and business groups, who would bear the cost of the higher premiums, were the major news agenda (Hankyoreh, 11/18/2006; Dong-A, 12/02/2006). In contrast, there were few media reports about priority-setting decisions, in particular on the idea of rationing in the selection of drugs, treatments or services.
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4.2.4. Reports on priority-setting procedures and principles As in Israel, the theme that appeared least often in the Korean newspapers was decision-making principles and procedures (15, or 8%). As noted above, most reports of announcements made by the MOHW do not discuss how the decisions were reached, who was involved in examining the issues or presenting evidence, how evidence was verified, and who was accountable for decisions. Only a few reports noted that there would be public hearings and debates where the government plan would be discussed by diverse parties. In a few cases, when the agenda was politically challenging, decisions were reported to have been made by a vote among the committee members. For example, the decision in 2002 to lower payments to medical providers was reported to have been decided by a committee vote, with 10 of 19 members voting in favor (Dong-A, 2/28/2002).
5. Discussion The current paper sought to study how priority setting and decision making in relation to the national basket of insurance benefits are portrayed to the public through the media. We analyzed 202 newspaper articles published over a period of ten years in Israel and South Korea, concentrating in both cases on the functions, role, character, processes, and actions of the committee charged with overseeing priority setting in its country: the Deliberation Committee in South Korea and the public National Advisory Committee in Israel [3,27]. This rich dataset allows us to derive interesting conclusions regarding the portrayals of priority-setting processes and outcomes in the two countries. The findings revealed interesting differences between the two countries. The most prevalent theme in the Israeli newspaper reports sampled was the complexity of the task faced by the HSB committee, with the key issues being budget constraints, moral and ethical questions, and efforts by different stakeholders to influence or change the committee’s decisions. In South Korea, on the other hand, this theme was not salient in the reports sampled. Instead, reports about benefits package decisions were found to be most frequent in South Korea, with most such reports focusing on expansion of the benefits package, while in Israel such reports were ranked second in our analysis. We also found considerable differences in the contents of reports on formal actions by or involving the committee. In Israel, the committee is reported as the main actor in priority setting, whereas in South Korea, it is the Ministry of Health and Welfare; the Korean committee seems to perform a secondary role that approves and confirms decisions by the MOHW. The Israeli articles sampled include many on the committee’s appointment, composition of the committee, and announcements of committee decisions (in many cases followed by a press conference), with heavy emphasis on the qualifications and prestigious backgrounds of individual members. The Korean reports rarely center on the committee itself, with almost no mention of the composition of the committee or the names and qualifications of its members. The committee is rarely referred to as
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the decision maker, but typically is reported as confirming decisions by the MOHW. The least reported theme in both countries was prioritysetting procedures and principles. This was particularly striking in the Korean sample, where only rarely were the principals or rationales behind decisions given. The Israeli sample included somewhat more reports dealing with priority-setting considerations, such as whether a treatment would save, extend, or improve the quality of life, and how many people were likely to benefit. Besides the differences in the content of the reports, it was intriguing to find a difference between the countries in the number of reports on priority setting in the HSB. While in Israel the keywords “health basket” and “drug basket” yielded 131 relevant articles from one leading daily newspaper, in South Korea even a broader search in a similar type of leading daily paper produced only 71 reports. According to this relatively limited search, there appear to be almost two times more reports on the HSB in Israel than in Korea. This finding appears to testify that the issue of priority setting in the health basket is much less salient in Korean than in Israeli society, and it raises interesting questions about the causes and implications of this difference. These differences between South Korea and Israel may reflect the countries’ different cultures [25]. Culture reflects society’s norms and values and affects the way members of society perceive and respond to events in the world around them [34–36]. Therefore, it is likely that the two countries’ different cultural contexts influence the prioritysetting mechanism in each, and the way it is portrayed in the media. In the current study we do not have the empirical tools needed to test this assumption, which offers scope for further studies. This study has some limitations. First, we sampled only one or two leading newspapers in each country. Choosing different newspapers might produce somewhat different conclusions, especially to the degree that news reports are influenced by a paper’s political color. Also, we did not include in our dataset articles published as editorials or commentary, so the media’s own perspectives may not be reflected in our analysis. In addition, the current research design makes it difficult to draw causal conclusions regarding the relationship between media reports and public attitudes toward and satisfaction with the health care system and its priority-setting mechanisms. Nor can the current research shed light on the mechanisms by which information published in the media shapes public support – a process that is in general poorly understood. Nevertheless, we believe that our findings stimulate the generation of hypotheses that can be tested empirically in future research. For example, differences between Israel and Korea in attitudes, trust, and satisfaction with the national health insurance system and its priority-setting procedures which were documented in previous studies [9,37,38] may be related to the differences in the newspaper reports found in this study. Media reporting on the sensitive issues and dilemmas that underlie the process of priority-setting decision making (as in Israel), rather than merely a focus on decision outcomes (as in South Korea), may make the process more transparent and increase public trust in how it
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is carried out. Transparency and public involvement are crucial to ensure public support for the process whereby national health care systems weigh competing drugs and treatments likely to benefit different populations in a world of limited resources [1,3]. It is likely that Israelis are happy to leave the knotty ethical issues to designated experts because media reports keep them informed about the work that is going on behind the scenes, whereas South Koreans want citizens and patients to have more say. Another factor that might well affect support for priority-setting decision making systems is the extent to which the decision makers are presented to the public as apolitical and their qualifications and professional characteristics are highlighted [39]. In our study, we found that the Israeli reports we analyzed, but not the Korean reports, kept readers informed about the qualifications of the people charged with making resource allocation decisions. Moreover, these individuals are portrayed as professionals and respected public figures who are working voluntarily, as a public duty. In South Korea, the actors presented to the public tend to be political figures or institutions, such as the Minister or Ministry of Health and Welfare. Such reporting might well have a symbolic influence on public trust and satisfaction with the process. Future studies might address other important questions as well. For example, to what extent do the Ministry of Health or other government agents influence the reported news? How do the countries’ political and cultural contexts affect both media reporting and public attitudes toward the priority-setting process? Do different levels of popular trust in the government, or in specific government agencies, affect satisfaction with the two countries’ priority-setting systems? Finally, to what extent do commercial considerations influence reporting in the two countries – for example, the reputed propensity of news organizations to report more “bad news” than “good news”, on the grounds that bad news presumably sells more papers? Other complex social and cultural factors may also be at work, and should be considered and controlled for in future studies. 6. Conclusion Our study contributes to the literature on priority setting in health care by reporting on the media’s portrayal of the priority-setting mechanisms in Israel and Korea, two countries that have not yet been well studied in this context. Although the health insurance systems and benefits package structures in Israel and South Korea have much in common [1,27], the current study – which is, as far as we know, the first to analyze media reporting on priority-setting decision-making – documented meaningful differences in reporting on priority setting in health care in the two nations. While this study could not empirically examine either the origins or the consequences of these differences, we can speculate that the different styles we observed may have a real-world impact on public trust in health care policy making, as suggested by previous findings that Israelis and South Koreans report differing levels of public satisfaction with their systems [8,9]. Together, the current and previous findings suggest that greater
public trust and support for priority-setting mechanisms are likely to be associated with media reports that (a) highlight socially sensitive issues and moral dilemmas, (b) present decision makers as apolitical qualified professionals, and (c) present more clearly defined principles and procedures – all acts which make the decision making process more transparent. We hope that the qualitative findings presented above will encourage researchers from different disciplines to continue the study of this important issue, and thereby to suggest ways of improving the public’s trust and satisfaction with the priority-setting procedures in each country.
Acknowledgement This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2012S1A3A2033416) to Minah Kang.
References [1] Greenberg D, Siebzehner MI, Pliskin JS. The process of updating the National List of Health Services in Israel: is it legitimate? Is it fair. International Journal of Technology Assessment in Health Care 2009;25:255–61. [2] Seidman GI. Regulating life and death: the case of Israel’s Health Basket Committee. Journal of Contemporary Health Law Policy 2006;23:9–63. [3] Shani S, Siebzehner M, Luxenberg O, Shemer J. Setting priorities for the adoption of health technologies on a national level—the Israeli experience. Health Policy 2000;54:169–85. [4] Daniels N. Symposium on the rationing of health care: 2. Rationing medical care—a philosopher’s perspective on outcomes and process. Economics and Philosophy 1998;14:27–50. [5] Guttman N, Shalev C, Kaplan G, Abulafia A, Bin-Nun G, Goffer R, et al. What should be given a priority—costly medications for relatively few people or inexpensive ones for many? The Health Parliament public consultation initiative in Israel. Health Expectations 2008;11:177–88. [6] Ham C, Coulter A. Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices. Journal of Health Services Research and Policy 2001;6:163–9. [7] Tal O, Hakak N. Early awareness and alert systems for medical technologies in Israel. International Journal of Technology Assessment in Health Care 2012;28:333–8. [8] Chinitz D, Meislin R, Alster-Grau I. Values, institutions and shifting policy paradigms: expansion of the Israeli National Health Insurance Basket of Services. Health Policy 2009;90:37–44. [9] Lee S-Y, Cho M-W, Suh N-K, Lee Y-G, Choi S. Achieving social consensus for health care resource allocation. Seoul: National Health Insurance Corporation; 2005 [in Korean]. [10] Bauer MW, Howard S, Hagenhoff V, Gasperoni G, Rusanen M. The BSE and CJD crisis in the press. In: Dora C, editor. Health, hazards and public debate: lessons for risk communication from the BSE/CJD Saga. Geneva: WHO; 2006. p. 125–64. [11] Hind D, Wailoo AJ, Sutcliffe P. Demands for ‘off-licence’ access to trastuzumab (Herceptin): content analysis of UK newspaper articles. Health Expectations 2011;14:38–47. [12] Baltussen R, ten Asbroek AH, Koolman X, Shrestha N, Bhattarai P, Niessen LW. Priority setting using multiple criteria: should a lung health programme be implemented in Nepal. Health Policy and Planning 2007;22:178–85. [13] Klein PG. New institutional economics. SSRN eLibrary 1998. [14] Bryant J, Coulter A, Ham C. Health priority dilemmas in developing countries. The Global Challenge of Health Care Rationing 2000;6:3–74. [15] Terry LM. An integrated approach to resource allocation. Health Care Analysis 2004;12:171–80. [16] Kapiriri L, Norheim OF, Heggenhougen K. Public participation in health planning and priority setting at the district level in Uganda. Health Policy and Planning 2003;18:205–13.
R. Factor, M. Kang / Health Policy 114 (2014) 226–235 [17] Bhatia M, Rannan-Eliya R, Somanathan A, Huq MN, Pande BR, Chuluunzagd B. Public views of health system issues in four Asian countries. Health Affairs 2009;28:1067–77. [18] Abelson J, Miller FA, Giacomini M. What does it mean to trust a health system? A qualitative study of Canadian health care values. Health Policy 2009;91:63–70. [19] Lasry A, Carter MW, Zaric GS. Allocating funds for HIV/AIDS: a descriptive study of KwaDukuza, South Africa. Health Policy and Planning 2011;26:33–42. [20] Hyder AA, Corluka A, Winch PJ, El-Shinnawy A, Ghassany H, Malekafzali H, et al. National policy-makers speak out: are researchers giving them what they need. Health Policy and Planning 2011;26:73–82. [21] Schejter A, Lee S. The evolution of cable regulatory policies and their impact: a comparison of South Korea and Israel. Journal of Media Economics 2007;20:1–28. [22] The World Bank. Open Data Services; 2013. [23] International Monetary Fund. Government finance statistics yearbook. Washington, DC: International Monetary Fund; 2010. [24] Levi-Faur D. The developmental state: Israel, South Korea, and Taiwan compared. Studies in Comparative International Development 1998;33:65–93. [25] Maman D. The emergence of business groups: Israel and South Korea compared. Organization Studies 2002;23:737–58. [26] Korea Press Foundation. Media Statistics Information System 2013. [27] Kim MK. Access to health care in Korea: universal but limited access. In: Exter Ad, editor. International Health Law: solidarity and justice in health care access. Antwerpen-Apeldoorn: Maklu; 2008. [28] Gross R, Rosen B, Chinitz D. Evaluating the Israeli health care reform: strategy, challenges and lessons. Health Policy 1998;45:99–117. [29] Gross R, Rosen B, Shirom A. Reforming the Israeli health system: findings of a 3-year evaluation. Health Policy 2001;56:1–20.
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[30] Luxenburg O. Technology assessment and setting priorities for the adoption on a national level—the Israeli experience. Stanford, CA: Technology and Outcomes Assessment for Health Care Policy Reform; 2007. [31] Hammerman A, Feder-Bubis P, Greenberg D. Financial risk-sharing in updating the national list of health services in Israel: stakeholders’ perceived interests. Value in Health 2012;15:737–42. [32] Strauss AL, Corbin JM. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, CA: Sage Publications; 1990. [33] Mason J. Qualitative researching, 2nd ed. London; Thousand Oaks, CA: Sage Publications; 2002. [34] Swidler A. Talk of love. Chicago/London: The University of Chicago Press; 2001. [35] Factor R, Mahalel D, Yair G. The social accident: a theoretical model and a research agenda for studying the influence of social and cultural characteristics on motor vehicle accidents. Accident Analysis and Prevention 2007;39:914–21. [36] Hofstede G. Culture’s consequences: comparing values, behaviors, institutions, and organizations across nations, 2nd ed. Thousand Oaks, Calif: Sage Publications; 2001. [37] Gross R, Brammli-Greenberg S, Matzliach R. Public opinion on the level of service and performance of the health care system ten years after the introduction of National Health Insurance. Jerusalem: Myers-JDC-Brookdale Institute; 2007. [38] National Health Insurance Corporation. The public satisfaction with the NHI system: a national survey of 2008. Seoul: National Health Insurance Corporation; 2009. [39] Factor R, Oliver AL, Montgomery K. Beliefs about social responsibility at work: comparisons between managers and non-managers over time and cross-nationally. Business Ethics: A European Review 2013;22:143–58.
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Health Policy journal homepage: www.elsevier.com/locate/healthpol
Review
Priority setting in health care as portrayed in South Korean and Israeli newspapers Roni Factor a , Minah Kang b,∗ a b
School of Criminology, University of Haifa, Mount Carmel, Haifa 31905, Israel Department of Public Administration, Ewha Womans University, Seoul, South Korea
a r t i c l e
i n f o
Article history: Received 13 April 2013 Received in revised form 6 August 2013 Accepted 6 December 2013 Keywords: Priority setting Health care allocation governance Content analysis Basket of services Newspaper reports
a b s t r a c t Studies have reported differences in the public’s understanding of, trust in, and satisfaction with its priority-setting processes and outcomes across countries. How the media frames and reports decision making processes and outcomes may both reflect and affect the public’s knowledge of and attitudes toward them. Nevertheless, no studies have analyzed how priority-setting decision making processes are portrayed in the media. We analyzed 202 newspaper articles published over a decade, from January 2000 through December 2009, in leading newspapers of Israel and South Korea. The findings reveal intriguing differences between the countries in both the number and content of the reports. The issue of priority setting is much less salient in Korean than in Israeli society. While the complexity of the task was the most prevalent theme in the Israeli reports sampled, benefits package expansion decisions were most common in the Korean reports. Similarly, the Israeli reports emphasized the qualifications and backgrounds of individual members of the decision making committee, but the equivalent Korean committee was not portrayed as a major actor, and so received less attention. The least reported theme in both countries was prioritysetting procedures and principles. These findings, along with results from previous studies which indicate that public satisfaction with the two systems differs between the countries, provoke several interesting future research questions. © 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The limited resources of nations and health care providers, along with the rapid development of expensive new health care technologies, make priority setting in health care systems unavoidable [1–3]. Priority setting is a complex task involving difficult, value-laden choices and painful decisions affecting various stakeholders, including the public and health care professionals [4]. Finding ways to
∗ Corresponding author at: Department of Public Administration, Ewha Womans University, 314 Posco-Bd, 11-1, Daehyun-dong, Seodaemu-gu, Seoul 120-750, South Korea. Tel.: +82 2 3277 4100; fax: +82 2 3277 4100. E-mail addresses: [email protected] (R. Factor), [email protected] (M. Kang). 0168-8510/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.healthpol.2013.12.003
ration and set priorities for limited public resources while making the process more systematic and transparent has thus become a critical policy agenda in many countries [5–7]. Across countries there seem to be differences in the public’s understanding of, trust in, and satisfaction with its priority-setting processes. For example, studies from Israel have found high trust in the country’s priority-setting procedures, with over two-thirds of the general public said to have trust or some trust in the system, and even greater levels of support among physicians [8]. On the whole, Israelis do not feel the public should have more say about the inclusion of new technologies in the health services basket offered citizens under the country’s national health insurance system, and they are comfortable not having a larger voice in the relevant ethical issues. In South Korea,
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however, the public are more likely to report a desire to participate in health care resource allocation. In one Korean survey conducted in 2005, 62.1% of the respondents said that such decisions should be made in consultation with the public or patient representatives [9]. The media are a mirror of public opinion on the one hand, and an instrument of social influence on the other [10,11]. Thus, how decision making processes and outcomes are reported in the media may both reflect and affect the public’s knowledge of and attitudes toward them. Nevertheless, although priority setting in health care systems has been extensively discussed in the literature [6,12–16], and a number of studies have surveyed or interviewed members of the public or patients in various countries [17–20], to the best of our knowledge, no studies have analyzed how these priority-setting decision making processes or outcomes in health care systems are portrayed in the media. To help fill this gap, the current study aims to explore the ways through which priority-setting mechanisms are presented to the public via the media in Israel and South Korea. Israel and South Korea have been in recent years the subject of several comparative studies in different fields [21]. Indeed, the two make good subjects for comparison, because while differing in important respects, including historical development and culture, they have a great deal in common. South Korea and Israel were both established in 1948, and both have democratic regimes (a parliamentary democracy in Israel, a presidential republic in South Korea). Both societies have been involved in continuous political and military conflicts, giving security issues an important role in policy making. The two countries had similar GDPs per capita (PPP) in 2011 ($28,809 in Israel and $29,786 in South Korea), and have similar levels of literacy [21–23]. Notably, for the purposes of the present study, both countries respect press freedom, which is protected by law or court rulings, and both have a thriving privately owned printed media: in 2010 Israel had nine dailies and South Korea had 11 [21–26]. And finally, both countries have publicly funded social insurance systems that have relatively short histories. The two systems provide mandatory and universal health insurance coverage to all citizens with a uniform benefits package. Despite these similarities, and particularly the similar histories of their health insurance systems, South Korea and Israel differ in key aspects of their priority-setting procedures, as well as levels of public satisfaction with health care decision making [3,25,27]. While to some degree these differences can doubtless be traced to aspects of the two society’s cultures and historical development, such an investigation is beyond the scope of the current study. Indeed, our concern here is less with the deeper origins of these differences than with the current role of the media in reflecting and propagating them. Specifically, using a comparative content analysis of news reports published in leading newspapers in South Korea and Israel, we aim to understand how the work of resource allocation decision makers is presented in the media of each country, and the implications of these media portrayals for both policy making and future studies on priority-setting processes.
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2. Background 2.1. The health care systems in Israel and South Korea The Israeli health care system is a mixed system with public and private components. The publicly funded social insurance system provides mandatory and universal health insurance coverage to its citizens. As stipulated by the Health Services Basket of the National Health Insurance (NHI) Law of 1995, basic services are funded through a tax paid by each adult citizen (currently 4.8% of the individual’s income) through Israel’s National Insurance Institute, and by direct government contributions. The law specifies a uniform benefits package – the National List of Health Services or Health Services Basket (HSB) – which provides coverage for basic care, delivered through four not-for-profit sick funds. The sick funds deliver services to their members through contracted providers or their own facilities based on a model similar to health maintenance organizations in the USA. In addition, the four sick funds are allowed to sell members supplemental coverage for services not included in the basic basket, and private insurance firms can offer insurance that covers both basic and additional services [1,2,5,28–31]. Like Israel, Korea has a compulsory social insurance system that provides universal health insurance coverage to its citizens, who pay a mandatory contribution. The scheme is financed by contributions from employers, employees, the self-employed, and from government subsidies. As of 2012, employees contribute 5.80% of their wages or salary, the same amount contributed by the employer. For the selfemployed, contributions are calculated based on various factors, including the householder’s income, assets, age, and gender. One of the distinct features of the Korean health care system that may be relevant to priority-setting decisions is the dominance of the private sector in the delivery of health care services. In the event of sickness or injury, the insured and their dependents are entitled to health insurance benefits, which consist of benefits in kind and in cash. The benefits package is the same for all population groups [27]. 2.2. Priority setting in Israel and South Korea 2.2.1. Israel Israel’s National Health Insurance law provides two mechanisms for adjustment of the health services basket. The first is an automatic annual update of the total cost of the HSB based on several economic and social indices, including a health costs index, population growth figures, and aging rates. The second gives parliament the right to add items to the HSB on condition that the government makes a sufficient budget available. The process of updating the HSB began toward the end of 1998, with the creation of a National Advisory Committee charged with considering the addition of new services [1–3,5,8,30]. The committee has about 20 members (the exact number varies from year to year) who are appointed by the Ministers of Health and Finance; they include Health and Finance Ministry representatives; medical doctors from the four sick funds and public hospitals;
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other members of the Israeli Medical Association; health economists; and professionals from the areas of medicine, ethics, and the social sciences. The choice of committee members is designed to ensure that different stakeholders’ opinions will be heard and considered [1,3,30]. When the time comes to update the HSB, each potential new drug or technology is assessed from many perspectives: clinical, epidemiological, economic, social, legal, and ethical. The initial stages of evaluation entail several layers of analysis by the Ministry of Health; the Ministry’s findings are then turned over to the committee for review and decision making. The stages in the process are as follows: (1) Proposed technologies are submitted to the Ministry of Health by various stakeholders such as the public, physicians, medical staff, administrators, professional associations, and companies. (2) A list of new proposed technologies is created. (3) This list undergoes initial screening by the Medical Technologies Administration, a unit of the Ministry of Health. (4) The technologies that passed the initial screening undergo comprehensive assessment (clinical, epidemiological, and economic). This stage includes extensive data collection and consultation with the Israeli Medical Association. (5) The Medical Technologies Forum, chaired by the head of the Medical Technologies Administration, prepares a list of recommended technologies, divided into three main categories. These recommendations are submitted to the National Advisory Committee to be used as background material for its discussions. (6) The committee makes its decisions. Finally, (7) the decisions are submitted to the government for approval [2,3,7,29]. The vast majority of the committee’s decisions are reached using a consensus process, so most decisions are made unanimously. Only once have the committee’s members been asked to vote. The public committee meets several times a year and, though its meetings are closed to the public, in 2005 deliberations were opened to representative of the media, and the committee’s activities are now covered by the press on a regular basis [8]. While in the first few years following its inception the committee was treated by the press and the public with great respect, in recent years, its procedures and members have been the object of criticism and various allegations of misconduct [2]. 2.2.2. South Korea Under the National Health Insurance Act of 1997, health care benefits are set by the Health Insurance Policy Deliberation Committee (hereinafter “Deliberation Committee”). The Deliberation Committee consists of 24 members, plus the Vice Minister of Health and Welfare, who serves as committee chair. The 24 committee members are selected to balance the interests of major stakeholders and are divided equally among three categories: purchasers and beneficiaries (e.g., employees, employers, farmers, and consumers); the medical and pharmaceutical sectors; and public bodies (the Ministry of Health and Welfare [MOHW], the Ministry of Strategy and Finance, the National Health Insurance Corporation [NHIC], and the Health Insurance Review and Assessment Service [HIRA]), along with academic experts. Representatives are selected by the relevant consumer, professional, or trade association or Ministry and appointed
by the MOHW for a term of three years. The committee meets when major agenda items come up, rather than on a regular basis. The meetings are not open to the public. Notably, the stages for making benefit coverage decisions differ from those in Israel in that the Deliberation Committee is in practice normally limited to approving decisions made by the MOHW. The typical stages are as follows: (1) companies submit new drugs or technologies to the HIRA for inclusion in the benefits package; (2) the application is reviewed by in-house staff and outside experts; (3) the Drug Reimbursement Evaluation Committee (DREC) makes a recommendation; (4) the NHIC negotiates the price of the recommended drugs or technologies; (5) the Deliberation Committee confirms the recommendation; and (6) the MOHW announces the decision. (For a comparison of the schematic stages of the priority-setting process in Israel and South Korea, see Table 1.) 3. Materials and methods 3.1. Data The data for the current research were based on articles reporting on resource allocation decision making in health care – i.e., priority setting in the health services basket – published in major South Korean and Israeli newspapers from January 2000 through December 2009. Since our main interest was news reports, and in order to reduce biases in the data due to newspapers’ political color, we did not include in our dataset articles published as editorials or commentary. We obtained the Israeli articles by searching the online archive of Haaretz. Haaretz is among the top three daily newspapers sold in Israel. We used the keywords “National Advisory Committee AND health basket” or “National Advisory Committee AND drug basket”. The search yielded 131 articles, which were then accessed manually from the library’s microfilm collection. For the South Korean articles, we initially searched the online archive of Dong-Ah Ilbo, which is the largest newspaper in the online database. We used similar keywords as in the Israeli search: “NIH coverage AND Health Insurance Deliberation Committee,” “Health Insurance Policy Deliberation Committee,” “benefit decision criteria AND KNHI,” and “Ministry of Health AND benefits coverage”. As the search yielded only 44 articles (only about a third of the number found in the Israeli paper), we conducted an additional search in a second newspaper, Hankyoreh Shinmun, which is among the top six sellers in Korea. This search yielded 71 articles. Because the Israeli data came from one newspaper and the Korean data from two, we handled the qualitative and quantitative analyses in different ways. First, for the qualitative analysis, we read and analyzed the articles from the two Korean papers separately. Despite their differing political colors – Dong-A Ilbo is rather conservative while Hankyoreh Shinmun is left-of-center – we could not find content-wise differences between them, and they produced the same order of subthemes. In the quantitative analyses, to ensure consistency between the Israeli and Korean datasets, we drew on the data only from Hankyoreh
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Table 1 A comparison of the schematic stages of the priority setting process in Israel and South Korea. Israel
South Korea
Submission of proposed technologies Application review in-house by the Medical Technologies Administration in Ministry of Health and through outside experts Recommendation of priority setting by the Medical Technology Forum in the Ministry of Health
Submission of proposed technologies Application review in-house by the Ministry of Health and Welfare and through outside experts Recommendation of priority setting by the Drug Reimbursement Evaluation Committee Negotiation of the price of the technologies by the National Health Insurance Corporation Confirmation of the recommendations by the Deliberation Committee Announcement of the decisions by the Ministry of Health and Welfare
Decision making by the committee Approval of the recommendation by the government and official announcement to the public
Shinmun, which had the higher number of articles. The final sample of Korean articles used in the quantitative analysis was thus 71.
and most of the themes were discussed in a similar manner over the years. In South Korea, we did observe some changes over time, which will be described below.
3.2. Method of analysis
4.1. Israel
The articles were analyzed qualitatively following Strauss and Corbin’s [32] and Mason’s [33] guidelines for qualitative research using a two-stage process. First, the articles were screened by the researchers and were read literally and interpretively in order to identify broad themes. These were indexed into analytical categories which represent key substantive topics. Then, the articles were read again and their content analyzed to identify more specific themes and categories. At this point, we counted the number of articles dealing with each of these themes and categories to produce a quantitative analysis. Finally, we compared the Korean and Israeli articles in terms of these themes and categories. Throughout the process, the articles were read in their original language by one of the researchers.
Table 2 shows the four main themes and 14 subthemes appearing in the Israeli articles in order of prevalence.
4. Results Tables 2 and 3 summarize the results of the review of the Israeli and South Korean articles respectively. The righthand column in each table shows the number of articles that cover a given subtheme or category. Since many articles discuss more than one category, the total number in this column exceeds the total number of articles that were analyzed. Four broad themes were identified for both countries: (1) the complexity of the task (due to ethical, budgetary and political considerations); (2) benefits package decisions arrived at (including decisions on the contents of the HSB and fees or premiums charged); (3) the composition of the committee, or formal actions by or involving it (e.g., appointment of members; announcements of decisions); and (4) priority-setting procedures and principles (including both broad ethical issues and the committee’s specific working procedures). Within these four broad groups, the researchers identified 11 (Korea) or 14 (Israel) more specific categories. The themes and categories are discussed in greater detail in the following sections. In addition, we conducted a longitudinal analysis of the reports in both sets of newspapers over the research period. In Israel, we observed no conspicuous changes over time,
4.1.1. Reports on the complexity of the task The most prevalent theme in the Israeli newspaper, appearing in over a third of the articles (94, or 39%), centers on the difficulty of the task facing the committee. The most prevalent key topic within this theme is the pressure of budget constraints. Many articles point out that the government’s allocated budget for the HSB is extremely small relative to the cost of new medical technologies that could be added to the basket, and consequently the committee faced the difficult, even impossible, task of selecting the most important among them. Typical citations include: “The committee was forced to make decisions subject to impossible priority-setting constraints. Ultimately only a sixth of the medicines and technologies brought before the Ministry of Health were added to the HSB.” (Haaretz, 01/06/2000) Indeed, some articles report that the government had not only failed to allocate a sufficient budget to the HSB, but was threatening to cut funding. The articles report the potentially negative consequences of this situation for patients: “[Some sick persons] will be doomed to die, and others will be sentenced to imperfect treatment instead of the best possible treatment that medicine can offer. This is because Ministry of Finance officials, with the backing of the Minister of Finance, are asking to cut the HSB, or in less severe cases not to add anything to it” (Haaretz, 12/30/2003). The second most prevalent topic, the physical and psychological burden of the task on the committee’s members, was reported in twenty-eight articles. This can be seen, for instance, in the following typical citations: “. . .impossible mission. . . some people must determine the destiny of the sick in Israel, who will leave orphans after him and who will see her grandchildren” (Haaretz, 03/19/2006)
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Table 2 Main themes and categories, Israel, 2000–2009. Theme
Category
Typical content
No. (%)
Complexity of the task (94, 39%)
Budget constraints
The budget is too small relative to the cost of drugs/technologies that should be included in the basket; description of the gap between the allocated budget and the needed drugs/technologies; the difficult task of the committee in setting priorities in light of the restricted budget; the consequences of the small budget The committee’s deliberations very difficult; long discussions; moral decisions; hard questions; meticulous screening work; the committee members are forced to determine destinies; life and death decisions; resignation of committee members; By the Health Minister, Ministry of Health, Israel Medical Association, members of parliament, the committee; description of the negotiations; announcements of budget increase Pressure from the public, pharmaceutical companies, senior physicians, Medical Association, etc. Disagreements regarding mental health drugs, the use of the drugs, what to exclude from the recommended list; protests of some members against the committee on government decisions
34 (14%)
Descriptions of the committee’s difficult task
Attempts to increase the allocated budget
Attempts to influence or change decisions Disagreements among committee members
Decisions on benefits package (61, 25%)
Drugs, treatments, and services recommended by the committee
Type and cost of drugs, treatments, and services brought before the committee Drugs, treatments, and services not included in the basket The committee (47, 19%)
Committee appointments
Formal announcements Submission and confirmation of recommendations by the government
Priority setting procedures and principles (41, 17%)
Principles for inclusion of drugs, treatments, and services
Procedures of the committee
Committee deliberations Total
“. . .the last battle of the HSB. . .the crucial deliberation over the HSB started at 4:00 am. . .after long hours of arguments and struggles. . .after all, the committee’s members are those who will have to look straight in the eyes of the patients who do not get required medicines and explain the considerations to them” (Haaretz, 12/24/2008) In this vein, there are several descriptions of the adverse physical environment where the committee’s discussions
28 (12%)
16 (7%)
9 (4%) 7 (3%)
Type, quantity, conditions covered (cancer, rape, pregnancy termination, Parkinsons, blood pressure, heart failure, depression, AIDS, asthma); type of patients who will benefit; expanding the treatment and groups covered; costs; recommendation of drugs/technologies that do not require extra budget Type and purpose of drugs/technologies; costs; how funded
15 (6%)
Types; reasons (economic and medical)
14 (6%)
Signing the letter of appointment for the committee’s members; composition and members of the committee – number, affiliation, current and past positions; members given prestige and recognition; number of meetings End of the committee’s work; committee’s decisions; press conference presenting the decisions Submission of recommendation to: the Health Council, Health Minister, government; by the committee’s chairman/Ministry of Health General Manager; confirmation of the committee’s recommendations by the government
21 (9%)
Will drugs/technologies save lives, extend lives, or improve the quality of life; will they help large/small population; are drugs/technologies essential, very high priority, high priority; the availability of generic drugs; options that will not increase expenses; the committee’s job is to weigh all considerations including ethical and social factors; groups with special needs (vulnerable populations, elderly, infants, etc.) Get initial list from the Ministry of Health; ranking of drugs/technologies; consultations with specialists; procedures not officially set; decisions by consensus/voting Deliberations are closed to the public; cancelation of protocol writings; opening deliberations to the press
32 (13%)
19 (8%) 7 (3%)
25 (10%)
9 (4%)
7 (3%) 243 (100%)
took place: “The deliberations took place in a small, packed, and choking room; the refreshments were poor” (Haaretz, 12/24/2008). The next three categories deal with pressure from various stakeholders, including the Minister of Health, the Israeli Medical Association, members of parliament, and the chair and members of the committee, to influence or change the committee’s decisions and the budget allocated to the HSB. There were several reports about disagreements among the committee’s members about the inclusion and
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Table 3 Main themes and categories, South Korea, 2000–2009. Theme
Category
Typical content
No. (%)
Decisions on benefits package (75, 39%)
Drugs, treatments, and services included by the committee Decisions to raise the insurance premium Decisions to change the fee schedule
Type, quantity, conditions covered; type of patients who will benefit (children, elderly, etc.); expected total cost Decision to raise premiums, decision not to raise premiums Decision to increase/reduce payments to providers, decision to lower drug prices Type, quantity, conditions covered; type of patients who would have benefited
32 (17%)
Drugs, treatments, and services not included in the basket The committee (59, 31%)
Formal announcements
Committee appointments
Complexity of the task (43, 22%)
Response from society
Disagreements among committee members
Budget constraints/surplus Priority setting procedures and principles (15, 8%)
Principles for inclusion of drugs, treatments, and services Decision-making procedures
The Ministry of Health and Welfare announced the committee’s priority-setting decisions, the Ministry announced the committee’s decisions to raise premiums, the Ministry announced the committee’s decision to change the fee schedule The committee made priority-setting decisions, the committee confirmed the government’s plan for priorities; The committee made insurance premium decisions, the committee made fee schedule changes Committee members and composition – number, affiliation, current and past positions, prestige and recognition Patients and citizen group resistance to insurance premium rise, provider group resistance to reduction in fees; patient/citizen group and business group resistance to increased fees Conflict among committee members about the fee schedule, protests of some members against the committee on government decisions Conflict among committee members about raising insurance premiums; protests of some members against the committee on government decisions Conflict among committee members about priority setting Deficit is expected to increase; huge deficit is expected Huge budget surplus, where to spend the budget surplus Catastrophic disease; groups with special needs (elderly, children, pregnant women); patient burdens, universality, effectiveness, etc. Decisions by consensus/voting within the committee; public hearings will be held, public opinion surveys will be conducted
21 (11%) 18 (9%) 4 (2%) 42 (22%)
14 (7%)
3 (2%)
17 (9%)
7 (4%)
5 (3%)
1 (1%) 8 (4%) 5 (3%) 10 (5%)
5 (3%)
192 (100%)
Total Note: In order to avoid bias due to duplicate reporting, only the articles in Hankyoreh Shinmun were counted to prepare this table.
use of different drugs, or individual members’ protests against decisions. 4.1.2. Reports on the benefits package The second most prevalent theme, appearing in about a quarter of the articles (61, 25%), is straightforward reporting about the drugs and technologies brought before the committee. Articles in this group report on drugs and technologies at all key stages in the deliberative process: those brought before the committee; those recommended (or not recommended) by the committee; and those ultimately included or not included in the HSB, following the final government-approval stage. These reports typically include the name of the medicine or procedure, the disease they treat, the cost, and the type of patients who will benefit. 4.1.3. Reports on the committee As can be seen from Table 2, 47 articles (about 19%) report on the committee itself – its composition, or formal actions by or involving it, such as appointments
and announcements. In most of the studied years the same ritual of appointing the committee was reported: e.g., “The Minister of Health, Nissim Dahan, yesterday signed the letter of appointment for the HSB committee’s members. . .Like last year, the head of the committee will be Professor Avi Israeli, former manager of Hadassah hospital” (Haaretz, 10/29/2001). As that quotation suggests, strong emphasis is placed on the qualifications of both the committee as a whole and its individual members. This classification also includes formal announcements made by the committee. These might be, for example, the committee’s recommendations – “The HSB committee recommended yesterday adding eight medicines and medical technologies” (Haaretz, 7/16/2003) – or confirmation of the committee’s recommendations by the government’s Health Council: “The Health Council yesterday approved the HSB committee recommendations” (Haaretz, 02/29/2008). Committee appointments or decisions are presented to the public through a press conference with the participation of the Minister of Health, the Ministry of Health General Manager, and the committee chair.
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4.1.4. Reports on priority-setting procedures and principles The last of the four broad themes centers on the procedures and principles that guide the committee in its deliberations on policy decisions. These issues appear in 41 articles (about 17%), and can be further divided into three subthemes. The first of these involves the thorny social and ethical considerations by which all new drugs and technologies must be judged: for instance, whether they are designed to save life, extend life, or improve the quality of life; the size and nature of the populations likely to benefit from them; and the availability of alternatives. The second involves descriptions of the committee’s operating procedures: not formal announcements, as described above, but reports on the committee’s day-today working procedures – its deliberations, consultations, and votes. The third comprises discussions of issues related to these working procedures, such as the fact that the deliberations are closed to the public. 4.2. South Korea As noted above, the same four broad themes emerged from the Korean articles as from the Israeli sample. However, the prevalence among the four broad themes differs between the two countries. Reports on the benefits package were most frequent, followed by reports on the committee. The complexity of the procedure was emphasized less in the Korean than in the Israeli media. Similarly to the Israeli case, reports on priority setting procedures and principles ranked last. The subthemes and categories emerging from the Korean articles also differed from those in Israel. The quantitative analysis of some of the subthemes revealed interesting patterns. For this reason, the major subthemes shown in Table 3 differ from those in Table 2. The four themes are discussed here in their order of prevalence in Hankyoreh Shinmun. 4.2.1. Reports on the benefits package Unlike in Israel, the largest group of articles in Korea (75, or 39%) deal with decisions made by the Deliberation Committee. Many of these deal with expansion of the benefits package or reduction of fees, so they appear to present mainly “good” news. For instance, 32 articles (about 17% of the total) describe the addition of new services, treatments, or drugs to the KNHI, compared with only four articles (about 2% of the total) dealing with decisions to exclude such drugs or treatments. The following is a typical report: “The Ministry of Health and Welfare today announced that the Insurance Policy Deliberation Committee has decided to include Enbrel injections for treatment of ankylosing spondylitis in the Korean NHI benefit package. Due to this decision, patients’ out-of-pocket cost for the medicine over nine months will decrease from 13,000,000 Korean won to 2,600,000 Korean won.” (Hankyoreh 04/28/2005) Interestingly, while many articles report on policy decisions vis-à-vis the benefits package, there are very few reports on why those decisions were made. Indeed, of the
32 articles discussing expansion of the HSB, only 2 discuss the rationales for those decisions. 4.2.2. Reports on the committee Reports on the Deliberation Committee made up the second-largest group in our quantitative analysis (59, or 31%). But this finding requires some explanation. In contrast to what we observed in Haaretz vis-à-vis the Israeli public committee, in the Korean newspapers the Deliberation Committee is not presented as a major actor in the story during the study period. In fact, the largest group of articles that we have classified under the rubric “formal actions by or involving the committee” actually refer, in the Korean case, to announcements by the Ministry of Health and Welfare. The committee appears to be regarded as a secondary body that approves and confirms decisions by the MOHW. For example, in 2005, after his visit to a children’s ward at a tertiary hospital in Seoul, Hankyoreh reported Minister Kim Guen-Tae’s promise that “the government will develop a policy to cover children’s health care expenditures this year. The plan will be instituted and implemented after it is discussed in the Committee meeting and confirmed” (Hankyoreh, 09/20/2005). Along with the limited reporting on the committee as a whole, news reports on the individual members of the committee were also uncommon. Unlike in the case of Israel, we found no reports on the composition of the committee or the names and qualifications of particular members during the study period. Only in a few instances did reports mention the chair of the committee, who is the Vice Minister of Health and Welfare. 4.2.3. Reports on the complexity of the task During much of the period of the study, from 2001 through 2005, budget constraints were mentioned in the Korean publications relatively infrequently, in contrast to the case in the Israeli newspaper. During this period, KNHI enjoyed a budget surplus. Accordingly, news reports from that period cover discussions on the need to expand the benefits package and where to spend the surplus (e.g., Dong-A, 12/03/2004; Hankyoreh, 11/28/2003). This may in part explain why relative to Israel, there were few reports on the complexity of priority setting in Hankyoreh during the study period – only 43, or 22%. Beginning in 2006, the implementation of the expansion produced unexpected expenditures, and the number of reports on concerns about potential budget constraints increased sharply. Still, even at that time, the Korean news reporting focused chiefly on rising insurance premiums rather than the effects of priority-setting decisions on the benefits package. For example, the government’s announcement to increase the insurance premium by 6.5 percentage points to address the potential budget constraints and harsh criticism by citizens’ groups and business groups, who would bear the cost of the higher premiums, were the major news agenda (Hankyoreh, 11/18/2006; Dong-A, 12/02/2006). In contrast, there were few media reports about priority-setting decisions, in particular on the idea of rationing in the selection of drugs, treatments or services.
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4.2.4. Reports on priority-setting procedures and principles As in Israel, the theme that appeared least often in the Korean newspapers was decision-making principles and procedures (15, or 8%). As noted above, most reports of announcements made by the MOHW do not discuss how the decisions were reached, who was involved in examining the issues or presenting evidence, how evidence was verified, and who was accountable for decisions. Only a few reports noted that there would be public hearings and debates where the government plan would be discussed by diverse parties. In a few cases, when the agenda was politically challenging, decisions were reported to have been made by a vote among the committee members. For example, the decision in 2002 to lower payments to medical providers was reported to have been decided by a committee vote, with 10 of 19 members voting in favor (Dong-A, 2/28/2002).
5. Discussion The current paper sought to study how priority setting and decision making in relation to the national basket of insurance benefits are portrayed to the public through the media. We analyzed 202 newspaper articles published over a period of ten years in Israel and South Korea, concentrating in both cases on the functions, role, character, processes, and actions of the committee charged with overseeing priority setting in its country: the Deliberation Committee in South Korea and the public National Advisory Committee in Israel [3,27]. This rich dataset allows us to derive interesting conclusions regarding the portrayals of priority-setting processes and outcomes in the two countries. The findings revealed interesting differences between the two countries. The most prevalent theme in the Israeli newspaper reports sampled was the complexity of the task faced by the HSB committee, with the key issues being budget constraints, moral and ethical questions, and efforts by different stakeholders to influence or change the committee’s decisions. In South Korea, on the other hand, this theme was not salient in the reports sampled. Instead, reports about benefits package decisions were found to be most frequent in South Korea, with most such reports focusing on expansion of the benefits package, while in Israel such reports were ranked second in our analysis. We also found considerable differences in the contents of reports on formal actions by or involving the committee. In Israel, the committee is reported as the main actor in priority setting, whereas in South Korea, it is the Ministry of Health and Welfare; the Korean committee seems to perform a secondary role that approves and confirms decisions by the MOHW. The Israeli articles sampled include many on the committee’s appointment, composition of the committee, and announcements of committee decisions (in many cases followed by a press conference), with heavy emphasis on the qualifications and prestigious backgrounds of individual members. The Korean reports rarely center on the committee itself, with almost no mention of the composition of the committee or the names and qualifications of its members. The committee is rarely referred to as
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the decision maker, but typically is reported as confirming decisions by the MOHW. The least reported theme in both countries was prioritysetting procedures and principles. This was particularly striking in the Korean sample, where only rarely were the principals or rationales behind decisions given. The Israeli sample included somewhat more reports dealing with priority-setting considerations, such as whether a treatment would save, extend, or improve the quality of life, and how many people were likely to benefit. Besides the differences in the content of the reports, it was intriguing to find a difference between the countries in the number of reports on priority setting in the HSB. While in Israel the keywords “health basket” and “drug basket” yielded 131 relevant articles from one leading daily newspaper, in South Korea even a broader search in a similar type of leading daily paper produced only 71 reports. According to this relatively limited search, there appear to be almost two times more reports on the HSB in Israel than in Korea. This finding appears to testify that the issue of priority setting in the health basket is much less salient in Korean than in Israeli society, and it raises interesting questions about the causes and implications of this difference. These differences between South Korea and Israel may reflect the countries’ different cultures [25]. Culture reflects society’s norms and values and affects the way members of society perceive and respond to events in the world around them [34–36]. Therefore, it is likely that the two countries’ different cultural contexts influence the prioritysetting mechanism in each, and the way it is portrayed in the media. In the current study we do not have the empirical tools needed to test this assumption, which offers scope for further studies. This study has some limitations. First, we sampled only one or two leading newspapers in each country. Choosing different newspapers might produce somewhat different conclusions, especially to the degree that news reports are influenced by a paper’s political color. Also, we did not include in our dataset articles published as editorials or commentary, so the media’s own perspectives may not be reflected in our analysis. In addition, the current research design makes it difficult to draw causal conclusions regarding the relationship between media reports and public attitudes toward and satisfaction with the health care system and its priority-setting mechanisms. Nor can the current research shed light on the mechanisms by which information published in the media shapes public support – a process that is in general poorly understood. Nevertheless, we believe that our findings stimulate the generation of hypotheses that can be tested empirically in future research. For example, differences between Israel and Korea in attitudes, trust, and satisfaction with the national health insurance system and its priority-setting procedures which were documented in previous studies [9,37,38] may be related to the differences in the newspaper reports found in this study. Media reporting on the sensitive issues and dilemmas that underlie the process of priority-setting decision making (as in Israel), rather than merely a focus on decision outcomes (as in South Korea), may make the process more transparent and increase public trust in how it
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is carried out. Transparency and public involvement are crucial to ensure public support for the process whereby national health care systems weigh competing drugs and treatments likely to benefit different populations in a world of limited resources [1,3]. It is likely that Israelis are happy to leave the knotty ethical issues to designated experts because media reports keep them informed about the work that is going on behind the scenes, whereas South Koreans want citizens and patients to have more say. Another factor that might well affect support for priority-setting decision making systems is the extent to which the decision makers are presented to the public as apolitical and their qualifications and professional characteristics are highlighted [39]. In our study, we found that the Israeli reports we analyzed, but not the Korean reports, kept readers informed about the qualifications of the people charged with making resource allocation decisions. Moreover, these individuals are portrayed as professionals and respected public figures who are working voluntarily, as a public duty. In South Korea, the actors presented to the public tend to be political figures or institutions, such as the Minister or Ministry of Health and Welfare. Such reporting might well have a symbolic influence on public trust and satisfaction with the process. Future studies might address other important questions as well. For example, to what extent do the Ministry of Health or other government agents influence the reported news? How do the countries’ political and cultural contexts affect both media reporting and public attitudes toward the priority-setting process? Do different levels of popular trust in the government, or in specific government agencies, affect satisfaction with the two countries’ priority-setting systems? Finally, to what extent do commercial considerations influence reporting in the two countries – for example, the reputed propensity of news organizations to report more “bad news” than “good news”, on the grounds that bad news presumably sells more papers? Other complex social and cultural factors may also be at work, and should be considered and controlled for in future studies. 6. Conclusion Our study contributes to the literature on priority setting in health care by reporting on the media’s portrayal of the priority-setting mechanisms in Israel and Korea, two countries that have not yet been well studied in this context. Although the health insurance systems and benefits package structures in Israel and South Korea have much in common [1,27], the current study – which is, as far as we know, the first to analyze media reporting on priority-setting decision-making – documented meaningful differences in reporting on priority setting in health care in the two nations. While this study could not empirically examine either the origins or the consequences of these differences, we can speculate that the different styles we observed may have a real-world impact on public trust in health care policy making, as suggested by previous findings that Israelis and South Koreans report differing levels of public satisfaction with their systems [8,9]. Together, the current and previous findings suggest that greater
public trust and support for priority-setting mechanisms are likely to be associated with media reports that (a) highlight socially sensitive issues and moral dilemmas, (b) present decision makers as apolitical qualified professionals, and (c) present more clearly defined principles and procedures – all acts which make the decision making process more transparent. We hope that the qualitative findings presented above will encourage researchers from different disciplines to continue the study of this important issue, and thereby to suggest ways of improving the public’s trust and satisfaction with the priority-setting procedures in each country.
Acknowledgement This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2012S1A3A2033416) to Minah Kang.
References [1] Greenberg D, Siebzehner MI, Pliskin JS. The process of updating the National List of Health Services in Israel: is it legitimate? Is it fair. International Journal of Technology Assessment in Health Care 2009;25:255–61. [2] Seidman GI. Regulating life and death: the case of Israel’s Health Basket Committee. Journal of Contemporary Health Law Policy 2006;23:9–63. [3] Shani S, Siebzehner M, Luxenberg O, Shemer J. Setting priorities for the adoption of health technologies on a national level—the Israeli experience. Health Policy 2000;54:169–85. [4] Daniels N. Symposium on the rationing of health care: 2. Rationing medical care—a philosopher’s perspective on outcomes and process. Economics and Philosophy 1998;14:27–50. [5] Guttman N, Shalev C, Kaplan G, Abulafia A, Bin-Nun G, Goffer R, et al. What should be given a priority—costly medications for relatively few people or inexpensive ones for many? The Health Parliament public consultation initiative in Israel. Health Expectations 2008;11:177–88. [6] Ham C, Coulter A. Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices. Journal of Health Services Research and Policy 2001;6:163–9. [7] Tal O, Hakak N. Early awareness and alert systems for medical technologies in Israel. International Journal of Technology Assessment in Health Care 2012;28:333–8. [8] Chinitz D, Meislin R, Alster-Grau I. Values, institutions and shifting policy paradigms: expansion of the Israeli National Health Insurance Basket of Services. Health Policy 2009;90:37–44. [9] Lee S-Y, Cho M-W, Suh N-K, Lee Y-G, Choi S. Achieving social consensus for health care resource allocation. Seoul: National Health Insurance Corporation; 2005 [in Korean]. [10] Bauer MW, Howard S, Hagenhoff V, Gasperoni G, Rusanen M. The BSE and CJD crisis in the press. In: Dora C, editor. Health, hazards and public debate: lessons for risk communication from the BSE/CJD Saga. Geneva: WHO; 2006. p. 125–64. [11] Hind D, Wailoo AJ, Sutcliffe P. Demands for ‘off-licence’ access to trastuzumab (Herceptin): content analysis of UK newspaper articles. Health Expectations 2011;14:38–47. [12] Baltussen R, ten Asbroek AH, Koolman X, Shrestha N, Bhattarai P, Niessen LW. Priority setting using multiple criteria: should a lung health programme be implemented in Nepal. Health Policy and Planning 2007;22:178–85. [13] Klein PG. New institutional economics. SSRN eLibrary 1998. [14] Bryant J, Coulter A, Ham C. Health priority dilemmas in developing countries. The Global Challenge of Health Care Rationing 2000;6:3–74. [15] Terry LM. An integrated approach to resource allocation. Health Care Analysis 2004;12:171–80. [16] Kapiriri L, Norheim OF, Heggenhougen K. Public participation in health planning and priority setting at the district level in Uganda. Health Policy and Planning 2003;18:205–13.
R. Factor, M. Kang / Health Policy 114 (2014) 226–235 [17] Bhatia M, Rannan-Eliya R, Somanathan A, Huq MN, Pande BR, Chuluunzagd B. Public views of health system issues in four Asian countries. Health Affairs 2009;28:1067–77. [18] Abelson J, Miller FA, Giacomini M. What does it mean to trust a health system? A qualitative study of Canadian health care values. Health Policy 2009;91:63–70. [19] Lasry A, Carter MW, Zaric GS. Allocating funds for HIV/AIDS: a descriptive study of KwaDukuza, South Africa. Health Policy and Planning 2011;26:33–42. [20] Hyder AA, Corluka A, Winch PJ, El-Shinnawy A, Ghassany H, Malekafzali H, et al. National policy-makers speak out: are researchers giving them what they need. Health Policy and Planning 2011;26:73–82. [21] Schejter A, Lee S. The evolution of cable regulatory policies and their impact: a comparison of South Korea and Israel. Journal of Media Economics 2007;20:1–28. [22] The World Bank. Open Data Services; 2013. [23] International Monetary Fund. Government finance statistics yearbook. Washington, DC: International Monetary Fund; 2010. [24] Levi-Faur D. The developmental state: Israel, South Korea, and Taiwan compared. Studies in Comparative International Development 1998;33:65–93. [25] Maman D. The emergence of business groups: Israel and South Korea compared. Organization Studies 2002;23:737–58. [26] Korea Press Foundation. Media Statistics Information System 2013. [27] Kim MK. Access to health care in Korea: universal but limited access. In: Exter Ad, editor. International Health Law: solidarity and justice in health care access. Antwerpen-Apeldoorn: Maklu; 2008. [28] Gross R, Rosen B, Chinitz D. Evaluating the Israeli health care reform: strategy, challenges and lessons. Health Policy 1998;45:99–117. [29] Gross R, Rosen B, Shirom A. Reforming the Israeli health system: findings of a 3-year evaluation. Health Policy 2001;56:1–20.
235
[30] Luxenburg O. Technology assessment and setting priorities for the adoption on a national level—the Israeli experience. Stanford, CA: Technology and Outcomes Assessment for Health Care Policy Reform; 2007. [31] Hammerman A, Feder-Bubis P, Greenberg D. Financial risk-sharing in updating the national list of health services in Israel: stakeholders’ perceived interests. Value in Health 2012;15:737–42. [32] Strauss AL, Corbin JM. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, CA: Sage Publications; 1990. [33] Mason J. Qualitative researching, 2nd ed. London; Thousand Oaks, CA: Sage Publications; 2002. [34] Swidler A. Talk of love. Chicago/London: The University of Chicago Press; 2001. [35] Factor R, Mahalel D, Yair G. The social accident: a theoretical model and a research agenda for studying the influence of social and cultural characteristics on motor vehicle accidents. Accident Analysis and Prevention 2007;39:914–21. [36] Hofstede G. Culture’s consequences: comparing values, behaviors, institutions, and organizations across nations, 2nd ed. Thousand Oaks, Calif: Sage Publications; 2001. [37] Gross R, Brammli-Greenberg S, Matzliach R. Public opinion on the level of service and performance of the health care system ten years after the introduction of National Health Insurance. Jerusalem: Myers-JDC-Brookdale Institute; 2007. [38] National Health Insurance Corporation. The public satisfaction with the NHI system: a national survey of 2008. Seoul: National Health Insurance Corporation; 2009. [39] Factor R, Oliver AL, Montgomery K. Beliefs about social responsibility at work: comparisons between managers and non-managers over time and cross-nationally. Business Ethics: A European Review 2013;22:143–58.
