Weaving Necessity

Much has been written on this topic in the scientific and policy world. Most reports aim for a substantive answer to this question, through a checklist for example. Despite all this work, necessity is seen as difficult to define and the solutions as difficult to use: checklists are often shelved.

For this reason, Tineke Kleinhout-Vliek of Erasmus School of Health Policy & Management wrote her dissertation on the use of necessity as a criterion in health care coverage decisions, to be defended 5 November 2020.

Turns out, there are many arguments pertaining to necessity. We are not only talking about medical need and the severity of the illness but also about the nature of the illness: is this really a disease or is it just part of life? Does it affect social functioning? Or dignity? Are there other people it has an impact on? And is relieving this burden a collective or an individual responsibility? In various case studies from abroad and at home, including very expensive medicines, paracetamol tablets and maternity care, Kleinhout-Vliek investigated the patterned but varying use of such arguments.

Varying use of necessity argumentations may seem problematic, as variation would indicate inconsistency and potential inequity between decisions. Instead, Kleinhout-Vliek shows that these variable necessity argumentations are used for delivering tailor-made decisions, to give the decision the right context. As the relevant context differs per health care technology appraised, the relevant necessity argumentations vary likewise. Well-contextualised health care coverage decisions contain necessity argumentations that are specific for this decision and are carefully woven together, which makes the decision able to withstand pressure from outside relatively well.