It is argued here that an economics centred on subjective utility-maximization is unsuitable for the analysis and policy grounding of health care provision. To some extent, the peculiarities of health care have been recognized by mainstream health economists, who sometimes abandon Paretian welfare considerations to focus on needs instead. This article examines important peculiarities of health care that are relatively neglected in the literature. Some of these concern health care needs: while health itself is a universal need, needs for health care provision are largely involuntary, varied, and idiosyncratic. These issues have important consequences for the planning of health care systems and the extent of transaction costs in any market-based system. These factors, combined with the inherent dynamism of modern health care needs and capabilities, create an opening for alternative approaches to health care economics.

This stimulating set of articles provides intriguing information and comments about medical governance in four countries. The commentary argues that the typology of governance approaches is not as useful as one would want for understanding either the political prospects or policy effects of governance measures. The politics of governance measures is distinctly related to efforts to avoid blame, and the effects of measures are better understood in terms of state capacity and a term, ‘authority’, that advocates of ‘governance’ usually avoid. Close attention to the requisites of authority provides some insight into the patterns of adoption and consequences of measures. These patterns are highlighted by comparing the four cases reviewed to experience in the United States.

There are four basic models of health service delivery: those that rely on trust, on command and control, on voice, and on choice and competition. All have their merits and demerits; but there are both theoretical and empirical arguments for preferring choice and competition in many situations. However, the relevant policies do have to be properly designed.

This article considers two key issues in health economics regarding the question of equity. First, why have health economists not resolved better the issue of what are equity and access? Second, the paper draws attention to the relative lack of analyses of equity concerns outside of health care. The question of whose values should prevail in equity is also addressed. On the first issue, there is an obsession with quantification in economics with the result that in analysing equity, in practice often ‘use’ has been substituted for ‘access’. The problem of defining access has thereby been by-passed. This has taken the pressure off trying to research access per se. Second, what is meant by equity and access are in part culturally determined. The continued efforts of health economists to treat equity as some universal construct are misplaced. The lack of effort on the part of health economists to look at equity more broadly than health care equity is concerning. Certainly, to be pursued in practice, equity in both health and health care need a shift in resources, which will be opposed by those who exercise power over decision making in health care and in society more generally. Currently health economists’ analyses say all too little about power and property rights in health care and in society. It is argued that the relevant citizens or communities which a health service serves are best placed to judge the access barriers they face and their relative heights. A useful definition of equity established by a citizens’ jury in Perth, Australia is used to exemplify this point. It is concluded that the often all too simplistic equity goals adopted in health economics (and sometimes public health discourse) need to be challenged. For health economists, there is a need for more of us to get involved in the issues around inequalities, class and power and the impact of these on health.

Discussion about the relative role of public and private in health care has evolved substantially across Europe since the 1980s. The previous, broadly ideological debate about state ‘versus’ market has been superceded by pragmatic considerations on how best to combine state ‘and’ market to achieve specific health sector outcomes. The London School of Economics debate about expanded patient choice demonstrated the extent to which pragmatism has gained the upper hand.

Health equity is one of the main avowed objectives of public health policy across the world. Yet economic evaluations in public health (like those in health care more generally) continue to focus on maximizing health gain. Health equity considerations are rarely mentioned. Health economists rely on the quasi-egalitarian value judgment that ‘a QALY is a QALY’ – that is QALYs are equally weighted and the same health outcome is worth the same no matter how it is achieved or to whom it accrues. This value judgment is questionable in many important circumstances in public health. For example, policy-makers may place rather little value on health outcomes achieved by infringing individual liberties or by discriminating on the basis of age, sex, or race. Furthermore, there is evidence that a majority of the general public wish to give greater weight to health gains accruing to children, the severely ill, and, to a lesser extent, the socio-economically disadvantaged. This paper outlines four approaches to explicit incorporation of equity considerations into economic evaluation in public health: (i) review of background information on equity, (ii) health inequality impact assessment, (iii) analysis of the opportunity cost of equity, and (iv) equity weighting of health outcomes. The first three approaches can readily be applied using standard methods of health technology assessment, where suitable data are available; whereas approaches for generating equity weights remain experimental. The potential benefits of considering equity are likely to be largest in cases involving: (a) interventions that target disadvantaged individuals or communities and are also relatively cost-ineffective and (b) interventions to encourage lifestyle change, which may be relatively ineffective among ‘hard-to-reach’ disadvantaged groups and hence may require re-design to avoid increasing health inequalities.

Compared to many applied areas of economics, health economics has a strong tradition in eliciting and using stated preferences (SP) in policy analysis. Discrete choice experiments (DCEs) are one SP method increasingly used in this area. Literature on DCEs in health and more generally has grown rapidly since the mid-1990s. Applications of DCEs in health have come a long way, but to date few have been ‘best practice’, in part because ‘best practice’ has been somewhat of a moving target. The purpose of this paper is to briefly survey the history of DCEs and the state of current knowledge, identify and discuss knowledge gaps, and suggest potentially fruitful areas for future research to fill such gaps with the aim of moving the application of DCEs in health economics closer to best practice.