Ordeals are burdens placed on individuals that yield no benefits to others; hence they represent a dead-weight loss. Ordeals – the most common is waiting time – play a prominent role in rationing health care. The recipients most willing to bear them are those receiving the greatest benefit from scarce health-care resources. Health care is heavily subsidized; hence, moral hazard leads to excess use. Ordeals are intended to discourage expenditures yielding little benefit while simultaneously avoiding the undesired consequences of rationing methods such as quotas or pricing. This analysis diagnoses the economic underpinnings of ordeals. Subsidies for nursing-home care versus home care illustrate.

This paper addresses how to think about the permissibility of introducing deadweight costs (so-called ‘ordeals’) on candidate recipients of goods in order to attain better outcomes. The paper introduces some distinctions between different kinds of value dimensions that should be taken into account when such judgements are made and draws from the literature on comparisons across different value dimensions in order to canvas what sort of situations one might arguably face when evaluating ordeals. In light of the distinctions drawn and the possibilities canvassed, the paper proceeds to outline what circumstances indicate which of the possible situations one is in.

The extent to which a system of services is in tune with the needs of the population can be expressed in terms of target efficiency, which includes horizontal target efficiency – the extent to which those deemed to need a service receive it – and vertical target efficiency – the corresponding extent to which those who receive a service actually need it. Vertical efficiency can be measured by looking only at those receiving services. To measure horizontal target efficiency in a population, one must have access to population surveys. Data were taken from the baseline survey of the Swedish National Study on Ageing and Care (SNAC study). The results show that more than 80 per cent of those dependent in personal activities of daily living in the studied geographic areas were users of public long-term care (LTC). Dependency in instrumental activities of daily living was identified as the most important predictor of using LTC. Vertical target efficiency was 83–95 per cent depending on age, gender and type of household, if need was defined as dependency in instrumental activities of daily living. It was considerably lower, 35–61 per cent when defined as dependency in personal daily activities. Overall, long-term target efficiency in Sweden must be regarded as high. Few persons who need public LTC services fail to receive them.