Weaving Necessity: Contextualisation Practices for Achieving Robust Health Care Coverage Decisions

All health care technologies covered through the basic benefits basket of the Dutch collective health insurance should be effective, provide value for money, and be necessary. This last criterion determines the extent of the collective solidarity. But how to establish whether a health care technology is necessary?

Through examining qualitative cases from the Netherlands and further afield, Tineke Kleinhout-Vliek describes how necessity is established in health care coverage decision-making practice. Manifold argumentations pertaining to necessity exist and are used by the Dutch National Health Care Institute and its appraisal committee (and their equivalents in several Western European countries) when deliberating on and formulating advised health care coverage decisions. Kleinhout-Vliek details the varied but patterned use of these necessity argumentations in cases ranging from highly expensive medicines to paracetamol tablets and maternity care.

Such varied 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 setting health care coverage decisions in context, that is, for contextualising them. As the relevant contexts differ per health care technology appraised, the relevant necessity argumentations vary likewise. Well-contextualised health care coverage decisions contain necessity argumentations that are carefully woven together. Weaving necessity makes these decisions robust: able to withstand pressure outside the decision-making setting.