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The purpose of this paper is to explore Croatian views about issues regarding bedside rationing decisions.

An online questionnaire was used to collect data from a sample of 243 Croatian citizens. In a context of hypothetical scenarios involving priority setting decisions taking by physicians, the present study elicits Croatian respondents’ views concerning: the ethical principles that should guide patients prioritization; the parties that should make prioritization decisions; and the likelihood of healthcare rationing becoming a reality. Descriptive analysis, factor analysis and parametric and non-parametric tests were performed.

Findings suggest that Croatian respondents: support multiple substantive rationing criteria, with an incident in favoring the worst-off, reducing inequalities in health, translated in the fair-innings argument and efficiency achievement; appoint health professionals as rationing decision makers; and do not seem to believe in the possibility of patient selection becoming a reality.

Favoring the worst-off, equalizing life time health and the pursuit of efficiency seem to be the criteria most preferred by Croatian respondents to guide rationing policy at the micro level.

This study is the first attempt to elicit Croatian opinions concerning several rationing criteria inherent in healthcare micro allocation decisions. Healthcare rationing is a serious challenge to Croatian policy makers and so it would be useful for the public’s perceptions and beliefs to be considered.

The current COVID-19 pandemic stressed the importance of discussing the problems surrounding the scarcity of healthcare resources. Healthcare rationing has been a constant issue, but in the present pandemic, the need to choose who to treat and who to let die became a pressing reality. What criteria to adopt or what protocol to follow is a difficult challenge politicians face because it involves moral judgments and/or ethical values. As there are multiple ethically permissible criteria to allocate life-saving medical resources and we will all bear the consequences of these rationing decisions, it is important to explore the appropriateness of each of these approaches. Here, the author describes the main rationing criteria proposed in the literature and explores their applicability to an absolute scarcity of resources as the current one. Finally, the author describes the ongoing COVID-19 pandemic in Portugal and proposes some guidelines to ensure a fair allocation of resources.

A literature review was made regarding some rationing protocols, and a qualitative research was followed to collect data regarding the number of daily infected and daily deaths by COVID-19.

Portugal has not, fortunately and so far, been as badly hit by COVID-19 as other European Countries. However a rigorous and explicit protocol is lacking to help health professionals at the frontline to take legitimate rationing decisions.

The author contributes for the discussion about life-or-death decisions by proposing some clinical practice lines that may be applied fairly and consistently.

This study is the first attempt to emphasize the need to set life-or-death guidelines in Portugal in a public health emergency and to propose some of these guidelines.

The purpose of this paper is to investigate the views of Bulgarian citizens about the relevance of lifestyles in the management of scarce resources through rationing and explore whether they are associated with participants’ characteristics.

A self-administered questionnaire was used to collect data from a sample of 322 Bulgarian respondents. Respondents faced a hypothetical rationing scenario where they have to decide whether information about five harmful health behaviours (smoking, excess alcohol consumption, illegal drug use, overeating/poor diet and engaging in dangerous driving (speeding and/or under the influence of alcohol and/or drugs)) should be relevant in priority setting decisions. Descriptive statistics and logistic regressions were performed.

The majority of respondents disagree with the idea that personal responsibility for illness should count in priority decisions. Notwithstanding, there seems to be a wider consensus in giving lower priorities to patients that engage in dangerous driving (excess of speed and/or under the influence of alcohol and/or drugs), illegal drugs use and excessive alcohol intake. Overeating/poor quality nutrition was the risky behaviour less condemned by respondents followed by smoking. Respondents’ sociodemographic, health and beliefs about rationing criteria had different impact in the penalization of the risk behaviours.

This study is the first attempt to awaken attention to the impact that personal responsibility for health may have on intergenerational access to healthcare.

The problematic surrounding patients' prioritization decisions are currently at the centre of political leaders' concerns. How to define whom to treat when there are not enough resources to treat everybody is the key question. This exploratory study aims to investigate the views of Bulgarian citizens regarding the relevance of the information concerning eight individual health-related behaviours in priority setting decisions: smoking, excess of alcohol, illegal drug use, overweight/obesity, speed driving, extreme sports practice, unsafe sex and overuse of internet and/or mobile devices.

Data were collected through a questionnaire where 322 respondents faced hypothetical rationing dilemmas comprising option pairs of the eight risky behaviours. Descriptive statistics and non-parametric tests were performed to define the penalization of each of the risky behaviours and to test for the association between this penalization and the respondent's health habits and sociodemographic characteristics.

Most respondents would refuse to grant access to healthcare based on patients' personal responsibility for the disease. Nevertheless, respondents were more willing to consider illegal drug use, excessive alcohol consumption, engagement in unsafe sex behaviours and smoking. Respondent's own interest or advantage seems to be somehow relevant in explaining the penalization of risk behaviours in priority setting.

This study shows that most respondents support the lottery criterion and thus do not want to see lifestyle prioritization in action.

This study is the first attempt to awaken attention to the impact that personal responsibility for health may have on intergenerational access to healthcare in Bulgaria.

The purpose of this study is to provide a decision support tool to deal with the problem of seting priorites among patients competing for limited health care resources. Limited resources and unlimited demands prevent health-care services to be provided to all those in need. This became publicity evident with the current Covid-19 pandemic. Although controversial, health care rationing has always existed and is now inevitable. Setting priorities becomes then inevitable. How to define those priorities is a complex and yet irresolvable issue mainly because it involves several and conflicting criteria, translated into efficiency and equity considerations. This is why multi-criteria decision analysis (MCDA) was introduced to health care as an appropriate decision-support framework for solving complex problems.

This paper proposes the application of two combined approaches – analytic hierarchy process (AHP)-Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) and AHP-VlseKriterijumska Optimizacija I Kompromisno Resenje (VIKOR), as decision support tools to rank patients with competing needs in a more effective and equitable way. A rationing scenario involving four patients, differentiated by personal characteristics and health conditions, is used to illustrate, test and compare the applicability of both approaches. After extraction of the relative weights of the prioritization criteria involved in the hypothetical scenario from paired wise comparison methods, TOPSIS and VIKOR priority setting methods were designed.

Results suggest that patients ranking from both combination approaches are similar and in accordance with the order made directly by health-care professionals. Therefore, the relative weights computed by AHP in combination with TOPSIS and/or VIKOR methods could be used with suitable applicability by health-care decision-makers.

This study is the first attempt to apply a combination of MCDA methods to patients’ prioritization context and the first to cross previous studies to deepen and consolidate the research.

This paper aims to investigate the Portuguese general public views regarding the criteria that should guide critical COVID-19 patients to receive medical devices (ventilators and IUC beds) during the current pandemic context. Based on rationing principles and protocols proposed in ethical and medical literature the authors explore how Portuguese general public evaluates the fairness of five allocation principles: “prognosis”, “severity of health condition”, “patients age”, “instrumental value” (frontline healthcare professionals should be prioritized during the pandemic) and “lottery”.

An online questionnaire was used to collect data from a sample of 586 Portuguese citizens. Descriptive statistics and non-parametric tests were used to define a hierarchy of prioritization criteria and to test for the association between respondents support to them and their socio-demographic and health characteristics.

Respondents gave top priority to prognosis when faced with absolute scarcity, followed closely by the severity of health condition, patient’s age with instrumental value receiving lowest support, on average. However, when the age of the patients was confronted with survival, younger-first principle prevailed over recovery. In a pandemic context, lottery was considered the least fair allocation method. The findings suggest that respondents’ opinions are aligned with those of ethicists but are partially in disagreement with the protocol suggested for Portugal.

This study represents the first attempt to elicit public attitudes towards distributive criteria during a pandemic and, therefore, in a real context where the perception is that life and death decisions have to be made.

The purpose of this paper is to seek to elicit, in a context of economic crisis, the social preferences for the microallocation of scarce healthcare resources.

Data were collected from an online questionnaire which includes a hypothetical rationing choice scenario with four patients differentiated by their personal characteristics and health states competing for treatments and a set of statements that embodies: distributive criteria for prioritizing patients; the authorship of these types of decisions; and the likelihood of these decisions to be taken. Descriptive statistics, factor analysis and non-parametric test were used for describing and validating the data.

Findings suggest that respondents: support a pluralism of distributive principles in prioritizing patients with an incident in utilitarianism and the reducing of inequalities in health, translated in the fair-inning and in emotional arguments of fragility; trust in the health professional to make prioritization decisions; and are conscious that rationing decisions will be real in the short term.

The pursuit of efficiency and the equalizing of a lifetime health seem to be the criteria that should guide any rationing policy at the micro level.

This study addresses simultaneously several ethical principles inherent to microallocation healthcare resources in a suitable context in which Portugal is facing an economic crisis and where, consequently, rationing healthcare policies gain prominence on the political agenda.

The purpose of this study is to examine the demand for credit and credit rationing conducted by formal, informal and emerging microfinance lenders in the four poor counties of China.

This paper extends the existing studies on credit rationing in rural China by comparing the determinants of credit rationing by three different lenders, the formal lenders rural credit cooperatives (RCCs), the informal lenders and the new microfinance institutions (MFIs).

MFIs are capable of reaching out to the even poorer households if they develop the loan products based on the income and expenditure flows of these households.

The determinants of credit rationing by three types of institutions are estimated separately.

RCCs in China shall change their policy of discrimination against female-headed households. RCCs shall also simplify the loan application procedures and assess the clients based on their repayment capacities rather than the age or assets alone. RCCs could learn from MFIs to use incomes from migrant workers as a criterion to assess the loan applicants.

gender equity for loan access.

This paper extends the existing studies on credit rationing in rural China by comparing the determinants of credit rationing by three different lenders, the formal lenders (RCCs), the informal lenders and the new MFIs.

The purpose of this study is to explore and compare citizens’ attitudes in Portugal, Bulgaria and Croatia towards rationing criteria that should support an explicit priority setting process at the micro level.

Preferences were collected through an online questionnaire containing 14 statements concerning lottery, economic and person-based priority criteria. Respondents indicated their level of agreement with each criterion. Non-parametric tests were applied to compare the levels of agreement among 355, 298 and 243 Portuguese, Bulgarian and Croatian respondents, respectively.

The three groups of respondents appear to be concerned with both a fair and efficient allocation of resources. The severity of health conditions and patient’s age were the criteria most accepted by the respondents. This study suggests that Portuguese, Bulgarian and Croatian respondents have similar social values concerning patient prioritization, although the Portuguese adhere slightly more to efficiency criteria and less to person-based and lottery criteria than Bulgarian and Croatian respondents.

A majority of respondents across the three countries report having opinion about the bedside rationing criteria. Portuguese, Bulgarian and Croatian respondents accept a combination of personal and economic criteria in patient’s prioritization.

This study represents the first attempt to compare citizen’s opinions of three member states of the European Union.

Research paper

Continuous introduction of advanced health technologies coupled with limited resources force governments to adopt rationing measures in all types of health systems. The mass media can influence the application of these measures by rising people and patients' expectations and demands for new forms of healing. This article intends to find evidence of this influence by reporting two recent cases which occurred in Portugal involving two innovative drugs, one for the treatment of hepatitis C and another for type I spinal muscular atrophy. The new drugs were not publicly funded despite promising excellent overall health outcomes because of their high cost and exaggerated burden on national health system (NHS).

A qualitative research was used to collect information conveyed by the conventional media and social networks.

After a strong dissemination through conventional and social media of the nonapproved treatments, the drugs swiftly garnered support among the public and triggered remarkable and relentless advocacy efforts. The findings of this paper suggest that society opinions and, by extension, the decision of policy-makers are very susceptible to the influence of the mass media.

New ways of sharing information are changing health research and public health.

These stories raise complex tensions and important questions about resource-allocation decisions involving scientific research or innovative medicine. Societal preferences seem very vulnerable to information conveyed by the mass media.

This study is the first attempt to awaken attention to the influence that Portuguese mass media may exercise on future healthcare rationing decisions.