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There is growing recognition that critical decisions concerning investments in new health care technologies and services should incorporate society's values along with the scientific evidence. From a normative perspective, public engagement can help realize the democratic ideals of legitimacy, transparency, and accountability. On a more pragmatic level, public engagement can help stakeholders understand the degree of popular support for policy options, and may enhance public trust in decision-making processes. To better understand public attitudes and values relating to priority setting in health care, researchers and decision-makers will have to employ a range of quantitative and qualitative approaches, drawing on different disciplines and methodological traditions.

Policy makers and program managers concerned with targeting resources to meet the rehabilitation needs of the nation cannot rely on the backlog of 18 cost-benefit studies to decide among alternative kinds and amounts of investment. Overly simplistic forecasting of the future earnings of rehabilitants, the insufficiencies of data concerning the benefits and costs of rehabilitation, and the extreme sensitivity of the cost-benefit model's results to its untested underlying assumptions argue against priority-setting based on intuitively appealing class-specific calculations that appear to show greater rates of return for investments in some kinds of disabled persons over others. Until substantial upgrading of the state of the art along certain recommended lines takes place, the political process looks like the only sensible and fair way to approach choice and the assertion ofpriorities.

This report is the first of a two-part report addressing different aspects of the priority setting process. The priority setting process includes standpoints, choices, information acquisition, information interpretation, decisions, and activities to win support for the various steps in this type of process. Setting priorities for collective resources requires conscious choices between different options, it takes place at different levels in a society, and it involves different types of actors (politicians, administrators, health care personnel, patients, and the public). This report presents several broad strategies from the body of international literature on priority setting in health care. The muddling through elegantly strategy dissociates itself from general rules or formulas for allocating resources in health care since these tend to make the process static. Rather, health care personnel should have substantial freedom to make decisions about the distribution of resources. The public has limited insight into the priority setting process, but is given the opportunity to judge the results. In the strategy for rational decision making, the acquisition of information is a key activity – usually the most important. Only the best available information, preferably acquired through scientific methods, should serve as a foundation for making decisions. Decision makers at different levels are expected to act rationally, i.e. guided by the available information they seek the optimum solution without allowing themselves to be influenced by extraneous factors. The strategy for pluralistic bargaining implies that priority setting involves the ability to make socially acceptable decisions, and that this bargaining process must be repeated again and again. According to this strategy, we reach the best possible solution to the prioritisation problem through transparency, participation of many different parties in the process, the ability to consider and analyse opposing arguments, and finally viewing the decision as being "reasonable". The community approach strategy assumes that strain on society will increase to gigantic proportions if we attempt to finance all potential medical interventions. There is a risk that along the way we will stray from the essential values of what constitutes a "humane society" and a "good life". A broad discussion should be initiated in the community to deal with the "impossible" value systems that lead in the wrong direction. The public should participate in this discussion, whereupon politicians and administrators need to develop "categorical standards" that are applied by health care personnel. The model of health care requirements combines elements of the rational and the pluralistic strategies. It includes the clarification of goals and principles, the utilisation of good information, and the understanding that prioritisation must be a continuous process at different levels that also considers the viewpoints of lay persons (consultation of patients and the public). Explicit and implicit decision making refers to the situation where elected officials are forced to explicitly indicate what should be financed while implementation of decisions at other levels involves an implicit process of prioritisation (not so much a conscious choice as a compelling condition). The transparency at one level serves as "protection" for the concealed process that must be carried out at other levels. If we focus solely on the transparency issue, the strategies themselves do not appear to differ substantially, except on a few points. However, such a conclusion would be entirely erroneous – substantial differences begin to appear as we carefully scrutinise the various strategies. This review suggests that we are not dealing with a single priority setting process, but rather with two processes – one concerning internal legitimacy and another concerning external legitimacy. Only when we make this sharp distinction does the content of the different strategies become truly apparent. The process of internal legitimacy is characterised by the ability to identify a knowledge base (scientific) and arguments for establishing priorities based on that knowledge. This is the only way that knowledge-based organisations like health services can begin to gain trust for the priorities. The model of health care requirements describes a reasonable model for establishing internal legitimacy in a priority setting process. Pluralistic bargaining, the community approach, and muddling through elegantly are priority setting processes concerned with improving the conditions for external legitimacy. However, they present two fundamentally different perspectives: to prospectively (ex ante) build confidence through guiding principles and a transparent and pluralistic decision making process, or to retrospectively (ex post) provide an opportunity to review and revise the results. Of the strategies reviewed, two emerge as being more attractive in regard to developing a priority setting process for health services in Sweden. These are the model of health care requirements to assure internal legitimacy and pluralistic bargaining to enhance the conditions for external legitimacy. ; This report is a translation from the Swedish report Prioriteringsprocessen Del I: Övergripande strategier with the same serial number 2003:3.