Objective During the last decades a vast body of literature has emerged on how to promote fair resource allocation of health resources (1-5). Accordingly, a broadly held view stresses the importance of achieving legitimacy in health prioritization to build trust, including processes based on reasonable values, transparency and inclusion (6). In this piece, we discuss how the reverse also holds, i.e, already established trust in existing institutions promotes conferred legitimacy in health resource allocation. As a consequence, we argue for a shift of perspective on what is required to justify fair priorities; from promoting legitimacy through fair processes to establish trust based on mitigation of unjustly distributed and implemented use of powers.
Method This paper is based on theoretically and empirically informed reflections.
Results Findings from the Comparative Covid Response study, suggest that not only is ‘ trust in a nation’s public health system…contingent on the specifics of each country’s institutional arrangements’, but also that ‘(t)rust in official advice correlates with trust in government’(7). These observations support our argument that placing in trust in difficult health priority settings to be fair, depends on the country’s institutions and correlate with existing, supportive trust in government. When such trust is lacking, policymakers can establish it by mitigating unjust use of powers. Based on an analytical approach to power, we suggest a reconceptualization of fair priority-setting that can promote this crucial trust.
Discussion Our conclusion has substantive implications for health priority-settings and health technology assessments: When trust in decision-making authorities and/or institutions is absent, organizing decisions-making processes according to frameworks for achieving legitimacy ‘in isolation’ from how the society is otherwise organized, is not sufficient for decision-making authorities to achieve fair priority settings. Policy-makers must also address and mitigate socially unjust implementation of powers to justify health priorities as ‘fair’.
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