The Politics of Drug Rationing in England and France: Developing Policies for Hard Choices

With advances in medical technologies, governments across the industrialised world have faced oft-conflicting pressures, such as providing sophisticated care, containing costs, and supporting the industry. This paper investigates how European countries have responded to this challenge of making medical technology available on the welfare state, focusing on policies towards funding pharmaceutical products through the health care system. Far from being a passive agent, governments have engaged in decision-making that affects the availability of drugs. They have developed systematic criteria to prioritise which drugs should be funded or rationed by the health care system. At the same time, they have faced pressure from societal actors, including the pharmaceutical industry and patient groups, to improve the availability of drugs. The paper examines the development of policies for drug funding and rationing in England and France over the recent decades, showing how these interactions of actors have taken place. Both countries undertook a series of reforms since the 1990s with similar organisational changes in decision-making in funding for drugs, such as the establishment of regulatory agencies to aid funding decisions. Yet the countries followed divergent policy trajectories with striking differences in the availability of drugs. In accounting for the varied trajectories, the paper shows how existing institutional structure as well as political factors affected the constellation of actors pushing for or against policy change, and resources and strategies that they deployed. This paper hence highlights the relative roles of institutional structure and political actors in policy-making for an issue with substantial distributive implications.