[Health economics: in search of efficiency]

Economic terms such as efficiency, optimality and social welfare carry strong positive connotations. Sometimes non-economists may overlook the substantive difference between the scientific definition of these terms and their use in common parlance. This difference will be highly relevant if and when economic statements about efficiency are presented or interpreted in a normative way, i.e., implying that efficiency equals social desirability. Any statement about efficiency rests on implicit or explicit assumptions concerning the appropriate effectiveness criterion because efficiency invariably is an instrumental or secondary objective only, subject to clarification of the primary objectives to be pursued. In the absence of an agreement on the primary objectives of a collectively funded health scheme, the pursuit of efficiency may lead to health care allocation decisions that are not in line with prevailing social value judgements. Therefore, exposition and acceptance of the specific value judgements underlying economic evaluations of health care programmes should be a prerequisite to any attempt towards their normative interpretation. As regards the implementation of cost benefit evaluation in health care, the cautious stance taken by the German Institute for Quality and Efficiency in Health Care (IQWiG) appears to be well justified in the absence of such a fundamental consensus, especially when these evaluations are meant to address issues of allocative efficiency.