Free Riding in Healthcare Through a Game-Theoretic Lens: A Cross-Domain Narrative Review and Conceptual Synthesis.

Area of Science:

• Health Economics
• Game Theory
• Public Health Ethics

Background:

• Free riding occurs when actors benefit from health-related public goods while contributing less than socially optimal.
• This dynamic is observed across vaccination, health insurance, universal health coverage, antimicrobial resistance, organ donation, and global health cooperation.

Purpose of the Study:

• To clarify how free-rider dynamics differ across various healthcare domains.
• To synthesize foundational economic, game theory, and public health ethics sources.

Main Methods:

• A narrative review with conceptual synthesis.
• Searches of PubMed and Scopus, complemented by citation tracking and foundational source inclusion.
• Mapping of sources by domain, actors, strategies, payoff structure, information conditions, time horizon, enforcement mechanism, and policy relevance.

Main Results:

• Free riding arises when private payoffs diverge from collective welfare, with distinct game structures in each domain (e.g., vaccination, insurance, antimicrobial resistance).
• Identified three key policy functions: altering payoffs, altering information/beliefs, and changing game structure/enforceability.

Conclusions:

• Game theory is a valuable mechanism-based framework for understanding and addressing free riding in healthcare.
• Policy effectiveness depends on empirical calibration, institutional context, ethical legitimacy, equity, information, behavioral responses, and enforcement capacity.
• Game-theoretic prescriptions may fail if political economy, power asymmetries, implementation capacity, access barriers, or trust are ignored.