Constructing effectiveness as a general legal principle of public healthcare systems: comparative insights from France, Germany, and England

In public healthcare systems, effectiveness is a central requirement for determining which services should be offered and reimbursed. Yet, due to its technical nature and to the need for specification through specialised bodies, the nature of this principle remains underexplored. This article bridges the gap by conducting a comparative analysis of effectiveness’ operation in three distinct healthcare systems: Germany, France, and England. We argue that effectiveness can be recognised as a foundational legal principle governing reimbursement decisions, revealing a substantive and a formal dimension. Substantively, effectiveness requires a consideration of an intervention’s ability to bring about a clinical benefit, accounting both for its desired outcomes and its risks. The applied evidentiary standard calls for a careful scrutiny of the available scientific evidence, as well as the state of medical knowledge. The exceptions to this standard are extremely limited and do not undermine the validity of the wider principle. Formally, the article emphasises the central role that administrative authorities conducting Health Technology Assessment (HTA) play, with delegated decisions ranging from the definition of the applicable evidentiary standards to the issuing of binding guidelines. It is argued that mechanisms must be put in place to ensure these bodies’ expertise, independence, and transparency.