Understanding public opposition to negative reimbursement decisions in healthcare: A systematic review

The pressure on publicly financed healthcare systems may necessitate decisions to not (or no longer) reimburse health technologies. Such decisions remain politically sensitive and often evoke public opposition, pressuring decision-makers to revoke or revise them. However, the elements that constitute public opposition remain unclear. This study addresses this gap by systematically reviewing the scientific literature. We searched Embase, Google Scholar, Google, and Startpage, and supplemented these with a hand search in 2021, updated in 2022 and 2024. Based on 81 articles, we developed a thematic framework of 21 categories grouped under the Five Ws-'Who, What, When, Where, and Why'-of public opposition to negative reimbursement decisions. Citizens, patients (and representatives), physicians, pharmaceutical companies, and politicians emerged as key actors. Opposition typically targets the outcomes and justifications of decisions, driven by high expectations, claims about effectiveness, or perceptions that decision-makers prioritize cost containment. Distrust in decision-makers and evidence-based decision-making may leave some actors-particularly citizens and patients-vulnerable to commercial driven information and misinformation. Other actors-including pharmaceutical companies, patient representatives, and politicians-may strategically use the media to shape opinion and amplify opposition. Public opposition is multifaceted. Understanding its dynamics may help align decision-making with public values and support efforts to address misconceptions and counter misinformation, thereby enhancing the acceptability of such decisions in healthcare.