OBJECTIVES: The National Health Insurance Law enacted in 1995 stipulates a list of health services to which all Israeli residents are entitled. For the past 20 years, the list has been updated annually, as a function of a predetermined budget, according to recommendations from the Public National Advisory Committee (PNAC), which evaluates and prioritizes candidate technologies. This study assesses the public legitimacy of PNAC's resource-allocation process and draws on this case study to offer general insight for increasing the public legitimacy of such processes worldwide.

METHODS: A qualitative analysis of public discourse documents about PNAC (articles in the print media, court rulings and parliamentary debates (N=119) was conducted to assess the perceived legitimacy of the PNAC by the Israeli public. Further content analysis of these documents and semi-structured interviews with stakeholders (N=70) revealed the mainstays and threats to its legitimacy. Data analysis for this study was conducted according to the "grounded theory" methodology and using MAXQDA software.

RESULTS: The PNAC enjoys ongoing support for its legitimacy in Israeli public discourse, which stem from its perceived objectivity, professional focus and transparency. The three major threats to its legitimacy pertain to: (1) the composition of the committee, particularly the lack of patient representatives; (2) its transparency model; (3) its decision-making principles.

CONCLUSIONS: To increase its legitimacy, the PNAC should include patient representatives, ensure the timely publication of its discussion transcripts, and incorporate cost-effectiveness analysis in its health technology assessments. This case study thus underscores the significance of inclusivity, transparency, and attendance to value-for-money considerations in healthcare resource allocation processes.