 The natural home of the CEA approach to allocation is at the institutional or meso-allocative level where decisions are made far from the individual bedside and are hidden from view in the form of hospital reimbursement policies and clinical guidelines. At the highest policy level of macro-allocation where overall national health budgets are developed, only the most technocratic of societies would have an explicit prioritization strategy based on CEA. In most democratic societies, health care budgets are determined by a complex interplay of politics and bureaucratic pressures. These forces tend to allocate more resources to urban areas, focus on curative rather than preventive services, and cater to special constituencies or those with the more highly paid lobbyists: all of which is demonstrably inefficient. Worse yet, in many countries, health care resource macro-allocation is governed by ability to pay, which is the most straightforwardly inefficient (not to say inequitable) allocation strategy there is. 