Equity - some theory and its policy implications

This essay seeks to characterise the essential features of an equitable health care system in terms of the classical Aristotelian concepts of horizontal and vertical equity, the common (but ill-defined) language of “need” and the economic notion of cost-effectiveness as a prelude to identifying some of the more important issues of value that policy-makers will have to decide for themselves; the characteristics of health (and what determines it) that can cause policy to be ineffective (or have undesired consequences); the information base that is required to support a policy directed at securing greater equity, and the kinds of research (theoretical and empirical) that are needed to underpin such a policy

Economics and ethics in health care

This editorial provides a review of the current ways in which health economics is impacting on policy and reviews some of the key ethical and value-judgmental issues that commonly arise in and as a result of the work of economists. It also briefly highlights the contributions of the authors of this special issue of the journal, all of which illustrate how economists have approached ethical issues in health service policy (both in its financing and its delivery), and some of which explore the major methodological matters that arise and go on to discuss their potential as sources of conflict or harmony with other approaches to the same question

National Institute for Clinical Excellence and its value judgments

The National Institute for Clinical Excellence (NICE) offers health professionals in England and Wales advice on providing NHS patients with the highest attainable standards of care. NICE gives guidance on individual health technologies, the management of specific conditions, and the safety and efficacy of interventional diagnostic and therapeutic procedures. Guidance is based on the best available evidence. The evidence may not, however, be very good and is rarely complete. Those responsible for formulating the NICE’s advice therefore have to make judgments both about what is good and bad in the available science (scientific value judgments) and about what is good for society (social value judgments). In this article we focus on the scientific and social judgments forming the crux of the institute’s assessment of cost effectiveness. Scientific value judgments and those relating to clinical effectiveness are considered elsewhere

Economics and public policy 0 NHS research and development as a public good

This paper analyses National Health Service R&D as a Samuelsonian public good. It also identifies other characteristics of NHS R&D: supplier-induced demand; information asymmetries; jointness in production of R&D, medical education and health care; multiplicity in research funding sources; uncertainty about research outcomes; the difficulty of measuring and valuing research outcomes; and the behavioural characteristics of the institutions which produce R&D. The principal conclusion is that a centrally planned approach is unlikely to solve the problems arising from these characteristics, whereas the creation of an appropriate institutional and behavioural framework is more promising. The recent reforms in the arrangements for supporting R&D in the NHS can be seen as a response consistent with this analysis, are outlined and set in their historical context.R&D; supply and demand

Evidence, Uncertainty and the Policy Pursuit of Fairness

The article considers the interrelationships between ideas of fairness and ideas of evidence, and how progress in the policy pursuit of fairness in health and healthcare has been plagued by problems with vocabulary, vagueness as to values, deplorable absences of relevant empirical knowledge and failure to address appropriate means of making decisions about fairness in health and healthcare. Specific proposals are suggested as possible ways forward.equity, fairness, evidence, uncertainty, healthcare policy

Rights, responsibilities and NICE: a rejoinder to Harris

Harris' reply to our defence of the National Institute for Clinical Excellence's (NICE) current cost-effectiveness procedures contains two further errors. First, he wrongly draws a conclusion from the fact that NICE does not and cannot evaluate all possible uses of healthcare resources at any one time and generally cannot know which National Health Service (NHS) activities would be displaced or which groups of patients would have to forgo health benefits: the inference is that no estimate is or can be made by NICE of the benefits to be forgone. This is a non-sequitur. Second, he asserts that it is a flaw at the heart of the use of quality-adjusted life years (QALYs) as an outcome measure that comparisons between people need to be made. Such comparisons do indeed have to be made, but this is not a consequence of the choice of any particular outcome measure, be it the QALY or anything else

Does cost-effectiveness analysis discriminate against patients with short life expectancy? Matters of logic and matters of context

The aim of this paper is to explore the claim of ageism made against the National Institute for Health & Clinical Excellence and like organisations, and to identify circumstances under which ageist discrimination might arise. We adopt a broad definition of ageism as representing any discrimination against individuals or groups of individuals solely on the basis that they have shorter life expectancy than others. A simple model of NICE?s decision making process is developed which demonstrates that NICE?s recommendations do not inherently discriminate on the basis of life expectancy per se but that scope for discrimination may arise in the case of specific technologies having identifiable characteristics. Such discrimination may favour patients with either longer or shorter life expectancy. It is shown that NICE?s policies, procedures and the context in which NICE makes its decisions not only reduce the scope for discriminatory recommendations but also – in the case of “end of life” treatments – increase the likelihood that NICE?s recommendations favour those with shorter, rather than longer, life expectancy.

Does Cost-Effectiveness Analysis Discriminate against Patients with Short Life Expectancy?

Does the use of quality-adjusted life-years (QALYs) in cost-effectiveness analyses (CEAs) of health care interventions necessarily discriminate against patients with short life expectancy compared with others? This paper reviews the arguments both that it does and that it does not, and demonstrates that whether the use of any time-dependent outcome measure in CEA will result in discrimination depends, in the context of any given choice between interventions, upon the choice of cost-effectiveness ‘threshold’ adopted by the decision maker, whether the incremental cost-effectiveness ratio (ICER) of the intervention for a subgroup of patients with relatively short life expectancy lies above the cost-effectiveness threshold, and whether the ICER for a subgroup of patients with longer life expectancy falls below the cost-effectiveness threshold. For discrimination to result against such patients requires that the long term ratio of costs to QALYs associated with the intervention be lower than the short term ratio of costs to QALYs. The implications for agencies which use CEA as part of their decision making are then discussed.

Four decades of health economics through a bibliometric lens

This paper takes a bibliometric tour of the past 40 years of health economics using bibliographic"metadata"from EconLit supplemented by citation data from Google Scholar and the authors'topical classifications. The authors report the growth of health economics (33,000 publications since 1969 -- 12,000 more than in the economics of education) and list the 300 most-cited publications broken down by topic. They report the changing topical and geographic focus of health economics (the topics'Determinants of health and ill-health'and'Health statistics and econometrics'both show an upward trend, and the field has expanded appreciably into the developing world). They also compare authors, countries, institutions, and journals in terms of the volume of publications and their influence as measured through various citation-based indices (Grossman, the US, Harvard and the JHE emerge close to or at the top on a variety of measures).Health Monitoring&Evaluation,Health Systems Development&Reform,Health Economics&Finance,Rural Development Knowledge&Information Systems,Health Law

Mark versus Luke? Appropriate Methods for the Evaluation of Public Health Interventions

The purpose of this paper is to demonstrate that a social decision making approach to evaluation can be generalised to interventions such as public health and national policies which have multiple objectives and impact on multiple constraints within and beyond the health sector. We demonstrate that a mathematical programming solution to this problem is possible, but the information requirements make it impractical. Instead we propose a simple compensation test for interventions with multiple and cross-sectoral effects. However, rather than compensation based on individual preferences, it can be based on the net benefits falling on different sectors. The valuation of outcomes is based on the shadow prices of the existing budget constraints, which are implicit in existing public expenditure and its allocation across different sectors. A ‘welfarist’ societal perspective is not sufficient; rather, a multiple perspective evaluation which accounts for costs and effects falling on each sector is required.cost-effectiveness analysis, decision rules, public health