An investigation of economic evaluation methods for public health interventions : meeting the needs of public health decision-makers

Abstract

Market failure typically arises from the provision of public goods in private markets due to their being non-excludable and non-rivalry in consumption. Consequently, public goods will generally be under-provided in private markets and government intervention is commonplace to help ensure efficient provision. Programmes for prevention in health can be considered public goods. Prevention largely falls within remit of public health which, since 2013, has been the responsibility of local authorities (LAs) in England. Due to limited resources to fund public health activities in England, the prioritisation of resources is paramount. Economic evaluation can assist in guiding resource allocation decisions. Recommendations for economic evaluation methods to appraise public health interventions are less clear than for health technologies. Identifying relevant methodologies for public health appraisal is important to address the complexity of public health programmes and the LA setting of public health decisions in England. This study aimed to engage public health decision-makers (PHDMs) to identify the most beneficial economic evaluation tool(s) to meet their needs. This research focused on a sub-sect of public health: interventions related to alcohol consumption. A systematic review was conducted to identify economic evaluations of interventions to reduce alcohol misuse since 2006. The majority of evaluations identified were cost-utility analyses (CUAs). Limited consideration of methodological challenges specific to public health was found. A qualitative interview study with PHDMs in North-East England was then conducted which identified limited use and knowledge of health economic tools amongst the PHDMs. A desire for the incorporation of broader outcomes in evaluations to incorporate the local decision-making context was established. Building on the outcomes from the review and qualitative study, a cost-benefit analysis (CBA) and social return on investment (SROI) were conducted to evaluate a brief alcohol intervention in schools. In order to conduct the CBA, a contingent valuation (CV) study was carried out to obtain a monetised measure of benefit. Despite debate in the literature on the suitability of the CV method to elicit true economic values for public goods, particularly for goods offering limited private consumption value, CV has been used in the field of environmental economics for decades to ascertain non-use values for goods. The method ii has also been used to value healthcare goods. The outcomes of the CV survey additionally provided information on the mechanics of the decisions made by the public via examination of predictors of willingness-to-pay for the intervention. It can also help elucidate reasons given in support of the intervention (or lack of), potentially relevant to PHDMs. Such examination help bridge the gap between the fields of health economics and psychology. Both the CBA and SROI identified positive societal benefit from the intervention. These results were shown to PHDMs at a workshop, alongside results from a previously conducted CUA and a cost-consequence analysis (CCA) of the same intervention. The workshop elicited PHDM attendees’ preferences for the practical use of methodologies. SROI was most preferred, yet concern remained over its use and interpretation by PHDMs. A “one-tool-fits-all” approach was doubted as being appropriate by some attendees. Combining CCA alongside another evaluation was proposed favourably by PHDMs. Providing locally relevant analysis via additional sensitivity analyses was also regarded as highly beneficial by attendees.