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Table 3 Summary of suggestions from key health economics commentators

From: Public health economics: a systematic review of guidance for the economic evaluation of public health interventions and discussion of key methodological issues

Source of published guidance Key points Theoretical paradigm underpinning guidance
Kelly et al. (2005) [3] Limited evidence of what interventions will work to reduce inequalities in health; evaluating single initiatives may fail to capture effects that rely on multiple interventions; behaviour needs to be changed in order to secure uptake of the intervention; difficult to isolate cause and effect due to multi-faceted nature of public health interventions; biological variation in clinical trials are much narrower than social variation in which public health interventions take place; public health interventions can change during their implementation; at what point is an intervention judged to have succeeded? As they advocate the use of cost-benefit analysis it could be said that the authors come from a theoretical base of welfarism.
Weatherly et al. (2009) [4] Attribution of effects: likely to be fewer controlled trials of public health programmes–other approaches will be necessary; measuring and valuing outcomes: other outcomes, apart from QALYs, may be relevant e.g. external outcomes not confined to the health sector alone; identifying inter-sectoral costs and consequences: costs and benefits may fall on many parts of the public sector; incorporating equity considerations: in many cases the main objective of the intervention is to reduce health inequalities. An extra-welfarist theoretical paradigm is used here in terms of concentrating on measuring benefits not adequately captured by QALYs.
Payne et al. (2012) [5] Valuation and Evaluation Research Theme (VERT) demonstrates that complex public health interventions have broader objectives than just health gain; maximising health gain is not a sufficient objective to achieve once cost and benefits outside the healthcare sector are recognised; public health guidance is more pragmatic than for clinical interventions and includes using alternative outcome measures (e.g. life years gained, cases averted) as well as QALYs; the authors suggest a move away from defining health benefits in terms of utility or QALY maximisation to consider non-health benefits and a measure of capability (or empowerment). A strong theoretical basis to this guidance is the capability approach. This is coupled with an extra-welfarist perspective where wider costs and benefits are considered.
Marsh et al. (2012) [34] Reviews methods that could be employed to capture wider range of benefits generated by public health interventions; economists need to embrace a wider set of modelling techniques to capture the effects of public health interventions the selection of which should be facilitated by the production of better data on behavioural outcomes; more valuation paradigms should be explored such as the capabilities and subjective well-being approach. The authors take an extra-welfarist perspective whereby wider costs and benefits are considered along with a wider range of modelling techniques. Behavioural economics is also a key theoretical underpinning where modelling of behavioural outcomes is considered.
  1. Summary of suggestions by key commentators relevant to the economic evaluation of public health interventions.