Public health economics -> Background information

Public-health interventions are becoming more and more susceptible to health-economic assessment, as is the case for interventions in other sectors of health care (for example, pharmaceutical care). In particular, in attempts to control the pharmaceutical market and its rising expenditures many countries have established regulations for market access of drugs and reimbursement, encompassing checks on cost-effectiveness of new drugs. Examples can be found in the Netherlands, Belgium and the UK. As a consequence, pharmacoeconomic methods have been used, refined and further developed, inclusive the specification of guidelines, clinical-trial-based approaches to cost-effectiveness (Fieller’s theorem and bootstrapping) and threshold analysis. With respect to the former we note that a pharmacoeconomic guideline for discounting (to cover time preference) is, for example, rather universal over Europe. With respect to the latter, we note that discussions on drugs (for example, statins) have given rise to exact thresholds for cost-effectiveness and cost-utility to be established (for example, € 20,000 per life-year gained in the Netherlands and ₤ 30,000 per QALY in the UK). Public-health interventions are now analysed and judged using the same guidelines, methods and thresholds, all originating from pharmacoeconomics.

Obviously, major differences exist between pharmaceutical and public-health interventions. This justifies our question: are pharmaco-/health economic guidelines, methods & thresholds as straightforwardly applicable to public health as is currently done? This question is relevant now, but its relevance will increase with a growing demand for cost-effectiveness analyses, to systematically include new public-health interventions. One may hypothesize that economic assessments of public-health interventions require different guidelines, other methods and public-health-specific thresholds. This is based on the preventive nature of many public-health interventions with often a long timeframe between investment and health gains, involving specific time preferences. Furthermore, randomised clinical trials are often lacking in public health, so other methods than trial-based ones are required (for example, transmission models in infectious diseases). Also, the type of life-year gained may generally differ for public health compared to pharmaceuticals, as public health is often directed at younger ages (for example, childhood vaccination programmes and prevention of sexually-transmitted diseases) compared to therapeutic drugs. We know that for some public-health interventions high thresholds are accepted (screening blood donors to enhance blood transfusion safety).

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