Economic evaluation of public health programmes : Constraints and opportunities

Abstract: The decision-making basis in health and medicine needs to be expanded by economic evaluations on public health programmes, to avoid that these are rejected without grounds when priorities are established. The first aim of this thesis is thus to assess the cost-effectiveness of three public health programmes, which were implemented in the Metropolitan area of Stockholm, Sweden during the period 1995-2004. The programmes evaluated represent different stages in the historical development of public health programmes, where the focus has shifted from healthcare sector-based to community-based that seek to create supportive environments for health. The smoking cessation program (Quit smoking, Gals; study I) was estimated to lead to societal cost-savings four times the programme costs and to health gains measured in QALYs (qualityadjusted life-years). The elderly safety promotion programme (Safe Seniors in Sundbyberg; study II) was estimated to impose zero societal costs and QALY gains. The diabetes prevention programme (SDPP; study III) might have been cost-effective in one programme area, cost-saving but without health gains in another area, and not cost-effective in the third programme area. The analyses were performed with the methodology recommended for economic evaluations of pharmaceuticals in Sweden to enable comparisons with other medical technologies. The thesis has shown that different types of public health programme can be cost-effective and that similar programmes potentially constitute a good way to use societal resources. Cost-effectiveness, however, is not a necessary condition for implementation of public health programmes, but financing is. The financing of community-based programmes was explored from two angles: the economic on incentives and resource allocation and the public health on whether local community participation had been achieved. Programme costs might be used as an indicator of local community participation, whereas a subsector financial analysis showed that the key local collaborator in Sweden, the municipalities, have clear financial incentives to collaborate in community-based elderly safety promotion programmes (study IV). The second aim of the thesis is to explore the appropriateness of the cost-effectiveness methodology for public health programmes, and both constraints and opportunities with the methodology were revealed. The monetary consequences of the programmes revealed opportunities to discuss the financing of community-based programmes. The constraints were found in the programme effects included in the cost-effectiveness analyses. Several valued outcomes from public health programmes that affect societal welfare and individual wellbeing are not reflected adequately, which lead to underestimates of the societal value of successful public health programmes. There are alternative methods for economic evaluations which might better reflect the societal value of public health programmes, currently discussed internationally and in Sweden. It remains an important task for future research to investigate whether, and which, alternative methods are more appropriate for public health programmes.