MEASURING THE VALUE OF PUBLIC HEALTH SYSTEMS

Abstract

I applaud Neumann et al.'s examination of the disconnect between health economists and public health practioners.1 Their findings are similar to the decade-old observations of Weinstein and Melchreit in the field of HIV prevention.2 The Centers for Disease Control and Prevention launched HIV prevention community planning in 1993 as a participatory process by which health departments were to garner broad, structured, evidence-based input when setting priorities.2 By 1994, the cost and effectiveness of HIV prevention programs were clearly identified as factors that should be considered in the community planning process and early technical assistance documents on economic evaluation became available.2 In 1998, Weinstein and Melchreit reflected on the nascent experiences of using economic evaluation in community planning and other HIV prevention policy making.2 They asserted that key barriers to further utilization of economic evaluation methods and data included: (1) lack of useful studies, (2) lack of in-house expertise, (3) conflicts of interest, (4) lack of generalizability of studies across jurisdictions, (5) studies focusing on individual interventions rather than on program portfolios, (6) legal prohibitions of cost-effective yet controversial interventions, and (7) unintended consequences of using economic evaluations.2 Weinstein and Melchreit also surveyed 57 health departments about using economic evaluations.2 Of the 26 health departments that participated in the survey, 14 had completed at least 1 economic evaluation since 1993.2 Interviews of respondents revealed that they found economic analyses very labor intensive and that the results were not always conclusive or comprehensive enough to clearly guide decision making.2 Nevertheless, Weinstein and Melchreit asserted that economic evaluation information was important for HIV prevention decision making and that more work to fine-tune the process was urgently needed.2 These findings seem mirrored by Neumann et al.,1,2 so we ask, why has so little changed and what can be done? I agree with Neumann et al.'s recommendations for furthering the use of health economics in public health practice. I also argue that we have too few conceptual frameworks that attempt to articulate how quantitative policy analysis can foster linkages between researchers and practitioners.3 Further, we need on-going analyst and practitioner partnerships able and willing to address policy questions under the high pressure demands of tight time limits and major public health consequences,4 and we need funding for such partnerships. Additionally, many practitioners are interested in performance standard-setting, and transparent, practical, underutilized methods like threshold analysis can be highly informative.5 Last, we should routinely include cost analyses in public health effectiveness studies so as to enable at least retrospective economic evaluations.6 We must act now to avoid having a third paper in 2018 that brings us again to similar conclusions.