Public health economics of body and mind: a health economist's perspective

Abstract

BackgroundIf public health is the science and art of how society collectively aims to improve health, and reduce inequalities in health, then public health economics is the science and art of how we choose to do this with limited resources. The spectrum of public health activities is broad; for example, environmental policy, infectious disease control, individual behaviour change, and informing government legislation. I draw together key methodological considerations for the design, undertaking, and analysis of economic assessment alongside trials of public health interventions spanning environmental change and behaviour change relating to the body and mind. The discipline of health economics has grown up alongside a medical model of health. Many public health practitioners and health economists interested in public health are realising that emphasis is shifting from traditional behaviour-change interventions towards interventions that aim to change physical environments and social norms and that might need government legislation. This shift means that health economists need to approach the economic assessment of the broad spectrum of public health interventions in a more creative way. Quality-adjusted life-years may not fully capture diverse benefits of public health interventions but are useful for benchmarking the cost effectiveness of public health against clinical services. Health economists who have focussed on notions of efficiency need now to think more about equity, in view of public health goals of reducing inequalities in health. The aim is to convey to a public health science audience the challenges and opportunities facing health economists interested in public health today. MethodsI show these challenges and suggest solutions by drawing on recent published and ongoing trials of public health interventions with a health economics component. Changing the environment was investigated in the CHARISMA trial by improvement of heating and ventilation in homes of children with asthma. Changing individual physical behaviour was investigated by assessment of a national exercise referral scheme in the NERS trial. Changing individual mental behaviour was assessed by bringing mindfulness into the workplace in the Gwynedd trial. FindingsEmerging lessons include (1) the need to think about how evidence of cost effectiveness is going to be used by government and local commissioners of services, within what time horizon, and what the expected interplay may be between stakeholders; (2) mounting evidence that the government needs to focus on altering physical environments (eg, local planning laws, speed limits) and social environments (eg, school and workplace culture); and (3) a readiness to recognise where behaviour change has proved successful in the commercial sector, delivered in groups or online (eg, Slimming World). These three examples of economic analysis highlight thinking on design of economic assessment, power calculation issues relating to economic analysis, micro-costing techniques, and choice and range of outcome measures. InterpretationFaced with real public health challenges, we are beginning to learn how to design, undertake, and analyse economic assessments of public health interventions. We are learning how to provide clear evidence-based information to policy makers. Concrete recommendations to ensure funding streams for health economists, such as through the public health research programme, will help to support a methodological advancement in this field. FundingPublic Health Wales.