Sam Watson’s journal round-up for 7th August 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. Lancet: Global Health [PubMedPublished 17th July 2017

Achieving universal health coverage is a key aspect of the UN’s sustainable development goals. However, what this means in practice is complicated. People need to be able to access health services free at the point of use, but once those services are accessed there needs to be sufficient labour, capital, skill, and quality to correctly diagnose and treat them. For many health systems worldwide, this will require large investments in infrastructure and staffing, but the potential cost of achieving these goals is unclear. This article sets out to estimate these costs. Clearly, this is a complicated task – health care systems are incredibly complex. From a basic microeconomic standpoint, one might need some understanding of the production function of different health care systems, and the marginal productivity of labour and capital inputs to these systems. There is generally good evidence of what is effective and cost-effective for the treatment of different diseases, and so given the amenable disease burden for a particular country, we could begin to understand what would be required to combat it. This is how this article tackles this question, more or less. They take a bottom-up costing approach to a wide range of interventions, governance requirements, and, where required, other interventions such as water and sanitation. However, there are other mechanisms at play. At national levels, economies of scale and scope play a role. Integration of care programs can reduce the costs, improve the quality, or both, of the individual programs. Similarly, the levels of investment considered are likely to have relevant macroeconomic effects, boosting employment, income, and subsequent socioeconomic indicators. Credit is due to the authors, they do consider financing and health impacts of investment, and their paper is the most comprehensive to date on the topic. However, their projections (~$300 billion annually) are perhaps more uncertain than they let on, a criticism I made of similar papers recently. While I should remind myself not to let the perfect be the enemy of the good, detailed case studies of particular countries may help me to see how the spreadsheet model may actually translate into real-world changes.

Precommitment, cash transfers, and timely arrival for birth: evidence from a randomized controlled trial in Nairobi Kenya. American Economic Review [RePEcPublished May 2017

A great proportion of the gains in life expectancy in recent years has been through the reduction of childhood mortality. The early years of life are some of the most precarious. A newborn child, if she survives past five years of age, will not face the same risk of dying until late adulthood. Many of the same risk factors that contribute to childhood mortality also contribute to maternal death rates and many low-income countries still face unacceptably high rates of dying for both mother and child. One way of tackling this is to ensure mothers have access to adequate antenatal and postnatal care. In Kenya, for example, the government legislated to provide free delivery services in government health facilities in 2013. However, Kenya still has some of the highest death rates for mother and child in the world. It is speculated that one reason for this is the delay in receiving services in the case of complications with a pregnancy. A potential cause of this delay in Nairobi is a lack of adequate planning from women who face a large number of heterogeneous treatment options for birth. This study presents an RCT in which pregnant women were offered a “precommitment transfer package”, which consisted of a cash transfer of 1000 KSh (~£7) during pregnancy and a further 1000 KSh if women stuck to a delivery plan they had earlier committed to. The transfer was found to increase the proportion of women arriving early to delivery facilities. The study was a fairly small pilot study and the results somewhat uncertain, but the intervention appears promising. Cost-effectiveness comparisons are warranted with other interventions aiming to achieve the same ends.

Bans on electronic cigarette sales to minors and smoking among high school students. Journal of Health Economics [PubMedPublished July 2017

E-cigarettes have provoked quite a debate among public health researchers and campaigners as we’ve previously discussed. E-cigarettes are a substitute for tobacco smoking and are likely to be significantly less harmful. They may have contributed to large declines in the use of tobacco in the UK in the last few years. However, some have taken a “think of the children!” position. While e-cigarette use per se among adolescents may not be a significant public health issue, it could lead to increased use of tobacco. Others have countered that those young people using e-cigarettes would have been those that used tobacco anyway, so banning e-cigarettes among minors may lead them to go back to the tobacco. This paper takes data from repeated surveys of high school students in the US to estimate the effects of banning the sale of e-cigarettes to minors on the prevalence of tobacco smoking. Interestingly, bans appear to reduce tobacco smoking prevalence; the results appear fairly robust and the modelling is sensible. This conflicts with other recent similar studies. The authors argue that this shows that e-cigarettes and tobacco smoking are complements, so reducing one reduces the other. But I am not sure this explains the decline since no increase in youth smoking was observed as e-cigarettes became more popular. Certainly, such a ban would not have reduced smoking prevalence years ago. At the very least e-cigarettes have clearly had a significant effect on attitudes towards smoking. Perhaps smoking was on the decline anyway – but the authors estimate a model with state-specific time trends, and no declines were seen in control states. Whatever our prior beliefs about the efficacy of regulating or banning e-cigarettes, the evidence is complex, reflecting the complex behaviour of people towards drugs, alcohol, and tobacco.

Credits

E-cigarettes and the role of science in public health policy

E-cigarettes have become, without doubt, one of the public health issues du jour. Many countries and states have been quick to prohibit them, while others continue to debate the issue. The debate ostensibly revolves around the relative harms of e-cigarettes: Are they dangerous? Will they reduce the harms caused by smoking tobacco? Will children take them up? Questions which would typically be informed by the available evidence. However, there is a growing schism within the scientific community about what indeed the evidence does say. On the one hand, there is the view that the evidence, when taken altogether, overwhelmingly suggests that e-cigarettes are significantly less harmful than cigarettes and would reduce the harms caused by nicotine use. On the other hand, there is vocal group that doubt the veracity of the available evidence and are critical of e-cigarette availability in general. Indeed, this latter view has been adopted by the biggest journals in medicine, The Lancet, the BMJ, the New England Journal of Medicine, and JAMA, each of whom have published either research or editorials along this line.

The evidence around e-cigarettes was recently summarised and reviewed by Public Health England. The conclusion of the review was the e-cigarettes were 95% less harmful than smoking tobacco. So why might these journals take a position that is arguably contrary to the evidence? From a sociological perspective, epistemological conflicts in science are also political conflicts. Actions within the scientific field are directed to acquiring scientific authority, and that authority requires social recognition. However, e-cigarette policy is also a political issue, and as such actions in this area are also directed at gaining political capital. If the e-cigarette issue can be delimited to a purely scientific problem then scientific capital can be translated into political capital. One way of achieving this is to try to establish oneself as the authoritative scientific voice on such matters and to doubt the claims made by others.

We can also view the issue in a broader context. The traditional journal format is under threat from other models of scientific publishing, including blogs, open access publishers, pre-print archives, and post-publication peer review. Much of the debate around e-cigarettes has come from these new sources. Dominant producers in the scientific field must necessarily be conservative since it is the established structure of scientific field that grants these producers their dominant status. But this competition is the scientific field may have wider, pernicious consequences.

Typically, we try to formulate policies that maximise social welfare. But, as Acemoglu and Robinson point out, the policy that may maximise social welfare now, may not maximise welfare in the long run. Different policies today affect the political equilibrium tomorrow and thus the policies that are available to policy makers tomorrow. Prohibiting e-cigarettes today may be socially optimal if there were no reliable evidence on their harms or benefits and there were suspicions that they could cause public harm. But, it is very difficult politically to reverse prohibition policies, even if evidence were to later emerge that e-cigarettes were an effective harm reduction product. Thus, even if the journals were to doubt the evidence around e-cigarettes, then the best policy position would arguably be to remain agnostic and await further evidence. But, this would not be a position that would grant them socially recognised scientific capital.

Perhaps this e-cigarette debate is reflective of a broader shift in the way in which scientific evidence and those with scientific capital are engaged in public health policy decisions. Different forms of evidence beyond RCTs are being more widely accepted in biomedical research and methods of evidence synthesis are being developed. New forums are also becoming available for their dissemination. This, I would say, can only be a positive thing.