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.
Making hard choices in local public health spending with a cost-benefit analysis approach. Frontiers in Public Health Published 29th June 2019
In this round-up I have chosen three papers which look broadly at public health economics.
While NHS healthcare funding has been relatively preserved in the UK (in financial terms at least, though not keeping up with demographic change), funding for local government public health departments has been cut. These departments commission early years services, smoking cessation, drug and alcohol treatment, sexual health, and lots of other services. A recent working paper suggests that marginal changes in Public Health funding produce a more favourable ICER than changes in NHS funding.
This is a neat paper looking at the cost-benefit for a subset of £14 million investment in public health programmes in Dorset, a county on the south coast of England, whose population is slightly older and more affluent than the England average. I try to go to Dorset every year, it has beautiful beaches with traditional Punch and Judy shows, and nice old towns where you can get out on a mackerel fishing trip.
This paper looks at the potential financial savings for each public health programme across different sectors of the economy. One of the big issues with public health as opposed to clinical interventions is the cross sector flow problem – you spend money on drug and alcohol treatment, but the majority of benefits are through prevented crime; or you prevent teenage pregnancy, and a lot of the benefits are to the welfare system (because women delay pregnancy until they are more likely to be in a stable relationship and working). This makes it hard when local councillors might say, ‘what’s in it for us?’
Figure 2 in this paper shows the cross sector flow issue clearly – the spend comes from local authority public health, but 94% of the financial benefits are in the NHS.
I think this study has a good blueprint that other local authorities could follow. The study applies an optimism bias reduction, so it is not just assuming that programmes will be as effective as the research evidence suggests. This is important as there may be a big drop off in effectiveness when something is implemented locally. Of course, sometimes local implementation might be more effective. But it would be nice to see this kind of study carried out with more real-world data. Although the optimism bias reduction makes it less likely to overestimate the cost-benefit, it doesn’t necessarily make the estimate any more precise. National outcomes data collection for public health programmes is weak or absent; better data collection might mean more evidence that prevention interventions provide value for money.
Impact of sugar‐sweetened beverage taxes on purchases and dietary intake: systematic review and meta‐analysis. Obesity Reviews [PubMed] Published 19th June 2019
A lot of health economics focuses on healthcare interventions. But, upstream, structural policy interventions have the capacity to be a lot more cost effective in preventing ill health. Sugary drinks (sugar sweetened beverages – SSBs) are a source of excess empty calories and increase the risk of cardiovascular disease, diabetes and early death. One of the first pieces of work I did as a grown-up academic was looking at a sugary drinks tax, which resulted in me getting up early one day and seeing this. At the time I thought it had roughly zero chance of being implemented. But the sugary drinks industry levy (SDIL) was implemented in the UK in April last year, and had a huge effect in terms of motivating the industry to reformulate below the thresholds of 5g and 8g of sugar per 100ml. Milk-based drinks like Frijj and Yazoo are exempt and still often have nearly 10g sugar per 100ml so there has been talk of extending the tax to these drinks. But Boris Johnson, the likely next UK Prime Minister, has come out against these ‘nanny state’ ‘sin taxes’ and said he will review them, seemingly despite there being a large scale evaluation of the SDIL, and a growing evidence base. There is a good twitter thread on this by Adam Briggs here.
Policies like the SDIL rely on price elasticity of demand (PED). But this PED varies depending, for instance, on how addictive something is and the availability of substitutes. For tobacco, because it is addictive, a 10% price increase might only produce a 5% reduction in demand.
This systematic review and meta-analysis looked at data from 17 studies in 6 jurisdictions and found that, on average, sugar consumption is unit elastic – a 10% price increase produces a 10% reduction in purchases. However, there was considerable variation between studies. The authors designed a bespoke risk of bias tool for this, as the traditional tools used for health interventions did not include all of the potential biases for an SSB tax evaluation; this checklist may be useful for future analyses of similar policies.
If the SSB duty produced a unit elastic response in the UK, it means that people aren’t spending more on SSBs, they are merely buying less of something that they don’t need and which damages their health. And maybe a few people, over many years, consume a bit less sugar, don’t get type 2 diabetes, don’t have to give up work, and are actually better off and can provide for their families for a bit longer. Of course, in the UK the picture is complex because of the different tiers of the duty, but reformulation has meant that people are consuming less sugar even if they don’t reduce their sugary drink consumption. Also, the revenue from the SDIL is spent on healthier schools, so it could be argued that the policy is a win-win.
The cost of not breastfeeding: global results from a new tool. Health Policy & Planning [PubMed] Published 24th June 2019
This study looks at the potential worldwide cost savings if breastfeeding rates were improved. Breastfeeding prevents cases of diarrhoea, obesity, maternal cancer, and other diseases and adverse outcomes. Low breastfeeding rates are a big problem in developing countries where formula costs a huge proportion of income (nearly 20% of average household income in India and Pakistan according to this paper) and water supplies may be contaminated. This study includes healthcare costs, and economic losses from early deaths and reduced IQ through sub-optimal breastfeeding, which total $341 billion per year worldwide.
The authors have said there is also going to be an online, and Excel-based, results tool.
I love reading such ambitious studies that cover the whole world. Producing worldwide estimates for costs is a difficult exercise and can have a danger of losing meaning. For instance, in developing countries, medical costs may be very low if health coverage is very sparse. If a country doesn’t spend anything on healthcare and you measure public health interventions in healthcare cost savings, then it looks like these public health interventions are not worth doing. That is why it is sometimes better to focus on DALYs (and potentially put a financial value on them, although this can be controversial) rather than financial costs. The study found the biggest absolute costs of not breastfeeding were in North America ($115bn), while biggest costs as a proportion of gross national income (GNI) were for sub-Saharan Africa, where not breastfeeding cost 2.6% of GNI.
It looks like two out of the three authors are men. Is there a problem with men being pro-breastfeeding? Why should a man tell women what to do with their bodies? Women shouldn’t feel stigmatised about their infant feeding choices. But for me it is not about telling women what to do. It is making sure the structures and social norms are there to support breastfeeding and that formula companies are regulated in how they market themselves and their products. Maybe men not caring enough about breastfeeding is what has got us to where we are now.