Measuring the benefits of health promotion programmes: application of the contingent valuation method

Willingness and ability to pay for breast cancer treatment among patients from Addis Ababa, Ethiopia: A cross-sectional study

INTRODUCTION

Breast cancer (BC) is the most common malignant neoplasm among women in Addis Ababa, Ethiopia. The willingness and ability to pay (WATP) for treatment is a contributing factor in the utilization of health care services. The World Health Organization Breast Cancer Initiative calls for 80% of patients to complete multimodality treatment and indicates payment as central factor to improve BC outcome. The objectives of this study are to identify how much female BC patients paid in Addis Ababa for BC treatment, their WATP for BC treatment, and the factors that affect WATP.

METHODS

The researchers collected data from 204 randomly selected BC patients who were treated in one of four different health facilities (one public and three private) between September 2018 and May 2019. A structured questionnaire was used to assess their WATP for BC treatment and multivariable regression to investigate factors associated with patients' WATP.

RESULTS

Of interviewed patients, 146 (72%) were at reproductive age. Patients' median expenditure for all BC treatment services was 336 US dollars (USD) in a public cancer center and 926 USD in privately owned health facilities. These amounts are in contrast with a reported WATP of 50 USD and 149 USD. WATP increased with increasing expenditure (OR 1.43; 95% CI 1.09 to 1.89 per 100 US), educational level (OR 1.37; 95% CI 1.02 to 1.85) and service quality (OR 1.34; 95% CI 1.04 to 1.72). In contrast, a monthly income increase by 100 USD corresponds to a 17% decrease of WATP (OR 0.83; 95% CI 0.70 to 0.99).

CONCLUSIONS

We demonstrated that BC treatment was very expensive for patients, and the cost was much higher than their WATP. Thus, we suggest that BC should be included in both social and community-based health insurance plans and treatment fees should consider patients' WATP.

Do public healthcare programs make societies more equal? Cross-country evidence on subjective wellbeing

BACKGROUND

Universal health coverage (UHC) aims to provide quality healthcare services and safeguard the population from the financial burden of catastrophic health expenditure. Its primary objectives are to improve longevity and enhance overall quality of life. This study investigates the relationship between UHC and the inequality in subjective wellbeing (SWB) and explores whether public health programs can reduce social inequality. By employing SWB inequality as a measure, we go beyond the conventional income-centric approach to assess social inequality.

METHODS

The SWB data used in this study are derived from the repeated cross-sectional survey obtained from the European Values Study (EVS) and the World Values Survey (WVS). We adopt an observational study design and employ statistical techniques, such as ordinary least squares, Oaxaca-Blinder decomposition, and the recentered influence function (RIF). The RIF, in particular, allows us to characterise the entire distribution of SWB, rather than focusing on a single point.

RESULTS

UHC programs are negatively associated with SWB inequality (-0.070, significant at 5%). The negative association is observed at the 5th, 50th, and 75th percentiles of the SWB distribution, whilst the association becomes positive at the 95th percentile. UHC programs do not contribute to the SWB inequality gap.

CONCLUSIONS

UHC programs exhibit an inequality-reduction property when the inequality is not severe or when countries are more equal. However, their effectiveness diminishes in the presence of extreme inequality. Health programs do not contribute to the existing SWB inequality gap between developed and developing countries. Strengthening the two dimensions of the UHC program (i.e., service coverage and financial protection) will ensure better health and wellbeing for all, and potentially foster a more equal and inclusive society.

Conceptualising 'Benefits Beyond Health' in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis

There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.

Assessment of willingness to pay for expanded carrier screening among women and couples undergoing preconception carrier screening

Background

Expanded carrier screening can provide risk information for numerous conditions. Understanding how individuals undergoing preconception expanded carrier screening value this information is important. The NextGen study evaluated the use of genome sequencing for expanded carrier screening and reporting secondary findings, and we measured participants’ willingness to pay for this approach to understand how it is valued by women and couples planning a pregnancy.

Methods

We assessed 277 participants’ willingness to pay for genome sequencing reporting carrier results for 728 gene/condition pairs and results for 121 secondary findings. We explored the association between attitudes and demographic factors and willingness to pay for expanded carrier screening using genome sequencing and conducted interviews with 58 of these participants to probe the reasoning behind their preferences.

Results

Most participants were willing to pay for expanded carrier screening using genome sequencing. Willingness to pay was associated with income level and religiosity, but not risk status for a condition in the carrier panel. Participants willing to pay nothing or a small amount cited issues around financial resources, whereas those willing to pay higher amounts were motivated by “peace of mind” from carrier results.

Conclusion

Women and couples planning a pregnancy value genome sequencing. The potentially high out-of-pocket cost of this service could result in healthcare disparities, since maximum amounts that participants were willing to pay were higher than a typical copay and related to income.

Valuing Meta-Health Effects for Use in Economic Evaluations to Inform Reimbursement Decisions: A Review of the Evidence

OBJECTIVE

This review explores the evidence from the literature regarding how meta-health effects (effects other than health resulting from the consumption of health care) are valued for use in economic evaluations.

METHODS

A systematic review of the published literature (the EMBASE, MEDLINE, PsycINFO, CINAHL, EconLit and SocINDEX databases were searched for publications in March 2016, plus manual searching) investigated the associations between study methods and the resulting values for meta-health effects estimated for use in economic evaluations. The review considered which meta-health effects were being valued and how this differed by evaluation approach, intervention investigated, source of funds and year of publication. Detailed reasons for differences observed between values for comparable meta-health effects were explored, accounting for the method of valuation.

RESULTS

The search of the literature revealed 71 studies of interest; 35% involved drug interventions, with convenience, information and process of care the three meta-health effects most often investigated. Key associations with the meta-health effects were the evaluation method, the intervention, and the source of funds. Relative values for meta-health effects ranged from 0.9% to 68% of the overall value reported in a study. For a given meta-health effect, the magnitude of the effect evaluated and how the meta-health effect was described and framed relative to overall health explained the differences in relative values.

CONCLUSIONS

Evidence from the literature shows variability in how meta-health effects are being measured for use in economic evaluations. Understanding the sources of that variability is important if decision makers are to have confidence in how meta-health effects are valued.

Outcomes in Economic Evaluations of Public Health Interventions in Low- and Middle-Income Countries: Health, Capabilities and Subjective Wellbeing

Public health programmes tend to be complex and may combine social strategies with aspects of empowerment, capacity building and knowledge across sectors. The nature of the programmes means that some effects are likely to occur outside the healthcare sector; this breadth impacts on the choice of health and non-health outcomes to measure and value in an economic evaluation. Employing conventional outcome measures in evaluations of public health has been questioned. There are concerns that such measures are too narrow, overlook important dimensions of programme effect and, thus, lead to such interventions being undervalued. This issue is of particular importance for low-income and middle-income countries, which face considerable budget constraints, yet deliver a large proportion of health activities within public health programmes. The need to develop outcome measures, which include broader measures of quality of life, has given impetus to the development of a variety of new, holistic approaches, including Sen's capability framework and measures of subjective wellbeing. Despite their promise, these approaches have not yet been widely applied, perhaps because they present significant methodological challenges. This paper outlines the methodological challenges for the identification and measurement of broader outcomes of public health interventions in economic evaluation in low-income and middle-income countries.

A qualitative study on the views of experts regarding the incorporation of non-health outcomes into the economic evaluations of public health interventions

Background

Public health interventions can impact a broad number of outcomes, including both health and non-health outcomes (NHOs). However, although it is often acknowledged that it’s important to take NHOs into account in economic evaluation studies, in practice these are often neglected. To address this issue, our study investigated expert views regarding the incorporation of NHOs into the economic evaluations of public health interventions, by means of a qualitative study.

Methods

A purposive sampling method was used to recruit the experts in the field of health economics and/or public health for this study. Twenty-two semi-structured interviews were held. After recording, the interviews were transcribed verbatim and entered in Nvivo. The data was analyzed using a thematic analysis to identify all important themes mentioned by the experts. Data collection and analysis was continued until saturation was reached. Multiple coding and validity checks were performed to further strengthen the rigour of our methodology.

Results

Based on the expert interviews, the following overarching themes were identified; Theme 1: NHOs on the individual level, direct social level and societal level. Theme 2: Pros and Cons regarding the development of a new instrument to measure NHOs. Theme 3: The most important requirements for a new questionnaire to be developed for measuring broader outcomes. Theme 4: Alternative methods which could be used for measuring and valuating NHOs in economic evaluations for public health.

Discussion

Our research findings indicate that the importance of NHOs and the need to measure them are universally accepted. Most of the experts acknowledge the importance of measuring broader outcomes and support the development of a new instrument to measure these. The experts, who do not support the development of a new instrument, question its usefulness and feasibility; i.e., they are not sure whether it is possible to valuate NHOs. Furthermore, experts have strong and sometimes conflicting views on the specific requirements of a new instrument to be developed for measuring NHOs. They did not identify a single preferred alternative method for measurement and valuation.

Conclusions

Most experts find a wide range of NHOs important and are in favor of developing a new instrument for identifying and measuring NHOs. Hence, an open discussion needs to be initiated with experts and other stakeholders about which steps need to be taken to move forward.

Predictors of willingness to pay for physical activity of socially vulnerable groups in community-based programs

Willingness to pay (WTP) is used to assess individuals’ value attribution to health-related quality of life interventions. Little is known about predictors of WTP for sport and physical activity in socially vulnerable groups in community-based physical activity (CBHEPA) programs. This study addresses the questions: What is the WTP for sport and physical activity of participants in CBHEPA programs, expressed in WTP_money and WTP_time? Which factors predict WTP_money and WTP_time? From the literature, predictors for WTP for sport and physical activity were identified: (1) personal and socio-economic predictors: income, education, age, and ethnic origin, (2) health-related predictors: perceived health, life satisfaction, sense of coherence, self-efficacy, (3) sport and physical activity-related predictors: duration and frequency of participation, leisure-time sport or physical activity, sport club membership, enjoyment, and membership fee. Data were gathered for WTP_money and WTP_time (n = 268) in 19 groups in an evaluation study of CBHEPA programs. Ordered probit was used for analyses. WTP_money was a monthly average of €9.6. WTP_time was on average 17.6 min travel time. Income was found as predictor for both WTP_money and WTP_time. Other predictors for WTP_money were: duration and frequency of program participation, enjoyment, and (former) sport club membership. Low income and younger age were found as predictors for WTP_time. Predictors for WTP_money are related to income and sport and physical activity experiences, for WTP_time to income and age. Short-term program satisfaction is probably more decisive for WTP_money than long-term perspectives of improving health-related quality of life.

Exploring Outcomes to Consider in Economic Evaluations of Health Promotion Programs: What Broader Non-Health Outcomes Matter Most?

Background

Attention is increasing on the consideration of broader non-health outcomes in economic evaluations. It is unknown which non-health outcomes are valued as most relevant in the context of health promotion. The present study fills this gap by investigating the relative importance of non-health outcomes in a health promotion context.

Method

We investigated the relative importance of ten non-health outcomes of health promotion programs not commonly captured in QALYs. Preferences were elicited from a sample of the Dutch general public (N = 549) by means of a ranking task. These preferences were analyzed using Borda scores and rank-ordered logit models.

Results

The relative order of preference (from most to least important) was: self-confidence, insights into own (un)healthy behavior, perceived life control, knowledge about a certain health problem, social support, relaxation, better educational achievements, increased labor participation and work productivity, social participation, and a reduction in criminal behavior. The weight given to a particular non-health outcome was affected by the demographic variables age, gender, income, and education. Furthermore, in an open question, respondents mentioned a number of other relevant non-health outcomes, which we classified into outcomes relevant for the individual, the direct social environment, and for society as a whole.

Conclusion

The study provides valuable insights in the non-health outcomes that are considered as most important by the Dutch general population. Ideally, researchers should include the most important non-health outcomes in economic evaluations of health promotion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0908-y) contains supplementary material, which is available to authorized users.

Consumer willingness to invest money and time for benefits of lifestyle behaviour change: an application of the contingent valuation method

OBJECTIVE

To use contingent valuation (CV) to derive individual consumer values for both health and broader benefits of a public-health intervention directed at lifestyle behaviour change (LBC) and to examine the feasibility and validity of the method.

METHOD

Participants of a lifestyle intervention trial (n = 515) were invited to complete an online CV survey. Respondents (n = 312) expressed willingness to invest money and time for changes in life expectancy, health-related quality of life (HRQOL) and broader quality of life aspects. Internal validity was tested for by exploring associations between explanatory variables (i.e. income, paid work, experience and risk factors for cardiovascular diseases) and willingness to invest, and by examining ordering effects and respondents' sensitivity to the scope of the benefits.

RESULTS

The majority of respondents (94.3%) attached value to benefits of LBC, and 87.4% were willing to invest both money and time. Respondents were willing to invest more for improvements in HRQOL (€42/month; 3 h/week) and broader quality of life aspects (€40/month; 2.6 h/week) than for improvements in life expectancy (€24/month; 2 h/week). Protest answers were limited (3%) and findings regarding internal validity were mixed.

CONCLUSION

The importance of broader quality of life outcomes to consumers suggests that these outcomes are relevant to be considered in the decision making. Our research showed that CV is a feasible method to value both health and broader outcomes of LBC, but generalizability to other areas of public health still needs to be examined. Mixed evidence regarding internal validity pleads for caution to use CV as only the base for decision making.

Willingness to pay for ovulation induction treatment in case of WHO II anovulation: a study using the contingent valuation method

OBJECTIVE

To measure the willingness to pay (WTP) of women aged 18-45 years to receive drug treatment for ovulation induction (ie, the social value of normal cycles of ovulation for a woman of childbearing age) in order to feed the debate about the funding of fertility cares.

SETTING

An anonymous questionnaire was used over the general population of Quebec.

PARTICIPANTS

A total of 136 subjects were recruited in three medical clinics, and 191 subjects through an online questionnaire.

METHOD

THE QUESTIONNAIRE CONSISTED OF THREE PARTS: introduction to the problematic, socioeconomic data collection to determine factors influencing the formation of WTP, and a WTP question using the simple bid price dichotomous choice elicitation technique. The econometric estimation method is based on the "random utility theory." Each subject responding to our questionnaire could express her uncertainty about the answer to our WTP question by choosing the answer "I do not know."

OUTCOME MEASURE

The WTP in Canadian dollars of women aged 18-45 years to receive drug treatment for ovulation induction.

RESULTS

Results are positive and indicate an average WTP exceeding 4,800 CAD, which is much more than the drug treatment cost. There is no evidence of sample frame bias or avidity bias across the two survey modes that cannot be controlled in econometric estimates.

CONCLUSION

Medical treatment for ovulation induction is highly socially desirable in Quebec.

Economic valuation of health care services in public health systems: a study about Willingness to Pay (WTP) for nursing consultations

Background

Identifying the economic value assigned by users to a particular health service is of principal interest in planning the service. The aim of this study was to evaluate the perception of economic value of nursing consultation in primary care (PC) by its users.

Methods and Results

Economic study using contingent valuation methodology. A total of 662 users of nursing consultation from 23 health centers were included. Data on demographic and socioeconomic characteristics, health needs, pattern of usage, and satisfaction with provided service were compiled. The validity of the response was evaluated by an explanatory mixed-effects multilevel model in order to assess the factors associated with the response according to the welfare theory. Response reliability was also evaluated. Subjects included in the study indicated an average Willingness to Pay (WTP) of €14.4 (CI 95%: €13.2–15.5; median €10) and an average Willingness to Accept [Compensation] (WTA) of €20.9 (CI 95%: €19.6–22.2; median €20). Average area income, personal income, consultation duration, home visit, and education level correlated with greater WTP. Women and older subjects showed lower WTP. Fixed parameters explained 8.41% of the residual variability, and response clustering in different health centers explained 4–6% of the total variability. The influence of income on WTP was different in each center. The responses for WTP and WTA in a subgroup of subjects were consistent when reassessed after 2 weeks (intraclass correlation coefficients 0.952 and 0.893, respectively).

Conclusions

The economic value of nursing services provided within PC in a public health system is clearly perceived by its user. The perception of this value is influenced by socioeconomic and demographic characteristics of the subjects and their environment, and by the unique characteristics of the evaluated service. The method of contingent valuation is useful for making explicit this perception of value of health services.

Consumer preferences for health and nonhealth outcomes of health promotion: results from a discrete choice experiment

OBJECTIVE

Health promotion (HP) interventions have outcomes that go beyond health. Such broader nonhealth outcomes are usually neglected in economic evaluation studies. To allow for their consideration, insights are needed into the types of nonhealth outcomes that HP interventions produce and their relative importance compared with health outcomes. This study explored consumer preferences for health and nonhealth outcomes of HP in the context of lifestyle behavior change.

METHODS

A discrete choice experiment was conducted among participants in a lifestyle intervention (n = 132) and controls (n = 141). Respondents made 16 binary choices between situations that can be experienced after lifestyle behavior change. The situations were described by 10 attributes: future health state value, start point of future health state, life expectancy, clothing size above ideal, days with sufficient relaxation, endurance, experienced control over lifestyle choices, lifestyle improvement of partner and/or children, monetary cost per month, and time cost per week.

RESULTS

With the exception of "time cost per week" and "start point of future health state," all attributes significantly determined consumer choices. Thus, both health and nonhealth outcomes affected consumer choice. Marginal rates of substitution between the price attribute and the other attributes revealed that the attributes "endurance," "days with sufficient relaxation," and "future health state value" had the greatest impact on consumer choices. The "life expectancy" attribute had a relatively low impact and for increases of less than 3 years, respondents were not willing to trade.

CONCLUSIONS

Health outcomes and nonhealth outcomes of lifestyle behavior change were both important to consumers in this study. Decision makers should respond to consumer preferences and consider nonhealth outcomes when deciding about HP interventions.

Exploring non-health outcomes of health promotion: the perspective of participants in a lifestyle behaviour change intervention

OBJECTIVE

To provide insights into health promotion outcomes that are not captured by conventional measures of health outcome used in economic evaluation studies, such as EQ5D based QALYs.

METHODS

Twelve semi-structured interviews and five focus group discussions were conducted with participants of a randomized controlled trial (n=52) evaluating the effectiveness of a theory-based lifestyle intervention in Dutch adults at risk for diabetes mellitus and/or cardiovascular disease. Transcripts were analysed by two independent researchers using a thematic analysis approach.

RESULTS

In total we identified twelve non-health outcome themes that were important from the participant perspective. Four of these were reported as direct outcomes of the lifestyle intervention and eight were reported as consequences of lifestyle behaviour change. Our findings also suggest that lifestyle behaviour change may have spillover effects to other people in the participants' direct environment.

CONCLUSION

This study provides evidence that in the context of lifestyle behaviour change EQ5D based QALYs capture health promotion outcomes only partially. More insights are needed into non-health outcomes and spillover effects produced by health promotion in other contexts and how participants and society value these. Methods to account for these outcomes within an economic evaluation framework need to be developed and tested.

Evidence-based refinement of health and social services: exploring the possibilities of intravention research

To promote evidence-based refinement of quality health and social services delivery and care, decision makers, researchers, and practitioners often undertake intervention research. Intervention research tests and describes new strategies for achieving desired outcomes. But theoretical, methodological, and practical issues continue to plague even alternative participatory approaches to intervention research, raising questions about its potential for promoting quality health and social services and care. In response to this persistent challenge, the authors of this article propose a radical solution, namely intravention research, laying out its unique features as well as its theoretical and practical implications. Their conceptualization sets the stage for dialogue on options for advancing research methodologies and methods that might better promote evidence-informed health and social services.

A study of the user's perception of economic value in nursing visits to primary care by the method of contingent valuation

Background

The identification of the attribution of economic value that users of a health system assign to a health service could be useful in planning these services. The method of contingent valuation can provide information about the user's perception of value in monetary terms, and therefore comparable between services of a very different nature. This study attempts to extract the economic value that the subject, user of primary care nursing services in a public health system, attributes to this service by the method of contingent valuation, based on the perspectives of Willingness to Pay (WTP) and Willingness to Accept [Compensation] (WTA).

Methods/Design

This is an economic study with a transversal design. The contingent valuation method will be used to estimate the user's willingness to pay (WTP) for the care received from the primary care nurse and the willingness to accept [compensation] (WTA), were this service eliminated. A survey that meets the requisites of the contingent valuation method will be constructed and pilot-tested. Subsequently, 600 interviews will be performed with subjects chosen by systematic randomized sampling from among those who visit nursing at twenty health centers with different socioeconomic characteristics in the Community of Madrid. The characteristics of the subject and of the care received that can explain the variations in WTP, WTA and in the WTP/WTA ratio expressed will be studied. A theoretical validation of contingent valuation will be performed constructing two explanatory multivariate mixed models in which the dependent variable will be WTP, and the WTP/WTA relationship, respectively.

Discussion

The identification of the attribution of economic value to a health service that does not have a direct price at the time of use, such as a visit to primary care nursing, and the definition of a profile of "loss aversion" in reference to the service evaluated, can be relevant elements in planning, enabling incorporating patient preferences to health policy decision-making.

Using a contingent valuation approach for improved solid waste management facility: evidence from Kuala Lumpur, Malaysia

This study employed contingent valuation method to estimate the willingness to pay (WTP) of the households to improve the waste collection system in Kuala Lumpur, Malaysia. The objective of this study is to evaluate how household WTP changes when recycling and waste separation at source is made mandatory. The methodology consisted of asking people directly about their WTP for an additional waste collection service charge to cover the costs of a new waste management project. The new waste management project consisted of two versions: version A (recycling and waste separation is mandatory) and version B (recycling and waste separation is not mandatory). The households declined their WTP for version A when they were asked to separate the waste at source although all the facilities would be given to them for waste separation. The result of this study indicates that the households were not conscious about the benefits of recycling and waste separation. Concerted efforts should be taken to raise environmental consciousness of the households through education and more publicity regarding waste separation, reducing and recycling.

Perception of the economic value of primary care services: a Willingness to Pay study

OBJECTIVE

Identify the economic value the user attributes to the visit to the family physician, in a setting of a National Health System, by the Willingness to Pay (WTP) expressed.

METHODS

Economic evaluation study, by the contingent valuation method. Questions were asked about WTP using a payment card format. Interviews were conducted with 451 subjects, in areas with different socioeconomic characteristics. An ordered probit was used to evaluate model's validity.

RESULTS

Median WTP expressed was euro18 (interquartile range euro8-28), not including "zero-answers" of thirty-four subjects (7.5%). This value represents 2% of average adjusted family incomes. Patients with higher incomes or with chronic illnesses presented a probability of 5-14 percentage points of expressing a high WTP. For every point of increase of patient satisfaction, the probability of presenting a WTP in the lowest range decreases 7.0 percentage points. Subjects with a low education level and those older than 65 expressed a lower WTP. Accessibility, risk perception, nationality and having private insurance were not related to the WTP expressed.

CONCLUSIONS

Users of primary care have a clear perception of the economic value of care received from the family physician, even in a framework of providing services financed by taxes and without cost at the moment of use. This value increases in subjects with higher incomes, with greater need for care, or more satisfied.

A cost-effectiveness analysis of a community-based diabetes prevention program in Sweden

Objectives:Lifestyle changes to prevent type 2 diabetes among high-risk persons have been shown to be cost-effective. This study investigates the cost-effectiveness of a community-based program promoting general population lifestyle changes to prevent diabetes.

Methods:The 10-year program was implemented in three municipalities in Sweden. Effectiveness was measured with a quasiexperimental cohort design, that is, risk factor levels in a population group aged 36–56 years at baseline and 8–10 years later (2,149 men; 3,092 women) in the program municipalities and a control area were compared. The incremental cost-utility analysis included future diabetes and cardiovascular disease-related health effects and societal costs (discounted 3 percent), estimated by a Markov model.

Results:In all areas, risk factor levels increased during follow-up, leading to increased societal costs of between SEK40,000 and 90,000 (1 Euro 2004 = SEK9.13; 1 US$ = SEK 7.35) and quality-adjusted life-year (QALY) losses between 0.12 and 0.48 per individual. Compared with the control area, the cost increases and QALY losses for women were more favorable in two program areas but less favorable in one, and less favorable for men in both areas (data unavailable for one municipality). The findings indicate that the program was cost-effective in only two female study groups.

Conclusions:Conflicting results on the cost-effectiveness of the program were obtained. As several potentially valuable aspects of the program are not included in the cost-effectiveness analysis, the societal value of the program might not be adequately reflected.

El concepto de willingness-to-pay en tela de juicio

La idoneidad del concepto de willingness to pay (disponibilidad a pagar) es revisado en las evaluaciones económicas que se realizan en el campo de la salud. Por un lado, existe dentro de la literatura económica un número importante de investigadores que señalan los múltiples problemas metodológicos que entrañan las estimaciones de willingness to pay. Por otro lado, aún el debate teórico-conceptual acerca de la agregación de las preferencias individuales dentro de una demanda agregada no ésta del todo resuelto. Sin embargo, durante los últimos 20 años la estimación de la disponibilidad a pagar dentro de las investigaciones económicas ha aumentado de forma significativa, siendo en muchos casos uno de los principales factores de la toma de decisión en políticas de salud. Plantease alguna de las limitaciones de esta técnica, así como el posible efecto distorsionador que podría tener sobre las evaluaciones económicas que se realizan en el área de la economía de la salud.