Considering consumer choice in the economic evaluation of mandatory health programmes: A review

Women and smoking—prices and health warning messages: evidence from Spain

OBJECTIVE

In Spain, fewer men are smoking every year yet the number of women smokers remains relatively high. This paper examines the impact of two anti-smoking policies (increased prices and obligatory pictorial health warning labels) on womens smoking decisions; generation cohorts are used to elucidate the determinants of those decisions.

DATA SOURCE

We have drawn 48,755 observations of women living in Spain from the Spanish National Health Surveys of 2001, 2003, 2006 and 2011.

DATA SYNTHESIS

Among the main results, we highlight that belonging to a particular generation modulates the manner in which individual characteristics and tobacco policies determine smoking decisions. For example, women's smoking was not considered as socially acceptable until the 1960s and therefore older women have lower smoking rates. However, for the younger female cohorts (generations X and Y) smoking was seen as an act of rebellion and modernity, so women belonging to these groups, irrespective of educational level, are more likely to smoke.

CONCLUSIONS

The price of cigarettes and pictorial health warning labels on cigarette packets also influence the smoking behaviour of Spanish women.

What is the public appetite for healthy eating policies? Evidence from a cross-European survey

World Health Organization estimates that obesity accounts for 2-8% of health care costs in different parts of Europe, and highlights a key role for national policymaking in curbing the epidemic. A variety of healthy-eating policy instruments are available, ranging from more paternalistic policies to those less intrusive. Our aim is to measure and explain the level of public support for different types of healthy eating policy in Europe, based on data from a probabilistic sample of 3003 respondents in five European countries. We find that the main drivers of policy support are attitudinal factors, especially attribution of obesity to excessive availability of unhealthy foods, while socio-demographic characteristics and political preferences have little explanatory power. A high level of support for healthy eating policy does not translate into acceptance of higher taxes to fund them, however.

Using the stated preference technique for eliciting valuations: the role of the payment vehicle

At the core of the stated preference method is choice of payment vehicle. Since payment vehicle is an intrinsic characteristic of a good, the choice of payment vehicle will naturally impact on the valuation of the good. Typical payment vehicles applied in the context of health are income tax levies, out-of-pocket payments at the point of consumption or private health insurance premiums. Where out-of-pocket payments will elicit use value only, private health insurance premiums will also disclose option value, i.e. the utility of knowing that one has access to a healthcare service should one need it. Income tax levies will disclose what in this paper is referred to as citizen's preferences, i.e. individual preferences that include use value, option value as well as (caring) externalities. This paper advocates that researchers design stated preference studies that encompass all relevant dimensions of value, and that serious thought is given to choice of payment vehicle. However, it is important to acknowledge that choice of payment vehicle has other potential implications for valuations. Payment vehicle and provider of services may be strongly linked in people's minds. If respondents implicitly associate a specific type of provider with a certain type of payment vehicle, it is important that any misperception is corrected by way of a precise description of the good being valued. Further, a pertinent issue is the extent to which respondents 'protest' to the stated preference question and how we should deal with these 'protesters'. No agreement currently exists about the procedure used to separate genuine zero values from protest values, nor about the treatment of protest responses in subsequent analyses. Beliefs are strongly associated with protesting, and exclusion of protest bids may therefore exclude individuals who have strong preferences for a payment vehicle. If it is acknowledged that payment vehicle is an intrinsic component of a good, exclusion of respondents who exhibit specific viewpoints may result in biased welfare estimates. Yet another issue is the presence of self-consciousness amongst respondents. If people derive utility from saying they are willing to pay for a public good (social desirability bias or warm glow), this potentially drives a wedge between people's stated value for a good in a survey and people's value for a good provided to them from the government. Tax payments are more binding than out-of-pocket payments. Payment towards public health programs via income tax may therefore generate lower consumer surplus than if the intervention was financed out-of-pocket with the option of opting out both in terms of participation as well as financially. Finally, only a few studies have looked at the impact of frequency of payments. The effect of temporal framing is clearly potentially important and at the same time an unavoidable component of the payment vehicle, yet it remains at present unexplored.

Measuring the loss of consumer choice in mandatory health programmes using discrete choice experiments

BACKGROUND

Economic evaluation of mandatory health programmes generally do not consider the utility impact of a loss of consumer choice upon implementation, despite evidence suggesting that consumers do value having the ability to choose.

OBJECTIVES

The primary aim of this study was to explore whether the utility impact of a loss of consumer choice from implementing mandatory health programmes can be measured using discrete choice experiments (DCEs).

METHODS

Three case studies were used to test the methodology: fortification of bread-making flour with folate, mandatory influenza vaccination of children, and the banning of trans-fats. Attributes and levels were developed from a review of the literature. An orthogonal, fractional factorial design was used to select the profiles presented to respondents to allow estimation of main effects. Overall, each DCE consisted of 64 profiles which were allocated to four versions of 16 profiles. Each choice task compared two profiles, one being voluntary and the other being mandatory, plus a 'no policy' option, thus each respondent was presented with eight choice tasks. For each choice task, respondents were asked which health policy they most preferred and least preferred. Data was analysed using a mixed logit model with correlated coefficients (200 Halton draws). The compensating variation required for introducing a programme on a mandatory basis (versus achieving the same health impacts with a voluntary programme) that holds utility constant was estimated.

RESULTS

Responses were provided by 535 participants (a response rate of 83 %). For the influenza vaccination and folate fortification programmes, the results suggested that some level of compensation may be required for introducing the programme on a mandatory basis. Introducing a mandatory influenza vaccination programme required the highest compensation (Australian dollars [A$] 112.75, 95 % CI -60.89 to 286.39) compared with folate fortification (A$18.05, 95 % CI -3.71 to 39.80). No compensation was required for introducing the trans-fats programme (-A$0.22, 95 % CI -6.24 to 5.80) [year 2010 values]. In addition to the type of mandatory health programme, the compensation required was also found to be dependent on a number of other factors. In particular, the study found an association between the compensation required and stronger libertarian preferences.

CONCLUSIONS

DCEs can be used to measure the utility impact of a loss of consumer choice. Excluding the utility impact of a loss of consumer choice from an economic evaluation taking a societal perspective may result in a sub-optimal, or incorrect, funding decision.