A sketchy outline to the main economic theories forms the introduction to this book. The authors skillfully invoke those theories in the end only to point out that the economic evaluation primarily serves as a pragmatic aid to decision making. The “blue book” systematises and summarises recent knowledge on the main types of economic evaluations, thereby providing a useful overview including sources of further readings. Economic evaluation is defined as a comparative analysis of alternative courses of action in terms of both their costs and consequences. The authors make clear that the subject matter of economics is the deployment of real resources whether they cost money or not, for example, time, and that the economic notion of cost differs from the accounting notion of expenditure.
The book is exhaustive and detailed with regard to descriptions of techniques and tools for evaluation of health care programmes. It provides interesting syntheses of new and emerging methodologies. It is less concerned with the theoretical and ethical foundations of these methodologies, which Allan Williams 1 calls libertarian and egalitarian, respectively. This book reminds the readers on the probalistic and normative origins of the utility concept in economics (utility as a preference measure) as compared with the ethical concept of utility as usefulness. Thus, it is aimed at readers familiar with basic health economic concepts and theories so as to recognise different equity criteria, assess transferability of the results, and avoid ideological pitfalls.
An income distribution can affect results of the willingness to pay approach and there is a risk of double counting if the income effects are adjusted for at the same time as the respondents include income effects of disease or treatment in their responses. As human beings tend to adapt to their living conditions subliminal thinking occurs. By analogy, the same should apply to the time preference of discounting rates. The referred popular wisdom that “a bird in the hand” is more valued probably applies to the considerations of an ordinary human, with rather small incomes and expected returns. Those with large incomes might hold different views on handy birds.
The authors point out that the economic evaluation only addresses one dimension of health care programme decisions and that questions related to efficacy, effectiveness, and availability should be answered before an economic evaluation takes place. There is an unchallenged assumption that health care inputs and outcomes are spatially and temporally separable and supply inducement absent. In the case of treatments of acute myocardial infarctions those dying outside hospitals are not counted. In reality the provision and delivery of health care coincides with consumption and cannot be separated, in particular in emergency contexts. Procedures and treatments cannot be stored like products of the manufacturing or drug industries; it is rather a matter of oversupply or undersupply of facilities and personnel in relation to health care needs or demands. It follows that the subjects of cost effectiveness evaluation as conceptualised in the book mainly are elective procedures. The effects of hospital teaching status on the outcome of acute myocardial infarction have been shown to be large. The authors use the classic assumptions of advantages of scale economies and scope economies omitting the recognised fact that there are diseconomies of scale in hospitals. 2 The evidence on the effects of the hospital teaching status and scale on outcomes compared with costs would deserve some comments. It is possible that the economic evaluation would appeal a broader audience if its examples extended behind “whether drugs or surgery are the most cost‐effective ways of treating angina”. 1
1. Williams A. Being reasonable about the economics of health. In: Culyer AJ, Maynard A, eds. Selected essays . Cheltenham, UK: Edward Elgar 1997
2. Dawson D. Organisational economics. In: Fulop N, Allen P, Clarke A, et al, eds. Studying the organization and delivery of health services. Research methods . London: Routledge 2001124–139.
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