Over the past few months, we have often remarked on the sloppiness of the mainstream media. Serious, impartial journalists seem to be an endangered species threatened with extinction. In their place, we have jobbers and job’s worths.

But what happens when those writing in outlets professing “academic rigour and journalistic flair” are academics?

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The story is based on the UK’s Joint Committee for Vaccination and Immunisation (JCVI) recommendation to stop immunising pregnant and lactating women against SARS-CoV-2 from next spring. The crux of the JCVI’s recommendation is based on the results of a “cost effectiveness analysis” Before we assess the content of the Conversation piece, let’s look at how the JCVI reached its conclusion.

JCVI explain: “The use of cost-effectiveness is a key pillar in the consideration of immunisation programmes, ensuring that the substantial investments in the programmes are a good use of public money, and that those funds would not be better spent on other healthcare interventions. This has led to a more refined approach to the targeting of the COVID-19 immunisation programme, with a focus on individuals where there is good evidence of a high risk of hospitalisation and/or mortality.”

The decision is based on economic logic, which is based on the notion of resource scarcity. These can be staff, time, buildings, capital, goodwill, funds, power, gas, and every other resource we use to meet a need.

As resources are scarce, it is necessary to make choices about what needs can be met and to what degree. The notion of scarcity (which is universal as no nation has infinite resources) implies a sacrifice. What I use to meet need A cannot be used for need B or C, and so on. 

Health economic analyses are based on these simple concepts: Whatever I use to meet need A cannot be used for alternative B. If I meet need A, then I will gain a benefit. However, a cost-benefit has been foregone for need B, as I have used my scarce resources for A (for B no costs, but no benefits either). In economic evaluation, costs are regarded as opportunity costs because the costs of our actions are benefits foregone (in this case, for not meeting need B).

So, economic logic is based on choice, and economic evaluation is the method and technique I use to make that choice. If I take a societal perspective, say in Canada or Italy, I consider the costs and benefits for all Canadians or Italians. If I take a narrower view, say those of police forces or health care workers, the costs and benefits of alternatives are those that fall on these sectors.

The other aspect that makes economic evaluation so critical is that whatever inputs go into my analysis are explicit, and indeed, in the last three decades, health economists have gone to great lengths to ensure the explicitness and accountability of their work. The best evaluations are those that list and source their inputs and assumptions. Economists have also strived to achieve the most robust and credible sources for their evaluation inputs. The play of uncertainty is also considered in what is called a sensitivity analysis, a sort of “what if” which tests the robustness of the conclusions at the variation of the input variables.

Efficiency means making the best use of available resources. There are two types of efficiency: Technical and Allocative.

Technical efficiency is when we have decided to go for option A and look for the most efficient way of meeting A.

When making big decisions across different sectors, we consider the goods and services that meet society's needs and wants and strive for allocation efficiency.

The measurement of inputs and outputs, costs and benefits could take up a whole series of posts; let us just finish by listing the steps to be taken when carrying out an economic evaluation (taken from a book written by an old geezer many moons ago):

So, the JCVI approach, as summarised in their document, is wholly consistent with health economic theory and practice. According to them, it makes the best use of public money, thus taking a societal perspective for the whole country.

Why this long preamble? In this short series, we will examine what the JCVI did and what the Conversation had to say about the decision. However, as the JCVI’s recommendation is based on a welfare state economic viewpoint and clearly expressed as such, the economic background is essential to understand as we go further into the analysis.

The two old geezers who wrote this post understand the need for rationing in healthcare.

Readings

Elementary Economic Evaluation in Health Care. 2nd edition. 

T Jefferson, VDemicheli, M Mugford. London: BMJ Books, 2000. ISBN 0 72791478 2