QALYs, DALYs, and HALYs: A unifying framework for the evaluation of population health.

We provide a unifying framework for the evaluation of population health. We formalize several axioms for social preferences over distributions of health. We show that a specific combination of those axioms characterizes a large class of population health evaluation functions combining concerns for quality of life, quantity of life and health shortfalls. We refer to the class as (unweighted) aggregations of health-adjusted life years (HALYs). Two focal (and somewhat polar) members of this family are the (unweighted) aggregations of quality-adjusted life years (QALYs), and of disability-adjusted life years (DALYs). We also provide new characterization results for these focal members that enable us to scrutinize their normative foundations and shed new light on their similarities and differences.

Ethically Acceptable Compensation for Living Donations of Organs, Tissues, and Cells: An Unexploited Potential?

The number of living donations of human organs, tissues, and cells falls far short of the need. Market-like arrangements to increase donation rates have been proposed, but they are broadly considered unacceptable due to ethical concerns and are therefore not policy relevant in most countries. The purpose of this paper is to explore a different approach to increasing living donations, namely through the use of ethically acceptable compensation of donors. We review the compensation practices in Europe and find a lack of reimbursement of incurred costs and lack of compensation for non-monetary losses, which create disincentives for donation. We draw on a well-known philosophical theory to explain why donors are rarely fully compensated and why many existing proposals to raise donation rates are seen as controversial or even unethical. We present and discuss three categories of compensation with the potential to increase donation rates in an ethically acceptable way.

Optimal price subsidies for appropriate malaria testing and treatment behaviour.

BACKGROUND: Malaria continues to be a serious public health problem particularly in Africa. Many people infected with malaria do not access effective treatment due to high price. At the same time many individuals receiving malaria drugs do not suffer from malaria because of the common practice of presumptive diagnosis. A global subsidy on artemisinin-based combination therapy (ACT) has recently been suggested to increase access to the most effective malaria treatment. METHODS: Following the recommendation by World Health Organization that parasitological testing should be performed before treatment and ACT prescribed to confirmed cases only, it is investigated in this paper if a subsidy on malaria rapid diagnostic tests (RDTs) should be incorporated. A model is developed consisting of a representative individual with fever suspected to be malaria, seeking care at a specialized drug shop where RDTs, ACT medicines, and cheap, less effective anti-malarials are sold. Assuming that the individual has certain beliefs of the accuracy of the RDT and the probability that the fever is malaria, the model predicts the diagnosis-treatment behaviour of the individual. Subsidies on RDTs and ACT are introduced to incentivize appropriate behaviour: choose an RDT before treatment and purchase ACT only if the test is positive. RESULTS: Solving the model numerically suggests that a combined subsidy on both RDT and ACT is cost minimizing and improves diagnosis-treatment behaviour of individuals. For certain beliefs, such as low trust in RDT accuracy and strong belief that a fever is malaria, subsidization is not sufficient to incentivize appropriate behaviour. CONCLUSIONS: A combined subsidy on both RDT and ACT rather than a single subsidy is likely required to improve diagnosis-treatment behaviour among individuals seeking care for malaria in the private sector.

Effects of food price shocks on child malnutrition: The Mozambican experience 2008/2009.

A propitiously timed household survey carried out in Mozambique over the period 2008/2009 permits us to study the relationship between shifts in food prices and child nutrition status in a low income setting. We focus on weight-for-height and weight-for-age in different survey quarters characterized by very different food price inflation rates. Using propensity score matching techniques, we find that these nutrition measures, which are sensitive in the short run, improve significantly in the fourth quarter of the survey, when the inflation rate for basic food products is low, compared to the first semester or three quarters, when food price inflation was generally high. The prevalence of underweight, in particular, falls by about 40 percent. We conclude that the best available evidence points to food penury, driven by the food and fuel price crisis combined with a short agricultural production year, as substantially increasing malnutrition amongst under-five children in Mozambique.

A new axiomatic approach to the evaluation of population health.

In this paper we explore the implications of normative principles for the evaluation of population health. We formalize those principles as axioms for social preferences over distributions of health for a given population. We single out several focal population health evaluation functions, which represent social preferences, as a result of combinations of those axioms. Our results provide new rationale for popular theories in health economics, such as the unweighted aggregation of quality-adjusted life years (QALYs) or healthy years equivalents (HYEs) and generalizations of the two, aimed to capture concerns for distributive justice, without resorting to controversial assumptions on individual preferences.

On the meaningfulness of testing preference axioms in stated preference discrete choice experiments.

A stream of studies on evaluation of health care services and public goods have developed tests of the preference axioms of completeness and transitivity and methods for detecting other preference phenomena such as unstability, learning- and tiredness effects, and random error, in stated preference discrete choice experiments. This methodological paper tries to identify the role of the preference axioms and other preference phenomena in the context of such experiments and discusses whether or how such axioms and phenomena can be subject to meaningful (statistical) tests.

The Chinese healthcare system: structure, problems and challenges.

We describe the structure and present situation of the Chinese healthcare system and discuss its primary problems and challenges. We discuss problems with inefficient burden sharing, adverse provider incentives and huge inequities, and seek explanations in the structural features of the Chinese healthcare system. The current situation will be further challenged in the future by an aging population, an increasing need for privatization and growing expectations about quality of healthcare.

An inquiry into the principles of needs-based allocation of health care.

The concept of need is often proposed as providing an additional or alternative criterion to cost-effectiveness in making allocation decisions in health care. If it is to be of practical value it must be sufficiently precisely characterized to be useful to decision makers. This will require both an account of how degree of need for an intervention is to be determined and a prioritization rule that clarifies how degree of need and the cost of the intervention interact in determining the relative priority of the intervention. Three common features of health care interventions must be accommodated in a comprehensive theory of need: the probabilistic nature of prognosis (with and without the intervention); the time course of effects; and the fact that the most effective treatments often combine more than one intervention. These common features are problematic for the concept of need. We outline various approaches to prioritization on the basis of need and argue that some approaches are more promising than others.

The lack of theoretical support for using person trade-offs in QALY-type models.

Considerable support for the use of person trade-off methods to assess the quality-adjustment factor in quality-adjusted life years (QALY) models has been expressed in the literature. The WHO has occasionally used similar methods to assess the disability weights for calculation of disability-adjusted life years (DALYs). This paper discusses the theoretical support for the use of person trade-offs in QALY-type measurement of (changes in) population health. It argues that measures of this type based on such quality-adjustment factors almost always violate the Pareto principle, and so lack normative justification.

Health care need: three interpretations.

The argument that scarce health care resources should be distributed so that patients in 'need' are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, each of which focuses on separate intuitions. Although this account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting-point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs-based priority setting to social welfare maximisation.

Axioms for health care resource allocation.

This paper examines principles of health care resource allocation based on axioms for individual preferences and distributive justice. We establish axioms for representing individual preferences by quality-adjusted life years (QALYs), as well as axioms for existence of a social welfare function depending only on QALYs. A symmetric Cobb-Douglas social welfare function is characterized by an axiom stating that social welfare is anonymous with respect to the distribution of individual life years. Replacing this axiom with an axiom of non-age dependence, we obtain a characterization of a utilitarian social welfare function with certain weights. Further, we give axioms for a social welfare function being a weighted sum of power transformations of individual QALYs.

Exponential health utility. A characterization and comments on the contribution by Happich and Muhlbacher.

In a recent contribution Happich and Muhlbacher proposed an axiom of constant absolute trade-off of life-years for health states, and studied the family of QALY models satisfying this axiom under expected utility and mutual utility independence between life-years and health states. Here we provide a complete characterization of the family of QALY models satisfying these conditions. This family should not be mistaken for the family of multiplicative exponential QALY models; in particular, it violates the zero condition.

A note on cost-value analysis.

We discuss 'cost-value analysis', a method for health care resource allocation suggested by Nord et al. (Nord E et al. Incorporating societal concerns for fairness in numerical valuations of health programmes. Health Econ 1999; 8: 25-39). Some difficulties and issues for future research are pointed out.