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The economics of public health


Project description

The Health Economics Theme's research team has contributed to a wide range of policy evaluations of interventions in the prevention of chronic and infectious diseases to improve population health (e.g. brief advice on and referral to exercise within primary care, promotion of breastfeeding, tobacco control, child vaccination, screening for abdominal aortic aneurysms, promotion of community based sport to increase physical activity). The study designs include clinical trials, quasi-experimental and observational methods as well as decision-modelling and econometric estimation.

Supporting methodological research in this area includes: testing alternative specifications for price in estimating the demand for sport and exercise; evaluating alternative methods to incorporate externalities of public health interventions within economic models; development of decision-support models for commissioners; and approaches to incorporating short term benefits and non-health benefits of public health programmes in economic evaluations.

Exploring transferability of HTA-type evidence in public health: the newly funded EQUIPT Project

Dr Subhash Pokhrel at HERG is leading a €2 million grant from the European Community’s FP7 programme to investigate the extent to which health technology assessment (HTA) type information could be transferred from one context to the other. Known as EQUIPT (European-study on Quantifying Utility of Investment in Protection from Tobacco), this three year project (Oct 2013 – Sep 2016) aims to provide policy makers and wider stakeholders with bespoke information about the economic and wider returns that investing in evidence-based tobacco control including smoking cessation agendas can generate. This project builds on earlier work that HERG did for the National Institute for Health and Care Excellence (NICE) on the Tobacco Return on Investment (ROI) Tools in England. The demand for ROI evidence in public health is on the rise, as the newly implemented Health and Social Care Act 2012 in England has placed much greater role for Local Authorities in health prevention, and given austere climate, this has resulted in much more demand for HTA (i.e. cost-effectiveness/ ROI) type information. The ROI tools are practical, customisable models to help make real-world decisions in context of local government decision-making. Through EQUIPT, the research team want to know the extent to which ROI concepts and tools are transferable to other European member states and how. [Read more on the EQUIPT website].

Funding body: European Community’s FP7 programme

Contact: Dr Subhash Pokhrel

Targeted interventions for prevention of cardiovascular disease: modelling the cost-effectiveness of CVD interventions in different socioeconomic groups

The PhD aims to develop methods to evaluate public health interventions for the prevention of cardiovascular disease (CVD), targeted at geographical areas, sub-groups of the population and at individuals, in order to estimate the cost-effectiveness and distributional impacts of the interventions. To do this, a simulation model will be constructed to model the different characteristics of individuals within the population and a distributional cost-effectiveness analysis approach will be used to quantify the impact of such interventions on variations in health inequalities. 

PhD research

Contact: Catriona Crossan (Supervisors:  Dr. Joanne Lord and Professor Julia Fox-Rushby)

Estimating impact of smoking on health-related quality of life

This recently completed research looked at the statistical association between individuals’ smoking status and their quality of life, as measured by EQ-5D, in the English general population. One of the important outcomes of this research is to provide ‘utility’ values, stratified by age and gender, according to several smoking categories (e.g. never smoker, ex-occasional smoker, ex-regular smoker, current light smoker, current medium smoker and current heavy smoker). All these values were adjusted for potential correlates via regression analysis and therefore present the ‘net’ changes in ‘utility’ due to smoking. This data is important for economic modellers who evaluate cost-effectiveness of interventions that affect, or are affected by, an individual’s smoking status.

Contact: Dr Subhash Pokhrel (PI)

An exploration of demand for physical activity

This PhD research focussed on understanding, from an economic perspective, the choices that individuals make about the extent to which they engage in physical activity. The empirical analysis involved econometric models to investigate varying indicators of physical activity behaviour using both primary and secondary data. The findings mainly suggest that time and money prices (costs per occasion of participation) of physical activity are inversely correlated with physical activity, and this is mitigated where the perceived benefits of physical activity, both health and non-health, are high.

(Awarded Waldock prize for research impact)

Contact: Dr Nana Anokye (Supervisor: Prof Julia Fox-Rushby)

A multicentre randomised controlled trial of an augmented exercise referral scheme using web-based behaviour change in individuals with type 2 diabetes, osteoarthritis or depression

This study evaluates the clinical and costs effectiveness of a parallel two arm patient randomised controlled trial. Patients will receive usual Exercise Referral Scheme -ERS (control) or usual ERS plus access to e-coach, and motivational and technical support (intervention). The target population is primary care patients with a medical condition (i.e. obesity, hypertension, type 2 diabetes, osteoarthritis or history of depression) deemed suitable for an ERS, in South West England, West Midlands and Glasgow. The economic analysis is two-fold, including; a within-trial cost-effectiveness analysis (from baseline to 12 months post randomisation) and beyond-trial modelling of long term expectations for cost-effectiveness, for the intervention versus control.

Funding body: National Institute of Health Research

Contact Dr Nana Anokye (Co-I)

(PI: Prof Adrian Taylor –Plymouth University)

Get Healthy Get Into Sport: Health and Sport Engagement (HASE)

The HASE study is a collaborative partnership between local community sport deliverers and sport and public health researchers. It involves designing, delivering and evaluating community sport interventions. The aim is to engage previously inactive people in sustained sporting activity for 1×30 min a week and to examine associated health and well-being outcomes. The study uses mixed methods. Outcomes (physical activity, health, well-being costs to individuals) will be measured by a series of self-report questionnaires and attendance data and evaluated using interrupted time series analysis controlling for a range of sociodemographic factors. Resource use will be identified and measured using diaries, interviews and records and presented alongside effectiveness data as incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. A longitudinal process evaluation (focus groups, structured observations, in-depth interview methods) will examine the efficacy of the project for achieving its aim using the principles of thematic analysis.

Funding body: Sports England

Contact: Dr Nana Anokye or Prof. Julia Fox-Rushby

 (PI: Dr Louise Mansfield – Brunel)

Health Start: Understanding the use of vouchers

Healthy Start, introduced in 2004, aims to enhance nutrition for vulnerable pregnant women, breastfeeding women and children up to age four. Given the potential for the scheme to have a positive impact on food poverty, it is important to understand more about factors affecting registration and uptake rates for the full range of eligible families. Information about the use of vouchers and vitamins is needed, including whether vouchers supplement spending on healthy food or simply displace existing resources. This project will evaluate the operation of Healthy Start within disadvantaged communities; provide evidence to inform its improved operation; and to test the feasibility of conducting an economic analysis. The project will use a range of qualitative and quantitative approaches to evaluate to the programme.

Funding body: Department of Health

Contacts: Prof. Julia Fox-Rushby, Dr Subhash Pokhrel and Dr Nana Anokye (PI: Professor Mary Renfrew, University of York)

Modelling the impact and incremental cost-effectiveness in Bangladesh and Peru of introducting vaccines against hepatitis B, Haemophilus influenzae type b and rotavirus into routine infant immunisation programmes, and of modifications to current programmes

Principal Investigators: Julia Fox-Rushby, Damian Walker, Shahdat Hossain, Claudio Lanata, Mary Penny, Andrew Clarke and Colin Sanderson

Collaborators: London School of Hygiene & Tropical Medicine, ICDDR, B, Bangladesh, Instituto de Investigacion Nutricional and Health Services Research Unit

Funding: DFID

  • This project estimates the cost-effectiveness of adding individual or combinations of vaccines (HBV, Hib and rotavirus) to the routine childhood vaccination schedules in Peru and Bangladesh and compares this with either not adding the vaccines or extending coverage of existing vaccinations
  • A micro-simulation model was developed to simulate the experiences of individuals from birth to death in a population over time. Individuals in the model have the following attributes:
  • Demographic: age, gender, living in urban or rural area;
  • Susceptibility to each type infection, dependent on maternal antibodies, history of infection and history of vaccination
  • History of vaccination, dependent on: vaccines in the model, vaccination schedules, trends in vaccination coverage
  • Outcome of disease, dependent on individual attributes & health care received.

Sources of data have included:

  • Demography: UN, DHS, National Statistics
  • Epidemiology: Literature reviews, expert consensus
  • Health Service Utilisation: DHS, expert consensus
  • Vaccination (control) parameters: WHO/UNICEF, DHS, literature review
  • Costs: field-based facility cost surveys, patient interviews, literature reviews


  • Pegurri E, Fox-Rushby J, Walker D (2005) The effects and costs of expanding coverage of immunization services in developing countries: A systematic literature review Vaccine 23, 13, 1624-35
  • Trama A, Walker D, Fox-Rushby J (2005) Introducing hepatitis B virus vaccine into the Expanded Programme on Immunization in Bangladesh: a proposed method to evaluate whether the existing infrastructure has the capacity Journal Population Health & Nutrition, 23, 1, 25-33
  • Fox-Rushby J, Castillo-Riquelme M, Fidan D, Batt K, Mosquera R, Hossain S, Penny M, Clark A, Lanata C, Walker D, Sanderson C (2005) Costs, effects and cost-effectiveness of Strategies to Increase Routine Immunisation in Low and Middle-Income Countries, Final Report to Vaccines & Biologicals, World Health Organisation
  • Walker D, Mosqueira NR, Penny ME, Lanata CF, Clark A, Sanderson C, Fox-Rushby JA (2004) Variation in the costs of delivering routine EPI and treatment of vaccine-preventable disease in Peru: implications for cost-effectiveness analysis Bulletin of the World Health Organisation, 82, 9, 676-682
  • Batt K, Fox-Rushby J, Castillo-Riquelme M (2004) The costs, effects and cost-effectiveness of strategies to increase coverage of routine immunisations in low and middle-income countries: A systematic review of grey literature and reflections on the value added to current evidence Bulletin of the World Health Organisation, 82, 9, 689-696

Disease control priorities in developing countries book

Principal Investigators: Julia Fox-Rushby, Anne Mills, Jo Mulligan, Phil Musgrove, Neal Halsey, Logan Brenzel, Mark Miller, Lara Wolfson

Collaborators: London School of Hygiene & Tropical Medicine, Johns Hopkins, Fogarty International Center (FIC) of the National Institutes of Health (NIH), the World Health Organization (WHO), and The World Bank.

Start Date: 01-08-2002 End Date: 01-04-2005

The Disease Control Priorities Project (DCPP) is a three-year project aimed at assessing disease control priorities and producing science-based analyses and resource materials to inform health policymaking in developing countries. The DCPP is a joint project of the Fogarty International Center (FIC) of the National Institutes of Health (NIH), the World Health Organization (WHO), and The World Bank. The DCPP was collaborated with partners around the world to generate information for national and international policymakers as they determine their health strategies and investments. The purpose of the study is to help developing countries establish health priorities and cost-effective health interventions based on careful analysis of the cost of disease burden and the cost of treatment and prevention. The demographic, epidemiologic, and economic information produced by DCPP will be shared through its new products, events, and tools including:

  • technical workshops involving experts and policymakers from developed and developing countries on estimating burden of disease and cost-effectiveness analysis;
  • interactive online discussions of the work in progress;
  • online, universally accessible DCPP working papers and other publications, available at www.nih.gov;
  • demographic, epidemiologic, and econometric information and materials to increase the capacity of developing countries to determine national priorities.

Economic evaluation alongside ARTISTIC- (A Randomised Trial In Screening To Improve Cytology)

Staff involved: Robin Dowie, Boyka Stoykova

Funding: NHS HTA R&D Programme

  • The ARTISTIC trial is investigating the role of Human Papilloma Virus (HPV) testing within the national cervical screening programme. The trial is taking place in Manchester, Stockport, Wigan, Leigh, Salford and Trafford, and began in June 2001. The study population comprises 25,000 women aged 20-64 who are attending general practices for routine cervical screening and who consent to having an HPV test.
  • The economic evaluation should provide evidence on the costs and benefits of adding HPV testing to liquid based cytology (LBC), provide an estimate of the effectiveness and costs of HPV as a stand-alone test, and address methodological issues in HPV testing. The perspective of the study is the National Health Service.
  • Cost-effectiveness results will be presented as an incremental cost per additional high grade smear detected, and as an incremental cost per life year gained and per quality adjusted life year gained (estimated by extrapolating from the trial endpoint using modelling techniques). Utilities for the cost-utility analysis will be elicited by means of a time trade-off survey.

Principal investigator: Professor Henry Kitchener, Professor of Gynaecological Oncology, Academic Unit of Obstetrics & Gynaecology, University of Manchester. 

Economic and Psychological Evaluation of the Multi-Centre Aneurysm Screening Study (MASS)

Staff involved: Martin Buxton, Helen Campbell and Jane Colehan (HERG), Theresa Marteau (UMDS)

Objectives: To assess the impact upon quality of life for men and their partners who are invited to participate in Abdominal Aortic Aneurysm (AAA) screening. To assess the impact of the screening programme and treatment on NHS and patient costs.

Methods: Quality of life will be measured using the SF36 and the EuroQol. In addition, anxiety and depression will be measured using questions from the Hospital Anxiety and Depression Scale (HADS), the State-Trait Anxiety Inventory (STAI) and the Life Orientation Test (LOT). A sample of patients who decline the invitation to attend the screening programme, screened negative patients and control patients will be requested to complete the questionnaire once. All screened positive patients and surgery patients will be requested to complete the questionnaire at intervals until 12 months post-screening or post-surgery. Retrospective data relating to resource-use/costs will be collected on 300 patients who undergo an elective AAA repair and 200 patients who undergo an emergency AAA repair.

Main collaborators: Mr Alan Scott (St. Richard’s Hospital, Chichester), Professor Nick Day (MRC Bio statistics unit) Mr Gareth Morris (Southampton General Hospital), Mr Graham Sutton (Queen Alexandra Hospital, Portsmouth), Mr Jack Collin (John Radcliffe Hospital, Oxford), Mr Nick Wilson (Royal Hampshire County Hospital, Winchester).

The cost effectiveness of brief advice for adults in primary care: reviews of economic evidence and economic modelling

To update public health guidance on the commonly used methods to increase physical activity in England, HERG was commissioned by the Centre for Public Health Excellence at NICE to undertake systematic reviews and economic modelling of brief advice interventions. Brief advice comprises verbal advice, discussion, negotiation or encouragement to do physical activity delivered by primary care professionals. A key consideration for economic modelling of this intervention is whether the simple decision analytic approach to modelling, existing approach in the literature, is warranted. Given that an individual’s behaviour may change over time, an explicit recognition of time in modelling the cost effectiveness of brief advice was explored.

Funding body: NICE

Contacts: Dr. Nana Anokye, Dr. Joanne Lord, Prof. Julia Fox-Rushby (PI)

Economic analysis of breastfeeding

Working in collaboration with key opinion leaders at the University of York, HERG is engaged in a study to estimate the economic impacts that are associated with breastfeeding in the United Kingdom. Evidence suggests that breastfeeding is beneficial to the health of the newborn both in the short term but also in the longer term by reducing the risk of developing long-term conditions. This includes a systematic review of the evidence on the effects of breastfeeding as well as modelling of potential cost-savings through improvement in current breastfeeding rates in the UK.

Funding body: UNICEF UK

Contacts: Dr Subhash Pokhrel, Prof. J Fox-Rushby (PI: Prof. Mary Renfrew, University of York).

The expenditure on and demand for sports and exercise: results of a national sample survey

This project has collected and analysed the first set of nationwide data on expenditure and perceived benefits associated with participation in sports and exercise (S&E). The overarching aim of the analysis was to explore how money and time prices, as well as perceived benefits are related with S&E in a population known to be physically active. Specifically, this project facilitated three important extensions to existing knowledge: (a) testing a range of alternative price specifications to determine specifications that are theoretically consistent and optimises variation in demand estimations; (b) examination of the role of price in demand for specific activities (swimming) to inform the formulation of activity specific policies; and (c) investigation of whether and how the relationship between prices and sport/exercise differ across subjective and objective measures of S&E

Funding body: Department of Health

Contacts: Dr Nana Anokye, Dr Subhash Pokhrel, Prof. Julia Fox-Rushby (PI)

Further development of the Tobacco Control Return on Investment Tool

The aim of this project is to develop a tool to help decision making in tobacco control at local and sub-national levels. This project has been completed and the actual tool and supporting documents can be downloaded from the above web link. Using this tool, different interventions, including pharmacotherapies and support and advice, can be mixed and matched to see which intervention portfolio or package provides the best 'value for money', compared with 'no-services' or any other specified package. This tool was produced for NICE and is expected to support commissioners and policy makers, in local authorities and the NHS, in their investment decisions. The tool builds on a previous project completed by HERG (Modelling the effects of tobacco control and smoking cessation).

Funding Body: NICE

Contacts: Dr Subhash Pokhrel (PI)

Modelling the effects of tobacco control and smoking cessation

Interventions to help prevent the uptake of tobacco or support smoking cessation are widely acknowledged to be cost effective. However, much of the evidence on these interventions has been generated using traditional approaches to economic evaluation, such as cost utility analyses, and a narrow health service perspective. Furthermore, the lifetime horizon adopted by many of these analyses is inapplicable to many health service professionals involved in the planning and delivery of services.

This research aims to collate the available evidence to produce models which are able to provide evidence that is directly applicable to the commissioning and planning of tobacco control and smoking cessation services. The model will aim to capture both short term and longer-term health and non-health benefits and costs, clearly identifying when costs and benefits are accrued and by whom. 

The outputs are expected to be made available to front-line health service planners. This research was conducted jointly with experts in the field of tobacco control and smoking cessation from the Universities of Nottingham, and the London Health Observatory.

Funding body: Tobacco Free Futures, Smokefree South West and Fresh- Smoke Free North East

Contact: Dr Subhash Pokhrel (PI)