Economic Evaluation of Health Promotion: Friend or Foe?

It is commonly believed that economic evaluation is hostile to health promotion and that the requirement for health programs to be cost effective will result in a distortion in the allocation of funds towards programs that can demonstrate short-run benefits as defined by inadequate outcome measures. The paper is concerned with the validity of this perception. It is argued that contrary to this belief economic evaluation has the potential for treating health promotional activities on an equal basis with other health interventions. The major obstacle to this does not arise from the theory of economics but from a lack of information about outcomes. Without this information any evaluation - economic or otherwise - is flawed. Two problems relating to the economic evaluation of health promotion activities are first considered. These are: (1) the potential for economic - or any other - evaluation to be counter-productive if applied to an `immature' project and (2) the discounting of future health benefits. The paper does acknowledge that the measurement of health outcomes is problematical. A fourfold classification of possible outcomes is suggested which is based upon a distinction between disease cure, health promotion, social justice and systemic change designed to promote either individual health or social welfare. The capacity of economics to incorporate these objectives is discussed. With respect to systemic change it is argued that summative economic evaluation is likely to be problematical as the benefits of systemic change are too difficult to predict with confidence. At best, formative evaluation may be undertaken to identify key variables that are likely to determine the desirability or otherwise of systemic change. By focussing attention upon such variables such analysis may influence the direction of health policy.