Abstract
In economic evaluations, the perspective is often taken for granted. The societal perspective is usually preferred by economists because it includes all resources, whether they are paid for or their use is foregone. Economics is about identifying the best use of scarce resources. On the other hand, the popular government perspective includes all government payments, encompassing payments for services or resources, as well as for transfer payments such as disability supplements. Mental illness is a major cause of disability payments, and so the government payments perspective figures prominently in mental health economic evaluations.
It is often not intuitive as to why government transfer payments are excluded from economic evaluations. After all, payments such as disability pensions can be affected by mental health treatments, and alternative mental health interventions can differentially affect resources costs and transfer payments, as well as mental health outcomes. But transfer payments are not immediately linked to resources; recipients of these payments will use them for resources, but they are not measures of resources themselves. And so economists do not include them in their societal perspective.
On the other hand, resources in mental illness will not always be the burden of the health ministry. As Dewa, Trojanowski, Cheng, and Hoch 1 show in their study on early psychosis interventions, resources are paid for by community support providers, the justice system, nongovernmental payers, and the health care sector. Indeed, costs paid for by the health care sector are far less than those paid for in the other sectors, about one quarter of the total (Table 2). Health economists in Canada most frequently use the government resources perspective. In the case of early psychosis interventions, these resource costs will amount to only one-quarter of the public-sector resource costs.
As Dewa et al. 1 show, the results of a cost-effectiveness analysis will be influenced by the perspective taken. The cost-effectiveness results favoured the <12-month group when the analysts used the health care perspective. When the broader, all-government perspective was used, the cost-effectiveness results favoured the >12-month group.
Which perspective should one use? Being a value-laden concept, the perspective taken will depend on who commissions the study. A government finance department will be most interested in an all-government perspective, including transfer payments, as these will be reflected in the government budget. A health department will be most interested in a government resources perspective, which is much narrower. As we broaden the perspective between the two, other perspectives will be preferred. Of course, government bodies have no direct interest in nongovernment resource costs, such as patient travel and caregiver costs. These costs, which are often preferred by economists, will be part of the broader societal perspective.
The area of mental health incorporates substantial social costs, justice department costs, education costs, and transfer payments. This means, as Dewa et al. 1 show, that if cost-effectiveness changes with perspective, then the body that uses the results of the study may well choose the wrong policy indicator. Since the policy makers end up making the decision, they should be educated as to the various perspectives and their meaning.