Public Health Assessment: Cost-Utility Analysis vs Cost-Benefit Analysis

This essay provides a comparative overview of cost-utility analysis and cost-benefit analysis for conducting economic evaluation of public health interventions. It evaluates a school-based intervention for reducing alcohol misuse among adolescents in the UK using CUA/CEA. The essay highlights the importance of selecting the appropriate approach for economic evaluation to improve the overall quality of life and health of the target population.

Running head: PUBLIC HEALTH ASSESSMENT
Public Health Assessment
Name of the Student
Name of the University
Author Note

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Introduction
Public health interventions have unique features in comparison to the
healthcare technologies and this increase additional challenge for conducting a
comprehensive economic evaluation (EE). High quality EE is important in order to
address any specific methodological challenges in the domain of the public health
decision making (Hill et al. 2017). Addressing alcohol misuse is a prioritised public
healthcare concern throughout the world. Under the perspective of the UK, it can be
stated that the young adults o the adolescents who are in their high schools and the
main victims of the alcohol misuse leading to poor healthcare outcomes (Public
Health England 2016). The following essay aims to provide a comparative overview
of the cost-utility analysis and cost-benefit analysis for conducting EE of the public
health interventions. This will be followed by the selection of CUA or CBA for the
analysis of one public health intervention targeted towards reducing the alcohol
misuse among the adolescents in school aged between 15 to 16 years under UK
healthcare system. The overall essay will help in understanding regarding how the
proper selection of the approaches for the economic evaluation of the public health
intervention is important in order to improve the overall quality of life and health of
the selected group of the target population.
Difference between cost-utility analysis (CUA) and cost-benefit analysis (CBA)
Cost-utility analysis (CUA) or cost-effectiveness analysis (CEA) is used to
determine the cost in the terms of utilities mainly in the domain of quantity and
quality of life. The incremental cost of the program from a definite point of view is
compared with the incremental improvement of health that is expressed in the unit of
quality adjusted life years (QALYs) (WHO 2019).
This type of analysis is regarded as controversial as it is difficult to provide
specific values over the health quality or on an improvement in the overall health
status as perceived by the different members of the society or individuals. CUA
mainly expresses the value for money in order to define single healthcare outcomes.
CUA is different from the CBA as it is used compare two different healthcare
interventions or public health approaches based on the parameters of the health-
related outcomes (WHO 2019).

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Cost-benefit analysis (CBA) defines evaluation of benefits in commensurate
mainly in the monetary terms. CBA is used to measure both allocative and technical
aspect of the health care. It is measured either within a single healthcare sector or
across the other sectors of the economy (Centre of Disease Control and Prevention.
2019). CUA is used to measure only the technical efficacy of any public health
interventions or public health policy. CUA is sometimes used for the measurement of
the allocative efficiency but within single healthcare sectors where only the
healthcare costs are included (U.S National Library of Medicine 2019).
In other words it can be said that CBA is defined as a form of economic
evaluation technique that helps in comparing the overall cost effectiveness of the
interventions with the overall benefits incurred. Here benefit is measured based on
the monetary units. CUA is a process of economic evaluation techniques that helps
in comparing cost per consequence of two more interventions. Here consequences
are measured based on the natural units (life years gained or saved years of life)
(Centre of Disease Control and Prevention. 2019).
Evaluation of the public health intervention
Hill et al. (2017) stated that characteristics that are specific to the
interventions targeted towards any specific public health in comparison to the
healthcare technologies, incur challenges for the proper evaluation of the public
health interventions. The overall reach of the consequences of the public health
intervention is broader in comparison to the healthcare technologies where a
particular beneficiary can be identified and the overall outcome of interest in health is
maximised. The time gap between the intervention implemented and outcome is
significantly longer in public health in comparison to the healthcare technology and
this further increase the challenges for evaluating the future costs and modelling the
long-term effects. Thus proper economic evaluation strategy must be selected for the
EE of the public health intervention. According to the National Institute of Health and
Care Excellence (NICE), the use of quality-adjusted life-years (QALYs) is best suited
to quantify the effectiveness of health care interventions from a health and social
care perspective. Thus in this essay, CUA or CEA will be used for the evaluate
one public health intervention targeted towards approximately 10 children or
adolescents between the age group of 15 to 16 years who are at risk of developing

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alcohol misuse. The evaluation of the public health intervention will be done based
on the healthcare set-up of UK and will be school-based intervention. CUA analysis
will be more suitable in comparison to the CBA as in CBA all the cost and benefit are
valued in the domain of the monetary terms by use of the willingness to pay (WTP)
approach such that the current values of benefits and costs can be compared
(Svensson and Hultkrantz 2017). In school-based intervention, there is no direct
relationship with the WTP as the government and the school authority give the
majority of the funding.
UK alcohol abuse among school children
Alcohol use and drunkenness trend to emerge during the adolescent years.
The majority of the young people residing in India start consuming alcohol or are
vulnerable to become victim o alcohol abuse in between the age group of 12 t 16
years. The gain in sudden independence and spending more time outside the home
in an unsupervised manner increase the vulnerability of alcohol misuse. Early
adolescent use of alcohol is associated with harmful social and behavioural
functioning like risky sexual behaviours, increased suicidal attempts, comorbid
substance abuse along with complex physical and emotional problems. The recent
survey conducted by WHO named Health Behaviour in School Children (HBSC)
highlighted that during the tenure of 2013 to 2014, nearly 219 460 adolescents
constituting 48 to 50% of the adolescent population are vulnerable towards
becoming victim of alcohol misuse in the UK and the vulnerability is higher among
the children between the age group of 15 to 16 years (World Health Organisation.
2014).
The intervention for the prevention of alcohol misuse among school children
The intervention that will be effective for the prevention of the vulnerability of
alcohol misuse among the school children in the UK will be promotion of the school
based awareness program in the presence of the parents. Under the school-based
awareness program, the teachers and the community level and mental healthcare
nursing professionals will be recruited in order to educate the adolescents about the
ill-effects of alcohol misuse. They will also be educated regarding how the
management of depression can be done by proper social support and alcohol

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consumption is not an intervention for the depression management. Under the
educational program, the parents will also be included and they will be educated
regarding how they must act as a support system for their children such that they
can overcome the vulnerability of developing alcohol misuse (McKay et al. 2018).
The overall cost-effectiveness of the procedure will be evaluated based on the
expenditure of recruiting the community health nurses and other resources like
power-point presentations and posters and other expenditure associated with
unwanted hospital admission or school absenteeism resulting from alcohol misuse.
The role of the community-level nursing professionals will be to educate the parents
and the adolescents about the ill-effects of smoking why smoking must be strictly
prevented. The role of the mental healthcare nursing professionals will be educate
the adolescents regarding self-management of depression without taking help of
intoxication (McKay et al. 2018). Gonzales et al. (2018) measured the effectiveness
of the steps towards alcohol misuse alcohol prevention programme (STAMPP) in
comparison to the other pharmacological interventions in the school-based level. The
analysis of the classroom-based intervention for the prevention on the alcohol
misuse is proved to be effective and the overall intervention is plausible. Agabio et
al. (2015) stated that the school-based intervention is helped in reduction of the
alcohol misuse along with the reduction of the other drug abuse among the
adolescence students between the age group of 12 to 15 years.
Rationale behind the analysis of the cost-effectiveness of intervention through
CUA/CEA
Evaluation of the CUA/CEA based on the formula
The main formula that is used for the EE of public health intervention through
CUA/CEA is highlighted below:
(Source: McKay et al. 2018)

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Through an assumption of the fixed budget and by the use of the health-care
perspective the overall threshold value must be based on the value (QALY) of the
present services that are displaced during the introduction of the new cost-increasing
intervention. In the UK, this approach works under the guidelines of the NICE. In
order to calculate the average value of the total displaced services under the
National Health Services in the UK. Claxton et al. (2013) stated that the threshold
value around GBP (UK currency) will be 13,000. Under a definite budget setting and
under particular societal perspective a proper adjustment to the threshold value must
be done such that the non-healthcare consequences are valued properly.
Evaluation based on the monetary benefits or fixed budget
The promotion of school-based health awareness program for the reduction of
the alcohol misuse has few fixed budget. The budget of this intervention is fixed as it
is based on the daily or weekly payment of the community-based and mental
healthcare nursing professionals. There will be no expenditure for the teachers as
the educational or the awareness program will be conducted within their duty hours.
The additional resources like over-head projector for giving the power-point
presentation will be recruited from the school itself. The poster however will be
allocated separate budget for printing. Thus the intervention is not cost increasing
and has a fixed budget and thus EE done through CEA or CUA will be helpful.
Moreover, here the evaluation will be done solely cost-per consequences here the
consequences include the presence of parents, the presence of the community
health nursing professionals and the presence of the mental healthcare nursing
professionals.
Evaluation based on quality adjusted life years (QALY)
The estimation of the cost in case of CEA is done based on the monetary
units. However, unlike the CBA, the benefits is not always have to be expressed
based on the monetary terms and is mainly expressed with the help of the quality
adjusted life years (QALY). Thus for the estimation of the cost for the school based
intervention for the prevention of the vulnerability of alcohol misuse will be done on
the monetary units like the financial budget against the wages given to the
community health nursing professionals, mental healthcare nursing professionals
and other raw resources. The analysis of the benefits will be done based on

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reduction in the vulnerability of the development of the alcohol misuse among the 10
selected pupils under the age group of 15 to 16 years. The estimation of the QALYs
will be done based on the improvement in the overall quality of life of the adolescents
like increase in the academic performance, decrease in the unwanted absentees in
the schools and decrease in the unwanted healthcare costs and complex mental
health issues. Barnes et al. (2016) are of the opinion that the reduction in the level of
the alcohol abuse among the young adults and the children helps to improve the
overall quality of life. The study conducted by Luquiens et al. (2015) highlighted that
the reduction in the consumption of alcohol or reduction of the consumption of the
first drink of alcohol in the early years of life reduces the risk of developing several
non-communicable diseases like type 2 diabetes mellitus, cardio-vascular disease,
obesity, and arthrosclerosis. Thus reduction on the development of the non-
communicable diseases help in improving the overall quality of life while improving
the health related outcomes.
Evaluation based on the incremental cost-effectiveness ratio (ICER)
Under the CEA, the incremental cost-effectiveness ratio (ICER) is given
special importance. It is defined as the ratio between the difference in the costs and
the overall differences between the two interventions. ICER can be stated in the form
of (C1 – C0)/ (E1- E0). Here C0 and E0 represent the cost and gain respectively
from undertaking no health interventions for specific health-related action for the
improvement of the overall health related condition. C1 and E1 are used to denote
cost and gain respectively of any specific action that is undertaken for the reduction
of the health-related complications. According to the data highlighted by the Public
Health England (2016), there are several alcohol related harms among the
adolescents and the same has been highlighted in the figure below.

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(Source: Public Health England 2016)
Public Health England (2016) also highlighted that the consumption of alcohol
or increase in the vulnerability of developing alcohol abuse among the adolescents is
associated with adverse social and other health related consequences. The social
health-related consequences include poor academic performance and poor
development of the intellect along with unhealthy family relationships. Alcohol-related
harm can also be tangible and is also associated with significant economic costs
along with injuries. It can also be intangible or can be severe like development of the
life-long disability and even death. Thus implementation of no specific public health
intervention for the reduction of the alcohol-related harm, increases the overall cost
of the lifestyle like increase in the expenditure of the parents due to poor academic
performance of the wards or increase in the expenditure of the parents due to
increased in the healthcare costs of their children. Several harms associated with
alcohol vary with age and the socio economic status and the same has been
highlighted below in the diagram.

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(Source: Public Health England 2016)
Cost and the intervention implemented
According to the Cabinet Office the economic costs of alcohol in England is
£21 billion in the year 2012 and this is equivalent to the 1.3% GDP and it make up to
the cost-associated with the other alcohol-related health disorders and other
diseases along with the alcohol related anti-social activities and crime. Thus in order
to reduce the overall cost to the family or to the society, effective interventions must
be implemented for the reduction in the vulnerability of the alcohol misuse among the
adolescent between the age group of 15 to 16 years. The application of the school
oriented and targeted intervention will be helpful in reducing the overall economic
and health-related harm to the selected group of population and at the same time
increasing the overall gain of the population (Public Health England 2016). This can
be skilfully done under the application of the incremental cost-effectiveness ratio
(ICER) of the CEA. This is however, not possible under the application of the CBA.
The reason behind this is CBA has concerned with the two main applications and
these include determination of whether an investment is sound or ascertaining of and
by how much its benefits outweigh the costs. The second application deal with
providing the basis for comparing the investments or decisions and comparing the
total expected costs for each of the option with the total expected benefits. While the

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first application of the CBA coincides with the CUA, the second application of the
CBA is not feasible in this case, as here, single intervention is taken under
consideration and no comparison is done (Pearce 2016; Muennig and Bounthavong
2016).
CUA is associated with certain benefits or advantages that make it an
important selection for conducting the EE of the public health intervention for the
reduction of the alcohol misuse vulnerability among the 10 pupils between the age
group of the 15 to 16 years. CUA enables comparison between intervention and no-
intervention with the help of the one common unit of measurement that is
money/QALYs. Since the total number of people taking part in the intervention
program is 10, the application of the CUA will be helpful in ascertain the
effectiveness of the overall outcome of intervention in comparison to the CBA
(Newcomer, Hatry and Wholey 2015). Moreover, when the overall size of the target
population is low (in this case it is 10) it is easier to measure the QALY in
comparison to the measurement of the monetary benefits which is mainly highlighted
in the CBA. Moreover, the life of the young adults or the adolescents, who are future
for the upcoming generation are priceless and there lies certain degree of the ethical
problems in placing financial values of benefit over the life of the people (Whiting et
al. 2015). The importance given towards the improvement of the overall quality of life
of the people is the reason why CEA is selected over CUA for the EE of the public
health intervention. However, there are certain disadvantage associated CEA like
absence of the incorporation of the patient’s willingness to pay (behavioral
economics) create a gap in understanding whether the designed intervention is
suitable for the implementation of the mass at large (Claxton et al. 2015).
Conclusion
Thus from the above discussion, it can be concluded that use of the CUA is
suitable for the analysis of the school based intervention, promotion of the
awareness against the vulnerability of developing alcohol misuse among the 10
pupils (15 to 16 years) under UK healthcare settings. Here the use of the CUA will be
used for the EE of the single proposed intervention for the target population. CUA
selected over the CBA because, CUA given importance over the QALY in order to
estimate the importance of the public health intervention unlike the CBA where

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importance is given towards the willingness to pay or the monetary benefits of the
public health interventions. Moreover, in the CUA or CEA, the measurement of the
effectiveness of the overall interventions is done base on the single unit rate than a
diverse unit. When comparison between two or more intervention is undertaken,
under the use of the large group of population, then the selection of the CBA is given
special importance under the healthcare sections or in the public health domain.

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