What Costs and Benefits Should be Counted in Health Technology Assessments and Guidelines? The NICE Perspective

The perspective of an economic evaluation defines what types of benefit and cost are counted when assessing the value for money of a health intervention. The health sector perspective counts health outcomes and health system costs, whereas a societal perspective includes effects relevant to other forms of public expenditure, such as benefits to educational attainment or economic productivity. This article describes how the National Institute for Health and Care Excellence evaluated the arguments for and against the adoption of a societal perspective and articulates the rationale for its decision to retain a health sector perspective in its value-for-money assessments but with flexibility to consider wider societal effects when they are especially relevant to the value of a health intervention. The appropriate perspective to take is dependent upon the objective function of the payer. Under specific conditions, a publicly funded payer could optimize decision making across public sector budgets by adopting a full societal perspective. However, there are a range of ethical, practical, and methodological problems that arise when trying to implement a societal perspective. These include a lack of evidence on the opportunity cost of nonhealth outcomes to calculate net effects, no robust methodology to inform trade-offs between health and nonhealth sector outcomes, and the discriminatory consequences of counting productivity effects. We discuss how these considerations are balanced against the need to consider the value of nonhealth effects during the technology evaluation and guideline production processes.