Inclusive evaluation of public health interventions

Public health interventions (PHIs) are critical for tackling many of Norway's and the world's greatest health challenges. In addition to the historical strides public health has made for reducing the spread of infectious diseases, there is hope that with further investments in PHIs the burden of chronic illnesses and health inequalities can also be reduced. Research has demonstrated that many PHIs have good value for money and that in the long term they can help contain health care costs for society. In parallel, there is a growing body of evidence demonstrating that policies in non-health sectors can have an even greater impact on population health than policies initiated within the health sector. Yet to this day, PHIs remain largely underfunded and under-prioritized when compared to clinical interventions. Rigorous evaluation of PHIs is indispensable for ensuring that they are properly prioritized. A lack of available data, methodological shortcomings and a weak evidence base are commonly stated reasons for the difficulties arising at the time of evaluation. Further, previous evaluations of PHIs have often been narrow: omitting costs, benefits beyond health, and impact on inequalities. Interventions promoting physical activity are among the PHIs for which we need more evidence. The lack of reliable evidence can ultimately lead to PHIs being overlooked by decision-makers. However, it has been argued that today's process for evaluation tends to be the largest impediment. It is described as fragmented and poorly linked to the policy-making process, and even jeopardizing the implementation of favorably-evaluated PHIs. A large majority of countries have formalized procedures for systematically compiling evidence and synthesizing information to support decisions for the introduction of new medical technologies in the clinical sector and for market authorization and reimbursement of new pharmaceuticals. However, an equivalent process for public health interventions (PHIs) does not always exists. Health commentators have called for expanding the use of health technology assessments (HTAs) processes to inform decision-making in public health. The objective of this project is to generate new tools and evidence to promote PHIs that are cost-effective, that generate both health and non-health benefits, and that reduce inequalities. The project will also aim to investigate and compare the experience of countries that have used HTA processes to evaluate PHIs and to learn from their experience, institution design and their evaluation and decision-making processes. We have now published the results for objectives I and II: New methods for evaluating public health measures are described in the book "Distributional Cost-Effectiveness Analysis", published by the renowned publisher Oxford University Press, edited by Cookson, Griffin, Norheim and Culyer (2020) . Furthermore, we have presented further method improvements for the evaluation of public health measures using social welfare functions in the book "Prioritarianism in Practice", edited by Adler and Norheim (2022) and published by Cambridge University Press. A final article on changes in public health due to a reduced tax on sugary products is available as a separate manuscript (Working Paper 2022). Furthermore, two economic evaluations of the construction of cycle paths in Oslo have been completed and published in the journals BMC Public Health (2020) and Health Economics (2021). We find that the construction of cycle paths in Oslo is both cost-effective and can contribute to reducing inequalities in health. For objective III, we have published three articles that look at medical method assessment as a tool for institutionalized evaluation of public health initiatives. A preliminary conclusion is that in Norway there is great scope for increased use of this tool. The research results may be relevant to municipalities, national authorities and a number of others who implement or are themselves affected by public health measures.

Hvilke folkehelsetiltak har prosjektet utviklet eller laget et bedre kunnskapsgrunnlag for? 1. Sykkelveier - Lamu et al. Is cycle network expansion cost-effective? A health economic evaluation of cycling in Oslo. BMC Public Health. Dec 07 2020;20(1):1869. - Lamu et al Cycle-network expansion plan in Oslo: Modeling cost-effectiveness analysis and health equity impact. Health Economics; 5 October 2021 2. Sukkerskatt - Averi Chakrabarti, Akshar Saxena, Jonas Minet Kinge, Ole Frithjof Norheim, Stéphane Verguet. The potential health and financial implications of a decline in soda taxes in Norway: findings from a modeling analysis. Working paper 2022. Hva vil prosjektet kunne bidra med for å bedre folkehelsen? 1. Metodeutvikling – økonomisk evaluering - Adler, Matthew D. & Norheim, Ole F. (eds.). Prioritarianism in Practice. Cambridge University Press 2022 - Cookson, Richard; Griffin, Susan; Norheim, Ole F.; Culyer, Anthony (eds). Distributional cost-effectiveness analysis: quantifying health equity impacts and trade-offs. Handbook: Oxford University Press; 2020. 2) Systematisk evaluering av folkehelstiltak - Cyr, Pascale Renée; Jain, Vageesh; Chalkidou, Kalipso; Ottersen, Trygve & Gopinathan, Unni (2021). Evaluations of public health interventions produced by health technology assessment agencies: A mapping review and analysis by type and evidence content. Health Policy. ISSN 0168-8510. 125(8), s. 1054–1064. 3) Bedre prioritering Norheim OF. Verdigrunnlag og prioriteringskriterier for folkehelsearbeidet. Notat utarbeidet på oppdrag fra Helse- og omsorgsdepartementet. 2018. Bedre helse og mindre helseulikhet - Cookson, Richard; Culyer, Anthony; Norheim, Ole F. "Principles of health equity" in Cookson, Richard; Griffin, Susan; Norheim, Ole F.; Culyer, Anthony (eds). Distributional cost-effectiveness analysis: quantifying health equity impacts and trade-offs. Oxford University Press; 30 September 2020. - Cookson, Richard; Griffin, Susan; Norheim, Ole F.; Culyer, Anthony. "Describing equity impacts and trade-offs" in Cookson, Richard; Griffin, Susan; Norheim, Ole F.; Culyer, Anthony (eds). Distributional cost-effectiveness analysis: quantifying health equity impacts and trade-offs. Oxford University Press; 30 September 2020. - Cookson, Richard; Griffin, Susan; Norheim, Ole F.; Culyer, Anthony. "Designing a distributional cost-effectiveness analysis" in Cookson, Richard; Griffin, Susan; Norheim, Ole F.; Culyer, Anthony (eds). Distributional cost-effectiveness analysis: quantifying health equity impacts and trade-offs. Oxford University Press; 30 September 2020.

Public health interventions (PHIs) are critical for meeting many of Norway's and the world's greatest challenges. Sedentary lifestyles, overweight, and non-communicable diseases are among them. Rigorous evaluation of PHIs is indispensable for ensuring that these interventions are properly prioritised. Yet, previous evaluations of PHIs have often been narrow: omitting costs, benefits beyond health, and impact on inequalities. Interventions promoting physical activity are among the PHIs for which we need more evidence. Moreover, today's process for evaluation tends to be fragmented and poorly linked to the policy-making process, thereby jeopardizing the implementation of even favourably-evaluated PHIs. The objective of this project is to generate new tools and evidence to promote PHIs that are cost-effective, that generate both health and non-health benefits, and that reduce inequalities. Specifically, we will: I) further develop newly proposed methods for inclusive evaluation of PHIs, i.e. economic evaluation that incorporates non-health benefits and distributional concerns; II) evaluate three clusters of PHIs promoting a) walking and cycling, b) lifestyle services for overweight or obese children, adolescents, and adults, and c) physical activity among socioeconomically disadvantaged women using the new methods; and III) identify and assess new ways to bridge the evaluation and implementation of PHIs. We will employ both quantitative and qualitative methods, including method development (subproject I), cost-effectiveness analysis (subproject II), and comparative policy analysis and interviews (subproject III). We will utilise data from multiple sources, including health surveys and the national burden of disease project. The project will help improve the evaluation and implementation of PHIs, and PHIs promoting physical activity in particular. The findings are directly relevant for municipalities, national authorities, and a wide range of other stakeholders.