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- Meili, Kaspar Walter, 1989-
(författare)
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Capability for broader cost-effectiveness in public health and social welfare : developing, valuing, and applyingcapability-adjusted life years Sweden (CALY-SWE)
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Spending in social welfare areas such as healthcare, wider public health, education, and social care consumes a major part of the public budget. Cost-effective resource allocation is a moral obligation towards both taxpayers and beneficiaries: tax money should be used efficiently, and it should be transparently accounted for. After all, economical management of resources is important for sustaining future prosperity and for addressing fundamental challenges such as climate change and demographic shift. In healthcare, cost‐effectiveness using quality-adjusted life years (QALYs) is a well-established tool to inform policymakers. Using cost per QALY implies that health-related quality of life (QoL), and not money, is an end on its own. Moreover, cost per QALY allows one to compare unrelated interventions by measuring the effects on the common QALY scale. However, for actors concerned with broader social welfare, such as the Swedish municipalities, QALYs may be less useful because their measurement focus is largely limited to health. Comparable outcome measures for broader social welfare are still sparsely available and employed, and a context-specific measure for Sweden is lacking. The aim of this thesis was to develop, value, and apply capability-adjusted life years Sweden (CALY‐SWE), a QoL outcome measure conceptually based on the capability approach, for broader social welfare and specific for Sweden.Within study 1, we organized a Delphi panel to select relevant capability attributes and then developed the phrasing for the questionnaire. The resulting questionnaire contains six attributes –health, social relations, financial situation & housing, security, occupation, and political & civil rights – each with three answer levels. The phrasing integrates an implicit threshold so that the sensitivity is focused on the lower range of the scale, thus incorporating equity considerations that relate to sufficientarianism and prioritarianism. In study 2, we developed a value set consisting of all quality weights for the 729 possible CALY-SWE states. We relied on health economic outcome methodology, namely hybrid modelling of discrete choice and time trade-off data that we collected in a cross-sectional web survey with representative sampling. This value set allows to aggregate the CALY-SWE answers into a single quality weight that can be used in cost‐effectiveness analysis to calculate CALYs. In study 3, we applied the CALY-SWE questionnaire and value set to describe the capability distribution in a cross-sectional representative sample of the Swedish population. In a framework of group comparisons, we estimated capability inequalities and shortfalls for different population groups. The results showed that there are capability inequalities for *disadvantage groups* as well as for groups with discriminative inequalities – *plurality groups*, for example between lower and higher education. For study 4, we applied CALY‐SWE in a cost‐effectiveness application to model the effects of a payroll tax reduction in Sweden from 2007 to 2016 (during the financial crisis) on young people not in employment, education, or training (NEET). The intervention was likely cost-effective from a societal perspective, but only with limited probability from a fiscal perspective, although definite statements regarding cost-effectiveness are challenging because a threshold value for a CALY is still lacking. The final chapter discusses the measure’s development, including normative choices, in relation to the Swedish social welfare and policy context, the capability framework as suggested by Amartya Sen, distributive justice, and other outcome measures in cost‐effectiveness evaluations. Important work remains – for example, assessing psychometric properties, developing the conceptualization of the 0 to 1 anchor scale for capability weights, and assessing a threshold value for a CALY. In conclusion, with the questionnaire development, value set elicitation, and demonstration of applications, important steps for CALY‐SWE were accomplished. Cost‐effectiveness evaluations in wider social welfare and public health using CALY-SWE are now possible.
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- Meili, Kaspar Walter, 1989-, et al.
(författare)
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Capability inequality: Does disadvantage or plurality matter more for policy? : A Swedish cross-sectional study on the population distribution and group differences of capability using CALY-SWE
- 2024
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Ingår i: Social Sciences & Humanities Open. - : Elsevier. - 2590-2911. ; 10
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Tidskriftsartikel (refereegranskat)abstract
- A better understanding of population distributions of capability and inequalities is relevant for public health and social welfare. We surveyed 3639 representatively sampled individuals on background characteristics and on self-reported capability using the capability-adjusted life years Sweden (CALY-SWE) questionnaire, which enables aggregating attribute-level answers into a quality weight score.We analysed the resulting capability distribution by comparing subgroups. Subgroups were formed along axes of inequality that we selected based on theoretical reasoning and relevance. We stratified into groupings of plurality and disadvantage, based on the human dignity principle and the needs and solidarity principle featured in the Swedish platform for healthcare priority-setting. While disadvantage factors come with inherent need-related disadvantages that explain inequality, such as unemployment, no such normatively acceptable reason exist for plurality factors, such as gender.The results averaged per individual showed marked inequalities for the disadvantage groups of individuals with poor self-rated health, long-term sick leave unemployment, and payment difficulties. For plurality groups, the largest inequalities occurred in groups with lower education and groups residing in urban areas, but generally inequalities were lower than disadvantage groups.On the population level, the largest aggregated disability inequalities occurred for self-reported ever NEET (persons who were ever involuntarily not in employment, education or training from age 16 to 29) and payment difficulties groups. Additionally, we assessed the contribution of covariates to these inequalities by counterfactually altering one covariate at a time in a multinomial logistic model of the CALY-SWE attribute-level answers. The most relevant covariates were employment situation, financial difficulties, income, and age group.For policy-making, this indicates the importance of both plurality and disadvantage inequality axes. Prioritization should adopt nuanced contextualizations of inequality when broadening the perspective beyond healthcare to wider public health and social welfare, for example, elderly care and education.
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