Professor Tony Culyer

CURRICULUM VITAE

 

Professor Anthony John (Tony) Culyer, CBE, BA, Hon DEcon, Hon FRCP, FRSA, FMedSci

 

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last update: November 2011  


 

 

 

Personal background

 

Present Status

Ontario Research Chair in Health Policy & System Design, University of Toronto

Professor of Economics, University of York, England

Adjunct Scientist, Institute for Work and Health, Toronto

Chair, WSIB Research Advisory Council (to March 2010)

Founding Co-Editor, Journal of Health Economics

 

Date of Birth

1 July 1942

 

Addresses

(Home, England): "The Laurels", Main Street, Barmby Moor, York, Y042 4EJ, UK

Tel. (0)1759-307177

E-mail: tonyandsiegi@btinternet.com

 

(Home, Canada): 80 Front Street East Suite 804, Toronto, Ontario, M5E 1T4, Canada

Tel: 416 369-9973

E-mail: tonyandsiegi@sympatico.ca

 

(University, Canada): Department of Health Policy, Management and Evaluation, University of Toronto, Faculty of Medicine, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario M5T 3M6

Tel: 416 978 7340

Fax: 416-978-7350

E-mail: tony.culyer@utoronto.ca

 

(University, England): Department of Economics & Related Studies, University of York, Heslington, York Y010 5DD, England

Tel: (0)1904-321420

Fax: (0)1904-433759

E-mail: ajc17@york.ac.uk

 

Web page: http://www-users.york.ac.uk/~ajc17

 

 

Marital Status

Married from 1966 to 2011 to same partner Siegi, with son and daughter, four grandchildren. Now widowed.

 

Secondary Education

Sir William Borlase's School, Marlow

The King's School, Worcester

 

University Education

Graduated Exeter University in 1964 (2(i)) in Economics, Exeter University

Leo T. Little Prize for best graduating student in Economics 1964.

1964-5 Graduate Student and Teaching Assistant at the University of California at Los

Angeles (plus Fulbright Travel Scholarship).

 

Degrees

B.A. (Hons), (Exeter) (1964)

Doctor of Economics, honoris causa (Stockholm School of Economics) (1999)

 

Honours

Founding Fellow of the Academy of Medical Sciences (1998)

Commander of the British Empire (CBE) (1999)

Fellow of the Royal Society of Arts (1999)

Doctor of Economics, honoris causa (Stockholm School of Economics) (1999)

Honorary Fellow of the Royal College of Physicians of London (2003)

 

 

Fellowships of Academies

Founding Fellow of the Academy of Medical Sciences (1998)

Fellow of the Royal Society of Arts (1999)

Honorary Fellow of the Royal College of Physicians of London (2003)

 

 

University Career

 

1964-65           Teaching Assistant, University of California at Los Angeles

1965-66           Tutor in Economics, University of Exeter

1966-69           Assistant Lecturer in Economics, University of Exeter.

1969-72           Lecturer in Economics, University of York

1971-79           Assistant Director, Institute of Social & Economic Research, University of York

1972-76           Senior Lecturer in Economics, University of York

1976-79           Reader in Economics, University of York

1976                Senior Research Associate at the Ontario Economic Council

Visiting Professorial Lecturer at Queen's University, Kingston, Canada

1979                William Evans Visiting Professor, University of Otago, Dunedin, New Zealand

Visiting Fellow, Australian National University, Canberra, Australia

1979-82           Deputy Director, Institute of Social and Economic Research, University of York

1979-               Professor of Economics, University of York (since 1982 in Department of Economics & Related Studies)

1983-84           Director of the Graduate Health Economics Programme, Department of Economics & Related Studies, University of York

1985-86           Visiting Professor, Trent University, Canada

1986-01           Head of Department of Economics & Related Studies, University of York

1989-94           Visiting professor, Department of Health Administration, University of Toronto

1990-91           (Oct-Feb) Visiting Professor, Institut für Medizinische Informatik und Systemforschung (Gesellschaft für Strahlen-und Umweltforschung), Munich, Germany

1991                (Apr-Sep) Visiting Professor, Department of Health Administration, University of Toronto

1991-94           Pro-Vice-Chancellor, University of York, England

1994-97           Deputy Vice-Chancellor, University of York, England

1995-96           Director, School of Politics, Economics & Philosophy, University of York

1996                (November) Visiting Professor, Central Institute of Technology, New Zealand

1997-01           Director of Health Development, University of York

1999-01           Director (Board Member) of York Health Economics Consortium

2001-03           Chair, Board of York Health Economics Consortium

2003-07           Visiting Professor, Department of Health Policy, Management & Evaluation, University of Toronto

2003-06           Chief Scientist, Institute for Work & Health, Canada

2006-07           Senior Scientist, Institute for Work & Health, Canada

2006-07           Senior Economic Adviser, Cancer Care Ontario

2006-10           Chair, Research Advisory Council of the Workplace Safety & Insurance Board (Ontario)

2007-               Ontario Research Chair in Health Policy and System Design, University of Toronto

2007-               Adjunct Scientist, Institute for Work & Health, Toronto

 

Affiliations

Academy of Medical Sciences, Health Economists' Study Group, International Health Economics Association, Royal Economic Society, Royal Society of Arts, Royal College of Physicians (London), Royal School of Church Music, Royal School of Church Music (Canada).

 

Journal Editing

1996-70           Acting Editor, Assistant Editor, Editorial Board member (various times), Social and Economic Administration.

1982-               Founding Co-editor, Journal of Health Economics

1984-85           Founding Editor, Nuffield/York Portfolios

1986-96           Advisory Editor, Social Science and Medicine

1976-84           Member, Editorial Board, Bulletin of Economic Research

1983-93           Founding Member, Editorial Panel, The Economic Review

1992-2002       Member, Editorial Board, Medical Law International

1994-2001       Member, Managing Committee, Journal of Medical Ethics

1995-2000       Member, Editorial Board, British Medical Journal

1996-2007       Founding Member, International Advisory Board, Clinical Effectiveness in Nursing

1998-2001       Member, Editorial Advisory Board, Handbook on Research Methods for Evidence Based Health Care

1999-2005       Member, Editorial Board, Zeitschrift für die gesamte Versicherungswissenschaft

2001                Guest Editor, Journal of Medical Ethics (Vol. 27, No. 4).

2009-               Editor in Chief, The Elsevier on-line Encyclopedia of Health Economics,

 

External Academic Advisory Boards

1989-92           Member, Methodological Advisory Group on Non-economic Loss, Ontario Workers' Compensation Board

1992-98           Member, Advisory Committee of the Canadian Institute for Advanced Research (Population Health Program)

1992-2001       Member, Advisory Committee for Centre for Health and Society, University College, London

1990-94           Member, Research Advisory Committee of the Institute for Work and Health (Toronto, Canada)

1997-2002       Member, Research Advisory Committee of Canadian Institute for Health and Work

1997-2003       Member, Research Advisory Committee of the Institute for Work and Health (Toronto, Canada)

2000-03           Trustee, The Canadian Health Services Research Foundation, Ottawa

2001                Member, International Scientific Advisory Committee, Unit of Health Economics and Technology Assessment in Health Care, Budapest University of Economics

2006-10           Member, International Advisory Board, Alberta Bone & Joint Institute

2006-10           Chair, Research Advisory Council, Workplace Safety and Insurance Board (Ontario)

2006-10           Member, Advisory Board, Centre for Research Expertise in Musculo-Skeletal Diseases, University of Waterloo

2006-10           Member, Advisory Board, Centre for Research Expertise in Occupational Disease, University of Toronto

2006-10           Member, Advisory Board, Centre for Research Expertise in Improved Disability Outcomes, University Health Network, Toronto

 

Professional Groups

1970-86           Founding Organiser, Health Economists' Study Group (HESG)

1970-               Member, HESG

1975-76,          Member, Scientific Committee of the International Institute of Public Finance

1975-90           Honorary Adviser to the Office of Health Economics

1977-85           Member, Organising Committee of International Seminar in Public Economics

1979-85           Founding Course Coordinator for the Health Economics option, Corporate Management Programme of King's Fund College, London

1980-82           Convenor, SSRC European Workshop in Health Indicators (for report, see publications)

1982-83           Member, Scientific Committee of the International Institute of Public Finance

1983-84           Director, York MSc. Programme in Health Economics

1987-88           Member, Institute of Health Service Management Working Party on Alternative Funding and Delivery of Health Services (for reports see publications).

1987-2001       Member, Conference of Heads of University Departments of Economics (CHUDE)

1988-93           Member, Standing Committee of CHUDE

1989-92           Member, College Committee of the King's Fund College, London,

1990-97           Member of Editorial Policy Committee, Office of Health Economics

1990-97           Member, Editorial Board, Office of Health Economics

1991-93           Member, Economics Association National Development Group on economics curriculum development

1991-92           Council member, Royal Economic Society

1992                World Health Organisation Adviser (economics of schistosomiasis control in Kenya)

1992                Member, Canadian Institute of Advanced Research (Review Panel on Population Health)

1992-97           Member, Kenneth J. Arrow Award in Health Economics (Prize Committee)

1992-92           Member, Institute of Health Services Management's "Future Health Care Options" Working Party

1994                President, Section F (Economics), British Association

1996                Member, ESRC Training Board Economics Area Panel

1996-2003       Member, Academic Advisory Council, University of Buckingham

1997                Member of World Health Organisation two-person mission to Kazakhstan on the privatisation and reform of health care services, February

1997-2001       Vice Chair, Office of Health Economics

1997-               Chair, Office of Health Economics Editorial Board

1988-93           Member, Standing Committee of CHUDE

2001-               Chair, Office of Health Economics Policy Board

2002-07           Member, Governing Board, International Health Economics Association

2004-               Chair, Office of Health Economics Management Committee

2004-06           Adviser, Canada Health Council

2005                Member, Ontario Health Technology Advisory Committee

2006-07           Senior Economic Advisor, Cancer Care Ontario

2006-07           Economic Advisor, Ontario Ministry of Health and Long Term Care

2006                Member, Ontario Ministry of Health and Long Term Care Equity Editorial Board

2006-08           Canadian Institutes for Health Research Michael Smith Prize in Health Research Committee

2007-               Member, Ontario Ministry of Health and Long Term Care Career Scientist Relevance Review Panel

2007-               Member, Ontario Ministry of Health and Long Term Care Health Research Advisory Council

2009-               Member, Hall Foundation Board (Canada)

2009-               Member Advisory Committee, NICE International

2009-               Member, Department of Health Policy Research Units Commissioning Panel

2009-               Member, Ontario Ministry of Health and Long Term Care, Health System Strategy Division, External Advisory Group

2009-               Member, Ontario Ministry of Health and Long Term Care Advisory Group on Productivity

2009-               Member, Ontario Ministry of Health and Long Term Care Steering Committee for Partnerships for Health System Improvement (CIHR project)

2010- 11          Member, Ontario Health Quality Council Advisory Committee

 

Principal Lectures

1976                Plenary Lecture, First Canadian Health Economics Symposium, Kingston

1980                Plenary Lecture, First Australian Conference of Health Economists, Canberra

1986                Woodward Lecturer, University of British Columbia

1986                Plenary Lecture, Third Canadian Conference on Health Economics, Winnipeg

1990                Perey Lecturer, McMaster University

1990                Champlain Lecturer, Trent University

1994                Francis Fraser Lecturer (British Postgraduate Medical Federation, London).

2001                Plenary Lecture Canadian Health Economics Study Group, Vancouver

2006                Sinclair Lecturer, Queen’s University, Kingston

2005                Plenary Lecture, Canadian Health Economics Study Group, Toronto

 

University (outside my Department) Management

1991-94           Pro-Vice-Chancellor, University of York

1994-97           Deputy Vice-Chancellor

1994-99           Member, Health Sector Group of the Committee of Vice-Chancellors and Principals

1997-2001       Director of Health Development, University of York

 

At various times Representative of University of York on Court and Council of Leeds University, 1978-85, member of Council, Nominations Committee, General Academic Board, Professorial Board, Member or chair of: Staff Committee, Finance Committee, Secretarial and Clerical Committee, Joint Negotiating Committee (Joint chair), Court, Council, Appointments to Court and Council, Vacancies Review Panel, Planning Committee, Administrative Planning Committee, Policy and Resources Committee, Equipment Subcommittee (minor spenders), VC's Advisory Group, VC's advisory committees on Academic Plan, Discretionary Salary Awards; Promotions Committee, Premature Retirement Committee, Leave of Absence Committee, Research Committee (chair), Awards Sub-Committee (chair), Health Liaison Group (chair), Board for Graduate Schools (chair), Undergraduate Admissions Committee (chair), Special Cases Committee (chair), Medical Services Committee (chair), Library Advisory Committee (chair), Joint Committee with AUT (chair), Heslington Lectures Committee (chair), University Committee (chair), King's Manor Resources Group (chair), Disciplinary Advisory Committee, IT Strategy Committee, Panel for Admin Library Computing and Other Related Staff (chair), Post-1995 Institutional Planning Group, Careers Advisory Group (chair), Alcuin Collaboration Group (chair), Alcuin Project Development Group (chair), Alcuin Project Steering Group (member), CVCP (in lieu of VC), Search Committee for new VC (1992), chair of any of the above chaired by VC in his absence, University and University College of Ripon & York St John Health Collaboration Steering Group (co-chair).

 

 

Principal Canadian Connections

1976                Senior Research Associate at the Ontario Economic Council and Visiting Professor, Economics Department, Queen’s University

1985-6             Visiting Professor, Trent University, Canada

1986                Woodward Lecturer, University of British Columbia

1989-90           Visiting Professor, Department of Health Administration, University of Toronto

1989-92           Member, Methodological Advisory Group on Non-economic Loss, Ontario Workers' Compensation Board      

1990                Commissioned to write paper on Equity in Health for Ontario Premier’s Council on Health, Well-Being and Social Justice

1990                Perey Lecturer, McMaster University

1990                Champlain Lecturer, Trent University

1991                (Apr-Sep) Visiting Professor, Department of Health Administration, University of Toronto

1990-4 and

1997-02           Member, Research Advisory Committee, Institute for Work and Health, Toronto

1992-02           Member, Advisory Committee of the Canadian Institute for Advanced Research Population Health Program

2000-3             Trustee, Canadian Health Services Research Foundation, Ottawa

2002-3            Member, Scientific Advisory Committee, Institute for Work and Health

2003-7             Visiting professor, Department of Health Policy, Management & Evaluation , University of Toronto

2003-6             Chief Scientist, Institute for Work & Health, Toronto

2003-4             Member, External Research Review Team for Cancer Care Ontario

2005-7             Adviser, Canada Health Council

2005-6             Member, Ontario Health Technology Advisory Committee (OHTAC)

2005-7             Member, CIHR Michael Smith Prize in Health Research Committee

2005-               Member, Scientific Committee, Alberta Bone & Joint Health Institute 

2006-               Member, International Advisory Board, Alberta Bone & Joint Institute

2006-7             Senior Scientist, IWH, Toronto

2006-               Advisor to MOHLTC on Citizens’ Council

2006-               Chair, WSIB Research Advisory Council

2006-7             Senior Economic Advisor, Cancer Care Ontario

2007                Chair, External Review Panel of Centre for Health Service Policy Research, UBC

2006-10           Chair, Research Advisory Council, Workplace Safety and Insurance Board (Ontario)

2006-10           Member, Advisory Board, Centre for Research Expertise in Musculo-Skeletal Diseases, University of Waterloo

2006-10           Member, Advisory Board, Centre for Research Expertise in Occupational Disease, University of Toronto

2006-10           Member, Advisory Board, Centre for Research Expertise in Improved Disability Outcomes, University Health Network, Toronto

2006                Member, Ontario Ministry of Health and Long Term Care Equity Editorial Board

2007-               Member, Value for Money Committee, Health Council of Canada

2007-               Member, Ontario Ministry of Health and Long Term Care Career Scientist Relevance Review Panel

2007-               Member, Ontario Ministry of Health and Long Term Care Citizen’s Council Advisory Committee

2007-               Member, Ontario Ministry of Health and Long Term Care Health Research Advisory Council

2008-               Chair, Advisory Committee to CCO Pharmaceutical Economics Unit

2008-               Member, Advisory Committee, Toronto Health Economics and Technology Assessment (THETA) Collaborative

2008-               Member, Clinical Standards, Guidelines and Quality Committee of the Board of Cancer Care Ontario

2009-               Member, Interim Scientific Committee, Occupational Cancer Research Centre, Toronto

2009-               Member, Ontario Ministry of Health and Long Term Care, Health System Strategy Division, External Advisory Group

2009-               Member, Ontario Ministry of Health and Long Term Care Steering Committee for Partnerships for Health System Improvement (CIHR project)

2010-               Member, Ontario Health Quality Council Advisory Committee

 

Current other roles

Co-editor, Journal of Health Economics

Chair, Office of Health Economics (London, England)

Adjunct Scientist, Institute for Work & Health, Toronto

Trustee and Council member, Royal School of Church Music

Director, Royal School of Church Music, Canada

Member, Citizens’ Council Committee, NICE

Member, Advisory Committee, NICE International

Member, MOHLTC Advisory Committee on Citizens’ Council

Member, MOHLTC Advisory Committee on R&D

Member, editorial boards of several other journals

Member, International Advisory Board, Alberta Bone & Joint Institute

Member, Advisory Board, Royal School of Church Music

Member, Board of Directors, Royal School of Church Music (Canada)

 

External Assessor for Chairs etc.

Durham (economics), Leeds (health economics), London School of Economics (social policy), London School of Hygiene & Tropical Medicine (health economics) (twice), Newcastle (health sciences), Oslo (health economics), Toronto (health economics), Southampton (health policy), UBC (economics) (twice)Northallerton Health Authority (Chief Executive), Office of Health Economics (deputy director), King's Fund (Chief Executive), National Institute for Clinical Excellence (Director of Appraisals), North Yorkshire Health Authority (Director of Primary Care), Director of R&D (NICE).

 

 

External Reviews of Departments

1989                Economics Department, McMaster University

1993                London Special Health Authorities (member of Thompson Committee)

1998                Wessex Institute and the Institute of Health Policy, Southampton University (with Charles Florey) 1

1999                McMaster University Centre for Health Economics and Policy Analysis (CHEPA)

2007                UBC Centre for Health Services Policy Research

 

National Health Service (England) Appointments

1975-84           Member, DHSS Research Liaison Groups (several)

1982-90           Member, Northallerton Health Authority

1990-92           Non-executive member, Northallerton Health Authority

1991-2001       Member, Central Research and Development Committee (CRDC) for the National Health Service

1992-93           Member, Central R&D Committee Mental Health National Steering Group (Goldberg Committee)

1992-94           Member, Yorkshire Health Research and Development Committee

1992-97           Member, CRDC Standing Group on Health Technology

1993-97           Chair, CRDC Health Technology Assessment (HTA) Methodology Panel

1992-93           Member, Review Advisory Committee on the London Special Health Authorities. (The "Thompson Report”, Special Health Authorities: Research Review, London, HMSO, 1993, chaired by Sir Michael Thompson)

1993-94           Chair, NHS Research Task Force on R&D to Review the Funding and Support of Research and Development in the NHS, (The "Culyer Report”): Supporting Research and Development in the NHS: A Report to the Minister of Health, London, HMSO, 1994

1994-99           Deputy Chair and non-executive member, North Yorkshire Health

Authority (reappointed to new Authority in 1996), (chair and member of several subcommittees of the Board)

1995-2001       Member, Northern & Yorkshire Regional Research Advisory Group

1995-2001       Member, Northern and Yorkshire Regional Universities Group for R&D

1995-99           Special Adviser, High Security Psychiatric Services Commissioning Board (HSPSCB)

1995-1999       Member, R&D Committee of the HSPSCB

1995-99           Member, R&D Commissioning Sub Group of the HSPSCB

1996                Member, Central R&D Committee Sub-Group on the Strategic Framework

1996-97           Member, National Working Group on R&D in Primary Care (“Mant Committee”)

1997-98           Chair, Department of Health Expert Workshop on DH Guidelines for Pharmaco-economic studies

1997-98           Adviser, Department of Health Comprehensive Spending Review Group on "Non front-line services"

1997-99           Special Adviser to NHS Director of R&D

1997-98           Chair, Central R&D Committee Sub-Group on Budget 1 Allocations to Trusts

1998-2002       Member, Healthcare Sector Group, Department of Trade and Industry and Department of Health Overseas Trade Services

1998-2000       Member, NHS R&D Exceptional Cases Advisory Group

1998-2000       Member, NHS R&D Strategic Review Sub Group

1998-2000       Member, NHS R&D Evaluation Strategy Steering Group

1999-2003       Vice Chair (and non-executive director), National Institute for Clinical Excellence

2007-10           Chair, NICE Research & Development Committee

2007-               Member, NICE Citizens’ Council Committee

2008-               Member, NICE International Advisory Committee

2008                Member, Department of Health Value Focus Group on the cost and benefit perspective of NICE

 

Other Government roles

1983-87           Member, Comac-HSR Committee of the European Commission

1995-97           Member, British Council Health Advisory Committee

1997-98           Member, Department of Trade and Industry Advisory Committee on Exports of Health-related Products

2005-07           Member, Economics Advisory Panel, Home Office

 

 

Recent publications (2007-10)

2007

Culyer A J. “Need - an instrumental view” in Richard Ashcroft, Angus Dawson, Heather Draper and John McMillan (Eds.) Principles of Health Care Ethics, 2nd Edition, Chichester: Wiley, 2007, 231-238.

 

Culyer A J. “When and how cancer chemotherapy should be privately funded," Oncology Exchange, 2007, 6: 47.

 

Culyer A J, McCabe C,  Briggs AH,  Claxton K,  Buxton M, Akehurst RL,  Sculpher M and Brazier J. “Searching for a threshold, not setting one: the role of the National Institute of Health and Clinical Excellence”, Journal of Health Service Research and Policy, 2007, 12: 56-59.

 

Robson LS, Clarke J, Cullen K, Bielecky A, Severin C, Bigelow P, Irvin E, Culyer AJ,  Mahood Q. “The Effectiveness of Occupational Health and Safety Management System Interventions: A Systematic Review”, Safety Science, 2007, 45: 329-353.

Culyer A J “Merit goods and the welfare economics of coercion” in Wilfried Ver Eecke (Ed.) Anthology regarding Merit Goods.  The Unfinished Ethical Revolution in
Economic Theory.
West Lafayette: Purdue University Press, 2007, 174-200 (reprinted from Public Finance, 1971, 26: 546-572.

Claxton K and Culyer A J, “Rights, responsibilities and NICE: A Rejoinder to Harris” Journal of Medical Ethics, 2007, 33: 462-464.

Culyer A J, “NICE misconceptions” The Lancet, September 11 2007, on-line at http://www.thelancet.com/journals/lancet/article/PIIS014067360761321X/comments

Culyer A J, “Equity of what in health care? Why the traditional answers don't help policy - and what to do in the future”

Culyer A J, McCabe C, Briggs A, Claxton K, Buxton M, Akehurst R, Sculpher M, Brazier J, “Searching for a threshold - Not so…”,  Journal of Health Services Research and Policy, 2007, 12: 190-191. (letter: reply to G Mooney, J Coast, S Jan, D McIntyre, M Ryan and V Wiseman).

Culyer A J, “Resource allocation in health care: Alan Williams’ decision maker, the authority and Pareto”, in A Mason & A Towse (eds.) The Ideas and Influence of Alan Williams: Be Reasonable –Do it My Way! Oxford, Radcliffe Publishing, 2007, 57-74.

 

2008

E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, pp. xvi + 295.

Chalkidou K, Culyer A J, Naidoo B, Littlejohns P “Cost-effective public health guidance: asking questions from the decision-maker's viewpoint”, Health Economics, 2008, 17: 441-448.

Claxton K, Briggs A, Buxton M, Culyer A J, McCabe C, Walker S, Sculpher M J   “Value based pricing for NHS drugs: an opportunity not to be missed?” British Medical Journal, 2008, 336: 251-254.

Brouwer W B F, Culyer A J, Job N,  van Exel A, Rutten F F H. “Welfarism vs. extra-welfarism”, Journal of Health Economics, 2008, 27: 325–338.

J Hurley, D Pasic, J Lavis, A J Culyer C Mustard and W Gnam, “Parallel payers and preferred access: how Canada’s Workers’ Compensation Boards expedite care for injured and ill workers”, HealthcarePapers, 2008, 8: 6-14.

J Hurley, A J Culyer, W Gnam, J Lavis, C Mustard and D Pasic, “Response to commentaries”, HealthcarePapers, 2008, 8: 52-54.

K Chalkidou, T Walley, A J Culyer, P Littlejohns, and A Hoy. “Evidence-informed evidence-making”, Journal of Health Services Research & Policy, 2008, 13: 167-173.

K Claxton and A J Culyer “Not a NICE fallacy: A reply to Dr Quigley”, Journal of Medical Ethics 2008, 34: 598-601.

A J Culyer, B Amick and A LaPorte. “What is a little more health and safety worth?” in E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 15-35.

A J Culyer and M Sculpher.Lessons from health technology assessment” in E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 51-69.

A J Culyer and E Tompa. “Equity”, in E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 215-231.

E Tompa, A J Culyer and R Dolinschi “Suggestions for a reference case”, in E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 235-244.

C McCabe, K Claxton and A J Culyer The NICE cost effectiveness threshold – what it is and what that means,” PharmacoEconomics, 2008, 26: 733-744.

K Chalkidou, A J Culyer, P Littlejohns, P Doyle, A Hoy. “Imbalances in funding for clinical and public health research in the UK: can NICE research recommendations make a difference?” Evidence and Policy, 2008, 4: 355-369.

J Hurley, D Pasic, J Lavis, C Mustard, A J Culyer, W Gnam. “Parallel
lines do intersect: interactions between the workers’ compensation and provincial
publicly financed health care systems in Canada.” HealthCare Policy, 2008, 3: 100-112.

2009

Chalkidou K, A J Culyer, B Naidoo, P Littlejohns "The challenges of developing cost-effective public health guidance: a NICE perspective", in S Dawson and Z S Morris (eds.) Future Public Health: Burdens, Challenges and Opportunities, Basingstoke: Palgrave Macmillan, 2009, 276-291.

 

A J Culyer, Deliberative Processes in Decisions about Health Care Technologies: Combining Different Types of Evidence, Values, Algorithms and People, London: Office of Health Economics, 2009, pp. 1-20.

A J CulyerHow Nice is NICE? A Conversation with Anthony Culyer”, Health Care Cost Monitor, Hastings Centre Blog, 2009.

M. J. Dobrow, R. Chafe, H. E. D. Burchett, A J Culyer, L. Lemieux-Charles Designing Deliberative Methods for Combining Heterogeneous Evidence: A Systematic Review and Qualitative Scan. A Report to the Canadian Health Services Research Foundation, Ottawa: Canadian Health Services Research Foundation, 2009, pp. 24 + 30, ().

 

2010

Cookson R, A J Culyer.  “Measuring overall population health - the use and abuse of QALYs”, in Killoran A, Kelly M (eds). Evidence Based Public Health: Effectiveness and Efficiency, Oxford: Oxford University Press, 2010, 148-168.

 

A J Culyer, The Dictionary of Health Economics, Cheltenham: Edward Elgar, 2010.

 

A J Culyer "Perspective and desire in comparative effectiveness research - the relative unimportance of mere preferences, the central importance of context", Pharmacoeconomics, 28: 1-9.

 

2011

K Claxton, M Paulden, H Gravelle, W Brouwer, A J Culyer. “Discounting and decision making in the economic evaluation of health-care technologies”, Health Economics, 2011, 20: 2-15.

R Chase, A J Culyer, M Dobrow, P Coyte, C Sawka, S O’Reilly, K Laing, M Trudeau, S Smith, J Hoch, S Morgan, S Peacock, R Abbott, T Sullivan. “Access to Cancer Drugs in Canada: Looking Beyond Coverage Decisions”, Healthcare Policy, 2011, 6: 27-35.

A J Culyer. “UK report: NHS ‘reforms’”, Health Care Cost Monitor, 2011, 1-2. The Hastings Centre, on-line at http://healthcarecostmonitor.thehastingscenter.org/anthonyculyer/u-k-report-nhs-reforms.

P Tso, A J Culyer, M Brouwers, M J Dobrow. Developing a decision aid to guide public sector health policy decisions: A study protocol”, Implementation Science, 2011, 6:46.

 

Current grants

Strengthening the health system through improved priority setting. Canadian Institutes of Health Research (Sustainable Financing, Funding and Resource Allocation), Co-investigators: Dr. Andreas Laupacis (PI), Dr. Doug Martin (Co-PI_, Dr. W. Evans, Dr. W. Levinson, Dr. T. Sullivan, Dr. S. Pearson, Dr. A. Hudson. $159,805 per year for 5 years, 04/2005 to 09/2010.

 

Dynamics of Parallel Systems of Finance: Interactions Between Canada's Worker Compensation Systems and Public Health Care Systems; Canadian Institutes of Health Research. Co-investigators: Dr Jerry Hurley (PI), Dr William Gnam, Dr John Lavis, Dr Cameron Mustard, Dr Emile Tompa. $75,000 for 1 year, Reference #: PPG-74820.

 

Several grant applications to CIHR with M Dobrow (Cancer Care Ontario) and others are currently being considered.

 

Recent grant

Conceptualising and Combining Evidence for Health System Guidance, Canadian Institutes of Health Research, Co-investigator Dr Jonathan Lomas, 2005.

 

 

Teaching Experience

 

Graduate

At various times have given lectures and seminars in Advanced Economic Theory (micro and macro), the Economics of Human Resources, the Economics of Social Policy, Health Economics, Social Policy Analysis, and given graduate classes on Social Policy to students of Social Administration. Supervised MSc, MPhil and DPhil thesis students. PhD external examiner at various Universities in the UK and overseas.

 

Undergraduate

At various times have given first year introductory lectures in Economics; second year lectures in Price Theory, Welfare Economics, Macroeconomics, and Investment Appraisal; third year lectures and seminars in Economics of the Social Services, Economics of Human Resources, Health Economics, Applied Economics, and Advanced Economic Theory. External examining.

 

 

 

Listed in

At various times:

Who's Who in Economics: A Biographical Dictionary of Major Economists 1700-1981 (ed. Blaug and Sturges), Wheatsheaf, 1983 (and subsequent editions)

Who's Who

Who's Who in Education

Who’s Who in America

Who’s Who in the World

The Academic Who's Who

The Universities' Who's Who

The International Authors' and Writers' Who's Who

People of Today

 

Recreation and other

Church music: Emeritus Organist and Choir Director in an Anglican rural parish church in England, Chair of the York District of the Royal School of Church Music 1983-95, Chair of North East Area Committee of the Royal School of Church Music 1995-2003, member RSCM Advisory Board 2002-4, Member of Council and Trustee RSCM, 2003-. Board Director of Royal School of Church Music (Canada) 2008-. Member of the York Diocesan Liturgy and Music Advisory Group 1995-99. Various roles in local Church of England (at various times Parochial Church Council member, Lay Chair of Parochial Church Council, Sometime Deanery Financial Adviser, Sometime Member York Diocesan Church Urban Fund, etc.). Amateur composer. Music generally. Gardening when time, weather and low back problems permit. DIY when time and LBP permit and urgency insists.

 

PUBLICATIONS

 

A. Articles

 

1.      A J Culyer. "Methodological error in regional planning: the South West Strategy", Social and Economic Administration, 1968, 2: 23-30.

 

2.      A J Culyer. "Holidays on the move", New Society, 11 April, 1968.

 

3.      A J Culyer, D C Corner "University teachers and the PIB", Social and Economic Administration, 1969, 3: 127-139.

 

4.      F M M Lewes, A J Culyer, G A Brady. "The holiday industry" in British Association, Exeter and its Region, Exeter: University of Exeter. 1969, 244-258.

 

5.      A J Culyer. "Pricing policies" in G. Teeling-Smith (ed.), Economics and Innovation in the Pharmaceutical Industry, London: Office of Health Economics, 1969, 35-50.

 

6.      A J Culyer. "The economics of health systems" in The Price of Health, Melbourne: Office of Health Care Finance, 1969, 36-62 (reprinted as ch.7 in J. R. G. Butler and D. P. Doessel (eds.), Health Economics: Australian Readings, Sydney: Australian Professional Publications, 1989, 145-66).

 

7.      M H Cooper, A J Culyer. "An economic assessment of some aspects of the organisation of the NHS" in BMA, Health Services Financing, London: British Medical Association, 1970, 187-250.

 

8.      A J Culyer. "A utility-maximising view of universities", Scottish Journal of Political Economy, 1970, 17: 349-68.

 

9.      A J Culyer, A K Maynard. "The cost of dangerous drugs legislation in England and Wales", Medical Care, 1970, 8: 501-509.

 

10.  M H Cooper, A J Culyer. "An economic survey of the nature and intent of the British National Health Service", Social Science and Medicine, 1971, 5: 1-13.

 

11.  A J Culyer. "Ethics and economics in blood supply", Lancet (i) March 1971.

 

12.  A J Culyer. "Social scientists and blood supply", Lancet (i) June 1971.

 

13.  A J Culyer. "The nature of the commodity 'health care' and its efficient allocation", Oxford Economic Papers, 1971, 23: 189-211 (reprinted as Ch. 2 in A. J. Culyer and M. H. Cooper (eds.), Health Economics, London: Penguin, 1973, also in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 148-157).

 

14.  A J Culyer. "Medical care and the economics of giving", Economica, 1971, 38: 295-303 (reprinted as Ch. 18 in M. Ricketts (ed.), Neoclassical Microeconomics, Vol. 2, Aldershot: Edward Elgar, 1989, pp. 310-18).

 

15.  A J Culyer. "A taxonomy of demand curves", Bulletin of Economic Research, 1971, 23: 3-23.

 

16.  A J Culyer. "Calculus of health", New Society, 23 September, 1971.

 

17.  A J Culyer, A Williams, R J Lavers. "Social indicators: health", Social Trends, 1971, 2:  31-42 (reprinted as “Health indicators” in Andrew Shonfield and Stella Shaw (eds.) Social Indicators and Social Policy, London: Heinemann, 1972).

 

18.  A J Culyer. "Merit goods and the welfare economics of coercion", Public Finance, 1971, 26:  546-72. (Reprinted in Wilfried Ver Eecke (2006) Merit Goods: The Birth of a New Concept. The Unfinished Ethical Evolution in Economic Theory. Ashland Ohio: Purdue University Press, 174-200).

 

19.  A J Culyer. "Appraising government spending on health services: The problems of 'need' and 'output'", Public Finance, 1972, 27: 205-11.

 

20.  A J Culyer. "On the relative efficiency of the National Health Service", Kyklos, 1972, 25:  266-287.

 

21.  A J Culyer."The market versus the state in medical care: a minority report on an empty academic box", in G. McLachlan (ed.), Problems and Progress in Medical Care, 7, London: Oxford University Press, 1972, 1-32.

 

22.  M H Cooper, A J Culyer. "Equality in the NHS: intentions, performance and problems in evaluation", in M. M. Hauser (ed.), The Economics of Medical Care, London: Allen and Unwin, 1972, 47-57.

 

23.  A J Culyer, A Williams, R J Lavers. "Social indicators: health" in A. Shonfield and S. Shaw (eds.) Social Indicators and Social Policy, London, Heinemann, 1972, (reprint of 1971 article in Social Trends).

 

24.  A J Culyer. "Comment on ‘Problems of Efficiency’", in M. M. Hauser, Hauser (ed.), The Economics of Medical Care, London: Allen and Unwin, 1972, 42-46

 

25.  A J Culyer, P Jacobs. "The War and public expenditure on mental health - the postponement effect", Social Science and Medicine, 1972, 6: 35-56.

 

26.  A J Culyer. "Indicators of health: an economist's viewpoint ", in Evaluation in the Health Services, London: Office of Health Economics, 1972, 23-28.

 

27.  A J Culyer. "L’efficienza relativo del Servizio Sanitario Nazionale Brittanico", Citta e Societa, 1972, March/April, 35-53.

 

28.  A J Culyer. "Social policy and government spending", Local Government Finance, 1972, 76: 353-357.

 

29.  A J Culyer. "Economic analysis - its practice and pitfalls", Local Government Finance, 1972, 76: 385-389.

 

30.  A J Culyer. "Pareto, Peacock and Rowley, and the public regulation of natural monopoly", Journal of Public Economics, 1973, 2: 89-95.

 

31.  A J Culyer. "Should social policy concern itself with drug 'abuse'?", Public Finance Quarterly, 1973, 1: 449-456.

 

32.  A J Culyer. "Hospital waiting lists", New Society, 16 August, 1973.

 

33.  A J Culyer. "Is medical care different?" in A. J. Culyer and M. H. Cooper (eds.) Health Economics, London: Penguin, 1973, 49-74 [reprint with changes of 1971 article in Oxford Economic Papers].

 

34.  A J Culyer. "Hospital waits", New Society, 6 December, 1973.

 

35.  A J Culyer. "Quids without quos - a praxeological approach", in A. A. Alchian et al. The Economics of Charity, London: IEA, 1973, 35-61.

 

36.  M H Cooper, A J Culyer. "The economics of giving and selling blood", in A. A. Alchian et al. The Economics of Charity, London, IEA, 1973, 111-143.

 

37.  J G Cullis, A J Culyer. "Private patients in NHS hospitals: subsidies and waiting lists", in M. Perlman (ed.), The Economics of Health and Medical Care, International Economics Association., London: Macmillan, 1974, 108-116.

 

38.  A J Culyer. "Economics, social policy and disability", in Dennis Lees and Stella Shaw (eds.), Impairment, Disability and Handicap, London: Heinemann for the SSRC, 1974, 17-29.

 

39.  A J Culyer. "Dialogue on blood 1", New Society, 24 March, 1974.

 

40.  A J Culyer. "Hospitals", New Society, 20 June, 1974.

 

41.  A J Culyer. "Introduction" to University Economics, (3rd Ed.) by A. A. Alchian and W. R. Allen, Prentice-Hall International, 1974.

 

42.  R L Akehurst, A J Culyer. "On the economic surplus and the value of life", Bulletin of Economic Research, 1974, 26: 63-78

 

43.  A J Culyer. "The economics of health" in R. M. Grant and G. K. Shaw (eds.), Current Issues in Economic Policy, London: Philip Allan, 1975, 151-173.

 

44.  A J Culyer. "Value for money in health", New Society, March 1975.

 

45.  A J Culyer, J G Cullis. "Hospital waiting lists and the supply and demand of inpatient care", Social and Economic Administration, 1975, 9: 13-25.

 

46.  A J Culyer, J Wiseman, J Posnett. "Charity and public policy in the U.K.: the law and the economics", Social and Economic Administration, 1976, 10: 32-50.

 

47.  J G Cullis, A J Culyer. "Some economics of hospital waiting lists in the NHS", Journal of Social Policy, 1976, 5: 239-264.

 

48.  A J Culyer. "Discussion of 'Health Costs and Expenditures in the U.K.' by M. H. Cooper", in Tei-wei Hu (Ed.) International Health Costs and Expenditures, Washington D.C.: U.S. Department of Health Education and Welfare, 1976, 109-113.

 

49.  A J Culyer. "Alternatives to price rationing: some unsolved riddles for British health economists", in R. D. Fraser (ed.), Health Economics Symposium, Proceedings of the First Canadian Conference, Kingston (Ontario): Industrial Relations Centre, Queen's University, 1976, 66-74.

 

50.  A J Culyer, J Wiseman. "Public economics and the concept of human resources", in Victor Halberstadt and A. J. Culyer (eds.) Human Resources and Public Finance,  (eds.), Paris: Cujas, 1977, 13-29.

 

51.  A J Culyer. "Blood and altruism: an economic review", in D. B. Johnson (ed.), Blood Policy - Issues and Alternatives, Washington D.C: American Enterprise Institute, 1977, 39-58.

 

52.  A J Culyer. "The quality of life and the limits of cost-benefit analysis", in L. Wingo and A. Evans (eds.), Public Economics and the Quality of Life, Baltimore: Johns Hopkins, 1977, 141-153.

 

53.  A J Culyer. "Drugs and Pareto - a methodological abuse", Public Finance Quarterly, 1977, 5: 393-396.

 

54.  A J Culyer. "Need, values and health status measurement", in A. J. Culyer and K. G. Wright (eds.), Economic Aspects of Health Services, London: Martin Robertson, 1978, 9-31.

 

55.  M F Drummond, A J Culyer. "Financing medical education - interrelationships between medical school and teaching hospital expenditure", in A. J. Culyer and K. G. Wright (eds.), Economic Aspects of Health Services, London: Martin Robertson, 1978, 123-140.

 

56.  A J Culyer, J. Wiseman, M. F. Drummond, P. A. West. "What accounts for the higher costs of teaching hospitals?" Social and Economic Administration, 1978, 12: 20-30.

 

57.  A J Culyer. "Economics and the health services: missionary role of economists", Surgical News, No. 5, Summer 1978, 2-4.

 

58.  A J Culyer. "Editorial", Epidemiology and Community Health, 1979, 33: .

 

59.  A J Culyer. “Comment on ‘Theories and Measurement in Disability’ by R. G. A. Williams”, Epidemiology and Community Health, 1979, 33: .

 

60.  A J Culyer. "Into the valley: review article of 'Charge' by A. Seldon", Social Policy and Administration, 1979, 13: 65-68.

 

61.  A J Culyer. "What do health services do for people?" Search, 1979, 10: 262-268.

 

62.  A J Culyer, J Wiseman. "Frameworks for evaluating economic effects of budget and financial transfers in the EEC", in Study Group on the Economic Effects of Budget and Financial Transfers in the Community, Part II, Brussels, Commission of the European Communities, 1979.

 

63.  A J Culyer. "Cost-sharing: financial aspects and policies", in B. Abel-Smith (ed.), Sharing Health Care Costs, Washington D.C.: National Center for Health Services Research; U.S. Department of Health, Education and Welfare, 1980, 18-19.

 

64.  A J Culyer. "Economics and the health services", in R. M. Grant and G. K. Shaw (eds.), Current Issues in Economic Policy, 2nd ed., London: Philip Allan, 1980, 164-186.

 

65.  A J Culyer, A K Maynard. “Treating ulcers with Cimetidine can be more cost-effective than surgery", Medeconomics, 1980 1: 12-14.

 

66.  A J Culyer. "Externality models and health: a Rückblick over the last twenty years", in P. M. Tatchell (ed.), Economics and Health: Proceedings of the First Australian Conference of Health Economists, Canberra: Australian National University Press, 1980, 139-157.  (reprinted with changes in The Economic Record, 1980, 56: 222-30).

 

67.  A J Culyer. “Discussion of ‘Universality and Selectivity in the Targeting of Government Health/Welfare Programs’ by D. Dixon” in P. M. Tatchell (ed.), Economics and Health: Proceedings of the First Australian Conference of Health Economists, Canberra, Australian National University Press, 1980, 11-17.

 

68.  A J Culyer, Heather Simpson. "Externality models and health: a Rückblick over the last twenty years", The Economic Record, September 1980, 56: 222-30. (Reprint with changes in P. M. Tatchell ed., Economics and Health: Proceedings of the First Australian Conference of Health Economists, Canberra: Australian National University Press, 1980, 139-157).

 

69.  A J Culyer, M. Pfaff, H. Hauser. "Report on financial aspects and policies" in A. Brandt, B. Horisberger and W. P. von Wartburg (eds.), Cost-Sharing in Health Care, Heidelberg: Springer, 1980.

 

70.  A J Culyer, A K Maynard. "Cost-effectiveness of duodenal ulcer treatment", Social Science and Medicine, 15C, 3-11, 1981. (Reprinted in shortened form in Bernard S. Bloom (ed.), Cost-Benefit and Cost-Effectiveness Analysis in Policymaking. Cimetidine as a Model, New York: Biomedical Information Corporation, 1982, 128-31).

 

71.  A J Culyer. "The IEA's unorthodoxy", in R. Harris and A. Seldon (eds.), The Emerging Consensus ...? London: Institute of Economic Affairs, 1981, 99-119.

 

72.  A J Culyer. "Acht Trugschlüsse über das britische Gesundheitswesen", Medita, 1981, 6: 22-27.

 

73.  A J Culyer. "European workshop on health indicators: a draft report", Revista Internacional de Sociologi, 1981, 39: 151-171.

 

74.  A J Culyer. "Economics, social policy and social administration: the interplay between topics and disciplines", Journal of Social Policy, 1981, 10: 311-29.

 

75.  A J Culyer. "Health, economics and health economists" in J. Van de Gaag and M. PerIman (eds.), Health Economics and Health Economists, Amsterdam: North-Holland, 1981.

 

76.  A J Culyer. "Economics, health and health services" in R. Clara et al, Health and Economy, Part 1, Antwerp: Antwerp University Press, 1981, 19-33.

 

77.  A J Culyer, A K Maynard. "Cost-effectiveness of duodenal ulcer treatment", in Bernard S. Bloom (ed.) Cost-Benefit and Cost-Effectiveness Analysis in Policymaking: Cimetidine as a Model, New York: Biomedical Information Corporation, 1, 128-13. (Reprint of 1981 Social Science and Medicine article).

 

78.  A J Culyer, A K Maynard, A H Williams. "Alternative systems of health care provision: an essay on motes and beams" in Mancur Olson (ed.), A New Approach to the Economics of Health Care, Washington: American Enterprise Institute, 1982, 131-150.

 

79.  A J Culyer, J Wiseman, M F Drummond, P A West. "Revenue allocation by regression: a rejoinder", Journal of the Royal Statistical Society, Series A, 1982, 145: Part 1, 127-33.

 

80.  A J Culyer. "Health services in the mixed economy" in Lord Roll of Ipsden (ed.), The Mixed Economy, London, Macmillan, 1982, 128-144. (reprinted in Magyar as "Egeszsegugyi szolgaltatasok a vegyes gazdasagban", Esely, 9113, 1991, 37-48).

 

81.  A J Culyer. "Egeszsegugyi szolgaltatasok a vegyes gazdasagban", Esely, 9113, 1991, 37-48).

 

82.  T Sandler, A J Culyer. "Joint products and multi-jurisdictional spillovers", Quarterly Journal of Economics, 1982, 97: 707-716.

 

83.  A J Culyer. "Assessing cost-effectiveness", in H. D. Banta (ed.), Resources for Health: Technology Assessment for Policy Making, Westport: Praeger, 1982, 107-120.

 

84.  A J Culyer. "The NHS and the market: images and realities", in G. McLachlan and A. Maynard (eds.), The Public/Private Mix for Health: the Relevance and Effects of Change, London, Nuffield Provincial Hospitals Trust, 1982, 25-55.

 

85.  A J Culyer. "Health care and the market: a British lament”, Journal of Health Economics, 1982, 1: 299-303.

 

86.  T Sandler, A J Culyer. “Joint products and multi-jurisdictional spillovers: some public goods geometry", Kyklos, 1982, 35: 702-9.

 

87.  A J Culyer. "A Hatekonysag Keresese a Kozuleti Szektorban: Kozgadzak contra dr. Pangloss" (trs. from English by Otto Gado), Penziigyi Szemle, 27, 1983, 378-384.

 

88.  A J Culyer. "Introduction" to Health Indicators, ed. A. J. Culyer, London, Martin Robertson, 1983, 1-22.

 

89.  A J Culyer. "Conclusions and recommendations" in A. J. Culyer (Ed.) Health Indicators, London: Martin Robertson, 1983, 186-193.

 

90.  A J Culyer. "Effectiveness and efficiency of health services", Effective Health Care, 1983, 1: 7-9.

 

91.  A J Culyer, J. MacFie, A. Wagstaff. "Cost-effectiveness of foam elastomer and gauze dressings in the management of open perineal wounds", Social Science and Medicine, 1983, 17: 1047-53.

 

92.  A J Culyer. "Public or private health services: a skeptic's view", Journal of Policy Analysis and Management, 1983, 2: 386-402.

 

93.  A J Culyer. "The marginal approach to saving lives", Economic Review, 1, 1983, 21-23.

 

94.  A J Culyer. "Economics without economic man?" Social Policy and Administration, 1983, 17: 188-203.

 

95.  A J Culyer, B Horisberger. "Medical and economic evaluation: a postscript" in A. J. Culyer and B. Horisberger (eds.), Economic and Medical Evaluation of Health Care Technologies, Heidelberg: Springer, 1983, 347-358. (Also published separately by the same publishers in German).

 

96.  A J Culyer. "La contribución del Análisis Económico a la Pólitica Social ", in J-J. Artells (ed.), Primeres Jornades d’Economia dels Serveis Socials, Barcelona, Impres Layetana, 1983, 17-34.

 

97.  A J Culyer. "Marco para la evaluación multidisciplinaria de los servicios sociales", in J-J. Artells (ed.), Primeres Jornades d’Economia dels Serveis Socials, Barcelona, Impres Layetana, 1983, 35-39.

 

98.  A J Culyer, A Wagstaff, J MacFie. "Foam elastomer and gauze dressings in the management of open perineal wounds: a cost-effectiveness study", British Journal of Clinical Practice, 1984, 38: 263-8.

 

99.  A J Culyer, J Posnett. "Profit regulation in the drug industry: a bitter pill?", Economic Review, 1984, 2: 19-21.

 

100.    A J Culyer. "The quest for efficiency in the public sector: Economists versus Dr. Pangloss (or why conservative economists are not nearly conservative enough)", in H. Hanusch (ed.), Public Finance and the Quest for Efficiency, Proceedings of the 38th Congress of the UPF, Copenhagen, Detroit, Wayne State University Press, 1984, 39-48.

 

101.    A J Culyer, J Posnett. "Would you choose the Welfare State?" Economic Affairs, 1985, 5: 40-42.

 

102.    A J Culyer. "What's wrong with economics textbooks?", Economics, 1985, 21: 15-17.

 

103.    A J Culyer. "A health economist on medical sociology: reflections by an unreconstructed reductionist, Social Science and Medicine, 1985, 20: 1013-21.

 

104.    A J Culyer. "On being right or wrong about the welfare state", in P. Bean, J. Ferris and D. Whynes (eds.), In Defence of Welfare, London: Tavistock, 1985, 122-41.

 

105.    A J Culyer. "Discussion" in N. Wells (ed.), Pharmaceuticals among the Sunrise Industries, London: Croom Helm, 1985, 218-224.

 

106.    A J Culyer, S Birch. "Caring for the elderly: a European perspective on today and tomorrow", Journal of Health Politics, Policy and Law, 1985, 10: 469-87.

 

107.    A J Culyer. "What dangers from medical monopoly?" Economic Affairs, 1986, 6: 56-7.

 

108.    A J Culyer. "The scope and limits of health economics (with reference to economic appraisals of health services)" in Oekonomie des Gesundheitswesen, Jahrestagung des Vereins für Socialpolitik, Gesellschaft für Wirtschafts- und Sozialwissenschaften, Neue Folge Band 159, 1987, Berlin: Duncker & Humblot, 31-53.

 

109.    A J Culyer. "The future of health economics in the U.K. ", in Health Economics: Prospects for the Future, ed. G. Teeling Smith, London: Croom Helm, 1987, 15-32.

 

110.    A J Culyer. "Assessing the costs and benefits of pharmaceutical research", in G. Teeling Smith (ed.), Costs and Benefits of Pharmaceutical Research, London: Office of Health Economics, 1987, 25-27.

 

111.    A J Culyer, C Blades, A Walker. "Health service efficiency, appraising the appraisers - a critical review of economic appraisal in practice", Social Science and Medicine, 1987, 25, 461-72.

 

112.    A J Culyer. "Technology assessment in Europe: its present and future roles", in E E H. Rutten and S. J. Reiser (eds.), The Economics of Medical Technology, Berlin: Springer, 1987, 54-79.

 

113.    A J Culyer. "Health economics: the topic and the discipline", in J. M. Horne (ed.), Proceedings of the Third Canadian Conference on Health Economics, 1986, Winnipeg: Department of Social and Preventive Medicine, University of Manitoba, 1987, 1-18.

 

114.    A J Culyer. "Discussion of R. G. Evans et al, ‘Toward efficient aging: rhetoric and evidence’", in J. M. Horne (ed.), Proceedings of the Third Canadian Conference on Health Economics, 1986, Winnipeg: Department of Social and Preventive Medicine, University of Manitoba, 1987, 170-1.

 

115.    A J Culyer. "Inequality of health services is, in general, desirable", in D. Green (ed.), Acceptable Inequalities? Institute of Economic Affairs, London: 1988, 31-47.

 

116.    A J Culyer. "The radical reforms the NHS needs - and doesn't", Minutes of Evidence Taken before the Social Services Committee, London: HMSO, 1988, 238-242.

 

117.    A J Culyer. “Comments on ‘Public Hospital Performance Assessment’ by Arthur Andersen and Co”., in Response From the Hospital Boards' Association of New Zealand to "Unshackling the Hospitals” the Report of the Hospital and Related Services Taskforce, Hospital Boards' Association, New Zealand, 1988.

 

118.    A J Culyer. "Medical care and the economics of giving", in M. Ricketts (ed.) Neoclassical Microeconomics, vol. 2, Aldershot: Edward Elgar, 1988, 310-318 (reprint of 1971 article in Economica).

 

119.    A J Culyer. "The normative economics of health care finance and provision", Oxford Review of Economic Policy, 5, 1, 1989, 34-58. (reprinted with changes in A. McGuire, P. Fenn and K. Mayhew (eds.) Providing Health Care: The Economics of Alternative Systems of Finance and Delivery, Oxford: Oxford University Press, 1991, 65-98, also in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 148-157)

 

120.    A J Culyer. "Commodities, characteristics of commodities, characteristics of people, utilities and the quality of life", in S. Baldwin, C. Godfrey and C. Propper (eds.), The Quality of Life:  Perspectives and Policies. London: Routledge, 1989, 9-27. (Reprinted 1994)

 

121.    A J Culyer. "The economics of health systems", in R. G. Butler and D. P. Doessel (eds.) Health Economics: Australian Readings, Sydney: Australian Professional Publications, 1989, 145-166 (reprint of 1969 article in The Price of Health).

 

122.    A J Culyer. "Implications of the Ministerial Review of the NHS", in Opportunities for the Independent Sector: Articles from the NHS Review, Annual Conference Review, Independent Hospitals Association, 1989, 6-9.

 

123.    A J Culyer. "A glossary of the more common terms encountered in health economics", in M. S. Hersh-Cochran and K. P. Cochran (eds.), Compendium of English Language Course Syllabi and Textbooks in Health Economics, Copenhagen: WHO, 1989, 215-234.

 

124.    A J Culyer. "Cost containment in Europe", Health Care Financing Review, Annual Supplement, 1989, 21-32. (reprinted in Health Care Systems in Transition, Paris: OECD, 1990.)

 

125.    A J Culyer. "Competition and markets in health care: what we know and what we don't, Part I", Cardiology Management, 1990, 3: 15-18.

 

126.    A J Culyer. "Competition and markets in health care: what we know and what we don't, Part II ", Cardiology  Management, 1990,  3: 36-38.

 

127.    A J Culyer. "Cost containment in Europe", in Health Care Systems in Transition, Paris: OECD, 1990, 000-000. (Reprint of 1989 article in Health Care Financing Review ).

 

128.    A J Culyer, B Luce, A Elixhauser. "Socioeconomic evaluations: an executive summary ", in Culyer (ed.), Standards for Socioeconomic Evaluation of Health Care Products and Services, Berlin: Springer, 1990, 1-12.

 

129.    A J Culyer, J W Posnett. "Hospital behaviour and competition", in A. J. Culyer, A. K. Maynard and J. W. Posnett (eds.), Competition in Health Care: Reforming the NHS, London: Macmillan, 1990, 12-47.

 

130.    A J Culyer , A K Maynard, J W Posnett. "Reforming health care: an introduction to the economic issues", in A. J. Culyer, A. K. Maynard and J. W. Posnett (eds.) Competition in Health Care: Reforming the NHS, London: Macmillan, 1990, 1-11.

 

131.    A J Culyer. "Funding the future", in The White Paper and Beyond: One Year On, (eds. E. J. Beck and S. A. Adam), Oxford: Oxford University Press (Oxford Medical Publications), 1990, 58-69.

 

132.    A J Culyer. "Incentivos: para qué?  Para quién?  De qué tipo?", in Associatión de Economia de la Salud, Reforma Sanitaria e Incentivos, Assoc. de Econ. de la Salud, Barcelona, 1990, 39-53.

 

133.    A J Culyer. "The promise of a reformed NHS: an economist’s angle", British Medical Journal, 302, 1991, 1253-1256.  (reprinted in Professional Judgment and Decision Making, Offprints (4), Milton Keynes, Open University Press, 1992, 19-22).

 

134.    A J Culyer. "The normative economics of health care finance and provision", in A. McGuire, P. Fenn and K. Mayhew (eds.) Providing Health Care: the Economics of Alternative Systems of Finance and Delivery, Oxford: Oxford University Press, 1991, 65-98 (reprint with changes of 1989 article in Oxford Review of Economic Policy).

 

135.    A J Culyer. "Conflicts between equity concepts and efficiency in health: a diagrammatic approach", Osaka Economic Papers, 1991, 40: 141-154.  (Reprinted in A. M. El-Agraa (ed.) Public and International Economics, New York: St Martins Press, 42-58).

 

136.    A J Culyer. "Egéazségügyi szolgáltatások a vegyes gazdaságban", Esély, 91/3, 1991, 37-48 (reprint in Magyar of Health services in the mixed economy, in The Mixed Economy, 1982).

 

137.    A J Culyer. "Incentives: for what?  For whom?  What Kind?", in G. Lopez-Casasnovas (ed.), Incentives in Health Systems, Berlin: Springer, 1991, 15-23 (reprint in English of article in Spanish in Reforma Sanitaria e Incentivos, 1990),

 

138.    A J Culyer. "Reforming health services: frameworks for the Swedish review", in A. J. Culyer (ed.) International Review of the Swedish Health Care System, Studiefoerbundet Naeringsliv och Saemhalle (Center for Business and Policy Studies), Stockholm, 1991, 1-49.

 

139.    A J Culyer. "The promise of a reformed NHS: an economist’s angle", in J. Dowie (compiler) Professional Judgment and Decision Making, Offprints (4), Milton Keynes: Open University Press, 1992, 19-22 (reprint of 1991 article in British Medical Journal).

 

140.    A J Culyer. "Hospital competition in the UK: a (possibly) useful framework for the future" in R. B. Deber and G. G. Thompson (eds.), Restructuring Canada’s Health Services System: How Do We Get There From Here?, Toronto: University of Toronto Press, 1992, 317-330.

 

141.    A J Culyer. "The morality of efficiency in health care - some uncomfortable implications", Health Economics, 1, 1992, 7-18.  (Reprinted in A. King, T. Hyclak, S. McMahaon and R. Thornton (eds.), North American Health Care Policy in the 1990s, Chichester: Wiley, 1993, 1-24).

 

142.    A J Culyer, E van Doorslaer, A Wagstaff. "Utilisation as a measure of equity by Mooney, Hall, Donaldson and Gerard: Comment”, Journal of Health Economics, 1992, 11: 93-98.

 

143.    A J Culyer. “Need, greed and Mark Twain's cat”, in A. Corden, E. Robertson and K. Tolley (eds.) Meeting Needs in an Affluent Society, Aldershot: Avebury, 1992, 31-41.

 

144.    A J Culyer. "Sjukvård och sjukvårdsfinansiering i Sverige" ("Health care and health care financing in Sweden"), in A. J. Culyer et al. Svensk Sjukyvård - Bäst i Världen? (Swedish Health Care - the Best in the World?), Stockholm: SNS Förlag, 1992, 9-31.

 

145.    A J Culyer. "Att reformera sjukvärden: ramar för den svenska genomgången" ("Reforming health services: Frameworks for the Swedish Review"), in A. J. Culyer et al. Svensk Sjukyår - Bäst i Världen? (Swedish Health Care - the Best in the World?), Stockholm: SNS Förlag, 1992, 32-65.

 

146.    A J Culyer. "Evaluation des technologies médicales: progrés des techniques et progrès de la science économique", in J-R Moatti and C. Mawas (eds.), Evaluation des Innovations Technologiques et Décisions en Santé Publiques, Paris: Coll. Analyse et Prospective, Eds INSERM, 1992, 37-47.

 

147.    A J Culyer (with 34 others). “The Appleton International Conference: developing guidelines for decisions to forgo life-prolonging medical treatment”, Journal of Medical Ethics, 1992, 18 (Supplement): 3.

 

148.    A J Culyer, E van Doorslaer, A Wagstaff.  "Access, utilisation and equity: a further comment”, Journal of Health Economics, 1992, 11: 207-210.

 

149.    A J Culyer. "Health, health expenditures, and equity", in E. van Doorslaer, A. Wagstaff and F. Rutten (eds.) Equity in the Finance and Delivery of Health Care: an International Perspective, Oxford: Oxford University Press (Oxford Medical Publications), 1993, 299-319,

 

150.    A J Culyer, A Meads. "The United Kingdom: effective, efficient, equitable?" Journal of Health Politics, Policy and Law, 1993, 17: 667-688.

 

151.    A J Culyer. "Health care insurance and provision", in N. Barr and D. Whynes (eds.) Current Issues in the Economics of Welfare, Houndmills: Macmillan, 1993, 153-175.

 

152.    A J Culyer. "The morality of efficiency in health: some uncomfortable implications", in A. King, T. Hyclak, S. McMahon and R. Thornton (eds.) North American Health Care Policy in the 1990s, Chichester: Wiley, 1993, 1-24 (reprinted from Health Economics, 1992).

 

153.    A J Culyer, A Wagstaff. "QALYs versus HYEs", Journal of Health Economics, 1993, 12: 311-323.

 

154.    A J Culyer. "Conflicts between equity concepts and efficiency in health: a diagrammatic approach", in A. M. El-Agraa (ed.) Public and International Economics, New York, St Martin's Press, 1993, 42-58 (reprinted from Osaka Economic Papers, 1991).

 

155.    A J Culyer. "EI mercado interior: un medio aceptable para conseguir un fin deseable", Hacienda Pública Española, 1993, 126: 39-49.

 

156.    A J Culyer, A Wagstaff.  "Equity and equality in health and health care", Journal of Health Economics, 1993, 12:  431-457 (reprinted in N Barr (ed.) Economic Theory and the Welfare State, Cheltenham: Edward Elgar, 2001, 231-257 and in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 483-509).

 

157.    A J Culyer, B Horisberger, B Jonsson, F F F M Rutten. "Introduction", European Journal of Cancer, 1993, 29A, Suppl 7, S1-S2.

 

158.    A J Culyer, B. Jonsson. "Ought cancer treatments to be immune from socio-economic evaluation? An epilogue", European Journal of Cancer, 1993, 29A, Supplement 7, S31-S32.

 

159.    A J Culyer. "NHS reforms: a challenge or a threat to NHS values?" The Health Business Summary, No. 11, October 1994, 3-4.

 

160.    A J Culyer. "Finding answers to simple questions", Parliamentary Brief, 1994, 3: 64.

 

161.    A J Culyer. "A proposal for a checklist of reputable economics journals for the UK profession", Royal Economic Society Newsletter, 87, 1994, 16-17.

 

162.    A J Culyer. "The Culyer report” (letter), The Lancet, 344, December 24/31, 1994, 1774.

 

163.    A J Culyer. "Economics and the incomplete case for public support for research" (letter), Journal of the Royal College of Physicians of London, 29, January/February 1995, 72.

 

164.    A J Culyer. "Cure at a cost", Times Higher Education Supplement, (supplement, Synthesis: Medicine), January 20, 1995, i.

 

165.    A J Culyer. "Need: the idea won't do - but we still need it", (Editorial) Social Science and Medicine, 1995, 40: 727-730.

 

166.    A J Culyer. "Supporting research and development in the NHS - Key points from the Culyer Report ", Refocus, 1995, Winter: 4-5.

 

167.    A J Culyer. "Supporting research and development in the National Health Service", Journal of the Royal College of Physicians of London, 1995, 29: 216-224.

 

168.    A J Culyer. "Supporting R&D in the NHS - some unresolved issues" in House of Lords, Minutes of Evidence Taken Before the Select Committee on Science and Technology, HL Paper 12-iv, London: HMSO, 1995, 168-176.

 

169.    A J Culyer. Evidence before House of Lords Select Committee on Science & Technology, Minutes of Evidence Taken before the Select Committee on Science and Technology, HL Paper 12-iv, London: HMSO, 1995, 183-195 (passim)

 

170.    A J Culyer, A Wagstaff.  "QALYs versus HYEs: A reply to Gafni, Birch and Mehrez", Journal of Health Economics, 1995, 14: 39-45.

 

171.    A J Culyer. "Preface: all is a flux yet all is the same!", in International Developments in Health Care, ed. Roger Williams, London, Royal College of Physicians, 1995, vii-x.

 

172.    A J Culyer. "Chisels or screwdrivers? A critique of the NERA proposals for the reform of the NHS", in A. Towse (ed.) Financing Health Care in the UK: A Discussion of NERA's Prototype Model to Replace the NHS, London: Office of Health Economics, 1995, 23-37.

 

173.    A J Culyer. "Taking advantage of the new environment for research and development" in M. Baker and S. Kirk (eds.) Research and Development for the NHS: Evidence. Evaluation and Effectiveness, Oxford: Radcliffe Medical Press, 1995, 37-49 (reprinted with changes in Baker and Kirk 1998).

 

174.    A J Culyer. "Fundamentals for promoting health gain efficiently and equitably in Northern Ireland: some reactions to the Consultation Document Regional Strategy for Health and Social W11being, 1997-2002", in Northern Ireland Economic Council, Health and Personal Social Services to the Millennium, Belfast, NIEC, 1995, 45-65.

 

175.    A J Culyer. "The NHS reforms - a challenge or a threat to NHS values?" in A. J. Culyer and Adam Wagstaff (eds.) Reforming Health Care Systems: Experiments with the NHS, Cheltenham: Edward Elgar, 1996, 1-14.

 

176.    A J Culyer, R G Evans. "Mark Pauly on welfare economics: normative rabbits from positive hats", Journal of Health Economics, 1996, 15: 243-251 (reprinted in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 148-157).

 

177.    A J Culyer. "A personal perspective on progress in research and development", in K. Aspinall (ed.) The York Symposium on Health, University of York, York, 1996, 33-44.

 

178.    A J Culyer. "The principal objective of the NHS ought to be to maximise the aggregate improvement in the health status of the whole community", British Medical Journal, 314, 667-669, 1997. (Reprinted with changes in B. New (ed.), Rationing: Talk and Action, London: King’s Fund and BMJ, 1997, 95-100.

 

179.    A J Culyer. "0 impacta da economia da saude nas politicas publicas", Nota Economicas, 1997, 7: 38-48.

 

180.    A J Culyer. "Maximising the health of the whole community: the case for", in B. New (ed.), Rationing: Talk and Action, London: King’s Fund and BMJ, 1997, 95-100. (reprint with changes of BMJ 1997 article).

 

181.    A J Culyer. "A rejoinder to John Harris", in B. New (ed.), Rationing: Talk and Action, London: King’s Fund and BMJ, 1997, 106-107.

 

182.    A J Culyer. “Altruism and economics”, in A. Nordgren and C-G. Westrim (eds.), Altruism, Society, Health Care, Acta Universitatis Upsaliensis, Uppsala, 1998, 51-66.

 

183.    A J Culyer. “Health and welfare resources at the University of York”, Health-Care Focus, February 1998, 13-14.

 

184.    A J Culyer. “Need - is a consensus possible?” Journal of Medical Ethics, 1998, 24: 77-80 (Guest Editorial).

 

185.    A J Culyer. “Foreword”, in M. Baker and S. Kirk (eds.) Research and Development for the NHS, Abingdon: Radcliffe Medical Press, 1998, vi-x.

 

186.    A J Culyer. “Taking advantage of the new environment for research and development” in Baker and Kirk (eds.), Research and Development for the NHS, Abingdon: Radcliffe Medical Press, 1998, 53-66.  (reprint with changes of 1996 edition).

 

187.    A J Culyer. “How could anyone imagine R&D’s trial test is better patient care?”, Health Services Journal, 9 April 1998, 18 (letter).

 

188.    A J Culyer. “The NHS - an assessment”, in L Mackay, K Soothill and K Melia (eds.), Classic Texts in Health Care, Oxford,  Butterworth Heinemann, 1998, 316-321 (Reprint of chapter 11 from Need and the National Health Service, 1976).

 

189.    A J Culyer. “How ought health economists to treat value judgments in their analyses?”, in M L Barer, T E Getzen and G L Stoddart (eds) Health, Health Care and Health Economics, Chichester, Wiley, 1998, 363-371.

 

190.    A J Culyer. “An input-outcome paradigm for NHS research in forensic mental health,” Criminal Behaviour and Mental Health, 1999, 9: 355-371.

 

191.    A J Culyer. “Economics and public policy:  research and development as a public good” in P C Smith (ed.) Reforming Markets in Health Care: An Economic Perspective, Buckingham, Open University Press, 2000, 117-137.

 

192.    A J Culyer, A Wagstaff. "Equity and equality in health and health care", in N Barr (ed.) Economic Theory and the Welfare State, Edward Elgar, Cheltenham, 2000. (Reprinted from Journal of Health Economics, 1993, 12: 431-457.)

 

193.    A J Culyer. “Economics and ethics in health care” (editorial), Journal of Medical Ethics, 2001, 27: 2001: 217-222.

 

194.    A J Culyer. “Equity - some theory and its policy implications,” Journal of Medical Ethics, 2001, 27: 275-283.

 

195.    A J Culyer. “Values, policy impact and the credibility of health economists”, in W R Swan and P Taylor (eds.)  Forward to Basics: Promoting Efficiency While Preserving Equity (Proceedings of the 7th Canadian Conference on Health Economics, CHERA/ACRES, Carleton University, Ottawa, 2001, 37-47.

 

196.    A J Culyer. “Introduction: Ought NICE to have a cost-effectiveness threshold?”, in A Towse, C Pritchard and N Devlin (eds.) Cost-Effectiveness Thresholds – Economic and Ethical Issues, London, Office of Health Economics, 2002, 9-14.

 

197.    A J Culyer, R S Taylor, J Hutton. “Developing the revised NICE appraisal technical guidance to manufacturers and sponsors: opportunity or threat?” PharmacoEconomics, 2002, 20: 1031-1038.

 

198.    A J Culyer, M Rawlins. “National Institute for Clinical Excellence and its value judgements”, British Medical Journal, 2004, 329: 224-227.

 

199.    A J Culyer, P Littlejohns, G Leng, M Drummond. “NICE clinical guidelines: Maybe health economists should participate in guideline development”, British Medical Journal, 2004, 329: 571 (letter).

 

200.    A J Culyer, M Rawlins. NICE and its value judgments: Authors' reply”, British Medical Journal, 2004, 329: 741.

 

201.    A J Culyer, A Castelli. “Rationing health care in Europe – the United Kingdom”, in J-Matthias Graf von der Schulenburg and M Blanke (eds.) Rationing of Medical Services in Europe: An Empirical  Study  - A European Survey, Berlin: IOS Press, 2004, 255-305.

 

202.    A J Culyer. “Involving stakeholders in healthcare decisions – the experience of the National Institute for Health and Clinical Excellence (NICE) in England and Wales”, Healthcare Quarterly, 2005, 8: 56-60.

 

203.    G M Anderson, S E Bronskill, C A  Mustard, A J Culyer,  D A Alter, D G Manuel.Both clinical epidemiology and population health perspectives can define the role of health care in reducing health disparities”,  Journal of Clinical Epidemiology, 2005, 58: 757-762.

 

204.    C Godfrey, S Parrott, G Eaton, A J Culyer, C McDougall. “Can we model the impact of increased drug treatment expenditure on the U.K. drug market?” In Bjorn Lindgren and Michael Grossman (eds.) Substance Use: Individual Behaviour, Social Interactions, Markets and Politics, Vol. 36 in Advances in Health Economics and Health Services Research, Amsterdam: Elsevier, 2005, 257-275.

 

205.    A J Culyer. Egészség-gazdaságtan, egészségügyi közgazdászok, és az egészségpolitikai döntéshozás politikája” (“Health economics, health economists and the politics of policy making”). In László Gulácsi (Ed.) Egészég-Gazdaságtan, Budapest: Medicina Könyvkiadó Rt, 2005, 35-44.

 

206.    A Szende, A J Culyer. “The inequity of informal payments for health care: the case of Hungary”, Health Policy, 2006, 75: 262-271.

 

207.    K Claxton, M Sculpher, A J Culyer, C McCabe, AH Briggs, R L Akehurst, M Buxton, J Brazier. “Discounting and cost-effectiveness in NICE - stepping back to sort out a confusion”, Health Economics, 2006, 15: 1-4.

 

208.    A J Culyer. “NICE's use of cost-effectiveness as an exemplar of a deliberative process”, Health Economics, Policy and Law, 2006, 1: 299-318.

 

209.    A J Culyer. “Paying for performance: neither the end of the beginning nor the beginning of the end”, HealthcarePapers, 2006, 6: 34-38.

 

210.    K Claxton, A J Culyer. “Wickedness or folly? The ethics of NICE’s decisions”, Journal of Medical Ethics, 2006, 37: 373-378.

 

211.    A J Culyer, J Lomas. “Deliberative processes and evidence-informed decision-making in health care – do they work and how might we know?” Evidence and Policy, 2006, 2: 357-371.

 

212.    A J Culyer. “Evidence, economics and values in coverage decisions”, in Steve Morgan (Ed.) Toward a National Pharmaceuticals Strategy, Vancouver: Centre for Health Services and Policy Research UBC, 2006, 10-11.

 

213.    A J Culyer. “The bogus conflict between efficiency and equity”, Health Economics, 2006, 15: 1155-1158 (Editorial).

 

214.    A J Culyer, R Saltman. “Privatization – assessing strategies in a central Asian republic”, in H. Zöllner, G. Stoddart and C. Selby Smith (Eds.) Learning to live with Health Economics, Copenhagen: WHO, 2006, III-95 - III-105 (copyrighted 2003, published 2006).

 

215.    A J Culyer.  “Welfarism vs. Extra-Welfarism”, Köz-Gazdaság Tudományos Füzetek (Public Economics Science Journal) 2006, 1: 89-101.

 

216.    A J Culyer. "The nature of the commodity 'health care' and its efficient allocation", in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 324-346 (reprinted from Oxford Economic Papers, 1971, 23: 189-211).

 

217.    A J Culyer. "The normative economics of health care finance and provision", in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006,  347-384, reprinted from A. McGuire, P. Fenn and K. Mayhew (eds.) Providing Health Care: The Economics of Alternative Systems of Finance and Delivery, Oxford: Oxford University Press, 1991, 34-58).

 

218.    A J Culyer, A Wagstaff. "Equity and equality in health and health care", in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 483-509, reprinted from Journal of Health Economics, 1993, 12:  431-457).

 

219.    A J Culyer, R G Evans. "Mark Pauly on welfare economics: normative rabbits from positive hats", in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 148-157 (reprinted from Journal of Health Economics, 1996, 15: 243-251).

220.    A J Culyer. “Need - an instrumental view”, in Richard Ashcroft, Angus Dawson, Heather Draper and John McMillan (Eds.) Principles of Health Care Ethics, 2nd Edition, Chichester: Wiley, 2007, 231-238.

221.    A J Culyer. “When and how cancer chemotherapy should be privately funded", Oncology Exchange, 2007, 6: 47.

222.    A J Culyer, C McCabe, A H Briggs, K Claxton, M Buxton, R L Akehurst, M Sculpher, J Brazier. “Searching for a threshold, not setting one: the role of the National Institute of Health and Clinical Excellence”, Journal of Health Service Research and Policy, 2007, 12: 56-58.

223.    A J Culyer. “Merit goods and the welfare economics of coercion” in Wilfried Ver Eecke (Ed.) Anthology regarding Merit Goods. The Unfinished Ethical Revolution in
Economic Theory.
West Lafayette: Purdue University Press, 2007, 174-200 (reprinted from Public Finance, 1971, 26: 546-572).

224.    K Claxton, A J Culyer. “Rights, responsibilities and NICE: A Rejoinder to Harris”, Journal of Medical Ethics, 2007, 33: 462-464.

225.     A J Culyer, C McCabe, A Briggs, K Claxton, M Buxton, R Akehurst, M Sculpher, J Brazier J. “Not so…”, Journal of Health Services Research and Policy, 2007, 12: 190-191. (letter: reply to G Mooney, J Coast, S Jan, D McIntyre, M Ryan and V Wiseman).

226.    A J Culyer. “NICE misconceptions”, The Lancet, September 11 2007, on-line at http://www.thelancet.com/journals/lancet/article/PIIS014067360761321X/comments

A J Culyer. “Equity of what in health care? Why the traditional answers don't help policy - and what to do in the future”,

228.    A J Culyer. “Resource allocation in health care: Alan Williams’ decision maker, the authority and Pareto”, in A Mason & A Towse (eds.) The Ideas and Influence of Alan Williams: Be Reasonable –Do it My Way! Oxford, Radcliffe Publishing, 2007, 57-74.

229.    L S Robson, J Clarke, K Cullen, A Bielecky, C Severin, P Bigelow, E Irvin, A J Culyer, Q Mahood. “The effectiveness of occupational health and safety management system interventions: a systematic review”, Safety Science, 2007, 45: 329-353.

230.    K Chalkidou, A J Culyer, B Naidoo, P Littlejohns. “Cost-effective public health guidance: asking questions from the decision-maker's viewpoint”, Health Economics, 2008, 17: 441-448.

231.    K Claxton, A Briggs, M Buxton, A J Culyer, C McCabe, S Walker, M J Sculpher.   “Value based pricing for NHS drugs: an opportunity not to be missed?” British Medical Journal, 2008, 336: 251-254.

232.    W B F Brouwer, A J Culyer, N Job, A van Exel, F F H Rutten. “Welfarism vs. extra-welfarism”, Journal of Health Economics, 2008, 27: 325–338.

233.      J Hurley, D Pasic, J Lavis, A J Culyer, C Mustard, W Gnam. “Parallel payers and preferred access: how Canada’s Workers’ Compensation Boards expedite care for injured and ill workers”, HealthcarePapers, 2008, 8: 6-14.

234.    J Hurley, A J Culyer, W Gnam, J Lavis, C Mustard, D Pasic. “Response to commentaries”, HealthcarePapers, 2008, 8: 52-54.

235.    K Chalkidou, T Walley, A J Culyer, P Littlejohns, A Hoy. “Evidence-informed evidence-making”, Journal of Health Services Research & Policy, 2008, 13: 167-173.

236.    K Claxton, A J Culyer.Not a NICE fallacy: A reply to Dr Quigley”, Journal of Medical Ethics, 2008, 34: 598-601.

237.    A J Culyer, B Amick, A LaPorte. “What is a little more health and safety worth?” in E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 15-35.

238.    A J Culyer, M Sculpher. “Lessons from health technology assessment”, in E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 51-69.

239.    A J Culyer, E Tompa. “Equity”, in E Tompa, A J Culyer, R Dolinschi. (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 215-231.

240.    E Tompa, A J Culyer, R Dolinschi. “Suggestions for a reference case”, in E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, 235-244.

241.    C McCabe, K Claxton, A J Culyer. The NICE cost effectiveness threshold – what it is and what that means”, PharmacoEconomics, 2008, 26: 733-744.

242.    K Chalkidou, A J Culyer, P Littlejohns, P Doyle, A Hoy. “Imbalances in funding for clinical and public health research in the UK: can NICE research recommendations make a difference?” Evidence and Policy, 2008, 4: 355-369.

243.    J Hurley, D Pasic, J Lavis, C Mustard, A J Culyer, W Gnam. “Parallel lines do intersect: interactions between the workers’ compensation and provincial publicly financed health care systems in Canada”, HealthCare Policy, 2008, 3: 100-112.

244.    Chalkidou K, A J Culyer, B Naidoo, P Littlejohns. "The challenges of developing cost-effective public health guidance: a NICE perspective", in S Dawson and Z S Morris (eds.) Future Public Health: Burdens, Challenges and Opportunities, Basingstoke: Palgrave Macmillan, 2009, 276-291.

245.    A J CulyerHow Nice is NICE? A Conversation with Anthony Culyer”, Health Care Cost Monitor, Hastings Centre Blog, 2009.

246.          Cookson R, A J Culyer.  “Measuring overall population health - the use and abuse of QALYs”, in Killoran A, Kelly M (eds). Evidence Based Public Health: Effectiveness and Efficiency, Oxford: Oxford University Press, 2010, 148-168.

247.          A J Culyer. "Perspective and desire in comparative effectiveness research - the relative unimportance of mere preferences, the central importance of context", Pharmacoeconomics, 2010, 28: 889-897.

248.          K Claxton, M Paulden, H Gravelle, W Brouwer, A J Culyer. “Discounting and decision making in the economic evaluation of health-care technologies”, Health Economics, 2011, 20: 2-15.

249.          R Chase, A J Culyer, M Dobrow, P Coyte, C Sawka, S O’Reilly, K Laing, M Trudeau, S Smith, J Hoch, S Morgan, S Peacock, R Abbott, T Sullivan. “Access to Cancer Drugs in Canada: Looking Beyond Coverage Decisions”, Healthcare Policy, 2011, 6: 27-35.

250.          A J Culyer. “UK report: NHS ‘reforms’”, Health Care Cost Monitor, 2011, 1-2. The Hastings Centre, on-line at http://healthcarecostmonitor.thehastingscenter.org/anthonyculyer/u-k-report-nhs-reforms.

251.          P Tso, A J Culyer, M Brouwers, M J Dobrow.Developing a decision aid to guide public sector health policy decisions: A study protocol”, Implementation Science, 2011, 6: 46.

252.          A J Culyer. Hic sunt dracones: the future of Health Technology Assessment – one economist’s perspective, Medical Decision Making, first published on November 18, 2011 as doi:10.1177/0272989X11426483, forthcoming Jan/Feb 2012.

253.          A J Culyer, Y Bombard, ­An equity framework for health technology assessments, Medical Decision Making, 0272989X11426484, first published on November 7, 2011 as doi:10.1177/0272989X11426484, forthcoming May/Jun 2012.

 

Reprinted articles

 

A J Culyer "The economics of health systems" in The Price of Health, Melbourne: Office of Health Care Finance, 1969, 36-62 (reprinted as ch.7 in J. R. G. Butler and D. P. Doessel (eds.), Health Economics: Australian Readings, Sydney: Australian Professional Publications, 1989, 145-66).

 

A J Culyer "The nature of the commodity 'health care' and its efficient allocation", Oxford Economic Papers, 1971, 23: 189-211 (reprinted as Ch. 2 in A. J. Culyer and M. H. Cooper (eds.), Health Economics, London: Penguin, 1973, also in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 148-157).

 

A J Culyer "Merit goods and the welfare economics of coercion", Public Finance, 1971, 26:  546-72. (Reprinted in Wilfried Ver Eecke, Merit Goods: The Birth of a New Concept. The Unfinished Ethical Evolution in Economic Theory. Ashland Ohio: Purdue University Press, 2006, 174-200).

 

A J Culyer "Medical care and the economics of giving", Economica, 1971, 38: 295-303 (reprinted as Ch. 18 in M. Ricketts (ed.), Neoclassical Microeconomics, Vol. 2, Aldershot: Edward Elgar, 1989, pp. 310-18).

 

A J Culyer, A Williams and R J Lavers "Social indicators: health", Social Trends, 1971, 2:  31-42 (reprinted as “Health indicators” in Andrew Shonfield and Stella Shaw (eds.) Social Indicators and Social Policy, London: Heinemann, 1972).

 

A J Culyer “The NHS - an assessment”, in L Mackay, K Soothill and K Melia (eds.), Classic Texts in Health Care, Oxford,  Butterworth Heinemann, 1998, 316-321 (Reprint of chapter 11 from Need and the National Health Service, 1976).

 

A J Culyer and Heather Simpson "Externality models and health: a Rückblick over the last twenty years", The Economic Record, September 1980, 56: 222-30. (Reprinted with changes in P M Tatchell (ed). Economics and Health: Proceedings of the First Australian Conference of Health Economists, Canberra: Australian National University Press, 1980, 139-157).

 

A J Culyer and A K Maynard "Cost-effectiveness of duodenal ulcer treatment", Social Science and Medicine, 15C, 3-11, 1981. (Reprinted in shortened form in Bernard S. Bloom (ed.), Cost-Benefit and Cost-Effectiveness Analysis in Policymaking. Cimetidine as a Model, New York: Biomedical Information Corporation, 1982, 128-31).

 

A J Culyer "Health services in the mixed economy" in Lord Roll of Ipsden (ed.), The Mixed Economy, London, Macmillan, 1982, 128-144. (reprinted in Magyar as "Egeszsegugyi szolgaltatasok a vegyes gazdasagban", Esely, 9113, 1991, 37-48).

 

A J Culyer "The normative economics of health care finance and provision", Oxford Review of Economic Policy, 5, 1, 1989, 34-58. (reprinted with changes in A. McGuire, P. Fenn and K. Mayhew (eds.) Providing Health Care: The Economics of Alternative Systems of Finance and Delivery, Oxford: Oxford University Press, 1991, 65-98, also in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 148-157).

 

A J Culyer "Conflicts between equity concepts and efficiency in health: a diagrammatic approach", Osaka Economic Papers, 1991, 40: 141-154.  (Reprinted in A.  M. El-Agraa (ed.) Public and International Economics, New York: St Martins Press, 42-58).

 

A J Culyer "The promise of a reformed NHS: an economist’s angle", British Medical Journal, 302, 1991, 1253-1256.  (reprinted in Professional Judgment and Decision Making, Offprints (4), Milton Keynes, Open University Press, 1992, 19-22).

 

A J Culyer "The morality of efficiency in health care - some uncomfortable implications", Health Economics, 1992, 1: 7-18.  (Reprinted in A. King, T. Hyclak, S. McMahaon and R. Thornton (eds.), North American Health Care Policy in the 1990s, Chichester: Wiley, 1993, 1-24).

 

A J Culyer and A Wagstaff "Equity and equality in health and health care", Journal of Health Economics, 1993, 12: 431-457 (reprinted in N Barr (ed.) Economic Theory and the Welfare State, Cheltenham: Edward Elgar, 2001, 231-257 and in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 483-509).

 

A J Culyer "Taking advantage of the new environment for research and development" in M. Baker and S. Kirk (eds.) Research and Development for the NHS: Evidence. Evaluation and Effectiveness, Oxford: Radcliffe Medical Press, 1995, 37-49 (reprinted with changes in Baker and Kirk Baker and Kirk (eds.), Research and Development for the NHS, Abingdon: Radcliffe Medical Press, 1998, 53-66.

 

A J Culyer and R G Evans "Mark Pauly on welfare economics: normative rabbits from positive hats", Journal of Health Economics, 1996, 15: 243-251 (reprinted in A J Culyer (Ed.) Health Economics: Critical Perspectives on the World Economy, London: Routledge, 2006, 148-157).

 

A J Culyer "The principal objective of the NHS ought to be to maximise the aggregate improvement in the health status of the whole community", British Medical Journal, 314, 667-669, 1997. (Reprinted with changes in B. New (ed.), Rationing: Talk and Action, London: King’s Fund and BMJ, 1997, 95-100).

 

 

B. Books

 

1.      A J Culyer, F M M Lewes and G Brady, The Holiday Industry of Devon and Cornwall, London, HMSO, 1970, pp. x + 263.

 

2.      M H Cooper and A J Culyer (eds.) Health Economics, London, Penguin Books, 1973, pp. 396.

 

3.      A J Culyer, The Economics of Social Policy, Martin Robertson, London, 1973 (Japanese ed. 1976), xii + 268.

 

4.      A J Culyer and F W Paish (eds.) Benham's Economics, Pitman, London, 1973, pp. xiv + 562.

 

5.      A J Culyer (ed.) Economic Policies and Social Goals: Aspects of Public Choice, London: Martin Robertson, 1974, pp. vii + 349.

 

6.      A J Culyer, Need and the National Health Service: Economics and Social Choice, London, Martin Robertson, 1976, pp. xii + 163  [chapter 11 reprinted as ch. 55 in Classic Texts in Health Care, 1998, eds. Mackay, Soothill & Melia]

 

7.      A J Culyer, J Wiseman and A Walker (eds.) An Annotated Bibliography of Health Economics, London, Martin Robertson, 1977, pp. xvii + 361.

 

8.      A J Culyer and V Halberstadt (eds.) Human Resources and Public Finance, Paris: Cujas, 1977, pp. viii + 309.

 

9.      A J Culyer and K G Wright (eds.) Economic Aspects of Health Services, London: Martin Robertson, London, 1978, pp. ix + 190.

 

10.  A J Culyer, Measuring Health: Lessons for Ontario, Toronto, University of Toronto Press for the Ontario Economic Council, 1978, pp. vii + 189.

 

11.  A J Culyer, The Political Economy of Social Policy, Oxford, Martin Robertson, 1980 (revised edition 1983), pp. xii + 340 (reprinted by Gregg Revivals, 1991).

 

12.  A J Culyer (ed.) Health Indicators: An International Study for the European Science Foundation, London: Martin Robertson, 1983 (also New York: St. Martin's Press, 1983), pp. xii + 223.

 

13.  A J Culyer and B Horisberger (eds.) Economic and Medical Evaluation of Health Care Technologies, Heidelberg: Springer, 1983 (trans. as: Technologie in Gesundheitswesen: Medizinische und Wirtschaftliche Aspekte, Heidelberg: Springer, 1984), pp. xxvi + 405.

 

14.  A J Culyer, Economics, Oxford: Basil Blackwell, 1985, pp. xxii + 737.

 

15.  A J Culyer and G Terny (eds.) Public Finance and Social Policy, Detroit: Wayne State UP, 1985, pp. xviii + 370.

 

16.  A J Culyer, C Blades, J Wiseman and A Walker (compilers) The International Bibliography of Health Economics (2 vols.), Brighton: Wheatsheaf, 1986, vol. 1, pp. xviii + 658; vol. 2, pp. xiv + 434.

 

17.  A J Culyer and B Jonsson (eds.) Public and Private Health Services: Complementarities and Conflicts, Oxford: Basil Blackwell, 1986, pp. vii + 242.

 

18.  A J Culyer, Health Care Expenditures in Canada: Myth and Reality; Past and Future, Canadian Tax Paper No. 82, Toronto: Canadian Tax Foundation, 1988, pp. ix + 110,

 

19.  A J Culyer (ed.) Standards for Socioeconomic Evaluation of Health Care Products and Services, Heidelberg: Springer, 1990, pp. xi + 184.

 

20.  A J Culyer A K Maynard and J W Posnett (eds.) Competition in Health Care: Reforming the NHS, London: Macmillan, 1990, pp. vii + 255.

 

21.  A J Culyer, The Economics of Health, Aldershot: Edward Elgar, 1991, 2 vols., pp. xiii + 402; pp. xiii + 407.

 

22.  A J Culyer, The Political Economy of Social Policy, Aldershot: Gregg Revivals, 1991, pp. xiii + 340 (reprint of 1983 book).

 

23.  A J Culyer, M L Barer and G Mooney (eds.) Some Recent Developments in Health Economics, published as vol. 34, No. 9 of Social Science and Medicine, 1992, pp. 123.

 

24.  A J Culyer, R G Evans, J-M von der Schulenburg, W P M M van de Ven and B A Weisbrod Svensk Sjukyård: Bäst i Världen? (Swedish Health Care: Best in the World?), Stockholm: SNS Förlag, 1992, ISBN 91-7150-430-3, pp. 211. (translation of two 1991 reports listed in section C).

 

25.  A J Culyer and A Wagstaff (eds.) Reforming Health Care Systems: Experiments with the NHS, Cheltenham: Edward Elgar, 1996, pp. xii + 177.

 

26.  A J Culyer and A Maynard (eds.) Being Reasonable about the Economics of Health: Selected Essays by Alan Williams, Cheltenham: Edward Elgar, 1997, pp. xvi + 371.

 

27.  A J Culyer and J P Newhouse (eds.) Handbook of Health Economics, Vols 1A and 1B,  Amsterdam, North Holland, 2000 (Vol. 1A, pp. xxiii + 890 + 86, Vol. 1B, pp. xxvi +  1,910 + 86).

 

28.  A J Culyer, The Dictionary of Health Economics, Cheltenham: Edward Elgar, 2005, pp. xiv + 390.

 

29.  A J Culyer, (Ed.) Health Economics: Critical Perspectives on the World Economy, 4 Vols., Abingdon: Routledge, 2006, Vol. 1, pp. xxvi + 545; Vol. 2, pp,. xi + 450; Vol. 3, pp. viii + 386; Vol. 4, pp. xi + 600.

 

30.  E Tompa, A J Culyer, R Dolinschi (Eds.) Economic Evaluation of Interventions for Occupational Health and safety: Developing Good Practice, Oxford: Oxford University Press, 2008, pp. xvi + 295.

 

31.  A J Culyer, The Dictionary of Health Economics, 2nd edition, Cheltenham: Edward Elgar, 2010.

 

C. Monographs, Pamphlets, Occasional Papers and Discussion Papers

 

1.      F. M. M. Lewes, A J Culyer and G A Brady, The Transport of Holiday makers in Devon and Cornwall, Exeter: University of Exeter, 1966, pp. 63.

 

2.      M H Cooper and A J Culyer, The Price of Blood, London: Institute of Economic Affairs, 1968, pp. 47.

 

3.      A T Peacock and A J Culyer, Economic Aspects of Student Unrest, London: Institute of Economic Affairs, 1969, pp. 23.

 

4.      M H Cooper and A J Culyer, The Pharmaceutical Industry, London: Dun and Bradstreet and Economists' Advisory Group, 1973, pp. xvi + 43.

 

5.      A J Culyer and A K Maynard, Some Major Issues in Health Policy, Dublin: National Economic and Social Council, 1977, pp. 94.

 

6.       A J Culyer, Expenditure on Real Services: Health, Milton Keynes: Open University Press, 1979, pp. 59.

 

7.      A J Culyer and M H Cooper, The Economics of Universities, Dunedin: University of Otago Discussion Paper 8103.

 

8.      A J Culyer, The Withering of the Welfare State? 1985 E. S. Woodward Lectures, Vancouver: University of British Columbia, 1986, pp. 41.

 

9.      A J Culyer, Whither the Welfare State? 1985 E. S. Woodward Lectures, Vancouver: University of British Columbia, 1986, pp. 41.

 

10.  A J Culyer, Health Service Ills: the Wrong Economic Medicine, York: Centre for Health Economics, University of York, 1986, Discussion Paper 16, pp. 30.

 

11.  A J Culyer, C Donaldson and K Gerard, Alternatives for Funding Health Services in the U.K., London: Institute of Health Services Management, Working Paper No. 2, 1988, pp. 26.

 

12.  A J Culyer, C Donaldson and K Gerard Financial Aspects of Health Services: Drawing on Experience, London: Institute of Health Services Management, Working Paper No. 3, 1988, pp. 73.

 

13.  A J Culyer and J Brazier, Alternatives for Organising the Provision of Health Services in the U.K., London:  Institute of Health Services Management, Working Paper No. 4, 1988, pp. 30.

 

14.  A J Culyer, J. Brazier and 0. O'Donnell, Organising Health Service Provision: Drawing on Experience, London: Institute of Health Services Management, Working Paper No. 5, 1988, pp. 76,

 

15.  A J Culyer (with others under the Chairmanship of Barbara S. Young Working Party on Alternative Delivery and Funding of Health Services: Final Report,), London: Institute of Health Services Management, 1988, pp. 54.

 

16.  A J Culyer and A Mills, (eds.) Perspectives on the Future of Health Care in Europe,  York: Centre for Health Economics, 1989, Occasional paper, pp. ii + 150.

 

17.  A J Culyer, Cost-containment in Europe, York: Centre for Health economics, University of York, 1989, Discussion Paper 62, pp. 42.

 

18.  A J Culyer, Competition and Markets in Health Care: What we Know and What we Don't, York: Centre for Health Economics, University of York, 1989, NHS White Paper Occasional Paper 3, pp. 29.

 

19.  A J Culyer, The Internal Market: An Acceptable Means to a Desirable End, York: Centre for Health Economics, University of York, 1990, Discussion Paper 67, pp. 25.

 

20.  A J Culyer, Ethics and Efficiency in Health Care: Some Plain Economic Truths, York: Centre for Health Economics and Policy Analysis, McMaster University, Canada, 1991, Health Policy Commentary Series C91-1, pp. 27.

 

21.  A J Culyer, Health, Health Expenditures and Equity, York: Centre for Health Economics, University of York, 1991, Discussion Paper 83, pp. 34.

 

22.  A J Culyer and A Wagstaff, Need. Equality and Social Justice, York: Centre for Health Economics, University of York, 1991, Discussion Paper 90, pp. 16; also in Report No 92.14 of Institute for Medical Technology Assessment, Erasmus University, Rotterdam, 1992.

 

23.  A J Culyer, Health Care and Health Care Finance in Sweden: The crisis that never was, the tensions that ever will be (and how to ease them), Stockholm: Studiefoerbundet Naeringsliv och Sarnhaelle (Center for Business and Policy Studies), Occasional Paper 33, 1991, pp. 30 (Published in Swedish as Svensk Sjukvård - Bäst i Världen?, Stockholm, SNS, 1992).

 

24.  A J Culyer, International Review of the Swedish Health Care System, (ed.), Stockholm: Studiefoerbundet Naeringsliv och Sarnhaelle (Center for Business and Policy Studies), Occasional Paper 34, 1991, pp. 198 (Published in Swedish in Sjukvård - Bäst i Världen?, Stockholm, SNS 19921

 

25.  A J Culyer, Need, Equity and Equality in Health and Health Care, York: Centre for Health Economics, University of York, 1992, Discussion Paper 95, pp. 29 (with Adam Wagstaff); also in Report No 92.14 of Institute for Medical Technology Assessment, Erasmus University, Rotterdam, 1992.

 

26.  A J Culyer, Equity in Health Care Policy, Toronto: Premier's Council on Health, Well-Being and Social Justice, 1992, pp. 31.

 

27.  A J Culyer with other members of the Committee, Special Health Authorities: Research Review, a Report by the Review Advisory Committee (The Thompson Report), London: HMSO, pp. 56, 1993.

 

28.  A J Culyer, Supporting Research and Development in the NHS, a Report to the Minister of Health by a Research and Development Task Force chaired by A. J. Culyer, London: HMSO, 1994, pp. 85.

 

29.  A J Culyer, Funding Research in the NHS, York: Centre for Health Economics, University of York, Discussion Paper 125, 1994, pp. 30.

 

30.  A J Culyer, Equality of What in Health Policy:  Conflicts Between the Contenders, York: Centre for Health Economics, University of York, Discussion Paper 142, 1995, pp. 21.

 

31.  A J Culyer, J-M. Graf von der Schulenburg and W. P. M. M. van de Ven, Swedish Health Care Revisited, Stockholm: SNS, Occasional Paper 71, 1995, pp. 26.

 

32.  A J Culyer, Economics and Public Policy - NHS Research and Development as a Public Good, York: Centre for Health Economics, Discussion Paper 163 (The York Series on the NHS White Paper - A Research Agenda), 1999, pp21.

 

33.  Godfrey, C., Eaton, G., McDougall, C. and A. J. Culyer, The Economic and Social Costs of Class A Drug Use in England and Wales, 2000, London: Home Office Research Study 249, Home Office Research, Development and Statistics Directorate, 2002 (pp. 62).

 

34.  A J Culyer,  Eaton, G., Godfrey, C., Koutsolioutsos, H., and McDougall, C. Economic and Social Cost of Substance Misuse in the United Kingdom – Review of the methodological and empirical studies of the economic and social costs of illicit drugs, (a report to the Home Office), York: University of York and Home Office, Centre for Criminal Justice Economics & Psychology, Research Series Report 03-01, 2002 (pp. 117).

 

35.  L Robson, J Clarke, K Cullen, A Bielecky, C Severin, P Bigelow, E Irvine, A J Culyer and Q Mahood The Effectiveness of Occupational Health and safety Management Systems: A Systematic Review (Full Report), Toronto: Institute for Work & Health, 2005, pp.153.

 

36.  L Robson, J Clarke, K Cullen, A Bielecky, C Severin, P Bigelow, E Irvine, A J Culyer and Q Mahood The Effectiveness of Occupational Health and safety Management Systems: A Systematic Review (Summary), Toronto: Institute for Work & Health, 2005.

 

37.  J. Lomas, A J Culyer, C. McCutcheon, L. McAuley, and S Law (2005), Conceptualizing and Combining Evidence for Health System Guidance. Ottawa: Canadian Health Services Research Foundation, 2005, pp.38.

 

38.  A J Culyer, Weighing up the evidence: making evidence-informed guidance accurate, achievable, and acceptable, (Convenor with Jonathan Lomas) 2006, Ottawa: Canadian Health Services Research Foundation, 14 pp.

 

39.  A J Culyer, Review of Citizens’ Councils and Recommendations for the Creation of a Citizens’ Council in Ontario as Mandated under the Transparent Drug System for Patients Act, University of Toronto Priority Setting in Health Care Research Group (with Andreas Laupacis, Doug Martin, Alan Hudson, Wendy Levinson, Terrence Sullivan,  Bill Evans, Steven Pearson, Irfan Dhalla, Tasha Jeyanathan) 2006.

 

40.  K Claxton, Mark Sculpher and  A J Culyer, Mark versus Luke? Appropriate methods for the evaluation of public health interventions, University of York: Centre for Health Economics Research Paper RP31, 2007.

 

41.  A J Culyer. Deliberative Processes in Decisions about Health Care Technologies: Combining Different Types of Evidence, Values, Algorithms and People, London: Office of Health Economics, 2009, pp. 1-20.

42.    A J Culyer. Health, distribution and fairness – sorting out the theory and matching it to future policy practice (notes for the Select Committee on Health), House of Commons Select Committee on Health, 3rd Report: Health Inequalities, Vol. 2, 2009.

 

43.  M. J. Dobrow, R. Chafe, H. E. D. Burchett, A J Culyer, L. Lemieux-Charles Designing Deliberative Methods for Combining Heterogeneous Evidence: A Systematic Review and Qualitative Scan. A Report to the Canadian Health Services Research Foundation, Ottawa: Canadian Health Services Research Foundation, 2009, pp. 24 + 30.

 

44.  A J Culyer, Y. Bombard. An equity checklist: a framework for health technology assessments, CHE Research Paper 62, York: Centre for Health Economics, 2011.

45.    Adam Wagstaff and A J Culyer Four decades of Health Economics through a bibliometric lens, World Bank  Policy Research Working Paper Series, 5829, 2011.

 

*Return to index


Current articles

 

Hic sunt dracones: The future of Health Technology Assessment – one economist’s perspective

Anthony J Culyer
University of Toronto (Canada) and University of York (England)

 

All effective treatment must be free

“Here be dragons” may not have actually appeared on any known early map of the world but it is on the ‘Lenox Globe’ of 1510 in the New York Public Library, and monsters, giant horned men, and other similarly terrifying beasts were certainly sketched in early maps of the remoter and mostly unexplored regions of the world. One may draw an analogy between such maps and the current state of Health Technology Assessment (HTA). There is a large terrain of well-researched and largely well-understood methods—economic, biostatistical, and epidemiological—on which most researchers are engaged in what is aptly called ‘normal science’ (Kuhn 1972). There are many important research topics, both applied and methodological, that customarily fill the pages of journals such as this and that are also ‘normal’ in the Kuhnian sense of operating within the conventional optimising paradigm of most cost-effectiveness analysis as illustrated by Drummond et al. (2005) and Gold et al. (1996), and many others. I do not intend to dwell here on research falling into this category. Nor do I intend, however, to devalue it by implying that it is somehow unadventurous or merely conventional.  On the contrary, HTA is a living example of the intense creativity that is possible within a paradigm, and HTA is not at all normal in respect of the amazing bridging that has taken place across conventional disciplinary (and faculty) lines, between clinical, statistical, and philosophical disciplines as well as social sciences, and it seems to me a considerable and highly unusual achievement that there should be so little misunderstanding between these disciplines. Indeed, an eavesdropper on a conversation between its practitioners would be hard-pressed to tell from language alone whether a speaker was an epidemiologist, a statistician, a clinician, an ethicist or an economist. This is what I imagine people may have in mind in making a distinction between multidisciplinarity and interdisciplinarity.

Fascinating though such an interdisciplinary story would be, that is not what I want to draw to your attention. My concerns about HTA relate to the fact that, when applied, it inevitably has a political context. It is political both with a large ‘P’ and a small one. The large ‘P’ relates to the political ideology of health services and springs from the notion of a public interest element of health services. This is an interest that can be cast in many languages for, example, in political language, ‘solidarity’; or, in Marxian language, ‘from each according to their ability; to each according to their need’;’ or, in neoclassical economic language, ‘public goods’ and ‘caring externalities’.  It finds particular expression in the idea, which I think can be first attributed to Archie Cochrane (Cochrane 1972), that the only health care warranting public financing or public delivery is health care that is demonstrably effective. Cochrane’s slogan, which I have stolen as the sidehead for this section, was “All effective treatment must be free” (Cochrane 1972). It is, of course, perfectly possible to argue that it would be a rather good marketing strategy for any private health insurance agency to claim that the only services it would cover would be those in which one could have confidence that they were truly effective, even cost-effective, for there must be a substantial fraction of any population for whom that would be an attractive bundle to purchase, whether privately or through taxes, since there seems little point, at least from a consumer’s point of view, in having to purchase services of no value.  Fascinating though this tack would be, like the interdisciplinary story I shall set it aside in order to dwell on the ‘small p’ political context. This is the context in which the political creator of NICE, Frank Dobson, when asked as Secretary of State for Health whether he thought it would work, said “probably not, but it’s worth a bloody good try.” Applied HTA is ‘political’ both in the sense that it inherently embodies value judgments, including ones about equity, or fairness, and in the sense that the identification and acceptance of value judgments of any kind requires a process within the body politic, one, moreover, that needs to have particular characteristics if it is to lead to acceptable decisions.

An economist’s angle

I ought to make plain the purpose of HTA and the key questions that it addresses – or ought to address. HTA exists to help public decision makers make evidence-informed choices at the level at which formulary, insurance coverage, and clinical guideline decisions are taken so as to advance the public’s health. HTA ought to be seen as an aid to thought; never a substitute for it. It is a tool and, as such, ought to be useful, credible and fit for purpose. It is not a chisel to be used as a screwdriver, nor a screwdriver to be used as a chisel. It should reveal what we do not know as well as what we do, what sort of confidence we may have in the available information, and be capable of indicating what other kinds of information would further aid decision makers. It ought to help decision makers integrate different kinds of information and expose the values that ought to underpin all such decisions. Regarding key questions, the main ones are very familiar: does an intervention (or ‘health technology’) ‘work’?  For whom does it work? How well does it work? Relative to what alternatives? At what cost? Is it worthwhile? Can it be introduced (or withdrawn) and used in fair ways? What values are embodied in the answers to the foregoing? And what is the legitimate source of those values?

Even though many other disciplines provide crucial inputs, especially empirical inputs, to answer these question, it is economics that has provided the overall analytical framework for Comparative Effectiveness Research (CER) and Cost-Effectiveness Analysis (CEA) in HTA. Economics has specifically prescribed a broadly utilitarian type of ‘optimization’ (constrained maximization), though the stipulation of ‘health’ rather than ‘utility’ as the maximand is a significant departure from utilitarianism as normally practised.   HTA’s long-standing concern over the way in which this maximand is distributed over a jurisdiction’s population is another departure, such distributional concerns being of sublime indifference to strict utilitarians. Economics has also specified the general character of the evidence required to determine probable cost-effectiveness (clinical of course, but also other evidence, especially that related to costs, non-clinical outcomes and outcomes affecting third parties). It is economists who insist on the separate roles of ‘science’ and ‘social value judgments’ and who have emphasized that what qualifies one to make judgments about the former rarely also qualifies one to make judgments about the latter. Economics has introduced the HTA world to some of its own vocabulary, which has been quickly understood and absorbed into the conventional practice of HTA: words (and the inevitable acronyms)  like incremental cost-effectiveness ratio (ICER); ‘publicness’, in the sense of a benefit whose enjoyment by one person does not diminish enjoyment for another; ‘opportunity cost’, in the sense of the most highly valued alternative use of the resources undergoing investigation; ‘social welfare function’ (SWF), in the sense of how the satisfied preferences of many individuals are linked or added up; ‘externality’, in the sense of the impact on others of one’s behaviour[1]. Economics has also brought some of its own techniques to the table: Quality-adjusted Life-years (QALYs) and other outcome concepts; discrete choice experiments (DCE) and other experimental methods (many in association with cognitive psychology); time preference and discounting. Indeed, it would be a challenge to find any method in use today that remains uniquely the property of any one discipline, including economics. A short list of such core disciplines ought to include anthropology, biostatistics, cognitive psychology, decision theory, epidemiology, ethics, ethnography, management, mathematics, political science, public administration, qualitative research, and social policy.

Despite this rich multi-disciplinary input, it remains the case that the current guidance, whether from institutions like NICE and OHTAC or academic textbooks and articles, fails to deal with equity, in the sense of fairness, with anything like adequacy. This brings me to the dragons that I think need slaying which, like sleeping dogs, have been left to lie but which, if aroused, are capable of more mischief and destruction than any dog.

Two dragons

The first dragon is equity and, in particular, how one may embody equity considerations into HTA. By ‘equity’ I mean interpersonal fairness in the receipt of health care and the distribution of its consequences. Economists have a well-developed corpus of theory, both for describing the characteristics of a first-best allocation of resources to production and the fruits of that production to final consumers. They also have a well-developed set of principles for putting that analysis to work in a second-best world. Complementing those principles is an impressive array of empirical tools. It is all adaptable to the circumstances of the public sector as well as the private. And it has been, moreover, adapted to the circumstances of health care and health.

What economists have never been able satisfactorily to do is develop any analysis of equity of comparable sophistication, comparable applicability and comparable mutual agreement. Nor, alas, has the vacuum been filled by anyone else, though Johri and Norheim’s review (2009) is a useful beginning. The consequence is that the committees that make recommendations about the adoption and funding of new health care interventions, or disinvestment in old ones, do not know how to address matters of equity. Nor do they know how to integrate such considerations into efficiency analyses. Economists are strong on what not to do. Do not identify equity with equality, nor health with welfare, nor need with priority. Do not assume that equity trumps efficiency, nor that efficiency trumps equity. The list may readily be prolonged. The trouble is that these prohibitions are nearly always what people do tend to ignore That is not surprising given that economists, along with ethicists and other social analysts, have failed to stipulate what it is that one do instead. By the same token, the aforesaid failure has, again not surprisingly, left an empirical void which stands in marked contrast to the evidential base that exists for efficiency studies, so that even if we suddenly knew what it is that we should do with respect to equity, we would hardly be able, as a practical matter, to do it. As it happens, I think there is a solution that will banish this dragon to even further reaches of our known landscape, but before revealing this I must turn to the second dragon.

The second dragon is associated with the first and, unless this dragon is also slain, or at least banished, it will make it mightily difficult to dispose of dragon number one. Dragon number two is our ignorance as to the character of a process that might enable us to integrate equity in HTA. Specifically, the challenge  is that we are short of an adequate understanding of the processes necessary for combining different types of evidence, evidence about different kinds of thing (monetary and non-monetary, qualitative and quantitative), and for articulating concepts that are not themselves evidential (such as equity).  It is not merely that processes can have characteristics that appeal in and of themselves -- characteristics like transparency, citizen engagement, openness, deliberation and contestability -- it is that characteristics such as these are to be valued for more than their intrinsic merits. They are, in short, necessary for the proper accomplishment of the tasks of HTA and, in particular, they are essential to the major task of merging equity satisfactorily with efficiency.

 

Philosophy, political science and social policy all address equity and, in the case of philosophy, have done so for many centuries. Administrative science, the law and management science have all addressed ‘processes’. But none of these disciplines has concerned itself deeply with HTA (with the exception of the sub-discipline of bioethics) and, typically, none has made the theory and practice of HTA their daily business. This accounts, I conjecture, for two unfortunate phenomena. The first is that the question whether the methods of HTA ought to be more intimately linked to the processes of real-world decision making has gone unaddressed. The two are treated as essentially unrelated activities. As a consequence, HTA – or at least the conventional practice within HTA of cost-utility analysis – has been described as a “perversion of science as well as of morality” (Harris 2005). Powers and Faden (2000) call attention to its “moral flaws”, an unfortunate judgment that hinges on the implausible proposition that those who use HTA methods, and CUA in particular, are moral morons wedded to the uncritical use of a single decision tool. The charge is a triple one: that the tool is a poor one, that it is used uncritically, and that it is the only one they use[2]. The other unfortunate phenomenon is that, despite these centuries of study, no one yet has come up with usable tools that would assist decision  makers and those who advise them to integrate the two great criteria of efficiency and equity and to devise effective (even cost-effective) processes for doing so.

It seems to me that the way forward is for those of us who are, as it were, HTA ‘insiders’ should grasp the challenges ourselves, perhaps in collaboration with some of the aforesaid colleagues from other disciplines (including the critics), but at any rate not in deferment to them, and set in motion a new research program designed to get to the heart of these matters. That is what I propose to try to boost in the rest of this paper.

Process

“Arguably the biggest threat to our public health care system is not our ability to pay for the increasing cost of care, but rather a loss of public confidence.” (Chase et al. 2010). While this loss of confidence parallels a general scepticism about the adequacy and fairness of public decisions across the board, health care has evidently not escaped it. For many (e.g. Mendelberg 2002, Petts 2004) the solution is citizen engagement and other processes of more direct democracy. I have much sympathy with sentiments such as these. However, that is not where I want to lay the emphasis here. I want, instead (or, perhaps, ‘as well’) to suggest that better processes would be useful not only for re-establishing confidence in general, but also for offering ways in which better decisions are likely to result.  A better process might be better in the sense that it is more ‘transparent’ and confidence-building on that account. Those are the intrinsic merits of a good process and are embodied in ‘accountability for reasonableness’ (Daniels 2000, Daniels and Sabine 2008). But it may also be a better process by virtue of the fact that it embodies more complete evidence, or more deeply investigated evidence, or by its better combining of many elements -- some evidential and others not, or through enabling a more complete addressing of equity and of its consideration alongside efficiency. By ‘process’ I mean the steps that are taken, and their organisation and management, from the earliest inception of an HTA (“what ‘technology’ is to be assessed?”) through its further scoping and refinement; selection of comparator technologies, identification of primary and secondary research; critical appraisal of the evidence; stakeholder comment, consultation and further deliberation; through draft guidance, recommendations or decisions; appeals; conclusions, recommendations and dissemination[3].

The processes that I particularly have in mind are: the possibility of external comment in order that interested parties may see what there is to comment upon; consultation, through which external parties are invited both to engage with decision makers and their advisers and to enter into discussion about whatever aspects of the process may be under way at the time, which includes assumptions, comparators, model building, literature review and matters to do with the intrinsic process itself; and finally, the most complete form of engagement, deliberation, in which relevant stakeholders actually participate in the decision making itself -- though probably excluding the final ‘determination’ or conclusion of the process, for which responsibility necessarily lies with those appointed to decide.

Issues that require resolution would be determined at a ‘high’ level, such as through the board of an organisation, or at ministerial or even cabinet level. Examples of such issues include: specifying the objective (health maximisation?), the available budget, the ‘threshold’ (lintel?) ICER, the discount rate(s) to be used, whether sophisticated programming or simple CEA is to be used, whether Multi-criteria Decision Analysis is an approved method, the choice of technologies to evaluate, and the comparators and equity requirements. Occasionally some of these might be determined at a ‘lower level’, which I take to be the level of the decision making agency or advisory committee. These lower level issues would generally include all of the following: testing the concept validity of outcome measures, assessing the quality of the science on a particular subject intervention and its comparators, interpreting and combining both qualitative and quantitative evidence (systematic reviews, other reviews, meta-analyses), linking, if possible, internal and external validity, weighing uncertainty, identifying absent information and deciding what to do in its absence, assessing ‘feasibility’ and manageable time lines, trading off conflicting desiderata and, finally, making recommendations or issuing guidance through (preferably tried and tested) Knowledge Translation methods.

A good many technologies do not easily ‘fit’ into the customary methods of HTA. Consider public health: its complex interventions, diversity of responsibility for the vectors of delivery (communities, schools, hospitals, prisons,…), heterogeneity of outcomes (better health, but also reductions in teenage pregnancies, reduced crime, reduced fear of crime, …), long time horizons (especially when the interventions involve culture change or challenge cherished beliefs) and programmatic character (prevention, screening). Or consider the simplifying assumptions, such as constant returns to scale, non-diminishing marginal value of QALY, or the simple additivity of outcomes, that are so often merely taken for granted rather than tested for their appropriateness. Also consider the character of evidence, especially when one widens the notion of ‘technology’ beyond pharmaceuticals: the greater dependence on multivariate observational studies and econometrics, the use of cheaper experimental methods than RCTs, and the kind of evidence required on value questions such as the value to be placed on a unit of outcome or the measurement of changes in ‘equity’. Then too consider what might be best regarded as a potential by-product of HTA: the possibilities it affords for raising the public understanding of risk and uncertainty, the reasons why one thing rather than another has been chosen, and the enhancement of the general credibility of guidance.

The ‘process’ has three important aspects. One is to ensure that divergent views are properly represented to minimize the chances that any one particular interest group should unfairly ‘capture’ the process. Another is to enable the wisdom and experience of other decision makers to be brought to the table. Their judgments, especially about value-laden and possibly controversial issues such as quality of science or the meaning of ‘equity’, may be wiser than those of the ‘official’ participants. A third is that the process itself is a means by which evidence is generated or at least brought before decision makers. Such evidence might relate to matters of ‘feasibility’ and ‘manageability’, where the experience of practical managers amongst the decision makers may be a useful input; to matters of external validity, where specific knowledge on the environments into which an intervention might be introduced may be essential; or to the appraisal of outcomes, where the fit of the outcome measures used in research studies with the experience of actual patients and their carers can be tested and possible biases identified and adjustments made on account of them. (Culyer 2009, Dobrow et al. 2009)

I have just listed some ‘issues’ and asserted some better ways of addressing them. My selection is not evidence-based, save in a somewhat experiential and necessarily partial way. Nor is it founded on any well-developed theory of ‘good’ decision making. It is therefore ad hoc. Most of the literature on these topics, such as it is, is assertive rather than analytical, ideological rather than scientific, strong on advocacy but weak on evidence. It is also written by the practitioners of many different disciplines and appears in places that seem very remote from any HTA concern[4].

Equity

Much the same applies, I fear, to the treatment of equity. Of course, equity, in its major sense of distributive justice and ‘fairness’ has been a central concern of moral philosophy since the days of classical Greece. Its modern students are well-practised in the business of typology (utilitarian – several varieties, deontological – again several varieties, theological, consequentialist, etc. etc.) but they have, with a few fine exceptions. (such as Daniels (2000) and Daniels and Sabin (2008) on decision processes, been quite extraordinarily bad at providing tools for the use of practical decision makers such as the practitioners and users of HTA

Even the most elementary ‘tools’, such as a typology of characteristic equity issues to form an ‘agenda’ for discussion at various stages of an HTA process, would be an advance on what we currently have. Such a typology might focus deliberation on such matters as the domains of equity. For example, there are equity issues regarding the use and distribution of health care inputs, the processes that determine who gets what, the evaluation of outcomes, and on the priority that ought to be attached to different diseases, or to prevention versus cure. Decision makers need to reflect on the appropriateness of the criteria used in respect of any of these, their inclusiveness, the relative weight to attach to each, and so on. Some red flags are provided in some jurisdictions by statute, as when there is a legal obligation to guard against discrimination by age, gender, disability, other demographics, workplace, education, institutionalized discrimination. However, not all jurisdictions cover all possible issues and matters of equitable concern may lie hidden in the depths of an HTA. There are also a number of ‘top level’ issues, such as whether there may be some principles on which all would agree as minimal requirements for equity, whether it is possible to enunciate some axiomatic statements that define what an ‘increase’ in equity might mean and how it might be recognised empirically, and there is always a need to establish the applicability of any such principles in the context in question.

Some of the ‘hidden’ equity biases that are likely always to need surfacing include embedded inequity – through which possible unfairness is ‘built in’ to concepts (e.g. omitted dimensions of outcome measure that discriminate against those for whom such outcomes are important), or framing effects in experimental approaches that bring in social class bias, or unfairness that is inherent in the intervention (e.g. a threat to autonomy through the removal of choice, as with some public health measures). There are also institutional biases, inequities resulting from practices in jurisdictional scope (e.g. health consequences not taken into account by some faith-based provider institutions, school boards or workplace managements) and the degree of concern many jurisdictions have with the distribution of consequences (health or not-health). There is also implicit stereotyping the use, often in all innocence, of definitions and concepts that exclude individuals or aspects of health-related welfare that have differential impact on individuals, and that make untested assumptions about what does and does not ‘matter’ to the people for whom the intervention exists.[5] Particular contexts (e.g. geography) may disadvantage some relative to others. Minimally, surely, one ought to test to see whether any of the following could affect the balance of advantage across different groups: the setting of care (e.g. home or institution), language, education or SES of clients, religious beliefs, stigma, or multiple deprivations.

Decision makers ought to ask, for example, whether the processes in HTA itself are biased by denying representation to people with a legitimate interest. Whether the interests of absentee stakeholders are properly considered – for example, those anonymous individuals for whom services will not be provided as a consequence of implementing the recommendations. Participants in HTA need to be self-aware and self-critical regarding their own procedures. Processes in delivery of the care under evaluation can be prejudicial to technologies for some types of client (e.g. those of low SES) and can favour those adept at negotiating their way through processes, or impose differential burdens on some clients (e.g. wage versus salary earners).

Then there are special claims such as claims of need (e.g. low initial health status?), of deservingness (e.g. choosing life styles that are hazardous to health?), of history (e.g. past endurance of ill-health, past receipt of the intervention), of desperation (e.g. ‘last chance’), of unfair innings (lived only a short life-span), of non-health consequences (other welfare effects), of willingness to pay (e.g. top-up payments). Sometimes the beneficiary is identified as a member of a group or even by name as is often the case with spectacular acts of medical – or other – rescue. Ought cases of extreme need be given special favour (Hope 2004 ch 3, Cookson et al. 2008)? What weight ought to be given to such claims either in general or in the context of a specific HTA? What weights actually are given (e.g. Cropper 1994, Johannesson and Johanson 1997, Johanson-Stenman and Martinson 2008)? Cumulative effects may escape proper attention, for example, cumulative past disadvantages or effects that might be relevant in assessing benefit or cost or their distribution across patients and other affected groups.

The point of these examples is that in the process of discussion and deliberation about a technology decision, all of these hidden problems need to be deliberately “surfaced” because ignoring them (being unaware of their existence, or aware but doing nothing about them) leads to a bad decision.   My suggestions are merely illustrative and are certainly not exhaustive. But who better to complete the list, maintain it through casuistry and careful recording of the reasons for decisions, and synthesize and consolidate it over time, than those involved in the process of HTA? Through such casuistry may we not build up case-based precedents to help decision-makers achieve consistency across interventions and over time, perhaps, eventually create a systematic ‘ethics of HTA’?

Deliberation

The slaying of both my dragons HTA requires, I conjecture, deliberation, with an emphasis on: process, from scoping a topic through evidence generation and synthesis to delivering guidance; consultation with legitimate stakeholders (usually also a source of evidence); and facilitated discussion. These all weak points in the current state of HTA, and they are all Cinderella research topics (but see Lomas et al. 2005, Culyer 2009, Dobrowe et al. 2009)  with multidisciplinary concerns.

I believe the ultimate product and measure of success would be the increase in confidence of participants, stakeholders and the public. This would be achieved by their understanding of the processes and knowledge that the best evidence was used, that the appropriate ‘experts’, lay and professional, had contributed, that all relevant evidence had been searched and considered, that all relevant stakeholders had their say and been heard, that key concepts (e.g. ‘outcomes’) had been tested for construct validity, that all relevant cost and benefits had been weighed and  included in calculations, that fair comparisons had been made (both between interventions and between individuals), that all relevant conceptual and empirical biases had been eliminated, and that the main risks had been assessed and undue risks not taken. I suppose, taken as a group, such outcomes might constitute evidence of a ‘good’ process.

To realize this ultimate product, however, HTA would be wise to broaden its horizons, turning away from what is largely just an algorithm to find ways to take seriously the myriad value and ethical issues which currently still have the unfortunate appearance of afterthoughts, tacked on to, but essentially excluded from, the core decision logic, and to develop an empirical program to rival, mutatis mutandis, that of CEA and CER. After all, non-monetary values, though less easily measured perhaps than monetary ones, are still subject to empirical estimation and the values that individuals actually cherish ought at the least to inform decision makers’ values. This is not merely a matter of expanding the algorithm but also, as I have tried to show, a matter of developing suitable processes that generate information through the participation of stakeholders while also facilitating the thoughtful assessment of what is known, combining it with revealed values, and producing multiple solutions to problems that are not uniquely soluble, like those on which there are deep divisions of principle in the community. To participate both in such processes and in the accompanying research program must surely be one of the more exciting prospects confronting today’s HTAers.

 

 

References

Brock DW. Ethical issues in the use of cost effectiveness analysis for the prioritization of health care resources, in Tan-Torres Edejert T., Baltussen R., Adam T., Hutubessy R., Acharya A., Evans DB., and Murray CJL (eds.) Choices in Health: WHO Guide to Cost-Effectiveness Analysis, 2003, 289-312.

Chase R, Levinson W, Hébert PC. The need for public engagement in choosing health priorities, Canadian Medical Association Journal, 2010, DOI:10.1503/cmaj.101517.

Cochrane AL. Effectiveness and Efficiency: Random Reflections on Health Services, London: Nuffield Provincial Hospitals Trust, 1972.

Cookson R., McCabe C., Tsuchiya A. Public healthcare resource allocation and the Rule of Rescue, Journal of Medical Ethics, 2008 34: 540-544.

Cropper, M.L., Aydede S.K., Portney, P.R. Preferences for life saving programs: How the public discounts time and age, Journal of Risk and Uncertainty, 1994, 8: 243-265.

 

Culyer AJ. Deliberative Processes in Decisions about Health Care Technologies: Combining Different Types of Evidence, Values, Algorithms and People, London: Office of Health Economics, 2009.

Culyer AJ. The Dictionary of Health Economics, Cheltenham: Edward Elgar, 2010.

Daniels N. Accountability for reasonableness: establishing a fair process for priority setting is easier than agreeing on principles, British Medical Journal, 2000, 321: 1300-1301.

Daniels N., Sabin JE. Accountability for reasonableness: an update, British Medical Journal, 2008, 337: a1850.

M. J. Dobrow, R. Chafe, H. E. D. Burchett, A J Culyer, L. Lemieux-Charles Designing Deliberative Methods for Combining Heterogeneous Evidence: A Systematic Review and Qualitative Scan. A Report to the Canadian Health Services Research Foundation, Ottawa: Canadian Health Services Research Foundation, 2009.

Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes. 3rd ed. New York: Oxford University Press; 2005.

Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-Effectiveness in Health and Medicine. 1st ed. New York: Oxford University Press; 1996.

Habermas J. The Theory of Communicative Action, Boston: Beacon Press, 1987.

Harris, J. It’s not NICE to discriminate, Journal of Medical Ethics, 2005, 31: 373-375.

Hope T. Medical Ethics: A Very Short Introduction, Oxford: Oxford University Press, 2004.

Johannesson, M., Johansson, P-O. Is the valuation of a QALY gained independent of age? Some empirical evidence, Journal of Health Economics, 1997, 16: 589 599.

 

Johansson-Stenman, O., Martinsson, P. 2008. Are some lives more valuable? An ethical preferences approach, Journal of Health Economics, 2008, 27: 739-752.

Johri M., Norheim OF. Can cost-effectiveness analysis integrate equity concerns? A systematic review of current approaches. Paper at the 12th Annual ISPOR Conference, Paris, 2009.

Kuhn TS. The Structure of Scientific Revolutions, 3rd ed. Chicago: Chicago University Press; 1996.

Lavery JV., Tinadana PO., Scott TW., Harrington LC., Ramsey JM., Ytuarte-Nunez CY., James AA. Towards a framework for community engagement in global health research, Trends in Parasitology, 2010, 26: 279283.

 

Lomas J., Culyer AJ., McCutcheon C., McAuley L., Law S. Conceptualizing and Combining Evidence for Health System Guidance. Ottawa: Canadian Health Services Research Foundation, 2005.

 

Mendelberg T. The deliberative citizen. In: MX Delli Carpini, L Huddy, R Y Shapiro (eds.) Political decision making, deliberation and participation, Research in Micropolitics Vol. 6. Elsevier: Amsterdam, 2002.

 

Petts J. Barriers to participation and deliberation in risk decisions: evidence from waste management, Journal of Risk Research, 2004. 2: 115-133.

 

Powers, M. and R. Faden. Inequalities in health, inequalities in health care: four generations of discussion about justice and cost-effectiveness analysis, Kennedy Institute of Ethics Journal, 2000, 10, 109-127.

Reuzel, R.P.B., G.J. van der Wilt, H.A.M.J. ten Have, and P.F de Vries Robbe, Reducing normative bias in health technology assessment: interactive evaluation and casuistry, Medicine, Health Care and Philosophy, 1999, 2, 255–63.

 

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­An equity checklist: a framework for health technology assessments

Anthony J Culyer, DEcon1* and Yvonne Bombard, PhD 2

 

1. Department of Health Policy, Management and Evaluation, University of Toronto, Canada; Centre for Health Economics and Department of Economics & Related Studies, University of York, UK

2. Department of Health Policy, Management and Evaluation, University of Toronto, Canada

 

Introduction

A challenge was recently presented to Health Technology Assessment (HTA) practitioners to address equity better in their analyses [1]. In this paper we attempt to meet that challenge, at least in part.  HTA is the systematic evaluation of the consequences of the use of a health care intervention (henceforth ‘technology’). Its principal purpose is to inform decision-making. Ethical considerations and non-economic social consequences were included in early general formulations of HTA [2]. However, it is only recently that attempts have been made to develop frameworks for considering methods of integrating ethics and a wider set of social consequences into HTA [3-7]. A comprehensive attempt to give practical guidance is that of the National Institute for Health and Clinical Excellence (NICE) in England and Wales [6]. One important ethical consideration is equity. Despite the significance of equity ideas in the design of many health care systems, pragmatic tools for integrating them into the efficiency categories of cost-effectiveness in HTA remain under-developed [8]. We attempt here a first step towards a pragmatic solution by providing a framework of equitable considerations of potential relevance in HTA decision making, giving examples of the ways in which such considerations might arise, and providing a summarized checklist which may itself be used as a decision tool by HTA decision makers or which could be further abbreviated as a desk-top aide-memoire. The framework is primarily intended for high-level decision makers who specify the criteria to be used by HTA advisory committees. The checklist if offered as a first approximation to a practical tool for use by such advisory committees.

 

Equity has many meanings in both academic and lay contexts [9-12]. The absence of an agreed theory of equity arises out of the absence of a general or monist theory of morality. There are moral theories that claim to be general, such as utilitarianism, though utilitarianism in its classical form is not directly concerned with equity. Non-utilitarian theories hold, variously, that the equitable distribution of health care resources is that which is to the advantage of the least advantaged person - so-called maximin theory. Deontological theory posits that an equitable distribution arises out of the duty each has to provide for others. Entitlement theory holds that an equitable distribution is the outcome of an equitable economic and social system (for a review of rival approaches see Veatch [13]). We do not attempt the Sisyphean tasks of selecting from or reconciling rival philosophies but suggest instead that equity issues concerning the use of health care resources in a decision-making context are best considered explicitly as pluralist. Rather than defining a priori what ‘equity’ is, we draw on a multidisciplinary literature and our own practical experience, to create an eclectic list of equity issues, which, if left unaddressed by decision makers, could be deemed by a reasonable person to be unfair or to lead to unfairness in the adoption, diffusion or consequences of a health technology.

 

Two domains of equity are especially relevant in HTA. One is fairness of the procedures used in the conduct of HTAs. The other is equity as a decision criterion, like efficiency, for ranking health care interventions. Equity in the first sense has, at least in part, been conceptualized as ‘accountability for reasonableness’ [10, 14-16] and has been adopted by some agencies  (e.g. NICE 2008). Equity in the second sense is a statutory requirement in several jurisdictions and is likely to be increasingly required: illegal discrimination will need to be addressed in all jurisdictions, such as the UK, where such legislation exists. However, such imperatives typically address only a subset of the concerns for equity that can arise in HTA. Unfortunately, there exists no substantive body of principled thinking that can serve as a sure, or even moderately agreed, foundation for a more comprehensive treatment of equity in HTA [11].

 

Equity in the sense of fairness in the way health care is financed, produced and distributed has been a founding principle of many health care systems throughout the world, and has resulted in systems that broadly fund activity according to ability to pay and distribute it according to need (especially in middle and high income countries). It would therefore seem appropriate for HTA equity criteria in such jurisdictions to be at least consistent with these broader ideals of health care.  Unfortunately there are major differences between definitions of ‘need’, measures of it and its application in HTA decisions [12] and it is far from clear what a criterion of need would require over and above the criteria of effectiveness and cost-effectiveness.

 

The standard approach to equity within HTA seems to operate at two distinct levels. The first is general, such as being aware of the difference between horizontal and vertical equity (noting that only the former involves attempting to achieve equity through the equality of something [9, 17]) or having an equal respect for everyone. Since not all inequalities are inequitable, nor all equalities equitable, we agree with Whitehead (1991) in making equity and inequity the focus of our attention rather than equality or inequality [18]. The second is specific, such as the application of differential weights to costs and benefits according to particular equity-related characteristics of those likely to be affected by the decision [19-27]). While there is merit in this outcome-based approach, in practice decision makers have difficulty in identifying circumstances in which departures from strict equality in the value of units of outcome could be justified, with the possible exception of end-of-life benefits which NICE, for example, explicitly treats as warranting special weights, but without specifying them in quantitative terms, and which others, such as Ontario’s Committee to Evaluate Drugs (CED), favour - though only implicitly[6]. Equity-focused ‘impact assessments’ are examples of procedures that have a focus specifically on the distribution of outcomes (e.g. Kemm et al 2006 [29]).

 

There is little guidance concerning what, justly, ought to constitute either the characteristics in question or the size of the weights. Some gather evidence regarding the public’s preferences, stakeholders’ perspectives or experts’ advice on either of these matters [26, 27, 30-36]. Empirical efforts to discover what ‘the public’ thinks about appropriate ways of trading-off benefit with cost also raise the fundamental ethical question of the extent to which HTA ought to embody such values, even when participants are well-informed.  It is possible that preferences may be unstable or that the values elicited change according to the amount of information that is given, the technology considered, whether the health state in question is merely anticipated or actually experienced. Even when all such confounders have been taken into account it is possible for there to be considerable variance around population means and the distribution of ethical values need not have a single mode. Ethicists might raise the objection that what is just or fair is not to be determined by populist vote, while others might contend that the preferences of elected representatives of the community in question should count rather than the preferences of those who elected them. Other methods have sought generalizable trade-offs between equity and efficiency [37, 38]. However, not all equity issues involve trade-offs with efficiency[7] [40] and none of these approaches addresses what ought to be done nor attempts to address the many other dimensions of equity that ought to be taken into account. The dimensions of equity typically considered (at least by health economists) are quite restrictive, being mostly concerned with distributive fairness and focused on health, the geography of health care, and income. Further, irreconcilable differences in values are glossed over, hidden stereotyping happens and reliance, save in the case of legislated requirements, is almost entirely upon intuition.

 

We propose the creation of a pluralist [41] ‘checklist’, that might be expanded and developed in the light of experience, consultation, deliberation and the transparency that ought to accompany it. In any specific decision context, not all the items in the checklist will be relevant – and perhaps none will be – but the intent is to minimize the risk of overlooking considerations of equity that might be relevant by ensuring that minds are open to matters that can easily be overlooked or, if not overlooked, that may be difficult to articulate, appraise or measure.

 

 

A proposed initial checklist

We propose a practical and adaptable initial framework (the ‘equity checklist’), as the basis for the development of a more comprehensive typology[8]. It is practical because it is intended as a sequence of ‘red flags’ to alert decision makers – and the designers of the systems within which they work – to matters of equity that might warrant integration into the usual efficiency analysis of HTAs. It is adaptable because the checklist as it currently stands is intended only as an initial step and what may be added is currently unknowable (at least, by us).

 

The checklist is an initial framework to inform discussion and decision at a relatively high level, to set criteria, and ensure that lower tier decisions – and the reasons for them – are incorporated into minutes and notes of the meetings at which they are taken, thereby enabling a dynamic process of comparison and consolidation as cases accumulate. In our approach, what is equitable or inequitable is less a matter for a priori definition than for discovery and subsequent categorization by those appointed by legitimate means to make such decisions. We hope that the checklist will help the process of discovering whether a consensus does exist and, where it does not, what the nature of the conflict may be and how it might most appropriately be dealt with.

Although the exercise is not intended to generate a consensus, establishing that there is no consensus on some of these questions is as important as seeking one [45]. While it may be possible to develop a consensus over time in a jurisdiction, or at least a consistency in the way equity matters are considered, it seems unlikely that such a consensus would ever be achieved across jurisdictions, where prevailing standards, cultures and political values could vary greatly.

 

The object instead is to enable all potentially relevant factors to be clarified and considered, along with any evidence pertaining to them, including any evidence generated in the actual process of consultation and deliberation. The process is intended to affect both the procedures of the HTA as well as the ‘final appraisal determination’.[9] It may also be used by agencies to determine the scope of equitable issues to be considered by advisory committees, with the consequence that some of the matters identified in the list would not in practice be open for discussion.

 

We propose that the equity checklist should: (a) be used as part of the process through which advisory bodies are given their terms of reference, (b) form a part of the scoping agenda prior to the selection of a candidate intervention and its comparators for HTA, (c) accompany the usual efficiency-related statistical and analytical, research and background briefing for decision makers, including systematic and other reviews, incorporating any anticipated equity issues  in the scoping stage; and (d) where appropriate (e.g. when equity issues of sufficient weight are identified to warrant detailed consideration) help to structure the discussion and composition of multi-disciplinary, multi-professional and ‘lay’ advisory groups during the assessment process.

 

We anticipate that the checklist will be developed in a variety of ways. One is through academic research and discussion, which will in turn inform the methodological guidance of HTA agencies. Others, which we have previously characterised as casuistry, are through the gradual building up of case studies of actual decisions, their reasoning, and their eventual analysis, synthesis and consolidation into statements of good practice at various levels of the decision making process. This will normally require digging deeper than the mere on-line consultation of the recommendations and decisions of advisory committees.  In this fashion, we expect to see an accumulation of case-based precedents that will help decision-makers achieve consistency across interventions, constantly remind them of factors that might otherwise be overlooked, together with suggestions of how they could be handled.

 

Elements of the Checklist

Equity versus equality

Decision makers may need reminding that equity and inequity are not the same as equality or inequality. When, however, inequalities are linked with postulated causes as when, for example, a concentration curve links health or ill-health to income, an inequality might be judged as also inequitable. Some inequalities are actually equitable as when, for example, someone with an urgent need to treatment receives it before another who is a less urgent case. In all cases, however, it is worth asking ‘equality (or inequality) of what?’ Common candidates include: need; deservingness or responsibility; capacity to benefit or be harmed; degree of incapacity or current health state; history of past health or ill-health; prognosis with and without the technology; health outcome - quality of life; and dependents (e.g. care-giving responsibilities). The ethical element derives from the postulated cause of the health inequality. Empirical causes judged to be ethically relevant commonly include income and wealth; social class; social deprivation; and life-style and behaviour. While the solution to inequity is likely to require addressing the underlying causes, an assessment of their mutability and the balance of cost and benefit in changing them, the range of remedies in HTA is typically narrower, lying within health care and typically within a rather small subset of health care technologies.

 

The language of equality and inequality is explicitly quantitative and it is always worth seeking empirical and quantitative information about how equal or unequal the relevant factors, outcomes or causes are and how equal or unequal it is felt they ought to be. Major unjust inequalities may rightly be perceived as more important to remedy than minor ones, though the relative costs or redress ought normally also to be taken into account. In all cases a judgement should be made as to whether the evidence on equity warrants any significant departure from the implications of the efficiency analysis, such as recommending the use of an intervention when its incremental cost-effectiveness ratio is above that normally deemed to be the maximum allowable, or not recommending one that is below that threshold, on grounds of its inequitable consequences.

 

Domains of equity

The matters for discussion under this category of the checklist relate to the appropriate focus on equity, for example, whether it should relate to health care inputs, processes or outcomes; whether it is the direct or indirect (perhaps unintended) consequences of the use and diffusion of the health technology that matter; whether there should be a disease focus, with patients being classified by, say, diagnostic group, or in some other way (say, by socio-economic status (SES)). If the identification of subgroups within a larger class of individuals could generate inequities, these should be explored. It is at this stage that some groups who might be affected by a technology can be (innocently but mistakenly) overlooked, as might be the case in interventions for parents that have significant side-effects on children. Such an omission would, of course, also bias an efficiency analysis as well as raising potentially significant equity issues [46]. For example, if we consider a screening technology that distinguishes between cancer patients who would benefit from a particular treatment from those who would not, then one domain of equity pertains to the consideration the implications for both sub-groups: not only the sub-group that benefits but also those who are disappointed.

 

Legal Obligations

Most jurisdictions will specify statutory requirements to consider justice and equity and there may be further administrative obligations placed on agencies by higher tier organizations or their own governing bodies. Anti-discrimination legislation may be quite specific in requiring specific factors to be taken into account and may go so far as to specify how and the discretion that is permitted the decision makers. Legal obligations may be absolute, in the sense that any inequality of the sort in question is illegal, or relative in the sense that discretion may be exercised regarding the extent to which a given inequality violates a principle of equity. Common dimensions include discrimination by age, religion, gender, disability, ethnicity, race, socio-economic status, nationality, language and sexual orientation. Other dimensions may have regulations we cover under other headings.[10]

 

General principles

Despite the difficulty in obtaining universal assent to specific ethical principles, it is always worth establishing whether some (probably simple) principles would in fact be agreed for all cases or in the context of the case under consideration. Some may be of inherently broadly applicable and become embodied as standard in the consideration of equity. Principles that might be worth discussing could include:

(a) The domain of equity shall be ‘current and prospective health’ not past health.

(b) Equity requires either the attainable equality of something or else its fair inequality.

(c) Fair inequalities in treatment exist when the inequality arises from a fair claim for being treated differently, such as an accepted claim of higher need.

 

It may also be possible to agree specific axioms relating to equity, such as the following cockshies:

Weak equity axiom 1: ‘if person A has a worse state of health than person B, then in determining the equitable allocation of an intervention having a given impact on a population including A and B the equitable solution ought to increase A’s health more than B’s, or reduce it less’.

or

Weak equity axiom 2: ‘if person A has a worse state of health than person B, then in determining the equitable allocation of a budget for interventions on a population including A and B the solution ought to include only interventions that on average increase A’s health more than B’s, or reduce it less’.

 

Embedded inequity

By embedded inequity we mean inequities arising from inherent characteristics of the analysis or intervention. This might arise from the use of specific concepts or tools. For example, it is generally recognised that the use of EQ-5D might discriminate unfairly against clients with cognitive impairment or with sensory deficits for whom it is not well-designed. Unfairness might also arise in the detail of the measurement process –.  EQ-5D may omit significant dimensions and thereby unfairly discriminate against patients for whom the omitted factors are key outcomes, such as relief of fatigue for people living with rheumatoid arthritis or anaemia. Time costs may not properly reflect opportunity costs for different social/employment groups, as when salary earners do not lose income when attending a clinic compared with the self-employed. Practical measurement and experimental methods may contain inequitable framing biases, or measures of inequality may over or underweight the extremes of a distribution of benefits or harms [48] or exclude relevant dimensions [49].

 

The systematic exclusion of vulnerable groups from clinical trials/research can lead to an absence of evidence on effectiveness in those groups, which in turn can result in inequitable denial of access. A now classic case of this bias is the exclusion of women from cardiovascular clinical trials despite the prevalence rate of cardiac disease amongst them (see Kim et al. 2009 [50]).

 

Embedded inequity might also arise from the inherent character of an intervention, such as denial of choice that can arise in some interventions such as water fluoridation, population-screening programs or (healthy) fixed school lunch menus, where the affront to freedom may bear more heavily on some than on others, such as those with religious dietary restrictions. The commonly made assumption that a quality-adjusted life year is of equal social value to whomever it accrues is an embedded assumption that may need modification if it is thought that the value (weight) placed on a QALY gain for one who is currently very sick ought to be higher than for one less sick [23]. 

 

Inequity may arise when the valuation basis of health outcomes is variable as when, for example, those who have actually experienced a condition (and its treatment) value its avoidance less than those who anticipate but have not experienced it [51]. More generally, if the prevalence of unstable valuations of outcomes is related to other characteristics, such as education or social class, then a suitable precaution might be to discover the views of those most directly affected by the intervention in question. There is a great deal of evidence of the considerable variability of preferences and valuations, and their susceptibility to framing and other effects, in the literature of cognitive psychology and experimental economics (e.g. Kahnemann and Tversky 2000 [52]).

 

Institutional bias

Institutional biases are those that are also embedded but in organizations rather than analytical methods or interventions. The equity issue here is whether the jurisdictional scope of agency or of its parent organization causes any costs or benefits that might be significant for equity to be omitted or distorted. For example, if major outcomes include effects such as reductions in teenage pregnancies or a reduction in the frequency of j-walking, these may not be a part of a Ministry of Health’s remit, belonging instead to a Ministry of Social Work or the Ministry of Transport. Conversely, the jurisdictional scope of ‘partner’ agencies or ministries might cause significant costs or benefits for health equity to be omitted or distorted (such as impacts on life expectation).

 

Other skews may exist in the distribution of the costs and benefits of interventions across ‘stakeholders’ that create inequity, as when workplace interventions have costs that fall mainly on owners and benefits that fall mainly on workers [53]. Institutional biases may cut across a myriad of domains, including the highest institutional levels such as health ministries, within agencies conducting technology appraisals, in provider institutions, in workplaces and other locations of care or intervention.

 

Implicit stereotyping

Implicit stereotyping occurs when assumptions are made about a condition and the desirability of treating it so as to ascribe those living with that condition as ‘abnormal’ or ‘undesirable’ [54]. For example, individuals who are deaf like to consider themselves as a group distinguished not only by deafness but also by a language (Sign) and resist the descriptor ‘disabled’ on the grounds that deafness is, in effect, a socially-constructed ‘disability’, and therefore need not be ‘treated’. Implicit stereotyping is especially likely when the culture of the ‘patient’ differs from that of the analyst. A dramatic example of the way in which ‘disease’ can be socially constructed is pinta (dyschromic spirochaetosis). This skin disease produces distinctive rose-coloured spots on the skin, which some Indians in South America once believed to be a sign of being healthy, and which was so prevalent among some tribes that the few single men not suffering from it were regarded as pathological to the point of being excluded from marriage [55][11]. To treat it therefore according to concepts of disease which are external to that culture is likely to imply that the value of treatment thus estimated would conflict with a value based on local Indian concepts and values. The danger for HTA in implicit stereotyping is that the externally perceived health gain relative to that perceived by the patient can be substantially different, and subsequent implementation becomes patronising or even stigmatizing.

 

Implicit stereotyping may be particularly expected for congenital and other chronic conditions. A check is actually to ask the target populations concerned through consultation and deliberation whether the measure or conceptualization of the health benefit or state is biased – or whether there may some members of the target group for whom this might be the case.

 

Contexts, behaviours and circumstances

This category includes aspects of the context of technology use that could, at least in principle, disadvantage some people relative to others (e.g. traveling from a remote home to a clinic or hospital) and thereby render an intervention cost-effective for one group but not for another (e.g. [31]). Any of the following circumstances could affect the balance of negative and positive consequences: demographics (age, sex, ethnicity, socio-economic status (SES)), location of delivery of care (e.g. home or institution), language, religious beliefs, sexual orientation, or multiple deprivation.

 

Some effects occur in unanticipated ways. For example, it was found in Rich et al. (1976) that the reliability of self-administered dipslide measures of bacteriuria taken at home by girls without symptoms varied significantly with the age and socio-economic status of the children performing the tests compared with costlier supervised sampling of the same girls [57]. In such cases, the cost-effectiveness of an intervention that is in all other respects the same will be higher for the younger and/or lower SES children.

 

There is considerable evidence that differential behavioural responses to public health measures according to SES may actually contribute in an unintended way to inequity, especially when utilization of an intervention is lower among more disadvantaged and ‘hard-to-reach’ populations or by ethnic minorities [8]. It can be all-pervading, for which the term