Four normative perspectives on public health policy-making and their preferences for bodies of evidence.

Calls for evidence-informed public health policy-making often ignore that there are multiple, and often competing, bodies of potentially relevant evidence to which policy-makers have recourse in identifying policy priorities and taking decisions. In this paper, we illustrate how policy frames may favour the use of specific bodies of evidence. For the sixth Dutch Public Health Status and Foresight report (2014), possible future trends in population health and healthcare expenditure were used as a starting point for a deliberative dialogue with stakeholders to identify and formulate the most important societal challenges for the Dutch health system. Working with these stakeholders, we expanded these societal challenges into four normative perspectives on public health. These perspectives can be regarded as policy frames. In each of the perspectives, a specific body of evidence is favoured and other types of evidence are neglected. Crucial outcomes in one body may be regarded as irrelevant from other perspectives. Consequently, the results of research from a single body of evidence may not be helpful in the policy-making processes because policy-makers need to account for trade-offs between all competing interests and values. To support these policy processes, researchers need to combine qualitative and quantitative methodologies to address different outcomes from the start of their studies. We feel it is time for the research community to re-politicise the idea of evidence use and for policy-makers to demand research that helps them to account for all health-related policy goals. This is a prerequisite for real evidence-informed policy-making.

The Public Health Status and Foresight report 2014: Four normative perspectives on a healthier Netherlands in 2040.

Policy-oriented foresight reports aim to inform and advise decision-makers. In value-laden areas such as public health and healthcare, deliberative scenario methods are clearly needed. For the sixth Dutch Public Health Status and Forecasts-report (PHSF-2014), a new approach of co-creation was developed aiming to incorporate different societal norms and values in the description of possible future developments. The major future trends in the Netherlands were used as a starting point for a deliberative dialogue with stakeholders to identify the most important societal challenges for public health and healthcare. Four societal challenges were identified: 1) To keep people healthy as long as possible and cure illness promptly, 2) To support vulnerable people and enable social participation, 3) To promote individual autonomy and freedom of choice, and 4) To keep health care affordable. Working with stakeholders, we expanded these societal challenges into four corresponding normative scenarios. In a survey the normative scenarios were found to be recognizable and sufficiently distinctive. We organized meetings with experts to explore how engagement and policy strategies in each scenario would affect the other three societal challenges. Possible synergies and trade-offs between the four scenarios were identified. Public health foresight based on a business-as-usual scenario and normative scenarios is clearly practicable. The process and the outcomes support and elucidate a wide range of strategic discussions in public health.

[How much should a gained life-year cost? Study on the assessment of a QALY]. / Hoeveel mag een gewonnen levensjaar kosten? Onderzoek naar de waardering van de QALY.

Increasing healthcare costs force policy makers to make difficult choices in the insurance package. In order to make rational choices, there must be an understanding of the healthcare costs as well as the value of the health that the care provides. Health economists have in recent years carried out extensive research into the value that people attribute to health. Health is of great social value, and is difficult to express in concrete monetary terms. One extra life-year in good health ('quality-adjusted life year', QALY) seems to be valued on average at no less than 50,000 euros by people. Methodology needs to be developed in this area so that study results are more uniform and can be better compared. Physicians and policy makers will thus gain more insight into the value of health.

[Cost-effectiveness: euros per QALY is not enough]. / Kosteneffectiviteit: euro's per QALY is niet genoeg.

The number of economic evaluations being published in scientific literature each year is increasing exponentially. Cost-effectiveness seems to be playing an increasing role in decisions about reimbursement or the implementation of curative or preventive interventions. A cost-effectiveness ratio represents the fraction between the costs and effects that are associated with an intervention. What costs are included in the numerator of the fraction? What assumptions on effectiveness and reach are made to express the denominator? Various examples have shown that small differences in assumptions can have significant consequences for the cost-effectiveness ratio. This holds true for presumptions on the long-term effects of an intervention as well as the willingness to participate in an intervention. Such assumptions and choices can sometimes highly determine the outcome of a cost-effectiveness analysis. For this reason, caution in interpreting results of cost-effectiveness analyses is warranted.

[Diabetes mellitus in the Netherlands: estimate of the current disease burden and prognosis for 2025]. / Diabetes mellitus in Nederland: schatting van de huidige ziektelast en prognose voor 2025.

OBJECTIVE: To estimate the number of people with diagnosed diabetes mellitus in the Netherlands in 2007 using a new method; to describe trends in the past; to predict the situation in 2025. DESIGN: Model calculations. METHODS: Based on five general practice records (Nijmegen Continuous Morbidity Registration [CMR], Netherlands Information Network of General Practice [LINH], Limburg Family Practice Registration Network [RNH-Limburg], Registration Network University Family Practices, Leiden and its environs [RNUH-LEO], and the transition project) the prevalence and incidence of diagnosed diabetes in the Netherlands in 2007 was estimated. Trends in the prevalence of diagnosed diabetes were estimated from the five records over the period 2000-2007. The prevalence of diagnosed diabetes in 2025 was estimated using the Dutch Chronic Diseases Model, which takes into account demographic developments and a further increase in obesity in the Netherlands in the future. RESULTS: In 2007, 740,000 persons (95% CI: 665,000-824,000) with diabetes were undergoing care. The incidence of new diabetes during 2007 was 71,000 (95% CI: 57,000-90,000). The prevalence of diagnosed diabetes increased by almost 80% in 2000-2007. The model projection resulted in an estimate of 1.3 million people with diagnosed diabetes in 2025, i.e. 8% of the Dutch population. There is a high level of uncertainty about these estimates. CONCLUSION: The increase in the number of diabetes patients in 2025 has consequences for care and will require measures to be taken in coming years in the areas of prevalence and care organisation.