Construct Validity, Reliability, and Responsiveness of the 10-Item Well-Being Instrument for Use in Economic Evaluation Studies.

OBJECTIVES: Economic evaluations of interventions in health and social care require outcome measures that capture their full benefits, including those beyond health. This study aimed to assess construct validity, test-retest reliability, and responsiveness of the newly developed 10-item Well-being instrument (WiX). METHODS: Data were gathered via an online survey in a representative sample of the adult general population in The Netherlands (N = 1045). Construct validity was assessed by inspecting convergent, structural, and discriminant validity, following the COnsensus-based Standards for the selection of health status Measurement INstruments methodology. Regression analyses of the WiX and its items on other validated measures of well-being were performed to assess the convergent validity of the instrument and the relevance of its items. Dimensionality of the WiX was assessed using exploratory factor analysis. To assess discriminant validity, several hypotheses in terms of well-being differences were assessed. Finally, a second survey was sent out 2 weeks after the initial survey (n = 563; 53.9% response rate) to assess the test-retest reliability and responsiveness of the WiX. RESULTS: The WiX showed to be correlated with alternative well-being measures as expected and able to sufficiently differentiate between relevant subgroups in the population. Moreover, the dimensionality analysis indicated that the WiX captures a broad array of elements relevant to well-being, including physical and mental health. The test-retest reliability was good, with an intraclass correlation coefficient of 0.82. CONCLUSIONS: The results regarding the WiX are favorable and indicate that this new instrument may be a promising alternative for existing measures of well-being for evaluating interventions in health and social care.

On spillovers in economic evaluations: definition, mapping review and research agenda.

An important issue in economic evaluations is determining whether all relevant impacts are considered, given the perspective chosen for the analysis. Acknowledging that patients are not isolated individuals has important implications in this context. Increasingly, the term "spillovers" is used to label consequences of health interventions on others. However, a clear definition of spillovers is lacking, and as a result, the scope of the concept remains unclear. In this study, we aim to clarify the concept of spillovers by proposing a definition applicable in health economic evaluations. To illustrate the implications of this definition, we highlight the diversity of potential spillovers through an expanded impact inventory and conduct a mapping review that outlines the evidence base for the different types of spillovers. In the context of economic evaluations of health interventions, we define spillovers as all impacts from an intervention on all parties or entities other than the users of the intervention under evaluation. This definition encompasses a broader range of potential costs and effects, beyond informal caregivers and family members. The expanded impact inventory enables a systematic approach to identifying broader impacts of health interventions. The mapping review shows that the relevance of different types of spillovers is context-specific. Some spillovers are regularly included in economic evaluations, although not always recognised as such, while others are not. A consistent use of the term "spillovers", improved measurement of these costs and effects, and increased transparency in reporting them are still necessary. To that end, we propose a research agenda.

Stakeholder perspectives on payment reform in maternity care in the Netherlands: A Q-methodology study.

Based on theoretical notions, there is consensus that alternative payment models to the common fee-for-service model have the potential to improve healthcare quality through increased collaboration and reduced under- and overuse. This is particularly relevant for maternity care in the Netherlands because perinatal mortality rates are relatively high in comparison to other Western countries. Therefore, an experiment with bundled payments for maternity care was initiated in 2017. However, the uptake of this alternative payment model remains low, as also seen in other countries, and fee-for-service models prevail. A deeper understanding of stakeholders' perspectives on payment reform in maternity care is necessary to inform policy makers about the obstacles to implementing alternative payment models and potential ways forward. We conducted a Q-methodology study to explore perspectives of stakeholders (postpartum care managers, midwives, gynecologists, managers, health insurers) in maternity care in the Netherlands on payment reform. Participants were asked to rank a set of statements relevant to payment reform in maternity care and explain their ranking during an interview. Factor analysis was used to identify patterns in the rankings of statements. We identified three distinct perspectives on payment reform in maternity care. One general perspective, broadly supported within the sector, focusing mainly on outcomes, and two complementary perspectives, one focusing more on equality and one focusing more on collaboration. This study shows there is consensus among stakeholders in maternity care in the Netherlands that payment reform is required. However, stakeholders have different views on the purpose and desired design of the payment reform and set different conditions. Working towards payment reform in co-creation with all involved parties may improve the general attitude towards payment reform, may enhance the level of trust among stakeholders, and may contribute to a higher uptake in practice.

Participatory Value Evaluation (PVE): A New Preference-Elicitation Method for Decision Making in Healthcare.

Participatory value evaluation (PVE) has recently been introduced in the field of health as a new method to elicit stated preferences for public policies. PVE is a method in which respondents in a choice experiment are presented with various policy options and their attributes, and are asked to compose their portfolio of preference given a public-resource constraint. This paper aims to illustrate PVE's potential for informing healthcare decision making and to position it relative to established preference-elicitation methods. We first describe PVE and its theoretical background. Next, by means of a narrative review of the eight existing PVE applications within and outside the health domain, we illustrate the different implementations of the main features of the method. We then compare PVE to several established preference-elicitation methods in terms of the structure and nature of the choice tasks presented to respondents. The portfolio-based choice task in a PVE requires respondents to consider a set of policy alternatives in relation to each other and to make trade-offs subject to one or more constraints, which more closely resembles decision making by policymakers. When using a flexible budget constraint, respondents can trade-off their private income with public expenditures. Relative to other methods, a PVE may be cognitively more demanding and is less efficient; however, it seems a promising complementary method for the preference-based assessment of health policies. Further research into the feasibility and validity of the method is required before researchers and policymakers can fully appreciate the advantages and disadvantages of the PVE as a preference-elicitation method.

Production Losses due to Absenteeism and Presenteeism: The Influence of Compensation Mechanisms and Multiplier Effects.

BACKGROUND: Productivity costs can form a large and influential component of total costs in an economic evaluation taking a societal perspective. In calculating productivity costs, estimating productivity losses is a central element. Compensation mechanisms and multiplier effects may influence these losses but remain understudied. Compensation mechanisms could reduce productivity losses while multiplier effects may increase them. METHODS: Data on productivity losses were collected in 2015 using an online survey among a sample of persons aged 15-65 years in The Netherlands who worked at least 12 h per week and reported to have experienced absenteeism and/or presenteeism during the past 4 weeks. A total of 877 respondents completed the survey that contained questions on productivity losses, compensation mechanisms, and multiplier effects. RESULTS: We found that 45.5% of the respondents reported absenteeism (average 6.5 days) during the past 4 weeks, losing on average 48.7 working hours, while presenteeism was experienced by 75.9% of respondents, with an average loss of 10.7 working hours. Compensation mechanisms were reported by 76.9% of respondents, compensating almost 80% of their lost production, while multiplier effects were reported by 23.6% of respondents, reducing the productivity of 4.2 colleagues by 27.8% on average, implying a multiplier of 2.1 in that subgroup. CONCLUSIONS: This study highlights that compensation mechanisms and multiplier effects are common and may substantially affect production losses. Investigating these mechanisms and effects further, as well as their interactions, remains important. Translating these findings into productivity cost calculations in economic evaluations is not straightforward and requires attention, especially since compensation mechanisms may not be costless and, for multiplier effects, the value of hours of colleagues may not be similar to that of the person experiencing health problems.

Preferences for investment in and allocation of additional healthcare capacity.

Policy makers need to make decisions regarding the allocation of scarce healthcare resources. We study preferences for investment in additional healthcare capacity and allocation between two regions, focusing on reducing waiting time for elective surgery for a physical health problem. We elicit preferences from a societal and an individual perspective, with unequal initial waiting times between the two regions. In an online survey, 1039 respondents were randomly assigned to one of three versions of the experiment: (1) a social planner perspective, placing respondents in the role of a policy maker; (2) an individual perspective where the respondent's own region was better off regarding initial waiting times; (3) an individual perspective where the individual's own region was worse off regarding initial waiting times. Respondents were asked to rank the status quo and five scenarios where the investment in additional capacity led to different distributions of shorter waiting times between regions. For all allocations we presented both the reduction in waiting time and the resulting final waiting time for both regions. We find that in version 1 of the experiment, preferences were in line with inequality aversion and Rawlsian preferences regarding final waiting time. In version 3, similar preferences were found, although here they also align with individualistic preferences. In version 2, preferences were more heterogeneous, with both individualistic and egalitarian preferences present. Concluding, individualistic and egalitarian preferences mostly concerned final waiting time. We therefore recommend policy makers to focus on the effect on final waiting time instead of the reduction of waiting time.

Estimating an anchored utility tariff for the well-being of older people measure (WOOP) for the Netherlands.

OBJECTIVE: Health economic evaluations using common health-related quality of life measures may fall short in adequately incorporating all relevant benefits of health and social care interventions targeted at older people. The Well-being of Older People measure (WOOP) is a broader well-being measure that comprises nine well-being domains. The objective of this study was to estimate a utility tariff for the WOOP, to facilitate its application in cost-utility analyses. METHODS: A discrete choice experiment (DCE) with duration approach was set up and fielded among 2,012 individuals from the Netherlands aged 65 years and above. Matched pairwise choice tasks, colour-coding and level overlap were used to reduce the cognitive burden of the DCE. The choice tasks were created using a Bayesian heterogeneous D-efficient design. The estimation procedure accommodated for nonlinear time preferences via an exponential discounting function. RESULTS: The estimation results showed that 'physical health', 'mental health', and 'making ends meet' were the most important well-being domains for older people, followed by 'independence' and 'living situation'. Of somewhat lesser importance were domains like 'social life', 'receiving support' and 'feeling useful'. The generated utility tariffs can be used to translate well-being states described with the WOOP to a utility score between -0.616 and 1. CONCLUSIONS: This study established a tariff for the WOOP, which will facilitate its use in economic evaluations of health and social care interventions targeted at older people, first of all in the Netherlands.

Viewpoints among experts and the public in the Netherlands on including a lifestyle criterion in the healthcare priority setting.

CONTEXT: It remains unclear whether there would be societal support for a lifestyle criterion for the healthcare priority setting. This study examines the viewpoints of experts in healthcare and the public regarding support for a lifestyle-related decision criterion, relative to support for the currently applied criteria, in the healthcare priority setting in the Netherlands. METHODS: We conducted a Q methodology study in samples of experts in healthcare (n = 37) and the public (n = 44). Participants (total sample N = 81) ranked 34 statements that reflected currently applied decision criteria as well as a lifestyle criterion for setting priorities in healthcare. The ranking data were subjected to principal component analysis, followed by oblimin rotation, to identify clusters of participants with similar viewpoints. FINDINGS: We identified four viewpoints. Participants with Viewpoint 1 believe that treatments that have been proven to be effective should be reimbursed. Those with Viewpoint 2 believe that life is precious and every effort should be made to save a life, even when treatment still results in a very poor state of health. Those with Viewpoint 3 accept government intervention in unhealthy lifestyles and believe that individual responsibility should be taken into account in reimbursement decisions. Participants with Viewpoint 4 attribute importance to the cost-effectiveness of treatments; however, when priorities have to be set, treatment effects are considered most important. All viewpoints were supported by a mix of public and experts, but Viewpoint 1 was mostly supported by experts and the other viewpoints were mostly supported by members of the public. CONCLUSIONS: This study identified four distinct viewpoints on the healthcare priority setting in the Netherlands, each supported by a mix of experts and members of the public. There seems to be some, but limited, support for a lifestyle criterion-in particular, among members of the public. Experts seem to favour the decision criteria that are currently applied. The diversity in views deserves attention when policymakers want to adhere to societal preferences and increase policy acceptance.

To what extent do citizens support the disinvestment of healthcare interventions? An exploration of the support for four viewpoints on active disinvestment in the Netherlands.

BACKGROUND: Active disinvestment of healthcare interventions (i.e. discontinuing reimbursement by means of a policy decision) has received limited public support in the past. Previous research has identified four viewpoints on active disinvestment among citizens in the Netherlands. However, it remained unclear how strong these viewpoints are supported by society, and by whom. Therefore, the current study aimed to 1) measure the support for these four viewpoints and 2) assess whether support is associated with background characteristics of citizens. METHOD: In an online survey, a representative sample of adult citizens in the Netherlands (n = 1794) was asked to rate their agreement with short narratives of the four viewpoints on a 7-point Likert scale. The survey also included questions on sociodemographic characteristics, health status, healthcare utilization, and opinions about responsibility and costs in the healthcare context. Logistic regression models were estimated for each viewpoint to assess the association between viewpoint support and these characteristics. RESULTS: The support for the different viewpoints varied between 46.8% and 57.7% of the sample. Viewpoint support was associated with participants' age, gender, educational level, financial situation, healthcare utilization, opinion on the responsibility of the government for the health of citizens, and opinion on whether the increase in healthcare expenditure and health insurance premiums is considered a problem. CONCLUSION: Resistance to active disinvestment may partially be explained by the consequences of disinvestment citizens anticipate experiencing themselves. Citizens considering the increase in healthcare expenditure a larger problem were more supportive of disinvestment than those considering it less of a problem.

Good Days and Bad Days: Measuring Health-Related Quality of Life in People With Epilepsy.

OBJECTIVES: Cost-effectiveness analyses typically require measurement of health-related quality of life (HRQoL) to estimate quality-adjusted life-years. Challenges with measuring HRQoL arise in the context of episodic conditions if patients are less likely-or even unable-to complete surveys when having disease symptoms. This article explored whether HRQoL measured at regular time intervals adequately reflects the HRQoL of people with epilepsy (PWE). METHODS: Follow-up data from the Epilepsy Support Dog Evaluation study on the (cost-)effectiveness of seizure dogs were used in which HRQoL is measured in 25 PWE with the EQ-5D at baseline and every 3 months thereafter. Seizure count is recorded daily using a seizure diary. Regression models were employed to explore whether PWE were more likely to complete the HRQoL survey on a good day (ie, when seizures are absent or low in frequency compared with other days) and to provide an estimate of the impact of reporting HRQoL on a good day on EQ-5D utility scores. RESULTS: A total of 111 HRQoL measurements were included in the analyses. Regression analyses indicated that the day of reporting HRQoL was associated with a lower seizure count (P<.05) and that a lower seizure count was associated with a higher EQ-5D utility score (P<.05). CONCLUSIONS: When HRQoL is measured at regular time intervals, PWE seem more likely to complete these surveys on good days. Consequently, HRQoL might be overestimated in this population. This could lead to underestimation of the effectiveness of treatment and to biased estimates of cost-effectiveness.

Willingness to Pay for Health-Related Quality of Life Gains in Relation to Disease Severity and the Age of Patients.

OBJECTIVES: Decision-making frameworks that draw on economic evaluations increasingly use equity weights to facilitate a more equitable and fair allocation of healthcare resources. These weights can be attached to health gains or reflected in the monetary threshold against which the incremental cost-effectiveness ratios of (new) health technologies are evaluated. Currently applied weights are based on different definitions of disease severity and do not account for age-related preferences in society. However, age has been shown to be an important equity-relevant characteristic. This study examines the willingness to pay (WTP) for health-related quality of life (QOL) gains in relation to the disease severity and age of patients, and the outcome of the disease. METHODS: We obtained WTP estimates by applying contingent-valuation tasks in a representative sample of the public in The Netherlands (n = 2023). We applied random-effects generalized least squares regression models to estimate the effect of patients' disease severity and age, size of QOL gains, disease outcome (full recovery/death 1 year after falling ill), and respondent characteristics on the WTP. RESULTS: Respondents' WTP was higher for more severely ill and younger patients and for larger-sized QOL gains, but lower for patients who died. However, the relations were nonlinear and context dependent. Respondents with a lower age, who were male, had a higher household income, and a higher QOL stated a higher WTP for QOL gains. CONCLUSIONS: Our results suggest that-if the aim is to align resource-allocation decisions in healthcare with societal preferences-currently applied equity weights do not suffice.

Willingness to pay for quality and length of life gains in end of life patients of different ages.

Health gains are increasingly weighted in economic evaluations of new health technologies to guide resource-allocation decisions in healthcare. In Norway and the Netherlands weights are, for example, based on the disease severity of patients. In England and Wales, a higher weight is attached to quality-adjusted life-years (QALYs) gained from life-extending end-of-life (EOL) treatments. Societal preferences for QALY gains in EOL patients are increasingly examined. Although the available evidence suggests that gains in health-related quality of life (QOL) may be preferred to gains in life expectancy (LE), little is known about the influence of EOL patients' age on these preferences. In this study, we examine the willingness to pay (WTP) for QOL and LE gains in EOL patients of different ages in a sample (n = 803) of the general public in the Netherlands. We found that WTP was relatively higher for QOL and LE gains in younger EOL patients. We further found indications suggesting that WTP may be relatively higher for QOL gains at the EOL, except for patients aged 20 for whom we observed a higher WTP for LE gains. Our results may inform discussions on attaching differential weights to QOL and LE gains in EOL patients of different ages with the objective to better align resource-allocation decisions with societal preferences.

The value of health-Empirical issues when estimating the monetary value of a quality-adjusted life year based on well-being data.

Decisions on interventions or policy alternatives affecting health can be informed by economic evaluations, like cost-benefit or cost-utility analyses. In this context, there is a need for valid estimates of the monetary equivalent value of health (gains), which are often expressed in € per quality-adjusted life years (QALYs). Obtaining such estimates remains methodologically challenging, with a recent addition to the health economists' toolbox, which is based on well-being data: The well-being valuation approach. Using general population panel data from Germany, we put this approach to the test by investigating several empirical and conceptual challenges, such as the appropriate functional specification of income utility, the choice of health utility tariffs, or the health state dependence of consumption utility. Depending on specification, the bulk of estimated € per QALY values ranged from €20,000-60,000, with certain specifications leading to more considerable deviations, underlining persistent practical challenges when applying the well-being valuation methodology to health and QALYs. Based on our findings, we formulate recommendations for future research and applications.

What influences the outcome of active disinvestment processes in healthcare? A qualitative interview study on five recent cases of active disinvestment.

BACKGROUND: Recent attempts of active disinvestment (i.e. withdrawal of reimbursement by means of a policy decision) of reimbursed healthcare interventions in the Netherlands have differed in their outcome: some attempts were successful, with interventions actually being disinvested. Other attempts were terminated at some point, implying unsuccessful disinvestment. This study aimed to obtain insight into recent active disinvestment processes, and to explore what aspects affect their outcome. METHODS: Semi-structured interviews were conducted from January to December 2018 with stakeholders (e.g. patients, policymakers, physicians) who were involved in the policy process of five cases for which the full or partial withdrawal of reimbursement was considered in the Netherlands between 2007 and 2017: benzodiazepines, medication for Fabry disease, quit smoking programme, psychoanalytic therapy and maternity care assistance. These cases covered both interventions that were eventually disinvested and interventions for which reimbursement was maintained after consideration. Interviews were transcribed verbatim, double coded and analyzed using thematic analysis. RESULTS: The 37 interviews showed that support for disinvestment from stakeholders, especially from healthcare providers and policymakers, strongly affected the outcome of the disinvestment process. Furthermore, the institutional role of stakeholders as legitimized by the Dutch health insurance system, their financial interests in maintaining or discontinuing reimbursement, and the possibility to relieve the consequences of disinvestment for current patients affected the outcome of the disinvestment process as well. A poor organization of patient groups may make it difficult for patients to exert pressure, which may contribute to successful disinvestment. No evidence was found of a consistent role of the formal Dutch package criteria (i.e. effectiveness, cost-effectiveness, necessity and feasibility) in active disinvestment processes. CONCLUSIONS: Contextual factors as well as the possibility to relieve the consequences of disinvestment for current patients are important determinants of the outcome of active disinvestment processes. These results provide insight into active disinvestment processes and their determinants, and provide guidance to policymakers for a potentially more successful approach for future active disinvestment processes.

Estimating the monetary value of health and capability well-being applying the well-being valuation approach.

BACKGROUND: Quality of life measures going beyond health, like the ICECAP-A, are gaining importance in health technology assessment. The assessment of the monetary value of gains in this broader quality of life is needed to use these measurements in a cost-effectiveness framework. METHODS: We applied the well-being valuation approach to calculate a first monetary value for capability well-being in comparison to health, derived by ICECAP-A and EQ-5D-5L, respectively. Data from an online survey administered in February 2018 to a representative sample of UK citizens aged 18-65 was used (N = 1512). To overcome the endogeneity of income, we applied an instrumental variable regression. Several alternative model specifications were calculated to test the robustness of the results. RESULTS: The base case empirical estimate for the implied monetary value of a year in full capability well-being was £66,597. The estimate of the monetary value of a QALY, obtained from the same sample and using the same methodology amounted to £30,786, which compares well to previous estimates from the willingness to pay literature. Throughout the conducted robustness checks, the value of capability well-being was found to be between 1.7 and 2.6 times larger than the value of health. CONCLUSION: While the applied approach is not without limitations, the generated insights, especially concerning the relative magnitude of valuations, may be useful for decision-makers having to decide based on economic evaluations using the ICECAP-A measure or, to a lesser extent, other (capability) well-being outcome measures.

United but divided: Policy responses and people's perceptions in the EU during the COVID-19 outbreak.

To understand the public sentiment toward the measures used by policymakers for COVID-19 containment, a survey among representative samples of the population in seven European countries was carried out in the first two weeks of April 2020. The study addressed people's support for containment policies, worries about COVID-19 consequences, and trust in sources of information. Citizens were overall satisfied with their government's response to the pandemic; however, the extent of approval differed across countries and policy measures. A north-south divide in public opinion was noticeable across the European states. It was particularly pronounced for intrusive policy measures, such as mobile data use for movement tracking, economic concerns, and trust in the information from the national government. Considerable differences in people's attitudes were noticed within countries, especially across individual regions and age groups. The findings suggest that the epidemic acts as a stressor, causing health and economic anxieties even in households that were not directly affected by the virus. At the same time, the burden of stress was unequally distributed across regions and age groups. Based on the data collected, we draw lessons from the containment stage and identify several insights that can facilitate the design of lockdown exit strategies and future containment policies so that a high level of compliance can be expected.

Well-being of Older People (WOOP): Quantitative validation of a new outcome measure for use in economic evaluations.

There is a need for comprehensive measures to evaluate the benefits of health and social care services for older people. The newly developed Well-being of Older People measure (WOOP) aims to capture all aspects that older people find important to their well-being. This study explores the validity and test-retest reliability of the WOOP. Between December 2017 and January 2018, an online survey was used to retrieve data from 1113 people aged 65 years and older in the Netherlands. Regression analyses on Cantril's Ladder scores were conducted to explore the relative importance of the items of the WOOP. Dimensionality was checked using exploratory factor analysis. Convergent and discriminant validity were investigated by relating the WOOP to several measures of health and well-being. Test-retest reliability was examined using data from 269 respondents that participated in a second online survey, distributed one week after the first. The items of the WOOP were significantly associated with Cantril's Ladder scores. When regressed simultaneously this was still true for all but the 'social contacts' item and one level of the 'acceptance and resilience' item. The dimensionality analysis revealed three factors, of which two included items of the WOOP and the EQ-5D-5L and the third only items of the WOOP. The WOOP correlated moderately to highly with physical health, and (very) highly with (mental) health and well-being measures. The test-retest reliability in terms of ICC was high, whereas the kappa for the items was fair to good, except for two items. Overall, the WOOP seems to capture aspects relevant to the well-being of older people adequately, and the results of first validity and reliability tests were satisfactory. Before the WOOP can be used in economic evaluations, further validation in a variety of health and social care settings is recommended, and utility weights need to be determined.

Happy with Your Capabilities? Valuing ICECAP-O and ICECAP-A States Based on Experienced Utility Using Subjective Well-Being Data.

Background. The ICECAP-O and the ICECAP-A are validated capability well-being instruments. To be used in economic evaluations, multidimensional instruments require weighting of the distinguished well-being states. These weights are usually obtained through ex ante preference elicitation (i.e., decision utility) but could also be based on experienced utility. Objective. This article describes the development of value sets for ICECAP-O and ICECAP-A based on experienced utility and compares them with current decision utility weights. Methods. Data from 2 cross-sectional samples corresponding to the target groups of ICECAP-O and ICECAP-A were used in 2 separate analyses. The utility impacts of ICECAP-O and ICECAP-A levels were assessed through regression models using a composite measure of subjective well-being as a proxy for experienced utility. The observed utility impacts were rescaled to match the 0 to 1 range of the existing value set. Results. The calculated experienced utility values were similar to the decision utility weights for some of the ICECAP dimensions but deviated for others. The largest differences were found for weights of the ICECAP-O dimension enjoyment and the ICECAP-A dimensions attachment and autonomy. Conclusions. The results suggest a different weighting of ICECAP-O and ICECAP-A levels if experienced utility is used instead of decision utility.

Willingness to pay for an early warning system for infectious diseases.

Early warning systems for infectious diseases and foodborne outbreaks are designed with the aim of increasing the health safety of citizens. As a first step to determine whether investing in such a system offers value for money, this study used contingent valuation to estimate people's willingness to pay for such an early warning system in six European countries. The contingent valuation experiment was conducted through online questionnaires administered in February to March 2018 to cross-sectional, representative samples in the UK, Denmark, Germany, Hungary, Italy, and The Netherlands, yielding a total sample size of 3140. Mean willingness to pay for an early warning system was €21.80 (median €10.00) per household per month. Pooled regression results indicate that willingness to pay increased with household income and risk aversion, while they decreased with age. Overall, our results indicate that approximately 80-90% of people would be willing to pay for an increase in health safety in the form of an early warning system for infectious diseases and food-borne outbreaks. However, our results have to be interpreted in light of the usual drawbacks of willingness to pay experiments.