Rev Esp Salud Pblica 2015;89: 119-123. N.

2- March-April 2015

EDITORIAL

PALS DONT EVALUATE PALS OR DO THEY?

Beatriz Gonzlez Lpez Valcrcel (1) and Vicente Ortn (2).

(1) Department of Quantitative Methods in Economics and Management. University of Las Palmas
de Gran Canaria. Las Palmas. Spain.
(2) Department of Economics and Business. Center for Research in Economics and Health. University
Pompeu Fabra. Barcelona. Spain.

Pals dont evaluate pals. Although the We organize our comments under the fo-
comment was traded at the pissoir in a health llowing headings: 1 / Give to Caesar what
administration facility many years ago, its is Caesars, 2 / Avoidable myopia of unduly
memory has always accompanied the author bounded economic evaluation (explicit or im-
most susceptible to use that type of toilets. plicit silos), and 3/ How to translate evalua-
The claim belongs to the type of heartfelt and tion knowledge into policy.
shocking statements such as democracy
raises crime: Its time for security companies TO CAESAR WHAT IS CAESARS...
to disembark in Spain heard very early in the
early post-francoist period at an airport- that It is good that scientific articles tend to
time seems to have ratified. Pals dont eva- include in their discussion the need for addi-
luate pals. tional research; at the very least it should be
useful to the authors. But just as there is non-
In this editorial we tackle the most sen- scientifically based innovation (container, pa-
sitive and controversial issues in economic lette, surgical check-list ...) the correct mea-
evaluation on the basis of three special colla- surement of social values and preferences can
borations1-3 seeking to increase the validity, also be obtained by means of the responsible
transferability and reproducibility of econo- participation of the citizenship: All of us, not
mic evaluation and published by Rev Esp just the beneficiary segment, when it comes
Salud Pub. Although the experts convened do to establishing priorities for the allocation of
not always reach consensus, the selection of publicly funded resources.
problems they single out is of value in itself:
the use of different perspectives, costs, health The threshold of social willingness to pay
outcomes and the extra value of end of life per year of quality-adjusted life based on ra-
treatments and rare diseases. Both the terms tios of incremental cost-effectiveness cant be
of discussion and the improvement proposals the sole criterion governing public decisions.
are useful. First, because decision-makers are concerned
about other objectives besides maximizing
Correspondencia
Vicente Ortn health (whether equity, the impact on public
Universidad Pompeu Fabra
vicente.ortun@upf.edu
opinion or the trade deficit) and second, be-
cause we citizens are also concerned about
DOI: other objectives. It is worth trying to collect,
 Beatriz Gonzlez Lpez Valcrcel et al.

weigh and scientifically assess other objec- helpless and potential functional illiterate in-
tives such as preventing further damage in fant focusing in its early years, even in ute-
the future, encourage scientific and technical ro (fetal alcohol syndrome), as it seems that
innovation, treat the socially disadvantaged, as much for health/welfare reasons as for jus-
look after the end of life or be sensitive to tice, no public investment exceeds the one in
rare diseases. The articles commented gather education5, particularly elementary and pres-
the advancements along those lines, advances chool education, since it facilitates equality of
that must be complemented, even replaced, opportunity, prevents poverty from becoming
with an institutional change promoting the dynastic and mobilizes the best human resou-
legitimacy of the decision-making process to rces without discrimination by social class6.
arouse a wider social agreement as the results To be sure, it would appear to be much more
of the economic evaluation are perceived as a cost-effective than two million euros per
reflection of social preferences. Considering quality-adjusted life year with lapatinib as
the lability and time-inconsistency of prefe- second-line breast cancer treatment ( 18,299
rences, the role of emotions, and the relative for 0.3 months, 732,000 by twelve months,
ignorance about how such preferences are ge- 2,000,000 per year if you take into account
nerated and, on the other hand, the knowledge the low quality of the ten days gained).7 Sta-
about the framing effect choices depending ted more generally: if we are concerned with
on how the problem is formulated and about health, action shall be taken on its most vul-
the important limits to rationality, credit is nerable determinants and there where greater
due to Sciences God but we must render unto efficiency would be achieved. But while the
the social functioning Caesar the practical methods for the economic evaluation of hard
measures for its improvement. technologies have been gradually standardi-
zed (the three articles that we comment are
AVOIDABLE MYOPIC an example), the public health policy impact
ECONOMIC EVALUATION assessment and the cost-effectiveness analy-
sis of public health community interventions
Economic evaluation is applied to a disea- are still methodologically wide open, suffer
se or group of diseases within a healthcare from inference technical problems, its exter-
context when alternative uses of public resou- nal validity is doubtful, because human be-
rces are in housing, transport and education. havior comes into play, which is much more
This short-sightedness when accompanied by uncertain and variable than the physiological
a tunnel vision, as fostered by a silos analy- parameters of human organs, and there are
sis, produces virtual blindness. The specific no incentives to finance the necessary studies
funding for antiviral therapy for hepatitis C because no exploitable patents would result
a much of a silo as the consideration in isola- from them.
tion of health benefits (Pharmacy, hospitaliza-
tion, primary ...) as if they were not substitu- FROM KNOWLEDGE
table among them, or the cancer silos that the TO IMPLEMENTATION
United Kingdom is beginning to reconsider.4
The silo enshrines the denial of the very basic Spain has advanced significantly more on
concept of always taking into account the be- knowing how to evaluate correctly, and doing
nefit we lose in the best available alternative. so, than in translating that knowledge into ac-
tion. We have more health technology evalua-
Without reaching the silo extremes, we tion agencies than any other country and since
incur myopia when we compare the chroni- the Medicines Act of 19908 there is a regula-
cally healthy child and chronically healthy tory framework for the economic evaluation
girl programs, since it appears that, if we of pharmaceuticals, extended to other benefits
were to follow the moral imperative of effi- by Royal Decree 1030/20069 and revalidated
ciency, we should analyze the program of the

120 Rev Esp Salud Pblica 2015. Vol. 89, N.2

 PALS DONT EVALUATE PALSOR DO THEY?

by Royal Decree-Law 16/201210. So despite and budgetary discipline functions. In seven

the existence of an important evaluative ca- years of work, GENESIS has issued over 1,000
pacity, major difficulties in the political arena evaluation reports, in contrast with the seven
(transparency, governance) prevent incorpo- therapeutic positioning official reports appro-
rating economic evaluation into healthcare ved in two years.
decisions, as argued by Artells, Peir and Me-
neu11. In hindsight, it is surprising that Spain The introduction of formal cost-effective-
has resisted the generalized regulatory move- ness criteria coverage and reimbursement de-
ment introduced in Europe by the fourth gua- cisions, and its institutionalization, should not
rantee (in 15 European countries, economic be delayed any longer, because it diverts the
evaluation is formally required for reimburse- focus of the discussion from expenditures and
ment of drugs). The burden of proof seems, at cuts, which only see one side of the coin, to
this stage of XXIst century, on the side of the the balance between health expenditures and
Spanish regulator, which is the rare exception outcomes. The choice over which technolo-
in the European environment. gies and/or procedures must be publicly fun-
ded should be based on explicit criteria (How
Moreover, the explicit rationality in co- much are we willing to pay for improvements
verage and reimbursement decisions should in effectiveness measured, for example, in
relieve governments. It prevents arbitrariness quality-adjusted life years?) and be suppor-
and avoids the side effects of indiscriminate ted by economic evaluation techniques. But
linear cuts and hasty decisions spurred by it takes more than a mere reference to the
threats short term exogenously imposed criterion of cost-effectiveness in the written
spending cuts, fear of losing votes. A strong regulation. We must move from the theory to
and independent agency, NICE style, offers action.
clear advantages to any government: better
resilience to the blackmail and pressure of Meanwhile, the cost per quality adjus-
the patient groups dancing to the sound of ted life year has soared, particularly in the
the industrys music, enhanced purchasing treatment of some diseases such as cancer12
power, better prices for new therapies, and and orphan drugs and rare diseases13 that al-
provision of horizontal equity guarantees for ready represent 15% of pharmaceutical ex-
the citizens. Do not forget that the British penditure in Spain.
NICE was born to end the postal code effect:
depending on where you lived, you would re- On the other hand, cost-effectiveness cri-
ceive treatment or not. Thats why it is so sur- teria will be welcome when introduced, but
prising that this step has not been taken para- evaluation should go beyond these procedu-
llel to the evaluation of clinical or therapeutic res and understood in a wider context.
quality, where we have advanced (therapeutic Evaluation, in a broad sense, should take
positioning reports or hepatitis C strategic place in the context of citizens who aware of
plan hepatitis C). It seems, therefore, that the their decisions and who are provided a trans-
argument might not be that pals dont eva- parent account of the origin and destination of
luate pals. Paradoxically, in fact, it is the pals public resources. But, to which extent are we,
of hospital pharmacy services, from different the citizens, responsible for this lack of eva-
Spanish hospitals, who have set up an unoffi- luation? In Spain, as in Italy, a large majority
cial and horizontally coordinated tool with of the population (74.1%)14 believes that the
the GENESIS project (Grupo de Evaluacin de state has primary responsibility for ensuring a
Novedades, Estandarizacin y Seleccin de decent life for its citizens. This broad support
Medicamentos). The group GENESIS assesses for an active role of the state is compatible
new medicines and replaces, however preca- with the acceptance of the market economy
riously, the rationally containment spending as the best economic system although, again,

Rev Esp Salud Pblica 2015. Vol. 89, N. 2 121

Beatriz Gonzlez Lpez Valcrcel et al.

Spain is placed in the most critical position lend a hand it would be feasible a sovereign
in that respect among all the countries analy- prioritization, not at the mercy of commer-
zed in the study of the BBVA Foundation on cial interests expressed by very different rou-
values.14 Spains position clearly differs in tes: from patient associations to professional
relation to a key market economy element, groups going through social media. Economic
as is the income differentiation according to evaluation, however, has the characteristics of
individual effort. A majority of 54.7%14 advo- a public good and Spain could even benefit
cates, in Spain, for a more balanced income from the reports of other countries and even
regardless of personal effort. From here to the afford a moratorium on non-incorporation of
waste in high-speed train lines (AVE) to all the new technology during a period in order to
Tablancas in Sepharads bull-hide theres only resemble wealthier countries and, especially,
a step. There is little point in showing that the those with a welfare state more consolidated
Spanish investment in AVE is socially ruinous than the Spanish one.
even at the more favorable line from Barcelo-
na to Madrid15 (the passenger traffic/km is the Fortunately the winds of the European
twentieth part of the Tokyo-Osaka line or the Union seem to blow favorably since an econo-
sixth of the Paris-Lyon line). Political authori- mic evaluation is required to assess EU funded
ties will claim that what matters is social co- policies such as active employment policies.
hesion, which could be achieved by making The regeneration that seems to live our socie-
sure an AVE line reaches every village (and by ty, and the availability of competent professio-
creating a university and a hospital in each). nals with rigorous evaluation methods signal
The reality is quite the opposite: The AVE de- an opportunity to improve both the countrys
grades the conventional train supply and harms democratic quality and the social returns of
both cohesion and equity16. The Spanish case their public expenditure and investment. The-
is extreme: the largest network in the world in refore, ultimately, pals do evaluate pals.
relation to population, second, after China, in
absolute terms, without the high densities of REFERENCES
demand to make AVE viable. 1. Oliva J, Brosa M, Espn J, Figueras M, Trapero M y
Key4Value-Grupo I. Cuestiones controvertidas en evalua-
Quite possibly Arruada is right when, cin econmica (I): Perspectiva y costes en la evaluacin
precisely to promote civic responsibility, he econmica de intervenciones sanitarias. Rev Esp Salud
proposes not so much more government as Pub. 2015; 89: 5-14.
better government, for this purpose more 2. Trapero-Bertrn M, Brosa M, Espn J, Oliva J y Ke-
y4Value-Grupo II. Cuestiones controvertidas en evalua-
information on cost, performance and quali- cin econmica (II): Perspectiva y costes en la evaluacin
ty of public service would lead us to place as econmica de intervenciones sanitarias. Rev Esp Sal Pub.
much emphasis on social issues as we place 2015; 89: 125-135. Available at: http://www.msssi.gob.es/
on our neighbors issues17. Report on costs and biblioPublic/publicaciones/recursos_propios/resp/revis-
ta_cdrom/vol89/vol89_2/RS892C_MTB.pdf
returns involve recognizing people as adults in
a scheme of benchmark quality competition, 3. Espn J, Brosa M, Oliva J, Trapero-Bertrn M y Ke-
y4Value-GrupoIII. Cuestiones controvertidas en eva-
with common and regulated prices (not a price luacin econmica (III): La evaluacin econmica de
competition at the expense of a quality that the intervenciones sanitarias en tres situaciones especiales:
user doesnt perceive). Enfermedades raras, los tratamientos al final de la vida
y las externalidades en las evaluaciones. Rev Esp Salud
A broad evaluation involves adaptive as- Pub. 2015; 89(3): en prensa. Available at:http://www.
sessment to prices, effectiveness and changing msssi.gob.es/biblioPublic/publicaciones/recursos_pro-
pios/resp/revista_cdrom/vol89/vol89_3/RS893C_JEB.pdf
risks and particularly monitoring interventions
4. Gonzlez Lpez-Valcrcel B, Meneu R. Hepatitis C,
and technologies along time bearing in mind negociaciones de precios y otras inflamaciones. Boletn
that innovations, some disruptive, will not Economa y Salud. 2015; 82. Available at: http://www.aes.
cease, and only with a population willing to es/boletines/news.php?idB=23&idN=1337

122 Rev Esp Salud Pblica 2015. Vol. 89, N. 2

 PALS DONT EVALUATE PALSOR DO THEY?

5. Heckman J. The developmental origins of health.

Health Econ. 2012; 21: 24-29.
6. Garca-Alts A, Ortn V. Funcionamiento del ascensor
social en Espaa y posibles mejoras. Gac Sanit. 2014; 28
(S1): 31-36.
7. Oyagez I, Fras C, Segu MA, Gmez-Barrera M,
Casado MA y Queralt M. Eficiencia de tratamientos on-
colgicos para tumores slidos en Espaa. Farm Hosp.
2013; 37: 240-59.
8. Boletn Oficial del Estado. Ley 25/1990, de 20 de
diciembre, del Medicamento. BOE nm 306 de 22-12-
1990.
9. Boletn Oficial del Estado. Real Decreto 1030/2006,
de 15 de septiembre, por el que se establece la cartera
de servicios comunes del Sistema Nacional de Salud y
el procedimiento para su actualizacin. BOE nm 222
de 16-09-2006.
10. Boletn Oficial del Estado. Real Decreto-ley 16/2012,
de 20 de abril, de medidas urgentes para garantizar la
sostenibilidad del Sistema Nacional de Salud y mejorar
la calidad y seguridad de sus prestaciones. BOE nm 98
de 24-04-2012.
11. Artells JJ, Peir S, Meneu R. Barreras a la introduc-
cin de una agencia evaluadora para informar la finan-
ciacin o la desinversin de prestaciones sanitarias del
Sistema Nacional de Salud. Rev Esp Salud Pub. 2014;
88: 217-31.
12. Oyagez I, Fras C, Segu MA, Gmez-Barrera M,
Casado MA y Queralt M. Eficiencia de tratamientos on-
colgicos para tumores slidos en Espaa. Farm Hosp.
2013; 37: 240-59.
13. Campillo C y Peir S. (2009): Enfermedades raras,
medicamentos hurfanos: el valor de la orfandad. Gest
Cln Sanit. 2009; 11: 119-26.
14. Fundacin BBVA. Departamento de Estudios Socia-
les y Opinin Pblica. Values and Worldviews. Madrid:
Fundacin BBVA; 2013. Available at: http://www.fbbva.
es/TLFU/dat/Presentacionvalues.pdf
15. De Rus G. Economic evaluation of High Speed
Rail. Stockholm: Expert Group on Enviromental Stu-
dies; 2012. Available at:http://www.ems.expertgrupp.se/
uploads/documents/hsr.pdf
16. Albalate D, Bel G. La experiencia internacional en
alta velocidad ferroviaria. Documento de Trabajo 2015-
02. Madrid: Fedea; 2015. Available at: http://documen-
tos.fedea.net/pubs/dt/2015/dt2015-02.pdf
17. Arruada B. Ms o menos Estado? El Pas, 15 de
marzo del 2015.

Rev Esp Salud Pblica 2015. Vol. 89, N. 2 123