The OHE recently published two reports on the broader value of vaccination in the UK. One report introduced a framework consisting of ten value elements to measure the ‘broader value of vaccination’. Table 1 below illustrates that, to date, only five out of these ten value elements are likely to be considered by both the National Institute for Health and Care Excellence (NICE) and the Joint Committee on Vaccination and Immunisation (JCVI), with a sixth value element likely to be considered only by the JCVI. Productivity costs for patients and carers are not among the elements likely to be assessed.
Table 1: Value elements likely to be considered for vaccines when evaluated by JCVI or NICE
Subsequently, the authors selected a set of ten vaccines that are currently in the R&D pipeline and are expected to come to market in the UK within the next few years. For each vaccine, they answered the question: On which of the value elements could this vaccine, when proven safe and effective, potentially show added value? The results show that the vaccines analysed might potentially generate substantial value on elements that are not typically assessed as part of health technology assessment (HTA) in the UK. Hence, they are at risk of being undervalued and potentially underused.
This gap – between value generation and value recognition – is particularly prevalent for potential value related to the productivity of patients and caregivers. The OHE analysis showed that 60% of vaccines studied will likely have an impact on the productivity of the vaccinated individual, and 80% of vaccines on the productivity of caregivers.
Vaccines: a dose of productivity
Vaccines affect the wellbeing and health of the vaccinated individual, which in turn affects their productivity and sometimes also the productivity of their caregiver(s) in many ways. Initially, vaccine administration may lead to productive time lost, which can be offset in the longer term by productive time gained from preventing morbidity and premature mortality. Productivity costs can thus be defined as costs associated with production loss and replacement costs due to illness, disability and death of productive persons, both paid and unpaid.
The avoidance of long-term morbidity, disability and premature deaths from vaccine-preventable diseases unlock productivity gains in the working population. While this creates value inside the health sector, for example through reducing absenteeism and presenteeism among health care professionals, most of these benefits fall outside the health care system. From a governmental perspective, productivity losses per worker translate into lost revenue from direct and indirect taxes, sick pay and potential losses in informal care if replaced by public services. The second OHE report estimated these costs for a selection of vaccination programs that are a part of the immunisation schedule in England, and that had previously been shown to be cost-effective to the NHS. For pneumococcal disease and human papillomavirus vaccination programs, for example, the productivity losses averted made up over 75% of the total financial ROI.
Productivity value has been shown to be a significant component of the value of vaccines in various studies (Sevilla et al., 2020, 2019; Jit et al., 2015; Bärnighausen et al., 2012, 2011)and can even manifest in higher growth rates of per capita gross domestic product (GDP) (Masia et al., 2018). In light of the unprecedented economic downturn resulting from the COVID-19 pandemic, consideration of the productivity implications of vaccines is more needed than ever. Some countries, like the Netherlands, include productivity costs by evaluating health technologies from a societal perspective or, like Belgium, through analyses in addition to the base case scenario (ISPOR, 2020). So what are the underlying reasons to usually exclude productivity costs in other countries, like England? (NICE, 2013)
Productivity costs controversies and trade-offs
Controversies about whether and how to incorporate productivity costs in cost-effectiveness analyses go back decades (Koopmanschap and Rutten, 1993; Brouwer, Koopmanschap and Rutten, 1997b; Weinstein et al., 1997; Brouwer, Koopmanschap and Rutten, 1997a)and some of them are unresolved (Krol, Brouwer and Rutten, 2013). In the UK, there are several reasons why productivity costs are currently not considered in the appraisal of health technologies in general – and for vaccines in particular.
Firstly, due to the ring-fencing of the NHS budget, the cost-effectiveness of vaccines and other health technologies is limited to costs that are relevant to the health care system and health gains measured in terms of quality-adjusted life-years. This excludes benefits and costs that fall into other sectors.
Secondly, the inclusion of productivity value can raise equity concerns. This may result from assigning larger weights to health technologies that are primarily aimed at diseases targeting population groups with (higher) earning potential, to the detriment of population groups in non-productive age, or who mainly carry out unpaid work or earn comparatively little (Williams, 1992). Inclusion might, therefore, compromise the strong preferences for ‘equal access for equal need’ (Olsen and Richardson, 1999).
Thirdly, there is no agreement on how to calculate productivity costs in a standardised matter (Pritchard and Sculpher, 2000). There is an ongoing debate about which estimates of productivity, for example as obtained from the human capital approach or the friction costs approach, are most accurate.
Finally, there is a need to improve the quality of evidence linking vaccines to productivity gains. For example, vaccines can potentially improve physical, educational, and cognitive outcomes in childhood and adulthood which contribute to raising the level of productivity in adulthood. Yet evidence and data quantifying the impact of vaccination on productivity gains via improvement in these non-utility capabilities are scarce (Jit et al., 2015).
Considering the productivity value of vaccines: let’s give it a shot?
The main hurdle is related to the evaluation perspective. In the UK, the evaluation of vaccines by the JCVI is that of the health system. This is consistent with the methods used by NICE to assess non-vaccine health interventions. Based on the current approach, the objective of healthcare decision makers is to maximise the amount of health in the system given a constrained budget.
Adopting this perspective to integrate productivity costs for all health technologies may be relatively straightforward from a methodological standpoint, but may compromise the general objective to maximise health (Claxton et al., 2010). Because productivity value is usually expressed in monetary terms, in theory, it is possible to incorporate it in the cost-per-QALY ratio. The risk of this approach is that too many resources may be displaced from technologies that improve health, in favour of others with large amounts of productivity value. This is an issue because public sector budgets tend to be siloed, and chances are low that the savings that productivity gains generate in other sectors are redirected to the health budget.
The way forward might make use of incremental steps. A starting point could be to agree on a set of standards to measure productivity value, and practical guidance to calculate the cost of absenteeism, presenteeism and unpaid work already exists (Krol and Brouwer, 2014). There was also a proposal put forward to regularly include a second reference case from a societal perspective for all health technologies and which would incorporate broader value elements (Sanders et al., 2016). As this is likely to increase the costs of technology appraisals, productivity costs would be a feasible broader element to start with.
Finally, there must be a debate on whether or not vaccines justify special treatment. As others argued, vaccines do not currently compete for resources with other health technologies on a level playing field (Beutels, Scuffham and MacIntyre, 2008). This would unavoidably lead to a discussion about who profits and who pays. The Treasury, employers, and labour unions would have to be part of such a process to explore new ways of enabling transfers from gained productivity in other sectors back to the health system, and suitable regulation would need to look at all related equity concerns.
Given the impact of COVID-19 – an example of a potentially vaccine-preventable disease which generates benefits outside of the health care sector that is likely to outweigh the health opportunity cost of the vaccination in the NHS – it is time to rethink how we value immunisation programs. Vaccine R&D costs are fixed and the herd immunity that results from immunisation against infectious disease is a public good. Markets have a problem to function properly under such conditions and a reduction in social welfare can be the consequence (Bloom, Fan and Sevilla, 2018). It is therefore in the UK’s best interest to reconsider how to value vaccination programmes in line with the government’s agenda around prevention. To best protect public health, new thinking is required.
Let’s give it a shot.
 Notes: The JCVI advises further research in quantifying the potential impact of vaccines in reducing the long-term burden of AMR (https://www.gov.uk/government/groups/joint-committee-on-vaccination-and-immunisation#research-recommendations); 2 Carers’ impact on QoL is considered when relevant: “The perspective on outcomes [includes] all direct health effects, whether for patients or, when relevant, carers”; 3Burden of disease is considered deliberatively. Severity is considered by means of the ‘end of life’ criteria, which allow a different weighting of the cost-effectiveness threshold when specific conditions are met; 4 The JCVI can in principle consider Enablement value. However, this is often not possible due to a lack of data or because the impact of this element is expected to be small. In such cases the enablement value may be part of the deliberative process (but not captured in the actual modelling); 5 The DHSC has announced a pilot programme of a ‘volume-delinked’ payment scheme, which will include a modified assessment approach of antibiotics. 6 It should be noted that NICE has no experience so far of assessing vaccination programmes and that normal health-related interventions do not create much transmission value. Consideration of transmission value by NICE may be likely if the assessment of vaccination programmes is included in their remit.
 This analysis of financial ROI included cost of vaccination and financial benefits from a governmental perspective and did not intent to include the monetised value from QALYs gained or the health opportunity costs of vaccination programs that were previously shown cost-effective to the NHS.
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