Public health economics: Should it be more offensive?

“The soft drinks tax can be expected to result in more than 4000 job losses across the UK” [ (Oxford Economics, 2016, pg 3). As public health moves further away from government provided or regulated activities, such as clean water, traffic safety and vaccination, and into policies directly impacting goods and services provided by commercial actors, statements such as these are becoming increasingly commonplace for those seeking to develop, implement and evaluate public health interventions. As commercial actors have a history of marshalling economics to go on the “offensive” in opposing policies, the question arises of whether, and if so how and when, health economics should similarly be mobilised?

Public health is increasingly involved in policies and interventions that impact on commercial entities, generating a substantial literature and concern around the behavior of these actors (https://www.who.int/news-room/fact-sheets/detail/commercial-determinants-of-health). This literature relates to the products or services that these commercial actors provide and the marketing and sales practices they engage in, of course, but also their use of, and response to, research and evidence related to policies that may negatively impact their activities. The tactics used by the tobacco industry to influence and negate public health campaigns to reduce smoking has long been subject to research (Saloojee & Dagli, 2000). These tactics have been similarly observed and examined with respect to alcohol (Hawkins et al., 2012). Most recently, with the emphasis for public health moving on to obesity and unhealthy diets, we have seen concern that the commercial food and beverage sector is operating in a similar manner (Brownell & Warner, 2009). The commercial sector is clearly very willing, and very able, to mobilise economics for “offensive” means to try and sink public health policies that may impact commercial activities.

Health economics, as an academic research discipline, takes what may be seen as a more objective approach to its role. Put simply, health economics typically seeks to establish the costs and benefits of the policy or intervention that it is engaged to evaluate. The problem, generally, with this approach is that it does not explicitly consider the key elements that the commercial sector is concerned with, and which commercial actors then use in an “economic offensive”. Many public health interventions concerned with diet, for example, have very little direct impact on the health sector; impacts that do occur tend to be positive, as reductions in the consumption of alcohol, soft drinks or unhealthy foods will not place a financial demand on health systems, and any health benefits will reduce demand for services. Similarly, such interventions often have very little direct impact on government; tax receipts from VAT may fall due to reduced product purchasing (though typically these losses are made up elsewhere as people simply shift expenditure to other products or services), or regulation enforcements, such as menu labeling, may increase government costs (Robinson et al., 2021).

These statements clearly highlight jobs, sector (hospitality), groupings (small retailers), geography (South East), and income (GDP loss). In presenting economic measures such as these, the commercial sector arguments often make further links to aspects of ethics or ideology, such as how they restrict consumer ‘rights’ around freedom of choice (Amos, 2019).

In contrast, health economics will typically focus on cost/savings to the NHS, impacts on QALYs, and national level results, though perhaps with a breakdown by SES categorisation, though some work on tax policies focuses on the impact on consumers (Bonnet & Réquillart, 2023; Dogbe & Revoredo-Giha, 2022). For example, if the suggestion that the policy on soft drink taxes should be extended to other products, such as crisps, it should not be surprising to see commercial (sponsored) work that will indicate the possibility of a major impact on employment and the economy in the city and surrounds of Leicester (Walkers), Bradford (Seabrook) and Norwich (Kettle Chips). But would our health economics typically look in detail at the local economies in those cities?

This disconnect is exacerbated by timing. Typically, the commercial sector will be producing “evidence” related to their concerns prior to the implementation of any intervention or policy—the purpose of course being to try and prevent, or change, that policy. In contrast, the health economics work will, perhaps naturally, tend to be related to an evaluation of the intervention which may be before or, within public health especially, after introduction, and thus possibly several years after the debate on the development of the policy. By this stage often the health economics evidence is then phrased in a more “defensive” manner—the evidence to challenge that from the commercial actors may not have been assessed (as it is without the usual remit to focus on, say, jobs in a specific city) and/or the losses indicated by the commercial sector may be real but the recourse is often either to focus on important savings to the NHS or the (usually long-term) gains in population health. This argument is clearly asymmetric.

To place public health (policy making) on a more level playing field, it is critical that health economists address this disconnect and move our (public) health economics to a more pro-active and similarly “offensive” state. We must move beyond an objective assessment and presentation of empirical evidence for evaluation, and into policy and intervention co-creation and support, with evidence that goes beyond what is usual for our discipline (Smith & Petticrew, 2010). We must move from a focus on the more usual direct costs and benefits of the intervention itself, to working through possible impacts (negative and positive) on commercial actors and the wider economy (Law et al., 2020a, 2020b). We must be prepared to be engaged in the debate that will occur on the impacts to these other actors, sectors and elements of the economy.

To move to this “offensive” use of health economics does not mean becoming “anti-commercial”. The commercial sector produces and delivers virtually all our goods and services, and as economists we would recognise the importance, benefit and legitimacy of the profit motive. Indeed, it would be naive to claim otherwise, and the need to work more closely with the commercial sector has been recognised elsewhere (White et al., 2020). Rather, it is about balance—balance of evidence, argument and its timing on key interests that surround a (possible) new policy. Our responsibility as health economists is not just to be objective researchers engaged in assessing costs and benefit of new interventions, but to look beyond an often-narrow remit, and ensure timely assessment of aspects of relevance to commercial actors. At its best, the use of “offensive” health economics will enable identification of “win-win” situations, or at least “win-no lose” situations, which may positively support greater public and commercial collaboration, or at least indicate that the potential loses being suggested by commercial actors can be refuted. At worst it will indicate where there are likely to be “win-lose” situations, in which case possible mitigating policies and/or identification of what and where the losses may occur may be discussed with our public health colleagues such that they can be better prepared.

“It's the economy, stupid.” is a phrase associated with the 1992 Presidential campaign by Bill Clinton, but this phrase neatly encapsulates the primacy of ‘popular’ economics mentioned earlier, and as outlined elsewhere (Smith, 2014). It is, of course, “the economy” where commercial actors seek to demonstrate (negative) impacts of policies. Which should give us cause to reflect perhaps: where the economic impacts often trump health impacts, as health economists surely our responsibility, and value to our public health colleagues, is to focus on assessing these wider impacts? Isn't it time for health economics to become more “offensive”?

There are no conflicts of interest.