Traditional cost-effectiveness measures measures treatment value based on how it affects your health. Health is often decomposed into longevity (i.e., survival) and quality of life while alive. However, Nobel laureate Amartya Sen argued that improvements in one’s life should be based on capabilities (a.k.a. opportunities, freedoms, advantages) to perform desired tasks rather than more abstract notions of utility. Metrics such as the various ICECAP questionnaires are able to quantify and value patient capabilities. While this “capabilities” based approach has been considered for adults by NICE and other international bodies (NICE 2014, Rowen et al. 2017), there are additional challenge in applying it to kids. A paper by Mitchell et al. (2021) examines some of these issues.
Therefore, the need for broadening the evaluative space in health economics from health functioning to a broader conception of capabilities appears as strong as the argument for making this shift in evaluations for adults, and the conceptualisation of capabilities may even need to be broader. The capability to aspire, noted as important for CYP [children and young people], can also be linked with a question about whether capabilities for CYP relate just to current well-being or should focus also on future well-becoming, that is, the opportunities for development a CYP has.
Another issue is determining what capabilities should be considered. For adults, one typically asks patients directly. For children, however, it may not be clear to children themselves what capabilities are valued to them or even if these capabilities are clear young children may not be able to communicate them to researchers. An alternative is to ask experts or caregivers for their opinion of which capabilities should matter to kids. While asking experts is easier, these approaches challenge “liberal theories of justice, including welfare economics, as it moves away from the individual as the key arbiter of what is best for them.” In fact, the authors call for the use of “creative, innovative or participatory (CIP)” research method” such as “draw, write and tell” to allow for kids to better share their own priorities and goals.
Another challenge is that measuring capability level in children is more challenging than in adults. In adults, many capabilities are relatively stable over time or change slowly. On the other hand, children’s capabilities change rapidly. For instance, if I first grader could read at a 2nd grade reading level, that would be considered high capabilities; if, however, upon reaching third grade two years later they still read at a 2nd grade level, then this would be considered a capabilities deficit. Additionally, priorities over capabilities may change over time. Young children may prioritize functional capabilities whereas teenagers may prioritize capabilities that impact their relationship with their peers.
Quantifying these capabilities is also a challenge. While standard gamble and time trade-off techniques could be used, in practice these survey techniques may prove too complex for some children, espeically those with limited mathematical abilities. Further, estimates of willingness to pay may be difficult to glean from children if they have never lived with their own firm budget constraint.
In short, considering a health technologies impact on children’s capabilities is a laudable goal, but one for which there are numerous methodological challenges to overcome.
- Mitchell PM, Husbands S, Byford S, Kinghorn P, Bailey C, Peters TJ, Coast J. Challenges in developing capability measures for children and young people for use in the economic evaluation of health and care interventions. Health Economics. 2021 May 25.