The Meliorist Project in health economics
探讨健康经济学家如何将研究成果转化为政策影响，分析政治、证据和沟通三大障碍，并提出通过人际网络、激励机制和职业规范来提升政策参与的成功率。
Health economics is driven by its applications to improve the health and well-being of individuals, people, and places. Health economists are intellectual descendants of 19th century meliorists (Bentham & Bowring, 1843) who believed that: (1) coordinated human activity could improve well-being and (2) scientific research to find causal connections between policies and human well-being is an important ingredient in ameliorative policy change. Although classical economists like Malthus, Marx, and Ricardo described equilibria of near perpetual suffering, health economists have observed and documented multiple pathways to escape from despair and early death (Deaton, 2013). Since World War II, the explosion of biomedical innovation and health spending has multiplied opportunities to invest in human health on both an individual and a population-wide scale. Being part of the cycle that moves innovation from bench to bed-side and street-side is a motivating feature of health economics. Studies also help to flag wasteful policies and technologies as well as improve understanding of the systematic perpetuation of disparities in health. Health economists bring evidence to bear that can help close the gap between possible and actual well-being. Gaps remain primarily for three reasons: 1) political differences block reform; 2) relevant evidence does not yet exist; 3) economic evidence is not considered or not believed. Problems of the first kind will seldom yield to more research in the short term. It is not a failure of economic scholarship when an enlightened policy-maker considers and understands a proposed evidence-backed reform and then partially (or fully) rejects it based on political or other criteria. Problems of the second kind, where evidence is lacking, are addressed in the daily practice of scholarship, grant-writing, and teaching in health economics. Despite its growth, the profession needs more scholars and there are critical regional shortages. Type three problems represent the commonplace tragedy of failed communication and translation of relevant scholarship to policy-makers. The problem where excellent health economics research exists but is not brought to bear should concern everyone. Squandered health economics research is a waste of research resources that can also waste lives and livelihoods. The problem is not that health economists do not concern themselves with policies and applied work. The profession makes myriad important contributions in technology assessment and in identifying systemic inefficiencies. But policy change takes more than applied research, it involves politics, and power, and social consensus. The professional training and toolkits of most health economists do not include methods for shepherding the policy process through contested political waters. While some economists have the good fortune to be in quasi-governmental positions of influence, many others are not. The research and teaching incentive systems of many academic economists do not reward effort to contribute to policy implementation in the political arena. Although there are multiple barriers to implementing policy change, there are many in the profession who succeed despite the obstacles. This essay will consider here two mirror questions: What approaches improve the success of health economists engaged in policy translation? How can we normalize policy implementation work as part of professional expectations in more settings? Although economics is defined as the ‘science of choice’, it is, surprisingly, not systematically called upon whenever policy choices are made. To investigate this paradox in the health care field, a study was carried out, based on questionnaires sent to about 50 senior health economists from 17 different countries, followed by telephone interviews for half of the sample (Rochaix & Beaufret, 2014). Several respondents raised the common misperception by decision-makers, patients, and professionals that health economics is mostly about costing, as one possible explanation for the rather faulty interface. Respondents acknowledged the lack of effort or competence by health economists to communicate with decision-makers, partly due to the lack of incentives. Regarding dissemination, it was noted that 1) top tier journals are not necessarily interested in policy-oriented research and 2) publications in professional journals are comparatively ranked less highly. Offering individual financial rewards based on the effective policy impact of research would be challenging because measuring impact requires tracing causality between research, recommendations, and decisions. But there was alignment on more subtle mechanisms that encourage interactions between policy-makers and economists. This would foster early mutual engagement and long term relationship building. One approach was to hold small closed-doors technical workshops involving a balanced representation of both academics and policy-makers. This recommendation has been implemented in France for the preparation of the 2018 health care reform which will increasingly rely on mixed payment schemes with a larger share for quality-based payments for providers (Aubert, 2019). Other solutions could include communication tools such as Massive Online Open Courses aimed at the general public. Interpersonal networks play a powerful role in normalizing policy engagement by economists and making it routine (Gruber, 2019). Most health economists are just two or three steps removed from a policy-maker who is interested in their topic. Closing those 2–3 steps should become a priority. Often it is with legislative staff or state and local officials where one can start to make the most difference. Getting time with these policy-makers is easier than one might think and it can pay off with more insightful, not to mention more relevant economic insights. One should be prepared to meet policy-makers where they are conceptually and ask how they frame the problem. Insistence on economic framing and economic jargon may be erudite but ineffective. In his presidential address to ASHEcon, Gruber described trying to enthusiastically explain to a gubernatorial candidate how a new policy would offer a Pareto improvement. The enthusiasm was not reciprocated (Gruber, 2019). One of the principal secrets to being policy-relevant is networking. Regardless of their work setting, health economists know that career development depends on networking. Economics is, after all, a social science, and economists must be inserted somehow into the social networks that constitute the health system in order to make primary and secondary observations. Many economists conduct formalized key informant interviews with health care providers, patients, and payers in order to do their job. Sometimes these individuals are human research subjects, but more commonly they are informal contacts whose shared perspectives drive economic insight. Becoming socially connected to health policy-makers is not something one is doing at the expense of time spent in scholarship, it is ultimately quite complementary to good scholarship. The units in which health economists work—their centers, institutes, agencies, and departments—play a determinative role in incentivizing work done to achieve implementation of policy reform and can make it a local norm. Associations have the capacity to spread norms for how to achieve policy change with health economics research across countries and regions and they can also spread norms for the presentation of professional credentials. One norm that could spread is how credentials are presented. For example, one could spread the practice where Curriculum Vitae includes a section like a ‘Practice Portfolio’ to highlight activities conducted to help research findings influence policy change. (See online Appendix for Example). By systematically documenting their policy practice activities, health economists are declaring an expectation that this translation work is as much a component of professional practice as the generation of new knowledge. The role of the modern health economist is primarily to observe and understand the health economy. Arrow's foundational 1963 paper forged health economists' consensus that there would never be an optimal laissez faire health economy (Arrow, 1963). Thus, to be a health economist is to be engaged in meliorism—to try to improve upon existing health systems that can never be perfect. A large part of health economics scholarship is meant to help in struggles for reform and system improvement. Health economists' recommendations need not always prevail, but they need to be heard and understood. Self-imposed expectations set incentives that can determine the effort level and success of policy engagement. Through the examples given here, we hope to have shown that policy engagement is vitally important, complementary to routine scholarship, and amenable to being fostered and documented. Data S1. Supporting information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.