COVID-19 vaccines should be evaluated from the societal perspective

Abstract

The COVID-19 pandemic demonstrates the importance of valuing vaccines from a broad societal perspective (SP), as opposed to a narrower health-payer perspective (HPP). COVID-19’s catastrophic global impacts extend not only to its health-related effects, but also to the profound macroeconomic losses caused by lockdowns required for disease control, leading to the worst global economic crisis in a century. COVID-19 vaccination (CV) has been the central policy tool for resolving this economic crisis, and it has been hypothesized that this macroeconomic benefit alone justifies the cost of CV many times over. Yet HPP-based vaccine valuations are wholly insensitive to this enormous benefit, not allowing it to influence the allocation of given health budgets nor the determination of the magnitudes of such budgets, thereby risking inadequate societal spending on CV. HPP allocates given health budgets to maximize only health, giving no weight to macroeconomic outcomes, causing allocative inefficiency by not allowing welfare-improving trade-offs of health for wealth. HPP assumes health budgets are optimal, not scrutinizing whether their scale adequately reflects the macroeconomic benefits of health spending, thereby risking productive inefficiency by foregoing health spending increases such as on CV that could raise both population-level health and wealth. These allocative and productive inefficiencies in turn distort for-profit R&D incentives, risking dynamic inefficiency. And since the socio-economic and health burdens of COVID-19 are disproportionately borne by the worse off, HPP’s failure to promote optimal levels of societal investment in CV may disproportionately burden the worse off as well, exacerbating inequality. Vaccine valuations from the societal perspective allow the allocation and determination of health budgets to reflect macroeconomic and distributional values, thereby promoting allocative, productive, and dynamic efficiency, as well as equity. These considerations of efficiency and equity support evaluating CV, and to ensure a level playing field, all vaccines, from a societal perspective.

Keywords:

• Covid-19
• vaccination
• societal perspective
• economic evaluation
• health payer perspective

JEL CLASSIFICATION CODES:

• I180

1. Introduction

COVID-19 has caused profound losses in health and broader social welfare around the world. As of June 2023, it has caused 18.5 million estimated deaths¹, making it one of the deadliest plagues in recorded history². Its health impacts include reduced life expectancy (1.33 years among those aged 15+ in a sample of 27 countries³) physical and mental health impairments, long Covid, interactions with comorbidities, health losses from delayed or foregone care, costs and strains borne by the health system and its workers, and the health shocks and insecurity from past and future variants⁴. Its impacts on broader social welfare span the economic, causing a global economic crisis larger than any in over a century and raising global poverty for the first time in decades, adversely affecting global gross domestic product (GDP), public finances, employment and income, and education^5,6; the social, raising isolation, impairing interactions with friends and family, and hindering participation in social life by going out to restaurants, shopping, churches, and parties^7,8; the political, causing restrictions on rights, political instability and conflict, deterioration in democratic norms, and a resurgence in authoritarian practices⁹; and other aspects of social welfare, such as reversing global progress toward the Sustainable Development Goals¹⁰. These impacts involve issues of distribution and uncertainty. The poor and unhealthy disproportionately bear COVID-19’s health and non-health burdens⁴. Uncertainty aversion implies that well-being losses come not only from expected declines in health and well-being but also uncertainty regarding the extent of actual decline¹¹.

COVID-19 vaccinations (CV) are the central element of COVID-19 prevention and control, supported by testing, treatment, and non-pharmaceutical interventions (NPIs) like masking and social distancing^12–14. Evidence is building of CV’s safety, effectiveness, and favorable benefit-risk ratio^15,16; and of its impact on both health and non-health aspects of social welfare, including on deaths, severe morbidity, healthcare use^17–21, and broader macroeconomic outcomes^6,22,–27. Immunity from CV and infection, along with the emergence of the less severe Omicron variant^28,29, have caused relatively steady declines in COVID-19 deaths – the most robust measure of pandemic severity–from pandemic highs in early 2021 (over 400,000 a month) to much lower levels in mid-2023 (7300 from mid-May to mid-June) ³⁰. In May 2023, the World Health Organization (WHO) lifted COVID-19’s status as a global health emergency³¹. Importantly, CV has been the central and indispensable policy tool for global socio-economic recovery. Indeed, it has been hypothesized that the global macroeconomic recovery benefits of CV during the emergency pandemic stage alone justify its global costs many times over, given benefits in the low trillion dollars and costs in the low hundreds of billions^{22,23,25,27,32,–34}. I call this hypothesis the “macroeconomic value case for CV”.

It is beyond this commentary’s scope to fully assess the macroeconomic value case, but I can support its plausibility with a simple back of the envelope estimate of CV’s benefit-cost ratio (BCR) during 2021, a year that begins with the global CV roll-out and ends with the emergence of Omicron. Global per capita gross domestic product (PCGDP) was $11,331 US Dollars (USD) in 2019, $10,896 USD in 2020, and $12,282 in 2021³⁵. So we can approximate COVID-19’s global macroeconomic cost at $11,331–$10,896=$435 per capita. We also see that PCGDP had more than fully recovered from its decline by 2021 when its level was higher than in 2019. The global roll out of CV occurred in 2021¹, coincident with PCGDP recovery. Assuming conservatively that CV undid half the macroeconomic impact of COVID-19, its global per capita macroeconomic benefit is $435/2=$218, which is 1.9% (=100*218/11,331) of 2019 global PCGDP. (Evidence to externally validate this $218 benefit estimate is currently scarce. As of this writing, a non-systematic review of the literature reveals no peer-reviewed estimate of CV’s impact on global GDP. However, Kirson et al.²³ estimate that in the US, CV produced $1.4 trillion in GDP gains, which is 6.5% of the US 2019 GDP of $21.4 trillion³⁶, which suggests my 1.9% estimate is indeed conservative.) By the end of 2021, about 1.15 doses per capita had been administered globally³⁷. I assume average price paid by the US federal government for Pfizer and Moderna vaccine doses in the pre-bivalent booster period ($21) is an upper bound estimate of global price per dose, take vaccine administration costs to equal the midpoint of a reported interval ($25–$40) for those costs³⁸, and take dose wastage to be 30%³⁹. This yields a price per dose inclusive of wastage and administration costs of ($21/0.7)+($25+$40)/2=$62.5, price per capita of 1.15*$62.5=$72, and a BCR of $217/$72 = 3, validating the macroeconomic value case. Such estimate is conservative in part because it ignores post-2021 macroeconomic impacts and adopts very high estimates of the dose price and administration and wastage costs.

(A back-of-the-envelope calculation of the BCR that incorporates both economic and health gains is also possible. The global value of lives saved from CV has been estimated at $6.5 trillion⁴⁰, which given a 2019 global population of 7.7 billion⁴¹ translates to a per capita value of $844. Combining the GDP and health gains gives a BCR of ($217+$844)/$72 = 14.7, which, again, is conservative since it ignores, among other things, health-related quality-of-life gains.)

Despite the end of the emergency pandemic phase, we are not out of the woods. Globally, deaths are over a thousand per week⁴², 30% of the world’s population has not received a single dose, almost half of health care workers and 2/3rds of elderly in low income countries still don’t have complete primary vaccination coverage, and less than a third of the global population has received a booster^42,43. What happens hereafter is a race between the emergence of variants of concern and disease control efforts. Key to the COVID-19 endgame is reducing severe cases – hospitalizations, deaths, and long Covid – relative to health system capacity and population. Severe cases constitute a significant part of the population health and health system burden of COVID-19, and it is in response to high or growing incidence of such cases that socio-economically damaging lockdowns become necessary. Severe cases, in turn, result from either highly virulent variants causing many severe cases among the infected, or less severe but highly transmissible ones causing many infections some proportion of which will be severe.

COVID-19’s proneness to mutation, coupled with the large numbers of global infected in whom such evolution can take place⁴⁴, the waning of acquired and natural immunity⁴⁵, stagnating global vaccination efforts–the share of the global population with at least one booster has effectively stayed unchanged throughout 2023³⁷–and ongoing risks of zoonotic spillovers⁴⁶ are all contributing to the risks of emergence of variants capable of causing large numbers of severe cases (see, e.g^47,48.) An important policy question each society must face is what level of disease control to seek. Global eradication and even national elimination appear implausible over the next few years^49–52. What seems most within reach is an endemicity involving a sufficiently low incidence of severe cases that the risk of outbreaks overwhelming the health system and requiring lockdowns is sufficiently low. Given CV’s well-documented effectiveness in reducing severe disease, and given the socio-economic costs of using lockdowns to suppress transmission, CV remains the central tool for reducing and maintaining a low incidence of severe cases, supported by testing, surveillance, treatment, NPIs, and other interventions in a “vaccines-plus” approach¹⁴. Vaccine uptake and research and development (R&D) must be sustained at high levels, potentially indefinitely, to extend immunity against severe outcomes to new variants, such as the currently prominent variants XBB.1.5⁴⁷, EG.5⁵³, and HV.1⁵⁴.

Such uptake and R&D require sustained investment by countries in current and future iterations of CV, which raises the issue of their long-term financing. Financing made available for CV during the emergency pandemic stage when the profound burdens to health and social welfare were manifest and self-evident may be less forthcoming when the rhythms of socio-economic life have returned to pre-pandemic normalcy, the threat takes the form of the much less tangible risks of variant emergence, and other challenges like economic growth and climate change demand increasing attention.

National-level vaccine financing is most proximately linked to reimbursement decisions made by national health payers (henceforth “payers”), often Ministries of Health (MoH) or equivalent. These decisions are typically informed by a Health Technology Assessment (HTA) performed by a National Immunization Technical Advisory Group (NITAG) ⁵⁵. A critical HTA element is an economic evaluation of a vaccine’s value-for-money (VfM) ⁵⁶. Such evaluation typically follows a set of guidelines approved by Ministries of Finance (MoF) or equivalent. Facilitating optimal financing of CV therefore requires appropriate assessment of CV’s VfM to support appropriate reimbursement decisions.

But there is a central unresolved policy debate that creates risks for such appropriate assessment. This is the question of the choice of perspective in economic evaluation of vaccines⁵⁷.

2. Choice of perspective

There are multiple possible perspectives including, e.g. the governmental and patient perspectives, but the paradigm polar opposite choices, and my focus, are the health payer and societal perspectives (HPP and SP, respectively). HPP is the dominant perspective worldwide, constituting the majority choice among NITAG economic evaluation guidelines that mandate some perspective⁵⁸, as well as the perspective most often used in peer-reviewed vaccine evaluations⁵⁹. I focus on two aspects of the choice of perspective, its implications for the allocation and determination of a health payer’s budget, as shown in Table 1. Many discussions focus on the former, underappreciating the latter, though both are important.

Table 1. Differences between the health payer and societal perspectives with respect to allocation and determination of the health payer’s budget, and relevance to Covid-19 vaccination (CV).

	Health payer perspective	Societal perspective
Allocation of the health payer’s budget	Allocate to maximize population health	Allocate to maximize population social welfare
	Relevance to CV: Ignore socio-economic benefits of CV	Relevance to CV: Include socio-economic benefits of CV
Determination of the health payer’s budget	Take the health payer’s budget as given and optimal	Raise or lower the health budget if the marginal social value from publicly funded health spending exceeds or falls below that of spending elsewhere in the public or private sector.
	Relevance to CV: Forego raising the health payer’s budget to help fund CV even if doing so would raise social welfare or population health	Relevance to CV: Raise the health payer’s budget to help fund CV if this would raise social welfare.

2.1. Health payer perspective

In many countries with tax-financed national health systems, the MoF or equivalent sets the health budget as a share of the central government budget and, by approving economic evaluation and reimbursement guidelines that require the MoH to adopt a HPP, implicitly instructs the MoH or equivalent to allocate such budget to maximize health⁵⁸. HPP is embedded within an extra-welfarist philosophical view according to which society should defer to the superior value judgments of MoFs^60,61. Such deference, according to extra-welfarism, implies society should accept both that health budgets be allocated to maximize health and that the size of the health budget is optimal. This implies that health budget al.locations should be sensitive only to health- and budget impacts, and insensitive to the non-health benefits of health technologies such as macroeconomic benefits, and that the question of what substantive factors or principles should determine the scale of that budget cannot even arise.

2.2. Societal perspective

The societal perspective is traditionally understood as the view that non-health impacts of health technologies should be considered in vaccine valuation (see, e.g^62,63.) But this statement of the view, by itself, is not sufficiently developed to be operationalizable. The most well-developed, traditional, and best articulation of SP is provided by preference welfarism (PW) ⁶⁴. PW claims that all policy decisions, including the allocation and determination of health budgets, should aim to maximize social welfare, where social welfare is some potentially equity-sensitive aggregate of individual welfare, and where individuals’ welfare reflect their preferences over their life circumstances like their health and wealth⁶⁵. (PW is a normative view, and hence differs from welfare economics, which is a sub-discipline of economics. PW is an important normative view considered and analyzed within multiple disciplines like welfare economics and moral philosophy, while welfare economics considers and analyzes many normative views including but not limited to PW.)

Adopting social and individual welfare maximization as a policy goal can be justified on the grounds that failure to do so would, by definition, lead to policies that make society and individuals worse off by producing lower levels of social or individual welfare⁶⁶. Measuring welfare in terms of preference-satisfaction can be justified on the grounds that failure to defer to individuals’ preferences in resolving trade-offs among aspects of their lives (e.g. health and wealth trade-offs) would violate the Pareto Principle. This principle says that if all individuals are indifferent between two policies then the value framework should assign them equal values; and if all but one individual is indifferent but one individual strictly prefers one policy over the other, then the value framework should assign the strictly preferred policy a higher value⁶⁷.

Preference welfarism can be operationalized in economic evaluations using cost-benefit analysis (CBA). CBA holds that whether a policy is better than the status quo depends on whether the unweighted sum across individuals of their willingness-to-pay (WTP) for all policy impacts relative to the status quo is positive. Since WTP reflects preferences, CBA is a possible operationalization of PW. The central feature of CBA, emphasized by the word “unweighted,” is that it holds or assumes that different individuals’ WTP are comparable or summable on a one-to-one-basis, so that, for example, a dollar of a poor person’s WTP counts the same as a dollar of a rich person’s WTP. This is insensitivity to policy- or ethically relevant interpersonal differences like ability-to-pay (ATP) or status quo levels of well-being can make CBA ethically unattractive.

But CBA can be extended to accommodate these differences by weighting different individuals’ WTP to adjust for those interpersonal differences. Different ethical theories would prescribe different weights. For example, utilitarianism would adjust WTP to account for differences in individuals’ ATP⁶⁵. Assume utility is a natural logarithmic function of income as survey evidence suggests⁶⁸, so the marginal utility of income is the reciprocal of income. Weighing individuals’ WTP by their marginal utility of income (a simplification of equation (3) in⁶⁷) would make the WTP of an individual who has 1/10th the income of another individual count 10 times as much as the WTP of that other individual. Some of the most exciting work in health valuation can be understood as developing the weights corresponding to different ethical theories, the three most important of which are utilitarianism; prioritarianism, which would take the utilitarian weights and multiply them by an additional weight that is larger for those with lower status quo levels of utility, thus making utility gains of the worse off count more than those of the better off, see⁶⁵ for approaches to quantifying such weights; and the equivalent income approach, which adopts different weights from utilitarianism and prioritarianism⁶⁷. For simplicity, I call this family of approaches “weighted CBA” (wCBA). These approaches show that health evaluation can rely on individuals’ WTP for policies, thereby satisfying the Pareto Principle, while still accommodating interpersonal differences and therefore distributional considerations, equity, and fairness in ethically robust ways. A technical detail is that utilitarianism and prioritarianism are welfarist but the equivalent income approach is not, so only utilitarian and prioritarian versions of wCBA are forms of PW⁶⁷.

Turning to allocation and determination of health budgets, PW supports allocating health budgets according to health technologies’ weighted benefit cost ratios (wBCRs, where benefits reflect health and non-health benefits, monetized using weighted WTP, and where costs should reflect only those borne by the health budgets). Health budgets should be raised or lowered depending on whether the wBCR to devoting extra resources to the health sector exceeds the wBCR that would result from devoting those resources to other uses elsewhere in the public or private sector. Thus, and in contrast to HPP, PW is sensitive to vaccines’ non-health impacts and offers substantive principles for health budget determination, without having to sacrifice equity.

2.3. Allocating a given budget and allocative efficiency

The first fundamental difference between HPP and PW is what’s maximized given the payer’s budget: health or social welfare. Consider two policies, A and B, that impose the same net burden on the payer’s budget, but A produces more health than B, while B produces more macroeconomic benefits than A. HPP will always prioritize A, while PW will weigh A’s health advantage versus B’s macroeconomic advantage. The smaller A’s health advantage and the larger B’s macroeconomic advantage, the more likely PW will prioritize B. To perform the requisite trade-offs between health and macroeconomic outcomes, PW can use the wCBA described above, monetizing health using individuals’ WTP for health as quantified in the CBA literature⁶⁹ and scaling up the health and macroeconomic gains of the worse off to the extent required by equity considerations.

This policy comparison shows that PW will yield a more allocatively efficient allocation of a given health budget than HPP. Allocative efficiency involves reconciling trade-offs on the production side with trade-offs on the demand side. The traditional criterion for allocative efficiency is that the marginal rate of product transformation between two goods (e.g. how much production of a first good must fall to raise production of a second good by one unit) equal consumers’ marginal rate of substitution between them (e.g. how much consumers are willing to give up of the first good to receive one more unit of the second). Assessing the relative value of the two policies above using wCBA, which trades off competing goods using individuals’ equity-weighted preferences for those goods, operationalizes this traditional criterion. The basic idea behind allocative efficiency is that rational individuals – whether rich or poor, healthy or unhealthy–make trade-offs between health and non-health benefits all the time: a small enough health loss in exchange for a large enough economic benefit is welfare improving. Health budget allocations should accommodate welfare improving trade-offs between health- and non-health goods, and failure to do so risks pareto inferior outcomes (i.e. outcomes making everyone – rich, poor, healthy, unhealthy–worse off than they could otherwise be). HPP refuses to impute any value to the non-health benefits of health technologies, which risks allocative inefficiency, and therefore pareto inferiority. The macroeconomic value case for CV implies vaccines can have significant non-health benefits ignored by HPP and that HPP’s risks of allocative inefficiency and pareto inferiority in allocating given budgets can be high.

A traditional concern with trading off health and economic benefits in the allocation of the health budget is equity⁶⁰. According to this concern, CBA values broad impacts of policies at individuals’ WTP for them, which can lead to prioritizing the needs of the wealthy who have higher ATP. But this concern can be defused. As stated above, CBA can be made as equity-sensitive and ATP-insensitive as we want by scaling up the worse off’s WTP.

A COVID-19-related episode highlighting HPP’s allocative inefficiency risks occurred in the United Kingdom (UK) in late 2021 when the Joint Committee on Vaccination and Immunization (JCVI), which advises UK health departments on immunization⁷⁰ and whose Code of Practice requires it to evaluate vaccines according to the HPP⁷¹, declined to recommend universal COVID-19 vaccination among 12-15-year-olds, holding that “[t]he margin of benefit, based primarily on a health perspective, is […] too small” ⁷². The UK’s Chief Medical Officers (CMO), in contrast, recommended such universal vaccination, stating that “the additional likely benefits of reducing educational disruption…recommend in favour of vaccinating this group” ⁷³. The UK Department of Health and Social Care ultimately adopted the CMO recommendations, its Secretary citing “keeping pupils in the classroom” as a central rationale for its decision [74,p.15]. Thus, in this instance, adherence to HPP would have forced the UK to forego what was clearly a socially acceptable trade-off of smaller health gains for larger educational gains.

2.4. Setting the health budget and productive efficiency

A second fundamental difference between perspectives involves whether the perspective offers any substantive principles or criteria for assessing the optimality of the size of the health payer’s budget itself. HPP offers no such substantive principles or criteria. In contrast, PW claims this health budget should be raised or lowered if the marginal social value from publicly funded health spending exceeds or falls below that of spending elsewhere in the public or private sector.

HPP’s assumption that any given health budget is optimal creates risks of productive efficiency, i.e. an outcome in which society has strictly less of all goods, or put in more traditional terms, an outcome in the strict interior of society’s production possibilities frontier. This is because it fails to recognize the possibility that some health expenditure increases could potentially generate strictly more of all goods.

For simplicity, assume only two goods in society, health and consumption, where consumption is a proxy for all non-health goods, including for the macroeconomic benefits of, say, CV. In this simple setting, productive efficiency requires that for any given level of population health, society enjoy the maximum feasible level of consumption, and vice versa. Society is thus productively inefficient if it is stuck in a situation where it can feasibly have more of both. Economics is often about trade-offs: to have more of one good, we often must accept less of another. But productive inefficiencies are particularly unattractive because they are situations in which improving matters doesn’t require trade-offs: we can have more of both things we value.

Pandemics like COVID-19 and large epidemics like, say, the 2014 West African Ebola outbreak are, simultaneously, shocks to population health and the economy, causing significant declines in economic living standards⁷⁵ in addition to substantial population mortality and morbidity. Vaccines like CV protect against both these shocks and thus are powerful promoters of both health and consumption simultaneously (e.g. 2.1 million deaths and $135 billion in productivity losses averted globally⁷⁶; see as well as my back of the envelope quantification of the macroeconomic value case).

HPP’s silence on optimizing levels of health spending creates risks of underfunding CV and other vaccines that simultaneously protect against health and economic shocks.

The macroeconomic value case for CV, recall, says that the macroeconomic benefits of CV alone (treat these as consumption benefits of size $X) justify the costs of CV (denote these costs $Y, inclusive of dose-, administration-, and wastage costs) many times over, at least during the emergency phase of the pandemic. This suggests that during this phase, X/Y is a very attractive BCR, even if its numerator understates the full BCR of CV since it ignores the health benefits. This suggests that raising the health budget by Y to fully accommodate CV (i.e. without having to displace any other health spending) during this phase would have been good VfM on purely macroeconomic grounds. But increasing the health budget by Y to fully accommodate CV not only by assumption raises consumption by X, it also raises population health, so long as CV produces more health than whatever expenditure it displaces, which seems plausible given CV’s powerful impact on population health^{17–19,22,23}. Thus, CV during the emergency pandemic phase (relative to a counterfactual where CV is absent but lockdown policies are maintained for disease control) is an example where increasing health expenditure could raise both health and consumption, a win-win requiring no health-wealth trade-offs.

While it is not clear the macroeconomic value case for CV holds for the post emergency phase, there may be a more general set of circumstances where raising health spending can raise both health and consumption, producing win-wins. Health spending increases that are cost-saving from a governmental perspective – i.e. where the government saves more in fiscal costs from disease than the required increase in health spending on prevention (see, e.g. rotavirus vaccination in Egypt⁷⁷) – are a possible example, and some pandemic preparedness efforts that protect against both health and economic shocks may be another.

What is remarkable about the HPP is that it is wholly deaf to the potential truth of the macroeconomic value claim. The narrowness of its value framework leads it to focus only on the health gains and health budget impacts of CV, ignoring its macroeconomic benefits, leading, as discussed above, to allocative inefficiency. And, importantly, given that it offers no substantive principle for setting the health budget and simply takes whatever its current level as given and optimal, it offers no support for expanding that health budget even when doing so could raise both health and consumption, risking productive inefficiency. Such productive inefficiency is also potentially pareto inferior: it risks making everyone have less health and consumption than they would otherwise. The risk that HPP could reduce population health by failing to support health-boosting increases in health expenditure is particularly ironic, given its overt goal of health maximization.

PW, in contrast, can fully accommodate the possibility and value of health spending increases that promote both health and consumption. It allows health spending to rise if the wBCR of the increased spending exceeds that which would result from allocating such spending elsewhere in the public or private sector, and the numerator of that wBCR is a potentially equity-weighted aggregate of the health and consumption impacts of such spending. If the wBCR of increased health spending is strong, then PW would endorse raising such spending.

2.5. Dynamic inefficiency and equity

HPP’s risks of allocative and productive inefficiencies create further downstream risks of distorting or weakening profit-based R&D incentives by under-rewarding vaccines that yield macroeconomic and other broad non-health benefits and by suppressing health spending and therefore under-rewarding health innovations in general. This can yield sub-optimal industry investment in R&D, which in turn deprives future generations of greater access to new health technologies that reduce their health and economic burdens. This foregone opportunity to benefit future generations through innovation is a dynamic inefficiency and extends the pareto inferiority to an intergenerational setting: HPP’s risks of producing allocatively and productively inefficient outcomes makes current and future generations worse off. Conversely, PW can optimize the allocation and determination of current health budgets, promoting allocative and productive efficiency and therefore well-being for current generations, while these efficiencies improve R&D incentives and therefore outcomes for future generations, thus making both current and future generations better off.

Finally, there is ample evidence that the health and economic burdens of COVID-19 are disproportionately borne by the worse off, e.g. increased infection and mortality risks faced by low-wage essential workers like first responders and service sector workers⁴, minority populations⁷⁸, adults with comorbidities⁴, communities with lower household incomes and higher unemployment⁷⁹, and communities with greater income inequality⁸⁰; disproportionate unemployment risk faced by ethnic minorities and low-wage workers⁸¹; disproportionate impact of school closures on disadvantaged students⁸²; disproportionate ability of higher-paid workers to benefit from working from home⁸²; and delayed access to vaccination among minorities, in rural areas, in hard-hit areas⁷⁸, and in poorer countries⁸³. This suggests that HPP’s failure to avert those burdens will weigh disproportionately heavily on the worse off. Even the worse off trade-off health for consumption and so suffer from HPP’s allocative inefficiency in the allocation of given health budgets. The worse off are potential beneficiaries of increased health spending that promotes both health and consumption, so HPP’s productive inefficiencies risk reducing both the worse off’s health and consumption. Thus, the allocative and productive inefficiencies of HPP harm the worse off, and a PW-based societal perspective’s reduction of the risks of such harms protect the worse off. Thus, the societal perspective can have superior distributional or equity effects than HPP.

As stated previously, a traditional concern with the societal perspective and with CBA is that the incorporation of non-health benefits could tilt prioritization towards addressing the needs of the wealthy, who have higher WTP for their benefits. However, wCBA addresses such traditional concerns so equity considerations should no longer be seen as a bar to broad-based valuation. Indeed, wCBA can show how equity considerations can support such broad-based valuation.

3. Conclusion

Long-term control of existing and future variants of COVID-19 requires ongoing use and funding of CV. Achieving optimal funding levels requires using the appropriate perspective for valuing CV. Adopting SP allows estimates of CV’s value-for-money to reflect both its narrow health impacts and its broader impact on the economy. It also allows the health budget to expand if necessary to accommodate CV. HPP risks allocative, productive, and dynamic inefficiency, as well as inequity. These considerations of efficiency and equity support evaluating CV, and to ensure a level playing field, all vaccines, from a societal perspective.

Transparency

Declaration of funding

This study was conducted as collaboration between Data for Decisions and Pfizer. This work was funded by Pfizer, Inc., through a contract with Data for Decisions LLC, a consulting firm, where JPS is an employee.

Declaration of financial /other interests

JPS has received financial support for his other research from, and performed other consulting services for, vaccine manufacturers, the Bill and Melinda Gates Foundation, the World Health Organization, and other for-profits and non-profits.

Author contributions

JPS is the sole author of this work and the sole person satisfying all ICMJE authorship criteria.

Reviewer disclosures

Peer reviewers on this manuscript have received an honorarium from JME for their review work but have no other relevant financial relationships to disclose.

Acknowledgements

No assistance in the preparation of this article is to be declared.