We should be careful when making claims that a given individual had a major impact on a given field. After all, much research is undertaken in teams and good ideas are quickly transferred and developed. There are, however, several reasons to suggest that Alan Williams made a major impact and that the field may have developed differently had he never become a health economist. I give five reasons below.
First, Alan was one of the first economists to be arguing for a seat at the table in healthcare policy making. Whereas economic analysis is now regarded as an important component of health technology assessment (HTA); in the 1970s, when Alan was first getting involved in health economics, many were questioning the role of economics and economists in healthcare decision making. The healthcare sector was largely regarded as being immune from efficiency considerations, and economists' methods were regarded as being deficient, given the problems with measuring and valuing health outcomes and the need to make assumptions.
The case for economic analysis is set out forcibly in Alan's paper “Cost-benefit analysis: bastard science and/or insidious poison in the body politic?” (1). Here he demolishes every possible argument against the use of economic evaluation for resource allocation decisions in the public sector. He points out that economic evaluation is an aid to decision making, not a substitute for thought. Choices in the allocation of scarce resources inevitably involve value judgments, and the role of formal analysis (like CBA) is to make these judgments explicit rather than to obscure them in “expert opinion” or “political considerations.” Wonderful stuff!
Second, Alan was the first person to set out clearly the basic principles of economic evaluation in health care. In his study “The cost-benefit approach” (2), Alan presented the first methodological checklist for economic evaluation and laid the groundwork for many to follow. This study still stands up to close scrutiny today and was one of the major reasons why economic evaluation has been one of the most successful areas of health economics.
Third, Alan was one of the first health economists to tackle the difficult area of health state valuation. Along with others, Alan produced several conceptual papers in the early 1970s and was greatly influenced by his collaboration with Rachel Rosser. However, it was through the development of the EuroQoL (EQ-5D) instrument in 1990 that the concepts became operationalized (3). The EQ-5D is, and always was, a truly international collaboration, but Alan was a major driving force. The EQ-5D is not the only instrument for measuring and valuing health states, and may not even be the best one, but its international impact is undeniable.
Fourth, in his later years, Alan had a growing interest in equity considerations and how these considerations might be incorporated in economic evaluations. The quality-adjusted life year (QALY), which Alan had done so much to promote, was typically applied using equal weights. That is, a QALY was valued the same no matter whom received it. Alan, and others, believed that this equality probably did not mirror societal preferences. The question was what to do about it. In a series of papers (4), Alan set out the notion of the “fair innings.” That is, the value of an additional QALY to an individual should relate, in some way, to the number of QALYs that individual had already experienced to date. The implication was that higher priority should be given to the young, who had not yet experienced many years of life, or to people who had experienced many years living with disability. Of course, this is not the only approach to dealing with issues of equity, but it is in my view a particularly good one.
Finally, Alan made a personal commitment, and contribution, to the field of health technology assessment through his membership of the International Society of Technology Assessment in Health Care (ISTAHC) and, subsequently, HTAi. He was a frequent attendee at meetings and also served as a Board Member of ISTAHC. His most strongly held view was that, whoever engaged in HTA, studies should be done ethically and not unduly influenced by the financial rewards that are sometimes available.
Perhaps things would have been the same without Alan, but I doubt it.
