Table 2.

Levels of decision making and potential consequences of considering soft costs and benefits

	Question posed	Likely effect of including soft costs and benefits*
		Vaccines only	All decisions†
Government	How much of the government's budget should be spent on health generally, as opposed to the other government sectors (eg, defence, education, etc)?	Investments in vaccines, and preventive health sector as a whole, become more cost effective in relation to other sectors	Interventions with beneficial impacts on typically ignored externalities (eg, environmental pollution, herd immunity) would gain in relative importance, and those with adverse impacts would lose importance
Health sector	What proportion of the health budget should be spent on vaccination programmes as opposed to other health-care or public-health interventions?	Most vaccines become more cost effective in relation to other health interventions	Interventions that prevent and cure disease, with a proportionately larger aggregate impact on the quality of life and/or productivity of patients and their families, become more cost effective compared with other interventions
Vaccination programmes	Which vaccinations should be given priority (eg, rotavirus, HPV, or pneumococcal conjugate vaccines)? Which schedules and formulations should be chosen (eg, Rotarix‡ or RotaTeq§ for rotavirus; Gardasil§ or Cervarix‡ for HPV, three or four doses of Prevenar¶ for S pneumoniae)?	Programmes that prevent disease, with a proportionately larger aggregated impact on the quality of life and productivity of patients and/or their families, become more cost effective compared with other vaccination programmes	..

HPV=human papillomavirus.

^*Costs and benefits arising to parties generally not considered relevant in guidelines for economic evaluation of pharmaceuticals for which public funding is sought. These third parties can consist of people not receiving the intervention, parents of patients, employers of patients, and employers in general.

^†Cost-benefit analyses do not routinely inform other sector decisions in many countries (eg, education, transport infrastructure, military, etc.). Politics may dominate rational decision rules in other sectors more than in health care.

^‡Produced by GlaxoSmithKline.

^§Produced by Merck.

^¶Produced by Wyeth.