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The unemployment rate in Akureyri was 5. Measures were however taken to address the problem in several ways with the municipal authorities to the fore.

The workshop is still open today, but with a more general function; employed and unemployed people alike attend the place and it is primarily considered a recreational facility where old expertise in handicrafts can be preserved and people can develop personal skills www.

Assistance to Companies and Start-ups There are various actors in the business support system. Municipalities in Iceland often run their own business or promotion agencies.

The Akureyri Region Business Agency is one of these institutes www. Finally, it acts as a link between supporting governmental institutions and local companies.

According to the managing director of the Akureyri Region Business Agency, the role of the company has however changed from being a reactive and defensive support for businesses in trouble to a proactive supporter promoting the area to investors in targeted industries.

Tourism currently has its own support agency in northern Iceland, located in Akureyri. This applies to property taxes, and electricity and water costs.

Innovation and new jobs in high technology and ITindustries. Cooperation projects between the University of Akureyri and the private sector.

There has not however been much continuity in the operation e. In October the research and innovation building Borgir was erected on the campus of the University of Akureyri, where several institutions e.

This may increase their cooperation and make their access to potential clients better. In spite of the relatively comprehensive support system, this is an obvious drawback.

The concentration of government jobs is disproportionately high in the capital region. Indeed, a number of institutions have moved to Akureyri in recent years, e.

In addition, other institutions have moved parts of their operations and run sub-divisions in the region.

Furthermore, several small institutions or sub-division in Akureyri have been established. The largest share of these types of actors is located in the Borgir research and innovation building on the campus of the University of Akureyri.

The most important addition to government jobs in the region is however the University of Akureyri. Importance has long been placed on trying to attract foreign investment into the area.

In a way, the emphasis on a large factory, a single solution, would have been in line with the previous development and characteristics of the region and its economy.

In the past few years however further discussion of the aluminium smelter or a smaller factory have taken place. It is apparent from what many of the expert interviewees have said that a relatively large workplace is considered desirable and it would be a welcome addition to the local labour market.

The Role of the Municipality in the Local Economy The role of the municipalities as regards the local economy has changed considerably in recent years.

Instead of being involved in the economy and even owning individual companies, the general role of the municipalities has changed into that of being a facilitator.

Municipalities are generally expected to provide the necessary infrastructure and in general to create a suitable environment for companies to operate in.

Evaluation of Policy Little in the way of the formal evaluation of policy initiatives in the region has taken place. The Minister of Industry, which is responsible for putting the regional development policy into practice, must each year deliver to parliament a report on the progress of regional development policy.

The aim here is to combine these individual experiences with the previously undertaken analysis of the institutions and structures of the income system.

Through the interviews, we are able to trace the factors that facilitate or hinder transitions within the income system. Moreover, these life stories can be a sensitive matter for the individual.

Their education levels range from primary education to a PhD. The area seems to be attractive to those who have relocated for either studies or work.

As can be seen from the labour statistics, activity rates are very high. As such, it was obvious that the individuals interviewed here did not want to talk much about the periods during which they were unemployed.

Those who were faced with this situation generally displayed a good survival instinct, e. The interviewee in question wanted an exemption from these embarrassing weekly visits since it was clear that a solution was being worked on.

It is apparent that those with a longer period of education behind them have more job opportunities and that the number of such opportunities in the region is growing considerably.

Nurses, lawyers, business administrators, and teachers have various opportunities. When it comes to certain other disciplines however, such as architects, geographers and social scientists with postgraduate degrees, far fewer jobs seem to be available.

Taking this into account then, the location of e. Those who had not obtained an education beyond the primary school level appeared to regret this.

This was apparently rather common in the textile, leather, and fur industries in Akureyri. These skills were not however easily transferable into other jobs and industries.

These connections can occur in several ways. Employees may lecture at the university, or they may recruit graduates from the university and so on.

In this way, reciprocal support is provided by the university on the one hand and the remaining institutional environment of the region on the other.

Alarming voices can however be heard regarding the future development of the region and the University.

The interviewee sees a lot of demand for these jobs in Akureyri but not much supply. This is also bad news for the University, as those who graduate, especially from the Faculty of Management or the Faculty of Information Technology face limited job opportunities in the area and thus may be forced to migrate from the area.

Commuting is something that a few of the interviewees had experienced. Both found it tiresome to drive this distance and hard for the family to be away for several days at a time.

All three mentioned the cost of commuting as considerable. It is clear from some of the interviews that the old in- dustries of Akureyri have been struggling for some two decades with considerable consequences for their employees.

They have in fact been virtual bystanders as these changes in the business environment of the Akureyri region, in Iceland and in a global context, occurred around them.

The interviewees were also concerned as to how the employment market was changing, and how also attitudes towards work were changing.

This again could relate to the increase in disability pensions, which is one of the most noteworthy changes in the Icelandic employment system in recent years.

Conclusions Permissive Factors for Sustainable Employment Here a few indicators of, and conclusions on the likely factors contributing to sustainable employment will be discussed, based on both the study of the economic environment of the region, including the expert interviews, and the working life story interviews with individuals.

The town of Akureyri is by far the largest outside the capital region. Moreover, there are few alternatives for those seeking an urban lifestyle outside the capital region and its immediate hinterland.

The Akureyri region appears in fact to have some attraction for young people. It was e. The educational institutions of the area are certainly one of its particular strengths.

This applies both to secondary and tertiary education. The existence of the University of Akureyri has to be considered one of the main factors contributing to sustainable employment in the region.

If potential customers are familiar with how the system works there is a good level of assistance available in the region.

This environment is however changing over time. Many companies have expanded in recent years. One important issue in this regard is the excellent level of air transportation to and from the capital region.

This makes it easy for business trips and meetings to occur, and makes it possible for a certain part of the workforce to commute between the regions on a weekly basis.

The municipalities, particularly Akureyri, have been proactive in planning for growth in the area by e. A growth in the number of those receiving disability pensions is alarming, and provides a general cause for concern in Iceland.

The industries in the region have been hit hard by foreign competition and this appears likely to continue.

Due to the topography there are continuous demands for better road connections over the mountains to the west and east of the region, i.

Furthermore, due to the long driving distance to the capital region there are increasing demands to shorten that distance, which is considered a drawback for industries in the region.

The University of Akureyri has been a vital addition to the economy of the region and it is thus necessary to allow the University to continue to grow and expand.

Emphasis on education has to be put at the forefront of any future regional strategy. Tax deductions or other incentives for those who want, or need, to commute to work over considerable distances would be desirable.

Increased emphasis on continuous training and retraining for those who want, or are forced, to change jobs is also important.

This applies in particular to those with lower education levels. Emphasis has to be put on programmes aimed at the rehabilitation of those disabled who could potentially be reintroduced back into the labour market.

Better road connections to better connect this labour market with the adjacent labour market areas to the east and west, and to better connect the area to the capital area are also required.

Nordic Innovation centre. Copenhagen: Nordic Council of Ministers. Akureyri: Samherji. Statistics Iceland : Labour Market Statistics.

Statistics Iceland. Internet Data Sources www. Source: Adjusted original from Gotland Municipality. How do people in Gotland make a living in a period of fundamental economic restructuring?

In this chapter, challenges to the income system in Gotland are discussed against the backdrop of the models and concepts presented in chapter 2.

The chapter begins with an introduction to Gotland providing the context for the income system on the island.

This section is followed by a discussion of the structural characteristics of the labour market and the workforce in Gotland.

Special interest is paid to transitions in the income system, while the individual experiences conveyed are linked to the structural framework of this system.

The chapter is based on information taken from an investigation of already existing reports, a general literature survey, key informant interviews, and a number of biographical interviews.

The fact that Gotland is an island lying some distance from the mainland has a number of implications for the issue of insular income systems.

Furthermore, its location also suggests the need for a larger public sector than the size of the population would otherwise suggest. Healthcare and emergency services, for example, cannot be shared with a neighbouring local authority.

Communication with the mainland is very important, and has improved in recent years. In addition, Gotland is subject to a pilot project relating to the changed division of regional responsibilities.

Some of the responsibilities normally held by the state at the regional level have been transferred to the local authority.

Statskontoret, This is highly relevant for this study, since these responsibilities include strategic work for regional development. The 49 Figure 5.

Source: www. One reason for this is the establishment and expansion of the university college. In contrast to many other regions in Sweden, Gotland has a small peak of net in-migration in the age groups around the retirement age.

Gotlands kommun, In the summer months, the population increases by around 20, In addition, around , tourists visit during each summer season.

Over time, we can see that there has been an ongoing population shift towards Visby. Gotland has a disadvantageous age structure with an ageing population.

There is also an important tradition of exploiting the limestone of the island, both as a raw material in stone works and for cement production.

Farm houses and outbuildings have also been turned over to other uses such as for housing, second homes, bed and breakfasts and workshops.

New niche products are also being produced from e. The manufacturing sector, apart from food processing, has traditionally been strongest on the northern part of the island.

Today this company is called Cementa and employs around people. Ericsson, later Flextronics, was a major manufacturing employer in Visby.

The location of the island has for centuries brought trade and visitors. In recent years, the establishment of Gotland University has resulted in an important expansion of the educational sector.

The University has build on these topics but broadened the course programme to a wider range of subjects. The public sector as a whole is the largest source of employment on the island.

Previously, the armed forces played a key role. The single largest employer on the island is Gotland council, which, as a unitary authority, carries responsibility for health and medical care as well as education, public transport, social services, and all of the other tasks of the local authorities.

There have been several rounds of state agency relocations in Sweden. Many individuals in the cultural sector are micro businesses and have started their own companies, often in the countryside.

Gotland is the county with the largest share of companies with less than 20 employees. Multiple job holding is still common, and households with assets such as a small farm, outhouses or perhaps machinery can earn their income from several sources today often with tourism in one form or another as playing an important part.

This is stressed in many of the interviews, both with key informants and the individuals that were interviewed about their working life biographies.

Structural Characteristics of the Gotland Labour Market The largest economic sector in Gotland in terms of employment is the public sector where the single largest employer is the unitary authority of Gotland Council employing almost 7, people in Gotlands kommun, Alongside the importance of the public sector, the Gotland economy has for long been characterised by agriculture and the food industry together with the tourism sector.

Other parts of the service sector have played a smaller role. Faktab Finans and Svenska Spel. Gotlands kommun, The ongoing restructuring of the Gotland economy has impacted quite severely in employment terms with around 2, jobs being lost in four years.

Prognos Gotlands Arbetsmarknad, As indicated above, both private and public sector jobs have been lost. Restructuring of the Public Sector The restructuring of the public sector includes sectoral shifts where the military bases are being closed down at the same time as the higher education sector is expanding rapidly.

According to a National Defence decision of , the regiment will be disbanded during a process that will run until the end of August The disbanding of KA3 was particularly troublesome from an employment point of view 51 since it was located in small settlement.

As compensation for job losses, the state has decided to allocate several government agencies, or parts of agencies, to the island over the next few years.

This is a policy that has been used previously, both in Gotland and in other parts of the country. We will return to this policy later in this chapter.

Another large public employer is Samhall with around employees. Samhall nationally, as well as on Gotland, have experienced cutbacks over the last few years due to a policy change which has seen the company being run in a more competitive manner.

Samhall has undertaken extensive activity on the island, something that is linked to the relatively limited opportunities for people in this group to attract other forms of income in a small labour market.

Private Sector Restructuring in Gotland Restructuring within the private sector includes the continuous decline in the agriculture and food processing sectors, and job losses in manufacturing, particularly relating to the closure of the large company Flextronics.

The track is also used as a testing facility, for training of driving skills and events. The island is also used for fashion shoots making use of the unique landscape and light on the island.

Some of these activities may not, on their own, contribute many new jobs, but they bring some employment and play a role in the place marketing of the island.

Employment in the agricultural sector has declined over a number of years. Furthermore, those in the younger generation that are interested in continuing with farming activities often adopt new approaches, such as ecological production and the use of advanced technology.

ALMI, Agricultural productivity on Gotland is below the Swedish average, but the open landscape is needed for conservation and tourism.

Faktab Finans, for example, a company started by a young local entrepreneur, has outlets in Stockholm, Copenhagen, 52 Oslo, and Helsinki.

There are also micro businesses that operate on the international market, both within manufacturing and in the service sector. One attempt to address this issue was a project in aiming at encouraging companies to expand.

ALMI has the task of stimulating growth and development in small and mediumsized companies and innovators. Compared with the national average, business start-ups by women in Gotland are quite common.

Many new companies are established in the crafts sector, e. A fairly common category of start-up entrepreneurs are women that have previously worked in the public sector and whose children have left compulsory schooling.

This is a recently established meeting-place, incubator, and studio focusing on interactive media, game development, and experience tourism.

However, the actual labour force is considerably smaller since not everyone in this age group is available for work.

A large share of the younger age groups are studying, while others, such as the disabled or otherwise incapacitated are also unable to participate in the labour force.

The actual labour force therefore consists of those that have a job and those that are unemployed.

According to the same statistics, approximately 26, of these had a job but only 22, were actually working. The tourism industry is very important for employment in Gotland.

Commuting Patterns It is not realistically possible to commute on a daily basis to and from Gotland. There are, however, a few people commuting a couple of days per week Table 5.

This means that people in employment and self-employment as a whole work comparatively long hours in Gotland. Key interviewees also indicate that there are Gotlanders that work extremely long hours during the tourist season and then have a more limited income from other sources during the rest of the year.

One of the interviewees that lived in Visby works in greater Stockholm, but does not travel every day. On a weekly basis, the number of commuters is greater and the opportunities for commuting have increased with the improvements in communications with the mainland alongside the investments in broadband technology on Gotland.

Unemployment in Gotland Compared to Sweden as a whole, Gotland had a lower unemployment rate until Since then, the situation has been somewhat reversed.

The restructuring of the labour market with major closures as mentioned above, has contributed to higher unemployment.

Many of these people are comparatively low skilled and need training courses to stand a better chance of re-entering the labour market.

There are few openings on the small labour market of Gotland for these young people particularly outside the tourist season. In addition to those unemployed there are also people taking part in labour market measures, such as training programmes and workplacements.

During , an average of 2. This means that total unemployment was 7. A fair share of those with higher education are incomers who often work in public administration, education and in the healthcare sector.

The share of people with higher education is comparatively low in the private sector. Despite this, there has been no change to speak of in terms of closing the gap between the share of the population in Gotland and the country as a whole in terms of higher education.

There are several educational institutions in Gotland. There is also a residential college for adult education with two sites.

About students study at the college on the winter courses. Gotland municipality runs the college. The private training company Lernia is also present in Gotland and is involved in a number of tailor-made training programmes.

There is a marked increase in the number of older women in this age group that are on sick leave. One reason mentioned for this is that many women have carried a double workload of paid employment and the main responsibility for housework.

Women have a larger share of sick leave than men in other age groups as well, and this is an international pattern.

Many in the older category have had a very long employment history in the defence sector or in e. When they were made redundant, they found that there was very little demand for their skills on the small Gotland labour market.

People with health problems and with functional impairments also run a risk of becoming marginalised not least as a result of the restructuring of Samhall mentioned above.

Quasi Market Solutions and Informal Income Income can be earned in other ways than through the formal, taxed economy.

Within this project there is no way of knowing how big the black economy is in Gotland and how it compares with that of other parts of the country.

Key inter- viewees have, however, pointed out that if you have a house, outhouses, and machinery, then there is an opportunity to earn some income in this way.

In such cases, simply advertising may not be enough. Gotland, along with many other health authorities, has undertaken recruitment drives at numerous medical meetings and fairs.

This model, which is further discussed in chapter 2, focuses on the labour market and transitions between this and other parts of the income system.

The previous section of the chapter dealt with key parts of the system in this study. Figure 5. There is the international and national framework, and in Gotland the local actors responsible for these issues such as the Council and the County Administrative Board.

The strategies for regional development in Gotland are expressed in the regional growth programme, which is a compulsory tool that all regions have to produce.

In Gotland, it is the Council that carries the responsibility for producing the growth programme. In this section a brief overview of key policies, actors and funding will be given.

The programme has been developed in a broad partnership where key actors, other than the Council and the County Administrative Board, include, e.

In terms of EU programmes, Gotland is entitled to Objective 2, and 3 funding, both of which are highly relevant to the theme of this study.

There have been over projects part-funded by Objective 3, which is aimed at skills development. Gotland also receives important EU funding related to 56 agriculture and rural development.

There is also funding through the common agricultural policy, which amounted to SEK million in This programme supports untried, innovative development strategies and aims at contributing to new employment.

Labour Market Policy and Initiatives The overarching role of labour market policy is to match supply and demand for labour. The most serious problem of the Gotland labour market is the marginalisation and exclusion of people from it.

Such exclusion is often the result of long periods of sick leave that may result in early retirement for health reasons.

This is done in various ways, including capacity-building and the training of those that need new skills in order to stand a better chance on the labour market enabling them to be better able to contribute in terms of competence development within companies and organisations.

Measures focussed on the unemployed people also include work-placements. Several key interviewees mentioned the ongoing work of improving this collaboration, and argued that it was easier to collaborate in Gotland then in larger labour markets.

Penninglotteriet, now Svenska Spel, mentioned above being a prime example of this. Other parts of the country have also gained state intuitions in this manner.

In recent years, Gotland has received state jobs as compensation for job losses in the defence sector and e. Not all state jobs are the result of relocations.

The County Administrative Board has published a list of new state jobs that are planned for Gotland as part of the latest national defence policy of base closures.

This list includes a total of full time jobs in at least nine agencies and state owned companies. The aim is to combine individual experiences with that of the institutions and structures of the income system dealt with thus far within the context of this chapter.

By conducting the interviews, we are able to trace the factors that facilitate or hinder transitions within the income system. Such information would not be available without focusing on individuals.

The information gained through the interviews illustrates the processes while highlighting the issues discussed against the backdrop of the models and concepts presented in chapter 2.

Ten Working Life Stories The life story interviews in Gotland were carried out in the autumn of Five of the interviewees lived in Visby at the time of interview, while the others lived in different parts of Gotland outside Visby.

In table 5. Together, the ten stories provide many interesting examples of how people make transitions in the income system e.

It is also worth adding a comment about the time factor in this research. The older interviewees in the lower skilled category have a secondary-level education gained during their adult life.

Today, very few people enter the labour market with only a basic education. We are mainly describing the current context and economy, but one has to remember that what e.

They certainly provide a wide range of experiences but also a number of aspects that several of these people share with 57 Table 5.

Four of these interviewees had spouses from Gotland. This factor, in combination with job opportunities and often a stress on the quality of life factor in Gotland were important for their decisions to move to Gotland.

Had the family connection not been there, then they would probably not have moved to the island. The job opportunity and quality of life factors were crucial in this case as well.

Only in one case was Gotland a new experience and the move was due to a job opportunity for the husband. The Proximity to Stockholm Is an Asset Many interviewees, both those born in Gotland and the incomers, stress the quality of life factors with living on Gotland.

Those factors include the easy access to the countryside, lower pace of life than in the Stockholm area, good environment for bringing up children, and, despite recent increases in the house prices particularly in Visby, the potential to get more space for the money than in the Stockholm region.

This latter factor is an advantage particularly for those living in Visby or its immediate surroundings. A crucial aspect here is that the employer pays for the annual travel pass with the airline.

In addition, a good quality IT infrastructure on the island is also important and therefore the expansion of broadband plays a role.

You have to compromise a bit regarding your work content and your pay. Almost all interviewees had had spells of education and training, in some cases moving to completely new careers.

This had happened either on Gotland or on the mainland prior to moving to the island. It was not necessarily unemployment or the risk of becoming unemployed that triggered these decisions, but often simply that the interviewee was bored with their current job and wanted a change.

Training and education relates to human capital, a theme that is discussed further in chapter 2. Many of the interviewees have also had periods of training or education as part of labour market measures.

Several interviewees had received these types of training courses due to unemployment following business closures or reorganisation. This interviewee had, at the time of the interview, a full time job that was supported by labour market measures.

This person illustrates an income history that is not uncommon. Entrepreneurs Start Their Own Businesses Another category of transitions are those that have become self-employed.

Entrepreneurship and self-employment is also dealt with in chapters 2 and 9. The three self employed interviewees in this situation, all women, had fascinating life stories and impressive creativity.

They were all aged 50 or over and had started their companies after their mid forties. All three had periods of work, studying, training courses, and staying at home with young children.

In many cases, they had combined several of these activities at the same time. They all mentioned that there have been institutional factors aiding them such as the ability to study as adults, and support in the shape of business start-up courses and coaching by ALMI.

Together we designed a package where I could get work practice in a company on the mainland and also practical help with the setting up of the new machinery in my own company.

Personal and professional contacts had also been important for some later transitions in the income systems.

This is examples of social networks and social capital that is described in chapter 2. It is not only in insular areas that people get jobs through their contacts, but on a small labour market where both demand and supply are limited, personal knowledge may play an important role.

In that situation, the recommendation through a personal network or the personal knowledge of someone may be crucial. Knowledgeable includes knowing about openings and opportunities on the island, something that is easier on a small labour market.

Financed by his redundancy package he took a computing course and was looking for a job more in line with his personal interests of the outdoor life.

She knew of an opening that matched and thus contacted the employer right away. The interview was quickly arranged and the person started work the following week.

Which factors contribute to a sustainable income system and which provide obstacles for such a system in Gotland?

Together with a brief discussion of these factors, some soft policy recommendations are provided. These aim to point out possible policy orientations to promote a sustainable income system, i.

Many of the current policy orientations and initiatives in Gotland regarding regional development strategies and labour market policies contribute towards a sustainable income system.

The limited size and population makes it easier for the Gotlanders to be made aware of job opportunities.

The supply of training and education has improved in Gotland, not least in terms of the establishment of Gotland University. With time, this may prove to be an important factor in the attempts to increase the school to university transition rates on the island.

An important actor in terms of career changes and of capitalising on ideas is ALMI, which supports business 60 start-ups and the development of already existing companies.

Another permissive factor for making a living in Gotland is the many types of public investments in infrastructure, communications, and IT.

A particular type of public investment is the state jobs that are located in Gotland as compensation for job losses in both the public and private sectors.

These bring job opportunities both directly and indirectly. Linked to the communication factor is the advantage of proximity to the Stockholm region.

Investment in communication and IT including in broadband and public transport on the island will continue to be an important policy orientation for the Gotland economy and labour market.

Most Swedes can put Gotland on the map and know of Visby. In general, people have a positive image of the island and this is important for the tourism sector.

The many visitors to the island bring income opportunities. The positive image of the island has the potential to be used more in the marketing of island produce, something that various projects are currently addressing.

The positive brand of Gotland may, over time, contribute to larger markets for Gotland produce, and thereby deliver greater income opportunities to the island.

Obstacles to Gaining a Sustainable Income One of the downsides with the smallness of the island is that the labour market is limited.

The fact that many people know each other also has its disadvantages. Every room is hence influenced by how we seem.

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Most venereal herpes is caused by HSV-2 discount ceclor mg otc. MolchanowBronislav Both Olsen and Parfit state that a pure interpretation of egalitarianism is absurd as it supports any solution where everyone is equal.

Elster referred to in Olsen , p. With maximin as the foundation, priority should be given to those who are worse off. In cases where this is done, inequalities are accepted.

If equality is the only considered factor, then a situation where someone is made worse off can be better because everyone is equal.

This view states that when concerned with equality, more priority should be given to those who are worse off from a moral standpoint.

This theory does not support the notion that equality in itself is of value, and thus avoids the levelling down critique of telic egalitarianism Norheim These theories of equity are the underlying ethical consideration for the different definition of severity, which to a greater extent establishes a gradation of severity levels than the underlying ethical concepts.

The chosen theories 21 Chapter 2: Theoretical framework constitute the theoretical backdrop for the more easily quantifiable severity concepts.

The fair innings approach The fair innings argument constitutes the theoretical framework for the main measure of severity suggested in the economic guidance.

This straightforward theory of fairness is based on the reasoning that there is some length of life that is considered a reasonable lifespan Harris Each individual has the right, as far as this right is possible to ensure, to a certain number of life years, the common threshold mentioned being 70 years three score years and ten Harris ; Williams A pure interpretation would lead to the conclusion that the youngest should always get first priority on the basis that anyone who is older have had more of an opportunity to reach their fair innings.

Another way to interpret the approach would be to say that neither have reached their fair innings, so neither should have priority before the other.

In this case the fair innings approach does not help with the priority decision. Ambiguous results like these can lead to questioning of the validity of this equity measure.

How will it help in deciding what to do in difficult situations like the one above? This is not necessarily a flaw, however, as the big task of making 22 Chapter 2: Theoretical framework priority decision is based of several elements put together, and never rests on a single decision criterion.

Williams states that it is not only the age at death that is relevant, but also the quality of the life that is lived Williams This suggestion then takes base in the use of QALYs instead of life years.

In fine-tuning his argument, Williams makes two suggestions of how to measure a fair innings. The first suggestion is a more dynamic approach where it is the present age that determines the expected lifetime QALYs and not the fair innings as defined at birth.

The older an individual gets, the higher is the QALE for the individual, but the significant differences only becomes evidential late in life.

The proportional shortfall approach The alternative measure of severity that is presented in the suggested economic guidance, but only for illustrative purposes and not suggested for use in future analyses, is the relative loss of QALYs.

Stolk et al. They make the 23 Chapter 2: Theoretical framework argument that this approach includes two partially contradicting criteria, namely the fair innings criteria and the severity-of-illness criteria.

The basic concept of severity-of-illness is that whoever has the lowest quality of life at point of intervention, is the one who is worse off and should get priority, all else equal Nord To be in a state of 0.

If a new intervention can change both states by 0. If you have to choose between the two patients, priority should be given to the first one.

The approach implicates the use of some sort of severity weight where states low on the quality scale are given more weight than higher values, thus making sure that the life years get less influence than quality when calculating QALYs.

The severity approach has concern for those who are worse off now and in the future Nord , as opposed to fair innings, which incorporates a whole lifetime.

The element of age thus becomes less relevant when using the severity approach. Both the fair innings approach and the severity-of-illness approach make important equity arguments Stolk et al.

A fair innings coincide with the equity concept of giving priority to those with the lowest quality-adjusted life expectancy, implicitly leading to priority of the young before the old.

Whoever is facing a large future relative loss is considered to be worse off. This means that two individuals facing immediate death can be considered equally worse off even if they are fifty years apart in age.

The 24 Chapter 2: Theoretical framework relevant issue is the QALY loss as a fraction of the remaining quality adjusted life expectancy.

With this approach the 60 year-old with a larger relative loss, gets priority before the 40 year-old who has a smaller loss in relative terms.

In absolute terms, the year old suffer the greatest loss. The balancing of the two equity concepts is as follows. The fair innings consideration is preserved through the assumption that all individuals want to reach a common or specific target of health.

Each individual wants to reach his or her own potential for health improvement, and when you are cheated of a large amount of the rest of your life, this is considered to be severe and unfair.

This target for health looks both in retrospect and to the future. Proportional shortfall also assumes that from the moment you get sick, you want to maximize the time you have left.

These different approaches of considering and measuring severity can and will lead to diverging results of who is considered to be worse off.

The choice of method will thus be important for the priority debate, and the case illustration provided in this thesis is meant as input in that debate.

An important element for this context is to choose evaluations that enable the calculation of severity. Economic evaluations of health care interventions can be different in a numerous ways: what they seek to evaluate, how the evaluation is conducted, which interventions that are compared, varying discounting rates for both costs and effects, whether or not quality of life is included, how quality of life is measured, the time horizon used, the perspective of the study, and so on.

A cross-comparison can therefore be very difficult, and maybe even impossible. Because this comparison is performed in the context of priority decisions, the quality of the chosen studies is also of great relevance.

To be able to carry out a credible comparison between a drug abuse intervention and a cancer intervention, these differences will have to be taken into account and made as uniform as possible.

Gold et al. They defined some main features of a good methodological approach, and Drummond et al. The Norwegian official report on cost benefit analyses makes the fundamental contribution on this subject for the Norwegian setting NOU The suggested guidance is, as previously pointed out, an attempt to carry on this idea of a cohesive approach for economic evaluations in the health care sector.

In addition, it will provide the two other priority criteria of effect and cost-effectiveness, thus leading to a transparent comparison and evaluation of the three defined priority criteria.

These three features make up some of the criteria defined by Drummond et al. In addition, the element of sensitivity, hereunder the enabling of verification and inspection is highly essential for the quality of the studies and the presented results.

Output The first important feature that should be present in both of the chosen studies is the health profile of the patient in question.

A health profile consists of both the remaining life years and the corresponding utility weight of the disease. Out of the three different types of analyses, as determined earlier, the cost-utility analysis with QALYs as the measured output stands out as the appropriate form for this comparison.

If this is not accessible, life years are an alternative resulting from cost-effectiveness analyses, and a search for proper utility weights will have to be done to convert life years into QALYs.

To be able to calculate severity in accordance with the guidance, one specific health profile is necessary, and that is the profile with standard intervention.

This illustrates for how long and with what utility an individual is expected to live with the treatment that is offered at the present time.

To calculate the QALY gain, which is the benefit of the treatment and the second of the priority criteria, a second health profile is also needed, and that is the health profile with new intervention.

The new intervention is what is being evaluated when conducting a 27 Chapter 3: Methodology and choice of studies cost-utility analysis or a cost-benefit or cost-effectiveness analysis for that matter.

Perspective The second feature that is important when comparing interventions both within patient groups and across disciplines, is the perspective used in the evaluations.

The perspective defines the viewpoint of the evaluation, and determines to some extent what costs to include in the cost-effectiveness evaluation.

This can have a crucial impact on the cost-effectiveness ratio presented in the results. There are mainly three different perspectives: patient, health care provider and societal perspective Drummond et al.

The important thing is that the studies being compared use the same perspective, since the choice of perspective can give highly diverging outcomes on both the cost levels and the resulting cost-effectiveness ratios.

The economic guidance stresses the fact that both a provider perspective and a societal perspective should be provided, and does not make a specific choice of either one of them Helsedirektoratet a.

In first-order priority decisions a societal perspective gives the extensive foundation needed to make the best decisions possible Helsedirektoratet a.

As a student in economics, it is the broader, 28 Chapter 3: Methodology and choice of studies overall, societal perspective that is the area of interest for this discipline.

Priority decisions within health care can have significant opportunity costs, and such broad effects can only be captured through a societal perspective.

In addition to the importance of considering the costs on a system level to make overarching decisions, this specific case study of drug abuse also makes for a societal perspective.

Drug abuse brings along several socio-economic problems like crime, incarceration, reduced ability to work and increased use of social services, which will be included when taking a societal perspective.

With a provider perspective only the direct costs of treatment are included. Studies presenting a societal perspective are therefore preferred for this comparison, but with the awareness that this is a comprehensive perspective to take, and that there is a lot of room for discretion when stating what a societal perspective actually includes.

A provider perspective can therefore prove to be a more reasonable and a straightforward choice. Time The final feature of time requires the evaluations to be done with a lifetime horizon.

To be able to evaluate severity and benefit throughout a whole lifetime, the health profile must also illustrate a whole life.

If such data is not available, extrapolations of short-term data can be done. The desired time horizon in new economic guidance is also that of a lifetime.

The time horizon should be so long that it enables to capture all the important differences in costs and effects of the comparing alternatives Helsedirektoratet a.

This is often done through sensitivity analyses. Different elements are varied one at a time to establish the effects of the different parameters and presumptions made in the main analysis.

An underestimation of the costs will for example lead to a more cost-effective result. If for example the difference between the lowest and the highest possible cost levels are large, great weight should be put on presenting both these scenarios.

Concluding remarks These three features of a QALY output for both the standard and the new intervention, the aim for a societal perspective and a lifetime horizon, constitute the main elements when trying to find appropriate, comparable studies.

In addition to these three features, the opportunity to illustrate some sensitivity considerations is also of importance.

Studies of cost and effect can, and are being done in a multiple of different ways. The data used in this comparison will be based on existing economic evaluations, and is therefore a result of what data that is actually available for use.

The comparison is based on the methodological approach of finding appropriate existing studies. Firstly, both of the treatments in the comparison should be relevant for the 30 Chapter 3: Methodology and choice of studies Norwegian health care setting.

If not, any results indicating more or less priority of these treatments, will be irrelevant in the context of Norwegian health care priorities.

The linkage to an actual priority debate should be as real as possible. This might be an obvious statement, but none the less an important one.

Secondly, the intervention for treating drug abuse should fulfil the two priority criteria of utility and cost-effectiveness, or at least not be discharged due to these two criteria.

Otherwise the effect of operationalizing a severity measure might not be meaningful in a comparative discussion. What would make an interesting case was if the cancer treatment was offered even though the effect was minimal and the costs were not proportional, and if the drug treatment proved to be both beneficial and cost-effective.

Then the effect of an operationalized severity measure could receive some standalone attention. This reasoning is based on the already stated notion that drug abusers are an under-prioritized patient group, while cancer patients receive both a lot of attention and have a lot of treatment options.

The search for a drug study To get an overview of the existing literature on studies of cost and effect of heroin abuse treatment, an initial search was done in the Medline database.

The search terms used were methadone and economics or buprenorphine and economics, and titles indicating information on cost and effect of treatment were extracted.

The different types of analyses were all relevant in this first search: cost-utility, cost-effectiveness or cost-benefit.

This first search was to get an impression of what kind of analyses that had been done, rather than a final decision to look at a medicinal treatment like methadone or buprenorphine as the only possible treatment options for drug abuse.

The search was limited to go only as far back as A similar search was made in the Cochran library, and a search in Google Scholar was also made to cross check the findings.

No specific studies on cost and effect of drug treatment were found here, but a report from the Norwegian Institute for Alcohol and Drug Research SIRUS has evaluated different interventions for drug abuse Melberg et al.

This was to find out if there existed analyses of cost and effect of other kinds of treatments than those of methadone or buprenorphine.

Other possible treatments could be detox, therapy and bed services. Search results An important source of information resulting from this search was a review study by Connock et al.

They have done a systematic review of the studies on cost and effect of methadone or buprenorphine treatment on opioid dependence Connock et al.

The search was made from or from the inception of the databases up until August Inclusion and exclusion criteria were applied by an experienced health economist and checked by another health economist.

They also conducted their own economic evaluation. Through this systematic approach they ended up with twelve different studies that got through their thorough evaluation of quality.

Nine of these twelve studies were found in the search made here. Two of those that were not found were from and , which this search did not cover, and one was not found at all.

By choosing one of the nine overlapping findings, it 32 Chapter 3: Methodology and choice of studies is with relative good confidence that the choice is adequate for this purpose of comparison.

The search for other kinds of interventions than those found in the main search, did not provide relevant results. The SIRUS-report evaluated the effect and costs of several interventions within the different therapies of inpatient treatment, outpatient treatment and maintenance treatment.

Measurements of the treatments effect were disease specific in this report and therefore not useful for cross comparison of different patient groups.

The results were, however, positive in the sense that the treatment resulted in reduction in drug use at a reasonable cost Melberg et al.

The most relevant intervention thus seems to be the maintenance treatments of either methadone or buprenorphine. There has been done several analyses of cost and effect on these interventions, and this gives an opportunity to apply the predetermined selection criteria.

Choice of intervention The different studies from the search show that there are multiple choices when considering what kind of intervention to analyse and what to compare it to, even within maintenance treatment; methadone vs.

The economic guidance clearly states that the comparative intervention should be the established treatment of the disease, and that comparing the new intervention to placebo or no treatment at all should be used for illustrative and sensitivity purposes Helsedirektoratet a.

The regional health authorities in Norway offer a couple of different treatment schemes to drug abusers today: emergency treatment, in- and outpatient treatment, maintenance treatment, treatment for those with a dual diagnosis and forced admission Helse Bergen There are also lowthreshold services and self-help groups for those with drug problems.

A 33 Chapter 3: Methodology and choice of studies reasonable choice of the compared interventions should therefore be some of these established treatments.

The drug treatment studies The nine overlapping findings from the search are listed in Table 3. The review study by Connock et al.

The utility or benefit of the treatments was also positive, but often not to a very large extent. Whichever study is chosen, they all fulfil the above-mentioned additional criteria that will allow for the severity measures to be the centre of the discussion.

The rest either produces the cost-effectiveness ratio of cost per QALY or cost per life year, which can be converted with utility weights.

The perspective does not directly eliminate any of the studies, but a societal perspective is preferred, and since some of the studies do take this perspective, it is preferable to choose one of them.

This reduces the studies down to number 7, 8 and 9. The final feature of time was a lifetime horizon. Heroin abuse and treatment is a life long situation for many.

As Zarkin et al. Extrapolation of monthly or yearly data is an alternative to demanding a lifetime horizon, but when taking base in existing studies with limited presentation of the underlying models, this is especially challenging.

Two of the studies present a lifetime horizon, namely studies number 1 and 9. The cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States Buprenorphine versus methadone maintenance: a cost-effectiveness analysis Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched day methadone detoxification Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials A randomised trial of the cost effectiveness off buprenorphine as an alternative to methadone maintenance treatment for heroin dependence in a primary care setting Benefits and costs of methadone treatment: results from a lifetime simulation model CUA New vs.

The main reason for choosing this study was exactly the simulation of a whole lifetime, and in addition the inclusion of societal costs as well as provider costs so that both perspectives could be illustrated in the comparison.

Even though this study states to be cost-benefit analysis, all of the costs are presented separately, and the effect of the treatment in life years is provided as well.

This enables an extraction of the treatment costs, and the life years can be converted to QALYs by using utility weights from the literature.

The drug study The article by Zarkin et al. The model simulates costs and benefits across the lifetime to a cohort of 1 million men and women using a Monte Carlo simulation model.

Throughout life the individuals can be in either of five different states every month: non-user, user, in treatment, incarcerated non-user and incarcerated user.

The authors state several reasons for choosing a dynamic model for their calculation. The model keeps track of the variables heroin use, methadone treatment, employment, crime, incarceration and the use of health care.

The different individual attributes included are age, gender, current heroin use, history of heroin use and methadone treatment, and current employment status.

Several attributes are not included, like social status, and the authors acknowledge the simplifications they have made, but make convincing arguments of including the most important variables and attributes Zarkin et al.

What the authors also point out is that, of all the parameters needed to calculate the transitions between states and the associated costs and benefits, as many as possible are from the existing literature.

The rest are assumed, calculated or derived from existing data. Examples of these parameters are the 36 Chapter 3: Methodology and choice of studies probability of using heroin at a specific age, the probability of committing a crime, the cost of criminal activity and so on.

The individuals enter the model at age 18 and leave at age 60 or at death. The comparator in this study is called the baseline model.

The baseline is supposed to represent the situation that best captures the key characteristics of heroin use and methadone treatment observed in previous studies.

Such a definition lacks an exact description of what exactly the baseline is, and this kind of ambiguous phrasing is common throughout several cost and effect studies.

The interpretation made here is that the baseline represents a modelled society where methadone is offered to a certain extent, and costs, benefits and life years at baseline are presented.

This falls in under the criterion of the guidance that the comparator should be the existing treatment practice, and not placebo or no treatment at all, to be able to establish the additional costs and effects that the new intervention will have.

As mentioned in the article, an increase in the probability of going into treatment can correspond to a policy measure set to increase the provision of treatment, examples being a program to educate abusers on the benefit of treatment or an increase in the number of treatment slots available Zarkin et al.

The measured cost-benefit ratio of an increase in the probability of going into treatment was This result states that for every single dollar of costs, there are 76 dollars in benefit.

The main reason for this high ratio is an increase in earnings, as 37 Chapter 3: Methodology and choice of studies well as a reduction in crime costs but this is not a significant change.

The new intervention also led to an increase of 3. These positive results of cost and effect, together with the appropriate time line, the effect presented in life years and a presentation of both the direct and the indirect costs, makes this an appropriate study for a cross-comparison with specific emphasis on severity.

The perspective should be societal to match the choice of drug study, but presentation of a provider perspective as well would be preferable so that both perspectives can be evaluated and compared.

Finally, the time horizon should be that of a lifetime. The comparative cancer study will take the role of being a reference study in this case.

A published study of cost and effect of a cancer treatment is in its simplicity the aim of this section. Economic analyses of cancer interventions seem to be of a much larger scope, and much more comprehensive.

In order of limiting the search process, and with the cancer study only being a reference case, a search for a Norwegian study was first done.

A further limitation was then made with regards to type of cancer. The types of cancer emerging from this search were breast cancer and colorectal cancer.

In order of not limiting the comparison to apply for only one gender, breast cancer was not an option. With colon cancer being one of the three most common cancer types for both genders in Norway Cancer Registry of Norway , a decision of looking at colorectal cancer seems to be an appropriate choice.

This limitation of cancer type makes the search task more manageable. Colorectal cancer is an often-used collective term for cancer in the colon and rectum Store Norske Leksikon Only one health economic study resulting from this simple search seemed relevant for this purpose of comparison Aaserud et al.

In this study the pharmaceutical bevacizumab was evaluated as an addition to first-line chemotherapy for metastatic colorectal cancer. This specific pharmaceutical was then used as a renewed search term.

With rapidly changing treatment programs in the context of cancer, evaluations can soon enough become out-dated. By looking for colon or colorectal cancer in the titles, a couple of results emerged as relevant Asseburg et al.

In press; Shiroiwa et al. A couple of health economic evaluations resulted from this search, but mostly these evaluations had a new intervention that was equal to the baseline of the studies from the previous findings, and thus seem to be of less relevance to the Norwegian setting.

None of the findings from the search on bevacizumab fulfilled all of the selection criteria. The review study found in Medline provided some useful information Tappenden et al.

The results, however, were exactly the same as another cost-utility publication by the same authors Tappenden et al. The final choice of a reference study can therefore with reason be the report by the Norwegian Knowledge Centre for the Health Services from found in the initial search Aaserud et al.

The reference cancer study The reference study conducts a health economic evaluation of using bevacizumab in treatment for metastatic colorectal cancer Aaserud et al.

The commonly used first line treatment for this patient group is 5-FU and calcium folinate combined with oxaliplatin or irinotecan Aaserud et al.

Bevacizumb is a costly pharmaceutical, and was at the time of the report registered for use in combination with the existing treatment.

The economic evaluation takes base in an assumed average patient with metastatic colorectal cancer that is younger than 70 years.

The new intervention of adding 40 Chapter 3: Methodology and choice of studies bevacizumb to the standard treatment was compared to the standard treatment itself.

The adding was done only in the first-line treatment. The second- and thirdline treatment was the same for both interventions. The calculations were done in a Markov model, which tracked the two treatment options.

The report did a costeffectiveness analysis with life years as the output. The report states that there were no good and relevant utility weights available for a QALY calculation Aaserud et al.

According to the study, average remaining life years with metastatic colorectal cancer is 2 years, and some live up to 3 years.

The treatment given at this stage of the disease is palliative care of chemotherapy. The time horizon of the study is from the start of bevacizumab treatment and until the end of complete treatment or until death occurs.

A lifetime perspective would have been preferable, but this will be commented upon later. The costs were presented from both a provider perspective and a societal perspective, but the only thing separating the two perspectives was the inclusion of value added tax VAT.

The societal perspective was without VAT as this only constitutes a transfer of money in this case. The study included costs relating to the following: pharmaceuticals, pharmacy time for mixing the pharmaceuticals, administrating the treatment, CT scans, policlinic consultation, prevention and treatment of side effects, the patients and their families expenses on travel, food and accommodation and symptomatic treatment.

The resulting output measures of the study was NOK per life year gained with a health service provider perspective, and NOK per life year gained with a societal perspective.

It is of relevance to provide some indication of the number of individuals that are actually prevailing these kinds of treatments in Norway, and an approximation of the cost levels.

An average estimate would be about 10 IDUs and most of these abuse heroin. Some of the statistics presented online by SIRUS looks at the offer of medically assisted treatment, hereunder methadone.

In there were patients in treatment across the country, the highest number over a period of 11 years. The number of patients on a waiting list or applying for treatment was , indicating a rather high coverage rate.

In the recent report by the Norwegian Directorate of Health it is presented that the average annual cost per patient in maintenance treatment is 90 Norwegian kroner Helsedirektoratet a, p.

At the baseline of the drug study used in this comparison, the cost level with a provider perspective was just above 21 USD in , which is within the same cost range.

The cost level referred to in the report included drug costs and the expenses for disclosure of these drugs. They also make a projection of the total costs of offering this treatment.

A different article draws a parallel to the actual budgetary situation of hospitals in connection with cancer treatment Johansson et al.

This article looks at cetuximab, a pharmaceutical similar to bevacixumab, in the context of colorectal cancer. According to the article, patients yearly have this diagnosis in the Health Region West, and of these could be eligible for the treatment.

With a minimum cost of Norwegian kroner per patient, this would total to about 80 million Norwegian kroner if all were to receive treatment.

The drug budget for the oncology unit at the University Hospital in Bergen, the largest hospital in this region, was about 30 million kroner in These expense numbers for both methadone and bevacizumab show that there is a significant amount of money tied up in treating both of these groups, which in turn can give a slight indication of what the alternative costs can be.

The total consecutive budget for the Health Region West in is approximately Keeping in mind that the expense figures are from two to seven years back, they have probably in real terms increased since then, and can thus make up an even larger share of the total budget.

These numbers leave a good foundation for discussing these two interventions in the context of health care priorities, and indicate the scope that is undertaken in dealing with such priorities.

These are mainly needed to enable the calculation of severity, as this is not normally included in costeffectiveness evaluations. Some cost tools are also needed to make the costs comparable across the patient groups.

Life table The most important tool for the calculation of severity is the Norwegian life table. This table, produced by Statistics Norway provides a couple of different parameters, among those the average remaining life years at every age level for both genders.

It is the expected remaining life years at a given age that is used in the calculation of severity, here used as a proxy for quality-adjusted life expectancy QALE.

See Appendix 1. A life table from was published by Statistic Norway in April , but the changes are so small that effects on the results provided in this comparison would be minimal.

Separate utility weights for drug abuse and cancer are needed, and sensitivity analysis will have to be done to establish how prone the results are to the specific weights used.

Drug abuse utility weights Utility weights used to define the quality of life with drug abuse were provided in several of the drug studies from the literature search Barnett et al.

Barnett et al. Zaric et al. They all similarly refer to the literature for other weights that limit activities, and which can therefore be seen in relation to drug abuse: moderate angina 0.

These weights of 0. If you get maintenance treatment, like methadone, your quality of life increases with 0.

The Handbook of Disease Burdens and Quality of Life Measures did not provide any additional information of the quality of life weights in connection with drug abuse.

It does, however, state that substance abuse impairs quality of life and treatment improves quality of life Preedy and Watson , p.

This supports the assumption that maintenance treatment provides higher weighting than being an IDU.

In an overview article by Earle et al. They have done a literature search from to to get an overview of the results of all the studies done.

According to this article the utility weights in connection with colon cancer range from 0.

The appraisal-guidance presents the results of two different providers: the manufacturer of the pharmaceutical and the assessment group.

The manufacturer use similar weights for the intervention group who got bevacizumab plus standard treatment and the control group who only got standard treatment.

A pre-progression health state was given the weight of 0. The assessment group also gave both groups similar utilities.

The pre-progression state was similar to that of the manufacturers 0. Also here the weights are linked to the health state irrespective of the evaluated treatment.

The literature gives diverging results, thus limiting the quality of the choice. The specific utility impact of receiving bevacizumab in connection with metastatic colorectal cancer seems to be lacking in the literature.

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