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HEALTH ECONOMICS: EPISTEMOLOGICAL ANALYSIS
Adelcio Machado dos Santos1
Marco Antonio Córdova Ransolin2
Daniel Tenconi3
Roberto Marton4
Solange Sprandel da Silva5
Abstract: This article aims to conduct a theoretical discussion on Health Economics, addressing
its foundations, importance, and applications within the context of public health policies. Using a
qualitative and bibliographic approach, the study explores classical and contemporary contributions
to the fi eld, highlighting concepts such as scarcity, effi ciency, equity, and resource allocation. The
analysis shows that health, as a public good and a social right, requires specifi c economic tools to face
its challenges, particularly in public systems like the Brazilian one. Economic evaluation in health
is presented as a key tool for effi cient resource management, allowing the selection of interventions
with the best cost-benefi t ratio. However, the article also addresses the limitations and challenges
of the fi eld, including the ethical complexity of economic decisions, the lack of qualifi ed data, and
the structural inequalities of health systems. Finally, future perspectives in Health Economics are
1 Doctor of Engineering and Knowledge Management (UFSC). Post-Doctorate in Knowledge
Management (UFSC). University of Alto Vale do Rio do Peixe (UNIARP).
2 Master’s student in Development and Society at the University of Alto Vale do Rio do Peixe
(UNIARP), Caçador/SC Campus. Bachelor of Laws from the University of Alto Vale do Rio do Peixe
(UNIARP), Fraiburgo/SC Campus. Orcid: https://orcid.org/0009-0002-5091-2123
3 Master’s degree in Development and Society from Uniarp. Federation of Industries and Com-
merce of Santa Catarina. Caçador. Santa Catarina, Brazil. E-mail: daniel.tenconi@sesisc.org.br. OR-
CID: https://orcid.0009-0001-0470-8044
4 PhD candidate and Master’s degree holder from the Postgraduate Program in Development
and Society (Uniarp). Graduated in Sociology and Politics (FESP/SP).
5 Law and Pedagogy. Master’s degree in Legal Science. Doctoral candidate in Regional Develop-
ment. Research Group: Education, Politics and Society. htpps://orcid.org/0009-0001-9274-030X
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discussed, involving the strengthening of value-based analyses, the incorporation of technologies, and
the training of qualifi ed professionals. It is concluded that Health Economics signifi cantly contributes
to the sustainability of health systems by promoting more rational, fair, and evidence-based decisions.
Keywords: health economics; economic evaluation; public policies; effi ciency; equity.
INTRODUCTION
Initially, Health Economics has been consolidating itself as a fundamental fi eld of study in
the contemporary scenario, as health systems face increasing challenges related to the scarcity of
resources, the increase in population demands, and the complexity of the services offered.
The pursuit of greater effi ciency, equity and sustainability in the management of resources
destined to health highlights the importance of economic analyses that guide public and private
decisions in this sector.
In a global context marked by demographic transformations, such as the aging of the
population, and the continuous advancement of medical technologies, it is essential to understand how
economic principles apply to the health area and how they can contribute to a more rational allocation
of scarce resources.
Health, meanwhile it is a constitutionally provided social right and a desirable good for
individual and collective well-being, is also confi gured as an economic good, whose supply and
demand are subject to market laws and political decisions.
However, unlike other sectors of the economy, health has specifi cities that challenge the
traditional logic of markets, such as the presence of externalities, the asymmetry of information
between service providers and users, and the uncertainty inherent in the results of treatments.
These characteristics make the health sector one of the most complex from an economic point
of view, requiring theoretical and methodological approaches that take into account its singularities.
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In this sense, Health Economics seeks to understand how resources are used to promote,
maintain, or recover the health of the population, investigating the costs and benefi ts associated with
different interventions, fi nancing models, public policies, and management practices. The problem
that arises, therefore, concerns the diffi culty in balancing the growing demand for quality health
services with the budgetary limits faced by public and private managers.
How to ensure that available resources are used as effi ciently as possible, without compromising
access and equity? How to evaluate, in economic terms, the impact of new technologies on health?
And, above all, how to base health decisions based on evidence that considers not only clinical effi cacy,
but also economic viability?
Therefore, this article proposes a theoretical discussion on the main foundations of Health
Economics, aiming to deepen the understanding of its contributions to facing the challenges that
permeate the sector. By exploring central concepts, such as economic rationality, resource allocation,
cost-effectiveness assessment and health fi nancing, it is intended to offer subsidies for critical refl ection
on the possible paths for a more effi cient and equitable management of health systems.
FUNDAMENTALS OF HEALTH ECONOMICS
Thus, Health Economics emerges as a specifi c fi eld of economic science that is dedicated to
the analysis of the production, distribution, and consumption of health-related goods and services.
Unlike other branches of the economy, this fi eld recognizes health as a particular good, whose nature
transcends traditional market logics.
According to Arrow (1963), one of the theoretical precursors of the area, the uncertainty
regarding the occurrence of diseases and the effectiveness of treatments compromises the market’s
ability to effi ciently organize the supply and demand of health services, making State intervention
essential.
In Pauly’s (1968) perspective, the asymmetry of information between service providers and
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users compromises the competitive market model idealized by neoclassical economics. In this context,
consumers do not have the necessary knowledge to accurately assess the quality and need of health
services, delegating important decisions to specialized professionals, which alters the conventional
relationship between supply and demand. Thus, the health market has structural fl aws that justify the
adoption of public policies and regulation.
The foundations of Health Economics were consolidated in the 1960s and 1970s, especially
through studies promoted by the British health system (NHS) and the World Health Organization
(WHO). According to Culyer and Newhouse (2000), the consolidation of this fi eld was marked by the
incorporation of quantitative methods for the evaluation of health interventions, aiming at economic
effi ciency and maximization of social well-being.
This approach has broadened the scope of economic analysis beyond the simple relationship
between costs and benefi ts, also considering ethical, social and distributive aspects.
For Folland, Goodman and Stano (2017), health should be understood as both a consumer
good and an investment good. As a consumer good, it provides direct utility to individuals, allowing
them to enjoy well-being and quality of life; As an investment good, health increases productivity and
reduces future costs associated with disease.
This duality reinforces the importance of health as an essential input for human and economic
development, increasing its relevance in public policy planning.
Grossman (1972) contributed signifi cantly to the understanding of health as human capital.
In its theoretical model, individuals accumulate “health stocks” throughout their lives and rationally
decide on investments in medical care, food, and physical activity. Health, therefore, is not just a
passive outcome, but an active choice that involves intertemporal decisions about consumption and
investment. This vision inaugurated a new strand within Health Economics, articulating the concepts
of microeconomics to the fi eld of individual and collective health.
Over the years, the development of Health Economics began to incorporate new issues, such
as equity in access to services and the sustainability of fi nancing systems. According to Oliveira and
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Elias (2012), the concept of equity has become central, especially in developing countries, where social
inequalities directly infl uence health indicators. The economic literature began to include analyses on
the distribution of health resources, evaluating the impacts of public policies on vulnerable population
groups.
When considering the specifi cities of the sector, Mendes (2018) highlights that health systems
work in a hybrid way, combining market elements with public fi nancing and provision mechanisms.
This characteristic makes the sector particularly sensitive to political decisions and the institutional
structure of each country. The presence of the State, through subsidies, regulation and direct provision,
is justifi ed not only by market failures, but also by principles of social justice and the common good.
Economic analysis in health also incorporates the concept of externalities, as exposed by
Drummond et al. (2015). When an individual receives a vaccine, for example, the benefi ts go beyond
the subject directly involved, contributing to collective protection – a positive externality. Such effects
are not properly internalized by the market, requiring public policies that encourage socially desirable
behaviors. Understanding these dynamics is essential for the design of effective and economically
justifi able interventions.
In countries such as Brazil, where the Unifi ed Health System (SUS) plays a central role in the
organization of services, the fundamentals of Health Economics are essential for the improvement of
public policies. According to Vianna and Silva (2014), the challenge of ensuring universal and equal
access to health requires economic evaluation instruments that guide budget choices, especially in a
context of chronic scarcity of resources and growing demands. The use of economic analysis, in this
scenario, becomes a strategic tool for prioritizing actions with greater social impact.
From the 2000s onwards, the literature began to emphasize the importance of health
technologies and the need for systematic evaluations that consider not only their clinical effi cacy, but
also their economic viability. Health Technology Assessment (HTA), as Santos and Novaes (2021)
point out, has become one of the main tools in Health Economics, allowing managers to make more
informed decisions about the incorporation of medicines, equipment, and procedures. This movement
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reinforces the multidisciplinary nature of the fi eld, which draws on knowledge from epidemiology,
statistics, administration, and economics.
In the international context, the incorporation of economic principles into public health
management has promoted reforms in health systems. As pointed out by Musgrove (1996), many
countries have sought more effi cient and sustainable fi nancing models, combining public and private
sources of resources, with the aim of expanding coverage and controlling costs.
These reforms refl ect a growing concern with the balance between economic effi ciency and
social justice, central themes for the foundations of Health Economics.
ECONOMIC PRINCIPLES APPLIED TO HEALTH
The application of economic principles to the health sector is essential to understand how
resources are allocated, what choices are made by economic agents, and how public policies can
infl uence health outcomes. Scarcity, a central concept of economics, is intensely present in the health
area, since the available resources – whether fi nancial, human or material – are limited in the face
of potentially infi nite needs. In this sense, it is necessary to employ economic tools and principles to
defi ne priorities and promote the best use of available resources, as stated by Phelps (2018).
The fi rst principle to be considered is the effi cient allocation of resources, which seeks to
maximize the benefi ts generated by a certain amount of inputs. In the context of health, this effi ciency
is not only measured in monetary terms, but also in relation to the clinical and social outcomes
obtained.
According to Drummond et al. (2015), allocative effi ciency occurs when resources are
directed to interventions that generate the greatest health gain per unit of cost, which requires the
application of methods such as cost-effectiveness, cost-utility and cost-benefi t analysis.
Another relevant principle is that of opportunity cost, which indicates that, when opting for a
certain health intervention, others were no longer implemented with the same resources. As Folland,
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Goodman and Stano (2017) point out, each health decision implies renunciations, and understanding
the opportunity cost is essential to justify evidence-based public policies.
Thus, a vaccination policy, for example, can be prioritized to the detriment of curative
actions, if it demonstrates a greater preventive impact with a lower cost per benefi t.
The principle of economic rationality should also be considered, even though, in the fi eld of
health, the behavior of agents is often not aligned with the strict rationality postulated by traditional
economic theory. Arrow (1963) already warned that uncertainty, the complexity of health services and
the asymmetry of information between professionals and patients limit the direct application of the
theory of rational choice.
That said, economic models seek to understand how individuals make decisions based on
preferences, budget constraints, and outcome expectations, contributing to the planning of more
responsive health systems.
The construct of externalities, especially relevant in public health, is also an economic
principle applied to the sector. According to Varian (2010), externalities occur when the actions of one
agent affect the well-being of others in a way that is not refl ected in market prices. In the case of health,
vaccines, prevention campaigns, and epidemic control measures generate positive externalities, as
they benefi t the entire community.
These situations justify state action, as a mechanism to correct market failures and guarantee
the collective interest.
Another fundamental principle is equity, which, although not originally an economic concept,
has become essential in the evaluation of health policies.
According to Culyer (2001), equity in health refers to justice in the distribution of resources
and accessibility to services. Health economics has begun to incorporate this principle, seeking ways
to measure and reduce inequalities, which represents an important development of the analysis of
social well-being. In Brazil, this perspective is particularly relevant, given the deep regional and
social inequalities in access to health services, as discussed by Oliveira and Elias (2012).
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The elasticity of demand for health services is another important principle in economic
analysis. Folland, Goodman and Stano (2017) explain that, unlike common goods, the demand for
health services tends to be inelastic, that is, little sensitive to price variations. This characteristic
stems from the essential nature of health services, especially in situations of urgency or severity,
which limits the action of price-based market mechanisms.
Consequently, public policies that directly subsidize or offer services become more effective
in ensuring universal access.
It is also important to consider the role of competition and monopoly in the provision of
healthcare services. According to Porter and Teisberg (2006), the introduction of elements of
competition between providers can improve the quality and effi ciency of services, as long as it is
accompanied by adequate regulation.
However, health has characteristics that favor the formation of natural monopolies – such as
in highly complex services or specialized laboratories – requiring State action to prevent abuses and
guarantee access.
Health fi nancing represents one of the main challenges in light of economic principles. The
theory of the public good, according to Musgrave (1959), helps to explain why the State should assume
responsibility for the fi nancing of basic health services, since such services have characteristics of
non-exclusion and non-rivalry. This justifi es the adoption of universal public systems, such as the
SUS in Brazil, which are supported by taxes and solidarity among taxpayers, as advocated by Mendes
(2018) and Vianna and Silva (2014).
In addition, the principle of fi scal sustainability is central to economic analyses in health.
According to Paim (2013), public systems face increasing pressures resulting from population aging,
the incorporation of new technologies and the increased burden of chronic diseases. In this scenario,
it is essential to adopt measures that ensure the fi nancial viability of the system without compromising
the principles of universality and integrality.
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HEALTH FINANCING MODELS
Health fi nancing is one of the most critical dimensions in public policymaking worldwide,
as it involves strategic decisions that directly affect the equity, effi ciency, and sustainability of health
systems.
The Health Economics literature points to three main fi nancing models: the Beveridgian
model, the Bismarckian model, and the market model, each with different structures for fi nancing,
provisioning, and regulating health services, and different consequences for users and the system as
a whole (Drummond, 2015; Mendes, 2018).
The Beveridgian model, initially implemented in the United Kingdom with the creation of
the National Health Service (NHS) in 1948, is based on the idea that health is a right of all and a
duty of the State. In this model, health services are fi nanced mostly through general taxes, and the
provision occurs, for the most part, by public institutions.
As reported by Culyer and Newhouse (2000), this model promotes universal access to health
services based on need, not on the ability to pay, representing a milestone in the consolidation of
public and equitable health systems.
According to Musgrove (1996), one of the main characteristics of the Beveridgian model
is administrative centralization, which allows greater cost control and standardization of services.
However, this structure can generate waiting lines and restrictions on access to more complex or
high-tech procedures.
The effi ciency of the model strongly depends on the State’s ability to manage resources and
plan the adequate distribution of services, which does not always occur in an optimal way, especially
in contexts of fi scal crisis.
In turn, the Bismarckian model, which originated in Germany in the nineteenth century, is
structured based on mandatory contributions to social security funds. In this arrangement, funding is
carried out through payroll taxes, paid jointly by employers and employees, and services are provided
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by public and private institutions.
As described by Saltman and Figueras (1997), this model combines the universalization of
coverage with regulated market mechanisms, allowing some freedom of choice on the part of users
and competition between providers.
This fi nancing system, according to Ferreira and Vieira (2008), presents a greater degree of
decentralization and participation of civil society, which can favor innovation and responsiveness to
local demands. However, the Bismarckian model can accentuate inequalities when there are no robust
mechanisms for redistribution between funds, especially in countries with a high level of informality
in the labor market, which makes it diffi cult to collect contributions.
The market model, on the other hand, is characterized by the provision and fi nancing of health
services mostly performed by the private sector. In this arrangement, individuals are responsible for
purchasing private health insurance or paying directly for the services used. In the United States, as
pointed out by Folland, Goodman and Stano (2017), this model predominated until the creation of
public programs such as Medicare and Medicaid, aimed at specifi c populations.
That said, the fragmentation and predominance of private insurance continue to be striking
features of the American health system.
According to Arrow (1963), the market model applied to health has serious limitations, such
as the asymmetry of information between patients and professionals, uncertainty regarding the results
of treatments, and the high costs of services.
These factors compromise consumers’ rational decision-making capacity and generate market
failures, which justifi es government intervention. In addition, the market model tends to exclude
signifi cant portions of the population, especially those with low income, accentuating inequalities in
access and health outcomes.
Brazil adopts a hybrid fi nancing model, with a predominance of the public sector represented
by the Unifi ed Health System (SUS), fi nanced by general taxes and organized in a decentralized
manner among the federative entities. According to Mendes (2018), the SUS incorporates principles
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of the Beveridgian model, such as universality and comprehensiveness, but coexists with a relevant
private sector, which includes private insurance and health plans accessible to a minority of the
population. This coexistence creates challenges in terms of equity and effi cient allocation of resources.
According to Vianna and Silva (2014), the chronic underfunding of the SUS compromises its
ability to provide quality services throughout the national territory, which leads part of the population
to resort to supplementary health. Public health fi nancing in Brazil, measured as a proportion of Gross
Domestic Product (GDP), is below the average of countries with universal health systems, which
aggravates structural and operational bottlenecks.
Constitutional amendments that froze public spending for long periods, such as EC 95/2016,
aggravated this situation by imposing limits on the growth of public investments in health.
In contrast, countries such as France and Canada adopt fi nancing models that integrate
elements of the Beveridgian and Bismarckian models, but with an emphasis on redistributive public
policies. According to WHO (2022), these countries have greater equity and effi ciency in their systems,
refl ecting well-structured, transparent, and sustainable fi nancing models.
The success of these models lies in the ability to secure stable sources of fi nancing and in
the judicious use of economic analysis to guide decisions on resource allocation and incorporation of
technologies.
Another important aspect in fi nancing models is the role of payments to service providers,
which can vary according to the system adopted. As Drummond et al. (2015) point out, payment
methods – such as fee-for-service, capitation or fi xed salaries – infl uence the behavior of providers
and the results of the system. Poorly calibrated payment models can induce excessive or insuffi cient
service delivery, affecting both costs and quality of care.
The economic evaluation of different fi nancing models is fundamental for the formulation of
evidence-based public policies. For Santos and Novaes (2021), the instruments of Health Technology
Assessment (HTA) and health economics can and should be used to compare fi nancing models, taking
into account not only allocative effi ciency, but also distributive justice and fi scal sustainability. The
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choice of a model should not be based exclusively on economic aspects, but should also consider the
social values and health objectives of society.
ECONOMIC EVALUATION IN HEALTH: CHALLENGES AND PERSPECTIVES
Economic evaluation in health is an essential instrument for rational and well-founded
decision-making in contemporary health systems. This is a fi eld that seeks to systematically compare
the costs and outcomes of two or more alternative health interventions, in order to support effi cient
and socially just choices.
According to Drummond et al. (2015), economic evaluation encompasses different methods,
such as cost-effectiveness, cost-utility, cost-benefi t, and cost-minimization analysis, each of which is
appropriate to different clinical, health, or political decision-making contexts.
The need for economic evaluations arises mainly from the scarcity of resources and the
growing demand for health technologies and services. As Culyer and Newhouse (2000) point out, no
health system, whether public or private, has unlimited resources to cover all possible needs.
In this sense, economic evaluations offer a methodological framework that allows prioritizing
interventions with the highest return in terms of health per unit of resource invested. This approach
rationalizes the use of public funds and amplifi es the positive impact of health policies.
Cost-effectiveness analysis is one of the most widely used, especially in public contexts,
as it allows the evaluation of which intervention provides better clinical results at the lowest costs.
According to Gold et al. (1996), this analysis is particularly useful in the choice of preventive therapies
or programs, where results can be measured in natural units, such as years of life saved or cases
avoided. When outcomes are adjusted for quality of life, cost-utility analysis is used, which incorporates
indicators such as the QALY (Quality-Adjusted Life Year), enabling comparisons between different
types of health interventions.
In turn, the cost-benefi t analysis, although more comprehensive, presents greater
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methodological complexity. According to Brouwer et al. (2007), this technique requires the
monetization of health benefi ts, which raises ethical and epistemological questions, especially when
trying to attribute fi nancial value to human life.
Nevertheless, this approach is useful in contexts where it is necessary to compare investments
in health with policies in other areas, such as education or infrastructure, providing an intersectoral
view of the economic impacts.
In Brazil, the institutionalization of economic evaluation in health gained strength with the
creation of the National Commission for the Incorporation of Technologies in the SUS (CONITEC) in
2011. As highlighted by Caetano et al. (2019), CONITEC’s central attribution is the analysis of clinical
and economic evidence to support decisions on the incorporation of drugs, equipment, procedures,
and clinical protocols. This initiative represents a signifi cant advance in the integration between
science, management and public policy, in addition to promoting greater transparency and legitimacy
in the choices made by the health system.
However, several challenges still persist in the effective incorporation of economic
evaluations in the formulation of public policies. One of the main obstacles is the absence of reliable
and standardized data, especially in developing countries. According to Oliveira and Elias (2012), the
scarcity of information on direct, indirect and intangible costs makes it diffi cult to apply economic
evaluation models, compromising their external validity. In addition, there are technical and
institutional barriers, such as insuffi cient training of specialized professionals and resistance from
segments of industry and the state bureaucracy itself.
Another important challenge is to reconcile effi ciency and equity criteria. As Norheim and
Asada (2009) observe, an intervention that presents excellent cost-effectiveness may not be equitable
from the distributive point of view, as it benefi ts only populations that are already socioeconomically
favored. This tension demands that economic evaluation not be understood as a purely technical
instrument, but as part of a broader political and social process, where distributive justice and
fundamental rights must be preserved.
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In addition to the technical and ethical aspects, there are challenges related to the advancement
of health technologies. The emergence of gene therapies, biologic drugs, and high-cost testing has put
new pressures on public and private budgets.
As Garau et al. (2020) point out, these technologies offer promising benefi ts, but they also
carry considerable risks, both from a clinical and fi nancial point of view.
In these cases, economic evaluations should be complemented by feasibility studies, budget
impact analyses, and periodic performance reviews, which requires greater articulation between
science, industry, and government.
With regard to future perspectives, there is a growing appreciation of approaches that
integrate health economics with social, environmental and population aspects. The proposal of value-
based healthcare, for example, has been gaining prominence on the international scene. According to
Porter (2010), this approach proposes that health systems be guided not only by reducing costs, but
by maximizing value for the patient, understood as the clinical result obtained in relation to the total
cost of treatment.
Such a vision requires user-centered indicators and performance-based payment models,
which represents a paradigm shift in health management.
Another relevant trend is the use of big data, artifi cial intelligence, and predictive models
in health economic evaluation. According to Kaplan and Porter (2011), the integration of clinical,
administrative, and sociodemographic data will allow for more accurate and personalized analyses,
facilitating population management and long-term planning.
This perspective points to a more dynamic health economy, based on real-time evidence and
guided by principles of equity and sustainability.
Finally, it is important to highlight the internationalization of economic evaluation practices
in health. Organizations such as the WHO, the World Bank, and the OECD have promoted common
guidelines and methodological standards, encouraging collaboration between countries and the
development of local capacities. For Oortwijn et al. (2021), this normative convergence is essential
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to ensure greater consistency, comparability, and quality in studies, strengthening the legitimacy of
political decisions and promoting more resilient health systems.
Consequently, it is observed that, as health systems become more complex and pressured by
new demands, the role of health economics tends to expand, contributing to more informed, fair, and
sustainable decisions.
FINAL CONSIDERATIONS
Health Economics presents itself as an essential interdisciplinary fi eld for the analysis,
formulation and evaluation of public policies and clinical decisions. By combining the principles
of economics with the specifi cities of the health sector, this branch of knowledge contributes to the
understanding of the mechanisms for allocating scarce resources in an environment characterized
by high demand, uncertainty and a strong presence of the State. As seen, the theoretical foundations
that support this area range from the behavior of the consumer of health services to the dynamics of
institutions and fi nancing systems.
Economic evaluation in health is consolidated as a strategic tool in defi ning priorities and
choosing more effi cient and effective interventions. Methods such as cost-effectiveness and cost-utility
analysis guide managers and policymakers in making more rational decisions, based on scientifi c
evidence and economic data. However, the effectiveness of these instruments is conditioned by the
existence of quality data, technical capacity and articulation between the various actors in the system.
The contemporary challenges of health economics are multiple and include technical, ethical
and structural aspects. The incorporation of new technologies, population aging, and the pressure for
equity require that health evaluation and management models be constantly reviewed.
In addition, it is essential to integrate social justice criteria into economic analyses, so that
decisions not only optimize costs, but also promote inclusion and universal access to care.
Future perspectives point to the growing sophistication of economic analysis, with the
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use of digital technologies, artifi cial intelligence and the integration of large databases. The value-
based approach, focused on health outcomes for patients, represents an important evolution in the
evaluation and fi nancing model. In this context, the training of trained professionals and institutional
strengthening are indispensable for the advancement of this agenda.
In epitome, Health Economics plays a central role in facing the contemporary dilemmas of
health systems. By offering analytical tools that articulate effi ciency, effectiveness, and equity, this
fi eld contributes to more sustainable and socially responsible decisions.
Finally, this requires a continuous effort to update the methodology, invest in data and provide
technical training, as well as an ethical commitment to health promotion as a right for all.
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