Background
Torture and its consequences have mostly received attention in the academic literature as a socio-political phenomenon with severe psychological ramifications. Nevertheless, torture is also assumed to be financially costly to society, not only in terms of treating the mental and physical sequelae, but also through lost productivity, as torture survivors often struggle to cope with day-to-day work. However, little is known globally or at a country level about the cost of torture to society. The measurement of cost is notoriously difficult, because the parameters involved are not easily defined and the data not easily captured [
1]. One study has attempted to model the cost societies incur as refugee-hosting countries; Mpinga and colleagues estimate the economic burden of torture in Switzerland, using estimates of prevalence of torture experience among refugees residing in Switzerland to model the socioeconomic consequences of torture at country level. Their study shows that the effects of torture create substantial economic losses to society. They found that the greater part of this loss is due to the indirect cost (approximately 10 billion CHF) related to the loss of productivity over a period of 30 years. By comparison, direct expenditure related to housing, healthcare, food and education over the same period amounted to roughly 130 million CHF [
2]. The authors acknowledge the potentially controversial nature of calculating the cost associated with being a country hosting traumatised refugees, but stress that their findings should be seen within a strong ethical perspective, using the economic argument to support the campaigns for the prevention of torture [
2].
The current crises in Syria and elsewhere leave little hope that the number of people traumatised by war and torture will diminish for many years. UNHCR estimates that in 2015 65.3 million people were displaced, the most ever recorded [
3]. Many, though not all of them, are forced to flee their own countries and seek asylum in Europe and elsewhere. In 2015, the number of first-time applicants for asylum in Europe increased to almost 1.26 million, more than doubling the number in 2014. This increase was mainly due to applicants from Syria, Afghanistan and Iraq [
4]. Among the refugees who come to Europe there will be a need for specialised help to deal with the after-effects of torture and other potentially traumatic experiences. It remains unclear how the current influx of refugees will fare in society, and what impact on the public finances of their host countries their presence will have. This impact will depend on several aspects, such as the age, gender, and skill-levels of the refugees. Research done by the Deutsche Bank and the German Institute for Economic Research (DIW) show that the economic consequences depend on how successful social and economic integration is, and the time-perspective employed in the analyses. Despite large initial cost, these institutions find that investment in refugees is worthwhile in a longer-term perspective [
5], with better outcomes modelled for successful integration efforts [
6].
The refugee population is far from homogeneous and the specific needs of individuals and their ability to integrate successfully may vary substantially. In particular, refugees who have been exposed to torture and other war-related traumas experience a range of physical and social problems that persist over time [
7]. The consequences of torture and war trauma include Post Traumatic Stress Disorder (PTSD), depression, anxiety, and chronic pain, which pose particular challenges for maintaining daily life and functioning [
8,
9]. Moreover, trauma has also been shown to affect the family through intergenerational transmission. A person who has suffered torture or war-related trauma may have profound difficulty in maintaining a family role both in relation to his or her spouse and in terms of parental responsiveness and role function [
10‐
12]. Not only do intimate partners of survivors display an elevated level of psychiatric symptoms and feelings of loneliness, among other things [
11], but studies show that parental PTSD and depression is strongly correlated with child distress [
13,
14]. Little is known about the relation between short-term health outcomes for refugees and the longer-term socioeconomic outcomes for the individual as well as the family. So far, the evidence we do have suggests that victimisation of individuals place an extra financial burden on the individual and the family. Family members might employ various coping strategies to address an increased burden of care, including taking up debt, stop going to school or work to care for the victim in the family [
15,
16].
Research evaluating rehabilitation programmes has tended for many years to have an exclusively clinical focus, especially in the specific area of rehabilitation for torture and war survivors [
17]. One aspect of ensuring access to good quality rehabilitative care for traumatised refugees also involves providing evidence of the societal cost of torture, and on the cost-effectiveness and the long-term economic impact of providing rehabilitative services [
18]. However, despite their importance, the economic implications of torture have not been a research priority [
19] and only few have attempted to document the economic viability of providing specialised care for tortured and war-affected populations [
20]. In Denmark, care for tortured refugees is available at specialised clinics across the country. However, no systematic effort is currently in place to screen refugees for torture trauma at the point of arrival to the country [
21]. Therefore the specific issues and challenges torture survivors face, may either not be addressed at all, may be managed in the Danish health care system at large or, if referred to a specialised clinic for refugees be addressed in this context. Moreover, despite public demand for documenting the effect of the resources spend on rehabilitative efforts and the long-term socioeconomic outcome for this group, no systematic effort has been carried out at this stage.
The present study addresses the gap in knowledge about the economic effects of rehabilitation programmes by evaluating a specific multidisciplinary rehabilitation programme for torture survivors, from the point of view of its economic viability. The rehabilitation programme was provided for a severely traumatized group of refugees living in Denmark. It is unique in that it addresses the socio-economic consequences of providing multidisciplinary rehabilitation by combining data on short-term self-reported health improvements with longer-term economic data covering labour income and expenditure on health services. The study is to our knowledge the only of its kind combining both a cost-utility analysis (CUA) and a partial cost-benefit analysis (CBA), using actual rather than modelled data, to answer the question of whether rehabilitation for survivors of torture and war represent ‘value-for-money’ (VfM) in a societal perspective. This information will aide policy makers in the allocation of expenditure in the Danish health system as well as provide crucial feedback to the specialised clinics who have direct contact with, and knowledge of, this population’s concerns and needs.
Discussion and conclusion
The rehabilitation of survivors of torture is of great importance, not only for the individuals concerned but for the societies in which they are living. DIGNITY in Denmark is a clinic offering specialised multidisciplinary rehabilitation for torture survivors. In the process of evaluating and testing such programmes, not only information on efficacy but also effectiveness is needed. This ‘value-for-money’ (VfM) perspective is increasingly important in a health care setting with limited resources, where decisions must be made on what health interventions to provide. This paper describes the procedure of two analyses to assist such decisions on VfM.
Torture is a complex phenomenon, which affects social, economic, physical and mental dimensions of the everyday lives of survivors and their families. In this study, we employed a societal perspective, investigating the cost-effectiveness and long-term economic benefits of providing multidisciplinary rehabilitation. The CUA was calculated based on a group of 45 individuals who had been in the rehabilitation programme in the period 2001–2004. The measured gain in QALYs showed that the intervention was cost-effective within the upper limit of the NICE ICER threshold, which is an internationally recognised comparator of health care cost. As it is our interest to elucidate changes in the relationship between the survivor and society, we disaggregated the gain in QALYs to each of the four domains (physical, mental, social and environmental) measured by the WHOQOL-Bref questionnaire and a more differentiated picture was revealed (see Table
2). The outcome data for the CUA covers roughly 23 months and the results for the psychological and physical domain shows little change. Considering the level of chronicity of the health problems survivors of torture and war experience, it is likely that data collected over a relatively short period might not reveal functional changes. The environmental domain on the other hand, showed a much larger increase in QALYs than the other domains (1.16 as compared to 0.82 overall). This domain is of special interest to this study as it provides information about the individuals functioning in society. It is well-known that PTSD and other symptoms are not static but can present themselves in recurrent relapses. Aggravation and escalation of symptoms can occur as environmental stressors interact with the trauma history [
38‐
40]. The environmental domain encompasses 8 questions covering topics ranging from how safe the respondent feels in daily life (Q8), the financial situation (Q12), the possibility of taking up leisure activities (Q14) and access to health care services (Q25), among others [
27]. The calculation of the ICER for the environmental domain is shown separately below. As is demonstrated, the result is below the suggested NICE threshold (190,000–290,000 kr.) of what is to be considered cost-effective, specifically for the integration into a new environment.
$$ {ICER}_{environmental}=\frac{166,112.56 kr}{1.16\; QALY}=143,200.5 kr\; per\;{QALY}_{environmental} $$
This is also the case in 2016 prices (185,500 kr. per QALY
environmental). While the environmental domain displayed a positive gain in QALYs, the result was quite different for the social domain. Disaggregated, the social domain accounted for a 0.74 loss in quality of life, on the surface indicating that the participants fare worse after treatment. However, this effect may be partly due to the qualities of the instrument. The WHOQOL-Bref questionnaire has the most question in the environmental domain (8) and the fewest in the social domain (3). Therefore, the changes in the score for the social domain makes this domain more sensitive to varying responses. Furthermore, the social domain covers the respondent’s satisfaction with his or her personal life (Q20), sex life (Q21) and support from friends (Q22) [
27]. While these questions represent important aspects of well-being, the specific focus of this study was how the treatment could potentially improve the study population’s functioning in society, which is why we placed emphasis on the environmental domain.
We found very few studies in the literature that could contextualise the results of the CUA and no study specific to our population in a high-income setting; one study in Australia found that trauma-focused cognitive behavioural therapy (TF-CBT) in combination with sertraline was superior to TF-CBT alone, non-directive counselling and the non-treatment alternative for sexually-abused girls with PTSD or PTSD and depression. The ICER the authors found amounted to AU$22,263 (approx. 102,400 kr.) which is well below the Australian ICER threshold of AU$50,000 (approx. 230,600 kr.) [
41]. Similarly, in a study of US war veterans with PTSD, prolonged exposure theory proved more efficient than sertraline along with an ICER of [
42].
For the CBA in the second stage of the study, we included objective, long-term data that could reveal the socio-economic outcomes for the study population over a longer period. An interesting picture was revealed, showing that the treatment never breaks-even in the individual level analysis while a substantial positive NSB is seen over the 14-year study period, when taking the family as the unit of analysis (see Fig.
4). Looking at the values for the NSB at both the individual level and at the family level, a trend is observed where the cumulative NSB over the period first increases and then decreases. Several aspects need to be highlighted in this respect; the individuals in the treatment group performed better with respect to individual income from 2001 to 2008. However, after this point the income started to decrease again. A similar trend is observed for the controls, though the decline from 2008 onwards is less marked. The trend is repeated for family income where the families of the treated individuals performed better than the families of the controls except for the years 2013 and 2014. The data on the expenses related to primary health utilisation show a mixed picture in which from 2006 onwards the expenses of individuals in the treatment group display an increasing trend while those of the controls remain relatively constant. As the study population is small, it is difficult to say whether the increase in primary health care expenditure is due to a change in health seeking behaviour induced by the rehabilitation or if the treatment and control group were systematically different in health seeking behaviour from the beginning.
Both individual and family income demonstrate that 2008 is a pivot point in terms of the overall trend (Fig.
4). The results should be seen in the context of the wider societal context and 2008 represent the onset of the financial crisis that also impacted the Danish economy. A study by
Statistics Denmark for a larger sample of migrants and refugees from some of the same countries (Iraq, Afghanistan and Turkey) confirms the trend towards a peak in 2008 [
43]. In
Statistics Denmark’s analysis, the declining trend in employment of refugees from Iran and Afghanistan and economic migrants from Turkey is also partly ascribed to the economic crisis. In such a situation, the individuals in our study population, who are vulnerable in various ways, might be particularly exposed to a contraction of the economy; at the onset of the financial crisis the study population is on average 43 or 44 years old, they suffer from health issues, generally have a low-skill level and thus it is likely that they faced challenges in retaining their job or finding jobs once the economic situation in Denmark improved after the recession.
Sensitivity analysis
In the calculation of the ICER, the cost per gained QALY amounted to 262,530 kr. in current prices. Of this cost, 122,864 kr. was overhead related cost and the remaining 139,666 kr. being the direct salary related cost. There are two considerations in this composition of this overall cost per QALY gained; One consideration is the accuracy in the estimation of the overhead share and the other being the difference in treatment composition, causing a variation in the salary component of the treatment cost. There was a degree of uncertainty about the overhead expenses as the evaluation was carried out some years after the treatment programme, and information about the organisational structure, inventory and staff was no longer complete. Moreover, as the treatment composition varied considerably, it is also worth considering whether the population included in the original study can be assumed to have received a course of treatment comparable to that of other patients in the clinic. To test the decision uncertainty, both inputs to the overall treatment cost were varied by 20% in either direction. This variation did not impact the conclusion in relation to the reference ICER threshold obtained from NICE. That is, the change did not move the established ICER below the NICE ICER threshold lower boundary of £20,000, or above the upper boundary of £30,000.
We also tested how the NSB would change if we equalised the two groups’ health expenditure in the primary sector as well as the outcome for a scenario where the financial crisis was assumed not to have happened. Despite the treatment and control group showing different trends, the actual magnitude of the primary health care expenditure did not significantly alter the outcome of the analysis either at individual level (NSB remained negative) or at the family level (NSB remained positive). However, under the assumption that the financial crisis in 2008 was the sole responsibility of the change in the income of the two groups, we kept the income level for this year constant from 2008 to 2014, which was exactly enough to reach break-even in 2014. Under this scenario, the NSB at the individual level became positive.
Does rehabilitation for traumatised refugees represent ‘value-for-money’?
The overarching goal of this analysis was to determine whether the specific rehabilitation provided at RCT (now DIGNITY) in 2001–2004 represents ‘value-for-money’. This question was answered through a CUA, looking at cost per QALY and a partial CBA that calculated the NSB, based on individual and family income and primary health care expenditure. The shorter-term focus of the CUA illustrated the cost-effectiveness of the multidisciplinary intervention at the individual level. The cost-effectiveness of the intervention might be greater if the ability of the intervention to support the study populations’ coping with everyday life and integration into society is emphasised. This is indicated by the disaggregated results for the environmental domain.
The partial CBA also indicated a positive effect; at the family level, the productivity gains by family members led to a positive NSB after only a couple of years and this gain persisted over the course of the study period. Therefore, based on the included parameters, the multidisciplinary intervention provided at DIGNITY from 2001 to 2004 was shown provide ‘value-for-money’ and to be an economically sustainable strategy. The results also show that the chosen study design can highlight important dynamics otherwise not revealed; in this study, it was done by taking a broader perspective, including multi-level variables and transgenerational effects when evaluating multidisciplinary interventions for torture or war survivors. By considering these parameters, the study has contributed an alternative perspective to focusing on symptoms. Many of the symptoms suffered by torture survivors are chronic in nature [
44‐
46], so their persistence may not adequately represent the change of functionality in society that the multidisciplinary rehabilitation provides.
Strengths, limitations and further research
There are several restrictions in the study that limit the strength of the conclusions. The effectiveness study carried out in 2001–2004, providing quality of life data to the CUA, was designed as a pre- and post-treatment study. Therefore, there is no control group and instead the baseline was used as the comparator. It is uncertain to what extent this baseline estimate represents an accurate depiction of what would have happened in the absence of treatment. However, and referring again to the long-term and persistent physical and mental health consequences of war and torture, it might be reasonable to presume that no significant improvement would have happened in the absence of treatment over the 23-month period and so the baseline data for quality of life is a good approximation of the alternative.
Disaggregating the QALY into the different domains helped us to gain more insight into the results of the rehabilitation programme. However, whether it is theoretically sound to do so is debateable. Another point that has been criticised is the reliance on an ICER threshold, as it might not adequately represent society’s willingness to pay for the programme. It has to be emphasised that the NICE threshold is a politically defined threshold, grounded in economic theory but not with an unproblematic transfer to practice [
37]. For this study, however, the ICER threshold as suggested by NICE, was necessary as no other cost-effectiveness analysis of an appropriate comparator treatment was available and as the ICER threshold has not been defined in the Danish context.
The CBA investigated socioeconomic outcomes for the study group over a 14-year period (2001–14), using data on individuals’ primary health care use, their labour income and the families’ labour income obtained from the Danish population registers. Other impact categories could have been of relevance but was not possible to include in this study and therefore should the CBA be regarded as a partial CBA. As this group suffer from serious mental health issues, memory bias is an important concern when including self-reported data. Hence, the use of long-term and objective register data is a key strength of the study as it supports and further qualifies the results measured at the clinical level. While the long-term perspective in the partial CBA provides valuable insight into economic outcomes that cannot usually be captured in shorter-term clinical follow-ups, this also presents challenges to finding a suitable control group which introduces a potential bias. To minimise this, it was decided that enrolling the patients currently in treatment or on the waiting list, represented the best approximation with respect to the potential covariates. Creating a sample from the general refugee population would not have allowed us to match participants on torture or war-related trauma exposure. The members of both the treatment and control groups were all eligible for DIGNITY rehabilitation, and had arrived in Denmark at the same time. Nevertheless, the members of the control group had accessed DIGNITY’s services much later. The reason behind this difference is not known, but it may be a difference between the two groups that could result in bias. Members of the control group could have had a different health seeking behaviour, or there may have been differences in the referral system.
When evaluating the effect of health interventions we often risk underestimating the true effect as a too narrow focus is employed [
22]. The welfarist approach underlies the CBA and several aspects have been criticised; Among others, it is based on a theoretical compensation principle, the implicit inclusion of income in the decision-making process (with social willingness to pay) and the central notion that health is valued in monetary terms (see [
47] for a discussion on these issues). The concept of QALY is part of an effort to move towards non-welfarist or extra-welfarist approaches and is inspired by Amartya Sen’s Capability approach focusing on freedoms of ‘beings and doings’ [
22,
47]. However, those who advocate for a more holistic approach to evaluations of health and social interventions argue that although health is maximised in this perspective, QALY as a concept has limited capacity to capture non-health and functional changes especially for chronic patients [
48]. This is a highly valid point also in the light of the complex intervention evaluated here as well as the chronic nature of the symptoms the patients in this study experience. At this point, nonetheless, no adequately tested instrument is available or was not available at the time the clinical data was recorded.
Yet, in this study we have attempted to address the challenges by including a range of variables and approached the ‘value-for-money’ perspective from two angles, using both self-reported, short-term and clinical data in combination with longer-term objective data on socioeconomic outcomes. Separately, the CUA and partial CBA show that the intervention is a sound economic strategy. Yet, the strength of the study is the combination of methods, data-sources and time perspective, which underline the conclusion: Rehabilitating severely traumatised refugees can generate economic benefits, not only to the individuals but also their families and society. Future research should take steps to include a larger sample size and more variables for a full CBA, such as data on hospital care and expenses related to social services or crime. Furthermore, as time passes the possibility to obtain more detailed socioeconomic information from the population registers on children of traumatised refugees becomes possible, allowing for an expansion of the analyses of intergenerational effects of trauma.