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© 2019 Background: Many individuals rely on family and friends to provide care outside of the formal healthcare sector. The need for caring is driven by many factors, including government policies toward health and social care, and increased prevalence of chronic and comorbid conditions. Informal care may give rise to “spillover” effects from the health of a cared-for individual to the health of carers. Spillover effects are rarely reflected in economic evaluations, in spite of growing research interest in this area, and recommendations from bodies such as the National Institute for Health and Care Excellence (NICE) and the Second Panel on Cost-Effectiveness that effects of this type be included in cost-effectiveness analysis. Objective: We explore the positive and normative issues to which the inclusion of carer spillover effects in economic evaluation may give rise and how future research might begin to address these challenges. Results: Positive challenges include the identification of causal rather than coincidental impacts on carers, selection into caring, and the measurement and treatment of spillover effects. The normative issues are related to these challenges, and particularly include impacts on equity, and spillovers that improve rather than reduce the health of carers. Conclusions: We argue that challenges including spillover effects in economic evaluation are considerable. Avenues for future research and possible solutions to these challenges include a re-orientation of analytic perspectives so that the impacts of caring on carers are accounted for where appropriate, and the design of studies to collect robust evidence to inform debate and guidance development in this area.

Original publication




Journal article


Value in Health

Publication Date





549 - 554