Our survey revealed a wide range of organisational mechanisms that have been used to secure health economics and economics advice by Australian governments. It also linked these mechanisms with the type of health economic functions that governments require to inform decision-making for policy and planning purposes. Our findings suggest that while health economics is established as part of the specialist public health workforce, the role is perhaps not as well-integrated into public health as other specialist areas, such as biostatistics. As further evidence of this, health economics was again raised in the most recent review of PHERP as a specialty area that still requires development .
Depending upon the type of health economic task at hand, health agencies use a number of different arrangements to meet that need. However, as observed by survey participants, not all the mechanisms will meet a given need equally well. Some questions that are commonly raised by government–for example, the cost and likely effect of interventions being implemented locally–can be difficult for external groups to answer, as much of the information required is held within the organisation. Further, government seeks answers to very practical questions and this may not readily correspond to the interests or expertise of external groups. None of the external mechanisms and very few of the internal mechanisms identified offer health services a true 'surge capacity' of health economics skills. Surge capacity can be required to provide, for example, advice on options for outbreak control  or to respond to urgent requests for budgeting options. There would be merit in investigating how well each of the mechanisms addresses different needs and to introduce a grading of usefulness to the responses.
Health departments varied also in the ease with which they were able to employ each mechanism. For example, successfully sourcing health economics capacity through external mechanisms is dependent upon suitable providers being identified and available. One jurisdiction noted that there were few local external providers from whom they could purchase these services. Establishing contracting arrangements through tender also takes time, and often advice is required quickly. Consequently, to streamline the process of contracting research, two jurisdictions had used 'preferred providers'; that is, small panels of pre-identified experts who were available to provide advice in areas of specialist knowledge. Membership of these panels was established through tendering processes.
We see in the mechanisms that have been identified both structures, such as position descriptions and contracting with experienced economists located in external centres, and strategies such as training. Structures ensure that people with the right skills are in place and are accessible, while strategies such as professional development provide opportunity for the development of skills required by the organisation for future capacity.
Training is also being used to ensure that staff responsible for accessing health economics expertise are efficient commissioners and users of that expertise, whether in-house or external. This was illustrated by a non-health department in NSW that had developed guidelines and training. Creating 'informed consumers' of health economics information is also an objective of the health economics module in the NSW Public Health Officer Training Program. This requires trainees to demonstrate a level of competence in health economics. We see similar developments internationally. For example, the National Institute of Health and Clinical Excellence in the UK has developed guidelines and frameworks for use by non-economist staff to ensure that cost-effectiveness questions are approached in a systematic way . Bringing health service staff in contact with health economists also potentially builds informal collegial networks. The importance of these kinds of networks to building links between policy and evidence were described by Nutbeam . Personal networks were described in one jurisdiction as enabling some staff to access advice from outside the organisation on a pro bono basis.
The mixture of structure and strategy points to important complementarities that exist among the mechanisms identified. One example of this is the provision of training programs–which requires access to competent trainers–who may also be the providers of high-level external expertise and advice to health departments.
The investigators are aware of at least two mechanisms for obtaining advice that were not described by participants. These were both external mechanisms. The first is where a formal agreement ensures that a quantum of advice is available on demand, provided either by an expert or a group of experts working either pro-bono or for a nominal fee. This is the mechanism that the NHMRC employs with its working groups and advisory groups. The second mechanism is where an external economist is retained to provide an agreed number of days' service.
A recent systematic review of the use of health economics by health authorities in the UK has questioned the capacity of health economics to assist government and concluded that more needed to be done '... to ensure alignment between the objectives assumed in economic analyses and the objectives facing decision-makers in reality'. This need highlights another gap revealed by Table 3, that few mechanisms allowed health economics to continue to develop as a field through methodological research. This function is most likely to be met through specialist research centres and unlikely to be supported through funding that is limited to answering specific service-based questions. Consequently, health departments need to be aware of the other objectives of external research groups lest the sustainability and utility of these groups and their capacity to meet more immediate, policy-relevant needs is diminished.
In conclusion, the potential offered by health economics was first recognised more than 30 years ago. Since then, the need for health managers to be informed by a wide range of skills including economics has been emphasised and re-emphasised [1, 22]. Most recently, Prime Minister Rudd, in an address to his heads of department and senior bureaucrats, stated: 'Policy innovation and evidence-based policy-making is at the heart of being a reformist government.' To achieve this end one of the seven elements of his government's vision for the Australian public service is developing evidence-based policy-making processes . It is encouraging therefore that departments of health across Australia are looking to engage with health economics and have a variety of means of doing so available to them. We have also demonstrated that it is possible to describe an organisation's need for specialist services as a set of functions or competencies and then identify the range of mechanisms through which those functions were met.