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2
Approaches to Measurement
and Costing Methodology
Several workshop participants noted that no comprehensive frame-
work for estimating the true economic and social burden of violence exists.
Speakers offered numerous theories for the lack of such a framework, citing
weaknesses in the knowledge base both in economic costing and in violence
prevention, difficulty in creating a universal algorithm for diverse settings,
and disagreements in types of costs to include. However, participants held
mixed opinions regarding the importance of creating such a framework and
the focus on relying on economic data.
The need for a robust methodology to calculate costs was best ex-
emplified by the desire to determine the cost-effectiveness of intervention
programs. Speaker Phaedra Corso from the University of Georgia outlined
three major reasons for accurately measuring costs:
1. To determine the true impact of violence beyond morbidity and
mortality,
2. To place violence in the context of and make comparisons to other
public health issues, and
3. To compare the cost of violence to the cost of preventing violence,
and determine the cost-effectiveness of intervention programs.
Ultimately, Dr. Corso felt that the goal of accurately estimating cost was
to determine the return on investment in both the public and the private
sectors. Speaker Jack Shonkoff of Harvard University agreed and empha-
sized the point that prevention is generally cheaper than a cure, stating that
“although you could always make improvements, the end point will never
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8 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
be as good as it would have been had you gotten things right in the first
place, and the cost of getting to a better place is going to be higher than the
cost of getting it done right the first time.”
However, some speakers cautioned against overreliance on economic
data because the complexity of violence does not always lend itself to quan-
tifiable impact. Some outcomes, such as pain and suffering, cannot be re-
duced to calculated costs, and relying solely on numbers would potentially
miss larger effects of prevention. Also, some outcomes of violence, when
calculated in terms of medical costs, suggest potential financial benefits
from preventing violence-related mortality. For example, speaker and Fo-
rum member Michael Phillips of the Shanghai Jiao Tong University School
of Medicine pointed out that survivors of suicide attempts often have on-
going psychological illnesses that require medical attention and can pose
a burden on the social welfare system through requiring subsidized health
care or disability. He referenced a study in which researchers determined
that $5 billion was saved in 1990 due to just over 30,000 suicides, which
did not take into account the costs of psychological and physical pain and
suffering, suggesting that suicide prevention should not be assessed solely
in terms of monetary cost (Yang and Lester, 2007).
Still, most speakers felt that determining the economic costs of violence
held some value and developing a framework for doing this would be useful
in showing the importance of primary prevention. The framework would
allow for comparisons across types of violence, types of impact, and types
of context. These speakers also noted that such a framework would be
most effective through accounting for social costs and that research into
developing a methodology for calculating costs of pain, suffering, and other
nontangible effects was important.
A number of factors that would be useful in thinking about a broader
process for calculating costs were discussed. Participants discussed ways of
categorizing costs, criteria for inclusion in cost calculations, noneconomic
effects, and placement of costs in a larger context.
In terms of categorizing costs, participants began with a matrix that
broke out costs by traditional economic categories and by ecological ele-
ments (see Table 2-1 and Box 2-1). For example, traditional cost categories
include health services, social services, workforce, community development,
and criminal justice. Ecological elements include individual, family, com-
munity, and societal. Thus, speakers were able to consider costs at various
intersections of these two axes, as well as the relative ease or difficulty of
obtaining such figures.
Dr. Corso further simplified the categories of costs into three: medi-
cal, nonmedical, and productivity. Medical costs include medical claims
and other acute costs, as well as the costs of long-term sequelae. At vari-
ous levels, these could include out-of-pocket expenses (individual), effects
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TABLE 2-1 Sample of Potential Costs of Violence at Various Ecologic Levels
Individual Family Community Societal
Economic development • Loss of personal • Access to business • Business tax revenue
investments establishments • Entrepreneurship
• Foreign direct investment
Criminal justice services • Legal services • Legal services • Reentry or recidivism • Court proceedings
• Legal services
• Incarceration
• Juvenile delinquency programs
• Policing (emergency
responders, patrol, and
investigative units)
• Victim compensation
• Violence training
Health services/ • Cardiovascular disease • Mental and behavioral • Behavioral health care
health effects • Mental health (internalizing health • Chronic disease treatment
or externalizing behaviors) • Emergency medical care
• Cancer • Infectious disease containment
• Chronic fatigue • Infectious disease treatment
• Chronic pain • Maternal health care
• Cognitive impairment • Pharmaceutical manufacturing
• Diabetes • Mental health care
• Infectious disease • Poison control
• Inflammatory disease • Surgical procedures
• Interference with treatment
plans
• Behavioral health
• Neurological disorders
• Physical injury
• Pregnancy complications
• Respiratory disorders
• Sexual dysfunction
• Surgery
9
continued
• Time of diagnosis
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TABLE 2-1 Continued
10
Individual Family Community Societal
Social services • Adult protective services
(in-home care, foster care,
nutrition services, case
management)
• Child protective services
(foster care, in-home
treatment, case management,
investigation)
• Crisis centers, domestic
violence shelters (housing
vouchers, disability and
unemployment services,
welfare and public assistance)
Perpetration of future violence • Normalization of violence • Intergenerational • Normalization of violence • Normalization of violence
• Risk-taking behavior relationships • Gender inequality • Gender inequality
Mortality • Death • Impact on family unit • Impact on community • Value of human life
structure • Life insurance
Educational system • Lower occupational • Funding based on student • Counseling services
attainment performance • Grade retention
• Decreased sense of • Property damage • Property damage
self-worth • Staff turnover • Resources for managing
• Economic dependence • Attendance and delinquent behavior
graduation rates • Graduation rates
• Student attendance
• Security services
• Special education for students
with disabilities
• Productivity loss
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Workforce • Development of • Workplace security • Human capital
employment skills • Payroll tax revenue
• Occupational attainment • Absenteeism
• Workers’ compensation
• Friction costs
• Presenteeism
Community development • Self-isolation • Collective efficacy
• Marginalization of specific
groups
• Property damage
• Property value
• Shared resources or space
• Social capital
• Transiency, displacement
Household resources • Education
• Health insurance
• Income
• Household size (single
parent, multifamily or
generation, unplanned
pregnancy, infertility)
11
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12 SOCIAL AND ECONOMIC COSTS OF VIOLENCE
BOX 2-1
Example of Ecological Approach to
Assessing Costs: Child Maltreatment
A child who is abused at home can experience behavioral difficulties in school.
If the school fails to identify and address such issues, the response may be limited
solely to punishment such as removal from class, detention, suspension, etc. The
child then misses school, is labeled a “troublemaker,” and may not reach full intel-
lectual potential due to these missed opportunities. Later repercussions can include
decreased employment or financial opportunities, increased stress due to lower
income, potential for perpetration of violence in future family settings, increased risk
for substance abuse, and chronic health outcomes due to stress. Other children
in school might also experience poorer educational quality due to the disruptions,
which can have similar effects on their earning potentials later in life.
These costs have the potential to extend further, to other individuals who come
in contact with the abused child or his classmates later in life. For example, the job
or income stress could result in workplace violence or other instability, affecting
other workers.
on indirect victims (family), cost of local care (community), and costs of
health insurance (societal). Productivity costs were defined as those related
to absenteeism, or absence from the workplace, which has costs to both
individuals and families (loss of income) as well as to community and soci-
ety (loss of profit to businesses). Dr. Corso also referenced “presenteeism,”
a less easily defined or calculated cost, which includes being present in the
workplace but not working to full capacity. Methods of calculating the
impact of presenteeism are less straightforward than absenteeism; however,
both are often calculated from the standpoint of lost wages. One possible
alternate method is to consider the willingness of society to pay a certain
price for prevention. Finally, she also discussed nonmedical costs, which
were all those costs that did not readily fall into the other two categories.
These costs are often not calculated or included in traditional calculations.
Two methods of cost reporting were also discussed by Dr. Corso—using
prevalence-based and incidence-based data. Prevalence-based data have the
limitation of providing an accurate picture of medical costs only, but not
other types of costs, and providing a picture of acute costs only. Incidence-
based data are not as robust, because they require reporting along the entire
life span and much violence is unreported. However, such an approach
would better parse nonmedical costs.
Speakers also discussed the difference between direct and indirect costs,
with the former being much easier to define. Dr. Corso suggested that most
nonmedical costs fall under indirect costs. Speaker Hugh Waters from the
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13
MEASUREMENT AND COSTING METHODOLOGY
RAND Corporation also mentioned that various types of indirect costs ex-
ist and specified the difference between a cost incurred in the provision of
care that is not part of the care protocol itself and the cost of an indirect
effect. Speakers Gary Milante from the World Bank and Theresa Betancourt
from Harvard University and the François-Xavier Bagnoud Center for
Health and Human Rights also named another important indirect cost—
the cost of inaction. Both cautioned against waiting too long for the full
picture of costs at the risk of waiting too long to act and prevent violence
from escalating. Dr. Milante also pointed out that determining the cost-
effectiveness of a program is important, but reducing the cost of inaction
could have greater impact than ensuring that a preventive intervention is
the most effective.
Along with the cost of inaction, several speakers suggested that op-
portunity costs be considered as well. Dr. Waters noted that certain costs
will be incurred by certain sectors regardless of whether violence occurs.
For example, medical and social services providers and infrastructure costs
will be paid. However, when resources are spent to address the effects of
violence, fewer resources are available to be allocated toward other issues.
Speaker Aslihan Kes from the International Center for Research on Women
pointed out that women who are victims of violence lose opportunities to
complete household or income-generating activities. Dr. Corso suggested
that productivity costs are often calculated in terms of opportunity costs.
The identification of noneconomic effects and the ability to place dollar
values on such effects was also a major discussion at the workshop. Some
participants strongly felt that such costs lie at the heart of the massive bur-
den of violence but are currently difficult to enumerate. Finally, the need to
place costs within a larger context was an important element of discussions;
as Dr. Shonkoff highlighted, the issue is not simply about saving money, but
also about ensuring a higher quality of life.
REFERENCE
Yang, B., and D. Lester. 2007. Recalculating the economic cost of suicide. Death Studies
31(4):351-361.
