Explicit incorporation of equity considerations into economic evaluation of public health interventions

Abstract

Health equity is one of the main avowed objectives of public health policy across the world. Yet economic evaluations in public health (like those in health care more generally) continue to focus on maximizing health gain. Health equity considerations are rarely mentioned. Health economists rely on the quasi-egalitarian value judgment that 'a QALY is a QALY'--that is QALYs are equally weighted and the same health outcome is worth the same no matter how it is achieved or to whom it accrues. This value judgment is questionable in many important circumstances in public health. For example, policy-makers may place rather little value on health outcomes achieved by infringing individual liberties or by discriminating on the basis of age, sex, or race. Furthermore, there is evidence that a majority of the general public wish to give greater weight to health gains accruing to children, the severely ill, and, to a lesser extent, the socio-economically disadvantaged. This paper outlines four approaches to explicit incorporation of equity considerations into economic evaluation in public health: (i) review of background information on equity, (ii) health inequality impact assessment, (iii) analysis of the opportunity cost of equity, and (iv) equity weighting of health outcomes. The first three approaches can readily be applied using standard methods of health technology assessment, where suitable data are available; whereas approaches for generating equity weights remain experimental. The potential benefits of considering equity are likely to be largest in cases involving: (a) interventions that target disadvantaged individuals or communities and are also relatively cost-ineffective and (b) interventions to encourage lifestyle change, which may be relatively ineffective among 'hard-to-reach' disadvantaged groups and hence may require re-design to avoid increasing health inequalities.

HTA – Algorithm or Process? Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

“…There is a notable lack of practical ethical tools for use in decision-making contexts. 16,17 The incorporation of health equity into HTA through the development of new algorithms and process design has, however, advanced in recent years [18][19][20][21][22][23][24] having been much impeded in the past by a multiplicity of ill-formulated concepts and values and a lack of a widely accepted normative source on which to build controversial choices. Research programmes are fortunately progressing in tackling the substantial theoretical and empirical difficulties in quantifying equity and financial impacts in ways suitable for integration in decision-making.…”

Maximizing Health or Sufficient Capability in Economic Evaluation? A Methodological Experiment of Treatment for Drug Addiction

“…The maximisation of health is only one approach to decision making and evidence shows that society might value different approaches more highly [19][20][21][22][23][24]. It is this thinking that has led some health economists to move away from this conventional approach of health maximisation and to explore alternative more 'egalitarian' approaches that give a greater allowance to distributional concerns [25][26][27][28][29]. One such approach, which was influenced by Rawls's theory of justice [30] and can be traced as far back as 1985 [31], is aiming to bring the members of society to a 'sufficient' threshold level of health.…”

Does MCDA Trump CEA?

“…For example, CEA researchers search for methods of bringing distributional concerns into cost-effectiveness [43][44][45][46][47]. It seems to us to be a substantial empirical question whether it is more helpful for decision makers to have considerations such as these embodied in a simple numerical decision rule (after some form of quantification and weighting) than it is for them to be laid out explicitly for consideration, with whatever qualitative and quantitative evidence that may be available, for a committee to consider and come to a view.…”