Hostname: page-component-77c89778f8-rkxrd Total loading time: 0 Render date: 2024-07-20T15:30:21.291Z Has data issue: false hasContentIssue false

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

Published online by Cambridge University Press:  01 April 2009

RICHARD COOKSON
Affiliation:
Department of Social Policy and Social Work, and Centre for Health Economics, University of York, UK
MIKE DRUMMOND
Affiliation:
Centre for Health Economics, University of York, UK
HELEN WEATHERLY*
Affiliation:
Centre for Health Economics, University of York, UK
*
*Corresponding author: Helen Weatherly, Alcuin A block, Centre for Health Economics, University of York, Heslington Road, York YO10 5DD, UK. Email: hlw4@york.ac.uk

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.

Type
Debate
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Alexander, F.E.et al. (1999), ‘14 years of follow-up from the Edinburgh randomized trial of breast-cancer screening’, Lancet, 353(9168): 19031908.CrossRefGoogle ScholarPubMed
Anand, S., Peter, F., and Sen, A. (2004), Public Health, Ethics and Equity, Oxford: Oxford University Press.Google Scholar
Berk, R.et al. (1985), ‘Social experimentation: a position paper’, Evaluation Review, 9: 387429.Google Scholar
Briggs, F., and Hawkins, R.M. (1994), ‘Follow up data on the effectiveness of New Zealand’s national school based child protection programme’, Child Abuse and Neglect, 18(8): 635643.CrossRefGoogle Scholar
Culyer, A. (2006), ‘NICE's use of cost effectiveness as an exemplar of a deliberative process’, Health Economics, Policy and Law, 1: 299318.CrossRefGoogle ScholarPubMed
Culyer, A.J. and Wagstaff, A. (1993), ‘Equity and equality in health and health care’, Journal of Health Economics, 12: 431457.CrossRefGoogle ScholarPubMed
Dolan, P.et al. (2003), ‘An inquiry into the different perspectives that can be used when eliciting preferences in health’, Health Economics, 12: 545551.Google Scholar
Dolan, P.et al. (2005), ‘QALY maximisation and people's preferences: a methodological review of the literature’, Health Economics, 14(2): 197208.Google Scholar
Dolan, P. and Tsuchiya, A. (2007), ‘Do NHS staff and members of the public share the same views about how to distribute health benefits?’, Social Science and Medicine, 64: 24992503.Google Scholar
Donaldson, C. (1999), ‘Valuing the benefits of publicly provided health care: does “ability to pay” preclude the use of “willingness to pay”?’, Social Science and Medicine, 49: 551563.Google Scholar
Drummond, M.et al. (2006), ‘Assessing the challenges of applying standard methods of economic evaluation to public health interventions’, Report prepared for the Department of Health Policy Research Programme, www.york.ac.uk/phrc.Google Scholar
Epstein, D.et al. (2006), ‘Mathematical programming for the optimal allocation of health care resources’, mimeo, University of York, available via www.york.ac.uk/inst/che/staff/epstein.htm (accessed 4 October 2006).Google Scholar
Katz, S.J. and Hofer, T.P. (1994), ‘Socioeconomic disparities in preventive care persist despite universal coverage: breast and cervical cancer screening in Ontario and the United States’, Journal of the American Medical Association, 272(7): 530534.CrossRefGoogle ScholarPubMed
Low, A. and Low, A. (2006), ‘Importance of relative measures in policy on health inequalities’, British Medical Journal, 332: 967969.CrossRefGoogle ScholarPubMed
MacIntyre, D. and Carr, A. (1999), ‘Evaluation of the effectiveness of the stay safe primary prevention programme for child sexual abuse’, Child Abuse and Neglect, 23(12): 13071325.Google Scholar
National Evaluation of Sure Start. (2005), ‘Variation in Sure Start local programmes’ effectiveness: early preliminary findings’, Research Report NESS/2005/FR/014, HMSO, London, available via http://www.surestart.gov.uk/research/evaluations/ness/latestreports/ (accessed 4 October 2006).Google Scholar
National Institute for Health and Clinical Excellence (2006a), Methods for Development of NICE Public Health Guidance, London: National Institute for Health and Clinical Excellence.Google Scholar
National Institute for Health and Clinical Excellence (2006b), ‘Inequalities in health’, NICE Citizen’s Council Report on health inequalities, http://www.nice.org.uk/page.aspx?o=410781.Google Scholar
Nord, E. (1995), ‘The person-trade-off approach to valuing health care programs’, Medical Decision Making, 15: 201208.Google Scholar
Nord, E. (1999), Cost-Value Analysis in Health Care: Making Sense of QALYs, Cambridge: Cambridge University Press.CrossRefGoogle Scholar
Parkin, P. C.et al. (1993), ‘Evaluation of a promotional strategy to increase bicycle helmet use by children’, Pediatrics, 91(4): 772777.CrossRefGoogle ScholarPubMed
Reading, R.et al. (1994), ‘Do interventions that improve immunisation uptake also reduce social inequalities in uptake?’, British Medical Journal, 308: 11421144.Google Scholar
Rice, V.H.et al. (1994), ‘A comparison of nursing interventions for smoking cessation in adults with cardiovascular health problems’, Heart and Lung, 23(6): 473486.Google ScholarPubMed
Sassi, F., Archard, L. and Le Grand, J. (2001), ‘Equity and the economic evaluation of healthcare’, Health Technology Assessment, 5(3).CrossRefGoogle ScholarPubMed
Secker-Walker, R.H.et al. (2002), ‘Community interventions for reducing smoking among adults (Cochrane Review)’ The Cochrane Library, Issue 3.Google Scholar
Shackley, P. and Dixon, S. (2000), ‘Using contingent valuation to elicit public preferences for water fluoridation’, Applied Economics, 32: 777787.Google Scholar
Tsuchiya, A., McCabe, C. and Wailoo, A. (2007), ‘Incorporating equity weights into cost-effectiveness analyses: opening Pandora’s box?’, Paper written for the Health Economics Study Group meeting at the University of Birmingham, January 2007.Google Scholar
Tugwell, P.et al. (2006), ‘Applying clinical epidemiological methods to health equity: the equity effectiveness loop’, British Medical Journal, 332: 358361.Google Scholar
Wagstaff, A., Paci, P. and van Doorslaer, E. (1991), ‘On the measurement of inequalities in health’, Social Science and Medicine, 33: 545557.Google Scholar
Williams, A. and Cookson, R. (2000), ‘Equity in health’, in Culyer, A.J.Newhouse, J.P. (eds.), Handbook of Health Economics, Elsevier Science B.V.Google Scholar
Williams, A. and Cookson, R. (2006), ‘Equity–efficiency trade-offs in health technology assessment’, International Journal of Technology Assessment in Health Care, 22(1): 19.Google Scholar
Williams, A., Tsuchiya, A. and Dolan, P.(2004), ‘Equity–efficiency trade-offs in health’, in Smith, P.C., Ginnelly, L. and Sculpher, M. (eds.), Health Policy and Economics: Opportunities and Challenges, McGraw Hill, pp. 64–87.Google Scholar
Williamson, T.H.et al. (1995), ‘Assessment of an inner city visual screening programme for preschool children’, British Journal of Opthalmology, 79(12): 10681073.Google Scholar