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


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.

Corresponding author
*Corresponding author: Helen Weatherly, Alcuin A block, Centre for Health Economics, University of York, Heslington Road, York YO10 5DD, UK. Email:
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Alexander, al. (1999), ‘14 years of follow-up from the Edinburgh randomized trial of breast-cancer screening’, Lancet, 353(9168): 19031908.
Anand, S., Peter, F., and Sen, A. (2004), Public Health, Ethics and Equity, Oxford: Oxford University Press.
Berk, al. (1985), ‘Social experimentation: a position paper’, Evaluation Review, 9: 387429.
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.
Culyer, A. (2006), ‘NICE's use of cost effectiveness as an exemplar of a deliberative process’, Health Economics, Policy and Law, 1: 299318.
Culyer, A.J. and Wagstaff, A. (1993), ‘Equity and equality in health and health care’, Journal of Health Economics, 12: 431457.
Dolan, al. (2003), ‘An inquiry into the different perspectives that can be used when eliciting preferences in health’, Health Economics, 12: 545551.
Dolan, al. (2005), ‘QALY maximisation and people's preferences: a methodological review of the literature’, Health Economics, 14(2): 197208.
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.
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.
Drummond, 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,
Epstein, al. (2006), ‘Mathematical programming for the optimal allocation of health care resources’, mimeo, University of York, available via (accessed 4 October 2006).
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.
Low, A. and Low, A. (2006), ‘Importance of relative measures in policy on health inequalities’, British Medical Journal, 332: 967969.
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.
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 (accessed 4 October 2006).
National Institute for Health and Clinical Excellence (2006a), Methods for Development of NICE Public Health Guidance, London: National Institute for Health and Clinical Excellence.
National Institute for Health and Clinical Excellence (2006b), ‘Inequalities in health’, NICE Citizen’s Council Report on health inequalities,
Nord, E. (1995), ‘The person-trade-off approach to valuing health care programs’, Medical Decision Making, 15: 201208.
Nord, E. (1999), Cost-Value Analysis in Health Care: Making Sense of QALYs, Cambridge: Cambridge University Press.
Parkin, P. al. (1993), ‘Evaluation of a promotional strategy to increase bicycle helmet use by children’, Pediatrics, 91(4): 772777.
Reading, al. (1994), ‘Do interventions that improve immunisation uptake also reduce social inequalities in uptake?’, British Medical Journal, 308: 11421144.
Rice, al. (1994), ‘A comparison of nursing interventions for smoking cessation in adults with cardiovascular health problems’, Heart and Lung, 23(6): 473486.
Sassi, F., Archard, L. and Le Grand, J. (2001), ‘Equity and the economic evaluation of healthcare’, Health Technology Assessment, 5(3).
Secker-Walker, al. (2002), ‘Community interventions for reducing smoking among adults (Cochrane Review)’ The Cochrane Library, Issue 3.
Shackley, P. and Dixon, S. (2000), ‘Using contingent valuation to elicit public preferences for water fluoridation’, Applied Economics, 32: 777787.
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.
Tugwell, al. (2006), ‘Applying clinical epidemiological methods to health equity: the equity effectiveness loop’, British Medical Journal, 332: 358361.
Wagstaff, A., Paci, P. and van Doorslaer, E. (1991), ‘On the measurement of inequalities in health’, Social Science and Medicine, 33: 545557.
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.
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.
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.
Williamson, al. (1995), ‘Assessment of an inner city visual screening programme for preschool children’, British Journal of Opthalmology, 79(12): 10681073.
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Health Economics, Policy and Law
  • ISSN: 1744-1331
  • EISSN: 1744-134X
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