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 quasiegalitarian
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.
