Health Technology Assessment (HTA) agencies generally look at prioritising the implementation of those health and social care interventions that demonstrate to be cost-effective, and thereby increase the efficiency of the health and social care system as a whole. However, cost-effectiveness often is not the only decisive criterion in the prioritisation process: equity considerations matter too.

Equity is in the HTA agencies’ mind
Stafinski et al. (2012) reviewed how HTA agencies around the world take their decisions, and observed that trade-offs between efficiency (i.e. maximising the gain from the use of health and social care resources) and equity (i.e. reducing health inequalities) are taken into account, but less clarity emerged on how agencies actually substantiate their efficiency/equity decisions. For example, the willingness to incorporate factors like solidarity (i.e. patients with greatest need should be given higher priority) and social benefit does transpire, but how these factors are operationalised is not always clear. What emerges is the recognition that efficiency should not be the only guiding light in specific circumstances, for example when treatments for rare conditions or end-of-life are assessed. In these cases, the solidarity principle would become superior to the principle that each quality-adjusted life year (QALY) is valued in the same way regardless of how gains or loses it, by applying greater weights to the QALYs accrued by those in greatest need.

OK…but how can we incorporate equity in HTAs?
Cookson et al. (2017) provide a useful guidance on how to make cost-effectiveness analyses (CEAs) equity-informative. Firstly, the authors explain the nature of health equity trade-offs, that is when interventions could be cost-effective but also reduce health equity (e.g. preventive interventions on lifestyle behaviours which may disproportionally benefit those living in advantaged areas) or could increase health equity without being cost-effective (e.g. costly interventions that target people living in remote areas with limited access to health services). It then becomes important to consider the net equity impacts triggered by interventions, in terms of how equal the distribution of opportunity costs is across the population (i.e. do the health losses generated by displacing resources to fund the new interventions hit more those who are already disadvantaged?).

Measuring equity in CEAs is typically done by developing equity impact analyses or equity trade-off analyses. Within the set of equity impact analyses, we find:

• Extended CEA (ECEAs) which focus on the distribution of health-related and financial risk protection benefits and are especially useful in those contexts where out-of-pocket payments can be substantial;

• Distributional CEAs (DCEAs) which look at the distribution of health benefits and opportunity costs, thus measuring net equity impacts for different sub-groups which could be weighed against a cost-effectiveness metric (i.e. net health benefit).

On the other hand, among equity trade-off analyses Cookson et al. (2017) discuss equity constraint analyses and equity-weighting analyses. The former analysis assesses how much health losses decision-makers are willing to accept in order to choose a fairer option. With the latter analysis equity weights are applied to people with specific characteristics (e.g. those living in deprived areas) or equity parameters are used to take into account the degree of concern around inequalities (e.g. an inequality aversion parameter), and the parameters’ weight can then be tested in sensitivity analyses.

The future looks bright(er)
While equity concerns are certainly varied and go beyond the mere health sphere (for example impacting on productivity and work patterns), these methodological advances reflect the increasing recognition that equity matters and should be accounted for in HTAs, as also documented by the development of equity checklists for HTAs (Benkhalti et al., 2021).

Author of this blogpost:
Dr Valerio Benedetto, UCLan and MIDAS Theme

What’s next
In the next blog, Valerio will investigate how the lack of resources may affect HTAs.

Some references:
• Cookson, R., Mirelman, A.J., Griffin, S., Asaria, M., Dawkins, B., Norheim, O.F., Verguet, S. and Culyer, A.J., 2017. Using cost-effectiveness analysis to address health equity concerns. Value in Health, 20(2), pp.206-212.
• Benkhalti, M., Espinoza, M., Cookson, R., Welch, V., Tugwell, P. and Dagenais, P., 2021. Development of a checklist to guide equity considerations in health technology assessment. International journal of technology assessment in health care, 37(1), p.e17.
• Stafinski, T., Menon, D., Philippon, D. J., & McCabe, C. (2011). Health technology funding decision-making processes around the world. Pharmacoeconomics, 29(6), 475-495.