title: Using Cost-Effectiveness Analysis to Address Health Equity Concerns.
abstract: This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health-the objective underpinning conventional CEA-and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and-crucially-who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs.
authors.affiliation: Centre for Health Economics, University of York, York, UK. Electronic address: richard.cookson@york.ac.uk.
authors.forename: Richard
authors.initials: R
authors.lastname: Cookson
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Mirelman
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Griffin
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Miqdad
authors.initials: M
authors.lastname: Asaria
authors.affiliation: Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
authors.forename: Bryony
authors.initials: B
authors.lastname: Dawkins
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
authors.forename: Ole Frithjof
authors.initials: OF
authors.lastname: Norheim
authors.affiliation: Department of Global Health and Population, Harvard University, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Verguet
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Anthony
authors.initials: A
authors.lastname: J Culyer
mesh_terms: D003362:Cost-Benefit Analysis / Q000379:methods*; D000069576:Health Equity; D006801:Humans; D011050:Policy Making; D013673:Technology Assessment, Biomedical
keywords: cost-effectiveness analysis; delivery of health care; health equity; technology assessment