Health equity, public health and associated health economic considerations
This overview covers the importance of health equity and how this relates to public health interventions. Given the aims of population health and its role in addressing inequalities, the source of funding and need for efficient allocation of constrained resource, it examines key areas for innovators of health technologies to consider, when demonstrating and communicating value of their interventions, as part of public health initiatives. It also reviews how approaches are changing in the evaluation of health technologies/interventions and subsequent decision making for public health interventions, including how evaluate the impact on health inequities.
Health inequality
Central to my values, especially in health, is the concept of equity. I have been fortunate to live in a country with universal healthcare and my work provides insight into the impact of different health systems, with differing funding approaches. For me, I value the benefits universal healthcare can have for individuals and at a population level; there is clearly more work that needs to be done to address inequalities, however.
Despite the advantages afforded by universal healthcare, the health of a population and its individuals is driven by a range of factors including socioeconomic, cultural and environmental conditions. To illustrate this, a 2010 strategic review by Marmot et al., which was commissioned by the then Secretary of State for health and called, “Fair Society, Health Lives”, highlighted that there is a clear gradient in life expectancy and years lived with disability, across socioeconomic groups in the UK.
It shone a light on how social and economic determinants of health drive many of the inequalities we observe and how these differences have wide ranging impacts on individuals, the population and the wider economy. The report identified the need for universal action across the whole of society and six priorities were identified, with the aim of reducing health inequalities, together with a call to action at national and local levels to drive delivery.
At the beginning of 2020 (pre-Covid19 pandemic), the Institute of Health Equity published a 10-year update to the original review. The report highlighted that in England, health measured by life expectancy had stopped improving, with health inequalities widening. The authors noted that improvements in life expectancy had been observed since the start of the 19th century, but these has started to slow dramatically from 2011. Notably:
- Among women in the most deprived 10% areas of England, life expectancy fell between 2010-2012 and 2016-2018.
- There were marked regional differences with greatest declines observed in the most deprived 10% of neighbourhoods in the North East and largest increases in the least deprived 10% of neighbourhoods in London.
- Mortality rates had increased for those aged 45-49.
These disparities were once again highlighted with the publication of a further review in January 2024, with Professor, Sir Micheal Marmot, commenting that “Our country has become poor and unhealthy, where a few rich, healthy people live. People care about their health, but it is deteriorating, with their lives shortening, through no fault of their own.”
So, why am I writing this?
On a personal level and as UK citizen, I find the situation in the UK disturbing and believe we should be doing all that we can to address these inequities. This however is not an attempt to provide commentary on the evident current complexities in UK society, rather it serves as an example to highlight some of the challenges that exist in delivering health at a population level.
For me, it highlights that:
- Population differences drive different outcomes and therefore to deliver for a population, decisions need to account for and accommodate these differences to support health equity.
- Given the impact, source of funding for public health interventions, combined with the current economic challenges (certainly in the UK, in 2024) and inevitable constrained resources; for any concerted effort to address inequities, there will be a need to prioritise interventions and make active funding choices. In doing so there will be the need for interventions to demonstrate their value.
- And of course, contextually, from a UK perspective, with worsening inequities, it highlights a need (and hopefully signals the required urgency) to address these.
Relevance for innovators of health technologies
The Marmot review and subsequent reports, highlight the importance of social determinants of health on observed inequalities and recommended interventions to address these & improve the health of the nation. As someone who works to innovate and develop health technologies, it is important to remember the role these preventative, treatment and diagnostic interventions have had in public health (e.g. vaccines), addressing areas of high burden and unmet need, and how they will continue to do so.
When considering these health technologies, access to these is fundamental for success, as innovators and for the people we hope can benefit from them. As innovators, equitable access and outcomes are therefore important factors that need to be considered, in the way we demonstrate value and how we navigate decision making processes for funding/reimbursement. Indeed, we should remember, the definition of HTA highlights that a key aim is promoting equitable, efficient, and high-quality health systems. Related to this, we are also seeing efforts to introduce distributional considerations in decision making for public health, including in the evaluation of health technologies.
As innovators, equity in health is therefore highly relevant and the challenges outlined above are not unique to the UK. If one considers macro-environmental dynamics associated with developing economies and population/demographic changes, these factors will be of importance to wider groups of health system/public health stakeholders, in ensuring efficient allocation of limited resource.
Areas for consideration as innovators
Given the role of health technologies in public health, the way in which health systems are funded and processes and methods for evaluation; from a health economic perspective, what are the areas that need to be considered? As innovators, it is important that we understand the aims of public health initiatives; the importance of addressing health inequalities; the challenges inherent in implementing public health interventions and the different methods & approaches of evaluation, including the consideration of health equity.
Aims in delivering public health interventions.
The broad aims of public health interventions are to improve the health of the population through clinical or other initiatives that may be delivered outside of conventional health services.
The scope of possible interventions is considerable with activities focused on three domains: health improvement, health protection and service improvement, with interventions including, water/sanitation, child protection, provision of antibiotics and vaccination, the welfare state, interventions that extend life, to name a handful.
Aims of tackling health inequality
As we have highlighted above, to deliver health at a population level, a one size fits all approach is insufficient. By understanding and addressing sources of inequity, there is the potential to improve health for the whole of the population, with downstream impact for individuals and the population.
Differences and Challenges associated with public health initiatives
Public health interventions are often complex interventions due to the properties of the intervention, what it aims to affect, how it is delivered and to whom and in what location. This means that that there are often challenges associated with the development, delivery and evaluation of these.
Challenges in evaluating public health interventions, include:
- Many interventions are preventative, which raises issues in measuring costs and outcomes over time.
- They are often delivered outside the health system.
- The identification, measurement and valuation of costs and outcomes over a relevant time horizon
- Attribution of health benefits, costs and cost savings to the intervention
- Identifying the relevant perspective for evaluation
- Choice between micro and macro approaches to evaluation
- The need for the inclusion of equity considerations in evaluation
- Delivery context of the intervention and the impact on evaluation
- Implications of the rule of rescue for interventions
- Availability of published guidance
- Theoretic economic roots for evaluation
Implications for economic evaluation in public health; include:
- Contextual agreement on determinants of health and health inequalities
- Relationship between upstream and downstream interventions
- The mediating role of behaviour change
- Separating cause and effect
- Biologic and social variation
- The absence of systematic development
- How and when effectiveness should be measured
- Differences between individual and population measures.
Approaches to economic evaluation
Typical approaches used in the evaluation of health technologies include cost effectiveness analysis and cost utility analysis, due to the extra-welfarist focus of evaluation in non-monetary terms. This familiarity will drive the basis of evaluation for public health interventions, alongside cost consequence analysis. Given the scope and heterogeneity of public health interventions, cost benefit analysis, grounded in neoclassical welfare economics, provides the ability to evaluate benefits across health and other sectors of the economy, using a common currency.
Whilst current approaches lean heavily on established methods of economic evaluation, these methods may not capture all costs and benefits of public health interventions. Initiatives have therefore been proposed to improve the capture, evaluation and modelling of effects, as well as the development of alternative ways to value benefits of public health interventions, which is discussed below.
The drive for equitable decision making via distributional cost effectiveness analysis.
Traditional approaches to the evaluation of health technologies have focused on aggregate efficiencies, rather than considering how cost and effects are distributed in an equitable manner. There is now a movement to introduce distributional aspects into analysis and decision making. This stems from the systemic differences observed between advantaged and disadvantage populations in health, in terms of access to health services/interventions and financial hardship due to out-of-pocket expenditure and the resulting impact of this inequality on different measures of health.
Current thinking and proposed adaptations to cost effectiveness analysis, to include distributional aspects, has the aim of providing information about the distributional consequences of an intervention. To achieve this, consequences are broken down by differing equity related variables such as disease classification/severity, proximity to death and socioeconomic variables that are relevant for a particular population or decision context. The concept goes beyond the attempts we have seen over the years to address equity aspects in the form of equity weighting and decision rules, e.g. based on end-of-life criteria. This adapted approach is not decision making but rather focuses on generating new information about distributional consequences, that can then be used as input into decision making.
Alternative ways to value benefits of public health interventions
We highlighted above, the familiarity of cost utility analysis and cost effectiveness analysis in the assessment of health technologies, drives the methodological foundation for the assessment of public health interventions.
Common measures used in cost effectiveness analysis and cost utility analysis focus on health outcomes. Health outcomes are either explicit (e.g. in the measurement of natural units) or captured with different outcome measures that assess health as whole, such as EQ-5D which then provides utility weights for the calculation of QALYs. Whilst preference-based measures of health include wider quality aspects such as mood, it is argued that the areas relating to wider wellbeing are diluted, at the expense of health measures such as pain; additionally, the methods used in valuing health states, mean people may ignore aspects such as income.
Given the goals of public health interventions, it is therefore argued whether these are appropriate measures to assess the impact of public health interventions, that are designed to have a broad population level impact. As an alternative, the measurement of wellbeing is a possible alternative. Traditional measures of wellbeing however do not provide suitable inputs for economic evaluation, with subsequent work focused on developing preference-based measures that incorporate more psychosocial concerns, such as the Investigating Choice Experiments Capability Measure (ICECAP) and Adult Social Care Outcome Toolkit (ASCOT).
Conclusion
In conclusion, health inequities are an important issue which have tangible impact on individuals and at a population level. These can be addressed via specific public health interventions but also can be considered within different interventions. As innovators of health technologies, our interventions have utility as/within public health interventions. This utility therefore means health equity is an important consideration when demonstrating and communicating the value of the health technologies we develop. In doing so, one should understand the role of public health interventions and the importance of health equity, the challenges associated with decision making, in delivery, how these are evaluated, together with the related complexities and evolution of evaluatio to aid the efficient allocation of constrained resource, in improving the health of a population.
References
Marmot et al. The Marmot Review: Fair Society, Healthy Lives – Strategic review of health inequities in England post-2010, February 2010
Marmot et al. Health Equity in England: The Marmot Review 10 Years On, The Institute of Health Equity, February 2020
Thomas, T. Health inequalities ‘caused 1m early deaths in England in last decade’. The Guardian 8th January 2024 .
Edwards, R & Atenstaedt, R. (2019) Introduction to public health and public health economics in Applied health economics for public health practice and research – 1st edition. Oxford University Press, Oxford
O’Rourke, B et al. Value Health. (2020); 23(6):824–825
Skivington, K et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ 2021;374:n2061 http://dx.doi.org/10.1136/bmj.n2061
Cookson, R et al. (2021) Introduction in Distributional cost-effectiveness analysis – Quantifying health equity impact and trade-offs – 1st edition. Oxford University Press, Oxford
Cookson, R et al. (2021) Principles of health equity in Distributional cost-effectiveness analysis – Quantifying health equity impact and trade-offs – 1st edition. Oxford University Press, Oxford
Timmins, N et al. (2023) Beyond the Average: Making Fairer Decisions for Public Health. University of York – December 2023
Husereau et al. (2022) Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluation. BMC Medicine (2022) 20:23 https://doi.org/10.1186/s12916-021-02204-0
Brazier, J et al (2017) Measuring and valuing health benefits for economic evaluation – 2nd edition. Oxford University Press, Oxford