Health equity, public health and associated health economic considerations
Thomas Bendall
All views my own | Product Strategy & Access Director | HTA, Reimbursement & HEOR | Strategic Planning | Access & Evidence | Pharmaceutical New Product Development & Positioning | Ambitious About Neurodiversity
Over recent months, I have seen a considerable amount written about health equity, a subject that is close to my heart and one that appears to have resonance more widely. Recently I saw a production of Nye, at the National Theatre in London. The production told the story of Aneurin “Nye” Beven, the government minister with the ambition that drove the creation of the NHS in the UK. The story has personal significance, but it also serves as poinent reminder of the societal circumstance for much of the population and the inequity in access to healthcare that existed in the UK before the availability of universal healthcare. The impact this had on individuals and wider society was palpable. The story served to highlight the challenges that had to be overcome to achieve this bold ambition and the benefits that resulted from this policy. It also provided an opportunity to reflect on how policies such as this (and others like it) should not be taken for granted, can easily be lost and that there is more work to be done (at home and further afield).
Having been fortunate to live in a country and during a time where I have access to universal healthcare and through my work, the insight I have gained into different health systems across the world, I appreciate (and value) the benefits universal healthcare can have for individuals and for wider society in helping drive health equity.
Health inequality
Universal healthcare alone does not address all inequalities when it comes to health. 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., called, “Fair Society, Health Lives” was commissioned by the then UK Secretary of State for Health. The review 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 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, to reduce health inequalities, together with a call to action at national and local levels to drive delivery.
At the beginning of 2020 (pre-COVID-19 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 have started to slow dramatically since 2011. Notably:
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.”
Beyond the immediate headlines, further highlighting that there is still considerable work to do, these reviews serve as examples of the challenges that exist in delivering health at a population level and the complexity in the way these can be addressed, through different public health levers and interventions, of which direct healthcare interventions are a part.
Relevance for innovators of health technologies
As someone who works to innovate and develop health technologies, one of my motivations for working in this industry is the role and impact preventative, treatment and diagnostic interventions can have, as part of the range of public health interventions available for use in what is a diverse ecosystem.
For me in my role, beyond the key takeaway messages, the Marmot review and associated pieces of work, highlight population differences drive different outcomes and that to deliver for a population and support health equity, decisions need to account for and accommodate differences across a population. They also highlight the importance that any intervention used in a public health context has to demonstrate its value. Given the source of funding for public health interventions, combined with the reality of constrained resources, there will be an inevitable need to prioritise interventions and make active funding choices.
As innovators, access to health technologies is fundamental for our own success and for those who may benefit from them. 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, that the definition of HTA highlights that a key aim is promoting equitable, efficient, and high-quality health systems. In relation to this, we are also seeing efforts to introduce distributional (equity) 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 the macro-environmental dynamics and diversity we see across economies and different population/demographic changes, these factors will be important to wider groups of health system/public health stakeholders, in ensuring the efficient allocation of limited resources.
Areas for consideration as innovators
From a health economic perspective, what are the areas that need to be considered, if one considers the role of health technologies in public health, how health systems are funded, and the processes and methods used for evaluation?
As innovators, we must 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.
The broad aim of public health interventions is 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, and interventions that extend life, to name a handful.
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 a downstream impact for individuals and the economy/society.
Public health interventions are often complex interventions due to their properties, what the intervention aims to affect, how it is delivered and to whom, and in what location. This means that there are often challenges associated with the development, delivery and evaluation of these.
Challenges in evaluating public health interventions include:
Implications for economic evaluation in public health; include:
Approaches to economic evaluation
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Typical approaches used in the evaluation of health technologies include cost-effectiveness analysis and cost-utility analysis, due to their extra-welfarist focus on 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 the 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 equitably. There is now a movement to introduce distributional aspects into analysis and decision-making. This stems from the systemic differences observed between advantaged and disadvantaged populations in health, in terms of access to health services/interventions, 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, have 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 to 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
As 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 a 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 well-being 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, which are designed to have a broad population-level impact. As an alternative, the measurement of well-being is a possible alternative. Traditional measures of well-being 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 inequality is an important issue that has a tangible impact on individuals and populations. Inequity can be addressed via specific public health interventions but also can be considered within different interventions. As innovators of health technologies, our interventions can provide benefits as/within public health intervention. These benefits mean 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, and how these are evaluated. It is also important to understand the complexities and evolution in the evaluation of different interventions, to aid the efficient allocation of constrained resources, in improving the health of a population.
References
1. Marmot et al. The Marmot Review: Fair Society, Healthy Lives - Strategic review of health inequities in England post-2010, February 2010
2. Marmot et al. Health Equity in England: The Marmot Review 10 Years On, The Institute of Health Equity, February 2020
3. Thomas, T. Health inequalities ‘caused 1m early deaths in England in last decade’. The Guardian 8th January 2024 .
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10. Timmins, N et al. (2023) Beyond the Average: Making Fairer Decisions for Public Health. University of York – December 2023
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