Two common health policy objectives are to improve population health and to reduce unfair health inequalities. Tools for addressing both concerns in health economic evaluation have been recently developed. In this paper, we will investigate how these can be applied to interventions at the population- and system-level, where the largest potential impacts on both equity and population health can be found. This will involve considering the practical and methodological issues that arise when conducting distributional analysis in the economic evaluations of these types of interventions, with a focus on low- and middle-income countries.

We will describe several potential challenges including:

1. Incorporating limited treatment effect heterogeneity estimated from quasi-experimental impact evaluation studies
2. Maximising the policy relevance of an evaluation given the (often) ex post nature of the impact study
3. Accounting for complexities in intervention funding and opportunity costs that are relevant for equity

We will illustrate these issues through a distributional cost-effectiveness analysis (DCEA) of the Family Health Programme (PSF) in Brazil – a community-level primary care intervention (more information here). Estimates of the effects of the PSF on mortality at the regional level will be used to model the impact on health inequalities between Brazilian states. Population health effects in terms of disability-adjusted life years will be estimated by combining the impact estimates with state-specific data on baseline disease prevalence and mortality. We will also explore a range of scenarios that account for different levels and distributions of health opportunity costs that arise from the intervention being funded through municipal, regional and federal health budgets.