Putting Health Equity and Economic Evaluation Hand in Hand: Possible or Impossible? 

Robert Malcolm

Project Director, YHEC

Reducing health inequity is a challenging global issue. The impact of new health technologies on health equity should be considered during the health technology assessment process in a range of countries. Countries and their respective HTA processes differ in how much emphasis they place on equity. Even when equity is a formal consideration, guidance on how to operationalise it is often limited. Moreover, political change can significantly affect how equity is prioritised. For example, the Health Equity Advisory Committee at the Center for Medicare and Medicaid Services in the US, which aimed to identify and reduce systemic barriers that people may encounter when trying to access government healthcare programs, was recently forced to disband. In this blog, YHEC’s Robert Malcolm shares his insights on the importance of incorporating health equity into economic evaluation, how we can do this, and what he hopes to see in the future in this area.

Tell us a bit about yourself and your role.
I’m a Project Director in YHEC’s Digital Health Technology and Population Health team. My undergraduate degree was in economics, and I previously worked as an Assistant Economist for the UK Government, where I evaluated the impact of the National Minimum Wage and Living Wage and optimised enforcement strategies. I then did a master’s degree in health economics, and I have been at YHEC for 5 years now. 

I’ve worked on projects across multiple areas, including pharmaceuticals and medical devices, but I tend to specialise in digital health technologies and public health interventions. This ties into equity in economic evaluations, which is a big interest of mine.

I’d like to add before we get into the questions about equity that I acknowledge I’m discussing this from a perspective of a white male. I recognise that there are a lot of inequities that I will not experience and so it’s important to listen to perspectives and experiences from a broad, diverse range of people. Hopefully by continuing the conversation, though, we will get more people involved in these discussions. 

Can you briefly explain what health inequalities are, the difference between health inequalities and health equity, and why they matter right now?
Health inequalities are avoidable and unfair differences in health outcomes among different population groups. It’s important to remember that there are numerous determinants of health – not just within healthcare. Education is a good example; however, there are also a lot of factors in healthcare that impact health inequalities too. Some factors can also intersect and may be somewhat correlated, which makes analysis more challenging.

Equity is the demand for everyone to have equal opportunities to healthcare or to maximise their health, whereas equality is about everyone having the same healthcare. For example, if there was equal healthcare, you would assume that there are an equal proportion of caesarean sections in different population groups in England. However, an equitable outcome is that there might be factors, such as religious beliefs, for why some women don’t have a caesarean section, so you might not necessarily get an equal outcome even though the level of access is the same. 

I often describe equity and inequality as two sides of the same coin – they’re not exactly the same but are usually very related, in the fact that inequities cause inequalities. There’s a great book by Kate Pickett called ‘The Spirit Level’ that summarises years of research and shows the impact that health inequalities can have on society. This isn’t just on the health system but also on the wider economy, which impacts everyone. So, this is a really important issue to consider when making healthcare decisions. Consequently, it is taken into consideration by a number of health technology assessment agencies. For example, aiming to reduce health inequalities is one of the National Institute for Health and Care Excellence’s (NICE’s) principles that guide the development of their guidance and standards [1]. According to NICE, one of the main reasons for its establishment in 1999 was to reduce geographic and socioeconomic variation in care (e.g. postcode prescribing). 

How does health equity currently affect the industry/patients/research space?
Health equity is gaining more and more attention within industry and research. When we think about a new intervention now, we also start to consider the impact it might have on health equity. Currently, the shortfall is how much we adopt implementation science. Implementation science is used to identify the factors that affect the uptake of a clinical innovation into routine use [2]. We can start to speculate what the impact of a new intervention might be, but without implementation science, we cannot be sure that what we think an intervention will do will actually happen in practice.

Often, there are a lot of barriers to introducing new healthcare interventions. Without implementation research up front, these barriers might not be identified and could cause challenges when rolling out the technology. Consequently, what is thought to be a positive intervention for health equity could actually widen health inequity. An example of this is bowel cancer screening in England [3]. It was considered a cost-effective thing to do, but when it was implemented, it showed that it widened health inequalities. This was due to lower uptake in more deprived areas.

Health equity is sometimes lacking in the research space at the moment but, hopefully, we’ll see this more systematically considered in the coming years.

Are there any recent advancements/methods in incorporating health equity into health economic evaluations?
Distributional cost-effectiveness analysis (DCEA) isn’t a particularly new method, but it’s been getting a lot more traction recently. DCEA does not just look at the overall net health benefit, but where that health is distributed. Specifically, aggregate DCEA is getting the most focus because it is slightly more pragmatic and feasible to implement with available data. However, aggregate DCEA still has data challenges, such as a lack of data on health outcomes stratified by relevant social groups. The other challenge is having a clear estimate of health opportunity costs, ideally stratified by relevant social groups. 

Aggregate DCEA, in very simple terms, is taking a cost-effectiveness model and working out who is going to benefit (i.e. considering prevalence and uptake by a measure of inequality), what the health opportunity cost is, and where the losses are going to be from those opportunity costs. Then, you can start to evaluate this across different levels of deprivation and quantify the equity impacts of a new healthcare intervention. There is potential to incorporate other characteristics, but only if the data can be stratified based on those characteristics, which may be really challenging. DCEA seems to be becoming the gold standard for quantifying health equity and was recently rolled into a modular update of NICE’s methods guide [4]. 

I suppose the focus of this now tends to be around England, but there are a lot of different metrics that can be used within DCEA. As data collection continues to improve in other countries, this method could (and will) start to be applied more globally. It’s worth noting that there are a lot of papers and conference abstracts being published that claim to be using DCEA but aren’t. Even though it’s a gold-standard method, it’s important to understand and be clear about what DCEA actually is and how to undertake this correctly [5]. Beyond DCEA, there are more qualitative and pragmatic methods that can be used to start to consider the impact of health equity. It’s not necessarily just DCEA or nothing [6].

What are the biggest challenges related to equity in health technology assessment that we need to address?
The biggest challenge is how we think about systematically incorporating decisions about equity into decision making. Globally, there are different health technology assessment bodies and government departments making decisions around healthcare. Some countries do consider health equity in their methods guidelines (e.g. Australia, Canada and Germany), while other countries don’t rank it so highly (e.g. Italy, Portugal) [7]. Even for countries that do consider it, there are different methods for incorporating it. It may be incorporated qualitatively or quantitively, or only certain factors may be considered. Intersectionality of factors can also impact this because in some areas they may be somewhat correlated (e.g. link between income, race, gender, crime) which can make analysis challenging. Countries may also make different decisions about how they trade this off to maximise population health. It’s important that health equity is incorporated in a systematic way that is transparent and replicable for other interventions and disease areas.

So, again, the big challenge is how we go about making these trade-offs and decisions. This goes beyond just health equity because there are other factors, such as environmental sustainability, that are also important to consider.

What opportunities does incorporating health equity into health economic evaluations present for the future?
Overall, research on health equity is really important because it can help decision makers make more informed healthcare decisions. Ultimately, this should lead to more transparent, and hopefully optimal, evidence-based policy decisions. If we start to quantify the impact on health equity so that we understand the scale, or if we undertake some qualitative work or implementation research, then we will have more available information and can make more informed decisions. For example, if you’re rolling out a new screening program and identify several barriers of why it’s going to be a problem in deprived areas, then you have more information to understand that implementing it will likely widen health inequity without additional implementation support. There is then a question, of how much are decision makers willing to pay to improve implementation so that it is more equitable? 

What ethical or social implications should be considered when making healthcare decisions with respect to equity?
This is a really challenging one. There are different ways to measure the impact on equity. In England, we typically use an index called the ‘index of multiple deprivation’. This basically quantifies lots of different things (income, employment, crime, education etc.) that feed into ranking deprivation across the country, which are rolled into an index score. However, there are lots of different ways that equity impacts can be defined, including race, gender and other characteristics.

This can introduce challenges with quantitative methods for incorporating health equity. You can quantify deprivation using these indexes, but a key question is how we then start to explore specific groups within society and understand if we are capturing all forms of equity or just one subset of the population. Are there parts of the population where we don’t know what the impact is? So, the real challenge is defining what group and what population in society we’re looking at for making these decisions. This is particularly difficult in quantitative research.

What do you hope the future holds for incorporating health equity into health economic evaluations, and how can we work towards that vision?
My hope is that we see movement towards a full mixed-methods approach when incorporating health equity in health technology assessment decision making. New methods that are getting more and more traction, such as DCEA, don’t provide the full picture of what the impact is going to be on health equity. The only way to show the full picture is to undertake both qualitative and quantitative research. Things like DCEA and other general, more pragmatic quantification methods can provide an idea of the size and scale of the potential impact. However, one thing that’s missing from any quantitative method is the context, and the understanding of intersectionality between different groups in society. You don’t get the full understanding of why there might be an impact on health equity, what the barriers are, and how to potentially solve these issues. Also, I can look at numbers all day, but they don’t provide the personal experiences that some people have in the health system; therefore, it’s important to gather other people’s perspectives. In research, you need these perspectives because the researchers may not have experienced these inequities directly, so it is important that a broad and diverse range of perspectives are considered. This is why the qualitative aspect is so important. It’s only when you start combining both quantitative and qualitative research that you start to understand the full impact that an intervention could have on health equity. 

I’m not saying it always needs to be a mix of the gold-standard approaches because there might not be sufficient data, budget, timelines or other factors to do this. Even using a more pragmatic quantitative approach in combination with qualitative research can provide a more holistic, rounded understanding than DCEA alone. Researchers shouldn’t be afraid to do something a little more pragmatic, if the other alternative is nothing, because it can still be beneficial. However, the limitations of more pragmatic approaches should be clearly detailed. 

How can YHEC help clients who wish to incorporate health equity into health economic evaluations?
At YHEC, we offer a range of services to help clients in this area. We have expertise in more complex methods like aggregate DCEA. Depending on the level of data available, we may even be able to do a full DCEA, which is where we augment the cost-effectiveness model to include measures and differences in effectiveness by equity.

We can also develop more pragmatic solutions, like inequalities calculators, to estimate impact across social groups or analyse electronic health records, like the Clinical Practice Research Datalink, to understand prevalence across different groups and how this might correlate with other factors. Finally, we have experience designing and conducting implementation science projects, including a range of stakeholder engagement and types of literature review, to identify barriers and optimise implementation. 

In a global setting, we can use different quantitative methods, such as extended cost-effectiveness analysis, which often focus on financial risk protection and income. Other countries may have different levels of data and restrictions on what is available, so we can advise and tailor the approach as necessary to support your understanding of health equity. 

Contact us

If you would like to find out more about how YHEC can support you in incorporating health equity into economic evaluations, contact us at: yhec@york.ac.uk

References
1. National Institute for Health and Care Excellence. Our principles.  [cited 16 April 2025]. Available from: https://www.nice.org.uk/about/who-we-are/our-principles. 

2. Bauer MS, Kirchner J. Implementation science: what is it and why should I care? Psychiatry research. 2020.283:112376. 

3. Asaria M, Griffin S, Cookson R, Whyte S, Tappenden P. Distributional cost‐effectiveness analysis of health care programmes–a methodological case study of the UK bowel cancer screening programme. Health economics. 2015.24(6):742-54.

4. National Institute for Health and Care Excellence. Modular update to NICE manuals: Health inequalities. Task and finish group report. 2025. [cited 16 April 2025]. Available from: https://www.nice.org.uk/guidance/GID-PMG10009/documents/supporting-documentation-3. 

5. Asaria M, Griffin S, Cookson R. Distributional cost-effectiveness analysis: a tutorial. Medical decision making. 2016.36(1):8-19. 

6. YHEC. No half measures: health inequalities in technology appraisal. 2023. [cited 17 April 2025]. Available from: https://yhec.co.uk/casestudies/no-half-measures-health-inequalities-in-technology-appraisal/. 

7. ISPOR. Pharmacoeconomic guidelines around the world.  [cited 17 April 2025]. Available from: https://www.ispor.org/heor-resources/more-heor-resources/pharmacoeconomic-guidelines/pe-guideline-detail. 

Posted: 04 June 2025