Efficiency Versus Health Equity in Health Technology Decisions

For decades, health technology assessment (HTA)-related decisions have almost exclusively been driven by quantitative evidence for a new technology’s efficiency, namely its comparative- and cost-effectiveness, as well as its predicted budget impact. HTAs are used globally to inform policy makers and assist them with healthcare resource allocation decisions. However, considering efficiency alone has a potential to negatively affect fairness, or equity, in terms of healthcare resource distribution. One of the more recent and noticeable examples is the COVID-19 pandemic, during which numerous groups were marginalized based on their socioeconomic status or geographic location. Even today, as many Americans eagerly await the arrival of the Omicron-specific booster, there are countries where less than 10% of the population has received a primary vaccine series.

Equitable access to healthcare resources during a global pandemic has become a hot topic, where not only between-country but also within-country resource distribution shortcomings have been discussed. Historically, it has been the responsibility of public health professionals to develop and implement initiatives to address group-level gaps. More recently, however, health economics and outcomes research (HEOR) professionals have contributed to this matter, raising the question of whether issues of equitable healthcare resource distribution should be incorporated during HTA analyses. Would such an approach help close the ever-expanding gap of health inequity? Richard Cookson, PhD, professor at the University of York’s Centre for Health Economics in the United Kingdom, argues that it is not only doable, but believes that every cost-effectiveness analysis should be accompanied by analysis that accounts for social distribution of benefits and costs. Similarly, Mohammad Ameel, MBA, head of Primary Healthcare, Technology & Innovations in South Asia at PATH in India, points out that cost-effectiveness should only matter after a particular intervention is ensured to reach the population in need for it. Naturally, the first step in this process is to define the concept of equitable distribution and identify reasonable measurements.

"Historically, it has been the responsibility of public health professionals to develop and implement initiatives to address group-level gaps. More recently, however, HEOR professionals have contributed to this matter, raising the question of whether issues of equitable healthcare resource distribution should be incorporated during HTA analyses."

The challenge of quantifying “fairness”
What gets measured—gets done (or in this case improved). Cookson emphasizes that quantification of equity is of paramount importance. “I want these numbers compared properly so that we are concerned about [equity] the same way that we are concerned about cost-effectiveness. They need to be numerically quantified so that equity issues are on the same level of playing field with other concerns.” Moreover, it is not sufficient to demonstrate that there is a “small health inequality reduction” in the same way as it is not enough to suggest that a certain technology has a “small effect.” Rather, the reduction in inequality must be quantified. Over the past 2 decades, the conversation of quantifying health equity alongside cost-effectiveness has gained momentum, and health economists have been working toward developing various frameworks and methodologies for effective and meaningful analyses.

One of the biggest roadblocks in many countries is the issue of improving data infrastructure—that is, collecting standardized sociodemographic variables that can then be readily applied in equity analyses. These are costly but invaluable undertakings; yet once these issues are resolved, the HEOR field has the analytical methodology already in place to apply these data. What Cookson refers to as a “quick and simple” distributional analysis is a relatively easy modeling method that can be built on top of an existing cost-effectiveness work. This method can provide insights in resource allocation for equity-relevant variables such as socioeconomic status, ethnicity, and geographic location. Other notable methods include multi-criteria decision analysis and weighting of willingness-to-pay thresholds in terms of disease burden.

“I want these numbers compared properly so that we are concerned about equity the same way that we are concerned about cost-effectiveness.” — Richard Cookson, PhD

The methods currently available are by no means perfect and are often viewed with criticism (similar to how QALYs were often disapproved of in their early years but are now used routinely). Nevertheless, they are a great starting point for understanding directionality and providing a rough estimate of the magnitude in which a new technology is advancing health equity. HEOR professionals must be careful to not tuck these results in a drawer and never look at them again, but rather to push for their implementation on a policy level.

From theory to practice
Theoretical frameworks and methodologies merely lay the groundwork but do not bring change to the table. The change happens once these frameworks are applied to real-world data and translated into action by policy makers. There are institutions, such as the National Institute for Health and Care Excellence in the United Kingdom, that are slowly starting to use distributional analyses to modify cost-effectiveness thresholds for public health guideline development. However, for now, health equity is not a standard consideration in the majority of HTA reports. Cookson points out that they have not yet been implemented for technology appraisals because there is a mountain of legal hurdles for manufacturers along the way.

This becomes an even more far-reaching goal in many lower- and middle-income countries. Cookson and Ameel agree that in some ways, including equity in health technology appraisals for these regions is arguably more relevant than looking at cost-effectiveness. Unfortunately, there are many countries where the underlying health economics work is yet to be done before any of the more sophisticated analyses can be introduced. Ameel points out that in the South Asia region the HTA implementation is very patchy. “Countries like Thailand have very good [HTA] implementation. In India and Indonesia, it is somewhat average, but in countries like Nepal and Bangladesh, they are yet to begin health technology assessments”, he explains.

"Theoretical frameworks and methodologies merely lay the groundwork but do not bring change to the table. The change happens once these frameworks are applied to real-world data and translated into action by policy makers."

Even if cost-effectiveness analyses are conducted, they are often underutilized. Ameel emphasizes that the reason why Thailand has been more successful than other southeast Asian countries in implementing HTAs in their decision making is because HTAs in the region have been institutionalized. HTAs have, similar to the case in the United Kingdom and many other countries, become part of the policy-making process. In fact, there are international research teams being created in many lower- and middle-income countries that extend cost-effectiveness analyses to consider equity-related measures, but as Cookson points out, this practice is not routine nor widespread. Furthermore, complicated political climates and lack of universal health coverage often affect the level to which such analyses are taken into account in the decision-making process.

Tradeoffs between efficiency and fairness
The question of how equity and cost-effectiveness weights should be distributed is not an easy one to answer. It seems inevitable that efficiency of a new health technology is always going to remain at the forefront of decision making. Ultimately, Cookson explains that including health equity measures in health technology appraisals is about shifting the priorities of manufacturer’s research and development (R&D) teams to account for the perspective of equity-efficiency tradeoff. The overarching goal is to evaluate whether a potential technology that is highly cost-effective is going to increase or decrease health inequality if it gets funded. For example, in a world where efficiency alone dictates decision making, a borderline cost-effective, late-stage cancer treatment technology that is likely accessible only to those of higher socioeconomic status might seem more appealing to the R&D teams. However, if decision makers decided to push for investments in treatments for illnesses that are less cost-effective but are disproportionately harming marginalized populations (such as diabetes), that would greatly reduce lifetime health inequalities among certain sociodemographic groups.

Additionally, Cookson suggests that special recommendations for preventive care coverage and delivery among hard-to-reach groups, something that currently lies on the shoulders of public health and primary care professionals, should be included as part of HTAs to make equity-sensitive decisions early on. It is not easy to determine the extent to which inclusion of equity in HTA is going to reduce the health disparities, but both Ameel and Cookson strongly believe that without it, the gaps in access to healthcare resources will continue to grow.

We’re slowly moving in the right direction
The COVID-19 pandemic exposed some of the major challenges communities of lower sociodemographic status experienced in accessing healthcare resources. While equity is clearly a multifold phenomenon and cannot be solved solely through its inclusion in HTAs, addressing these issues prior to a new technology’s entering the market might help reduce these disparities. In some cases, we already see the equity-efficiency tradeoff in action. For example, some treatments for hepatitis C are highly cost-effective yet require large overall spending in terms of the total healthcare budget. However, since these treatments reduce overall health inequity, funding for them tends to be more generous than we would expect in a world where only budgetary issues mattered. So, it appears that we’re on the right track.

"It is not easy to determine the extent to which inclusion of equity in HTA is going to reduce the health disparities, but without it, the gaps in access to healthcare resources will continue to grow."

HTA is one of the most important tools that many policy makers around the world use to drive decisions about healthcare resource allocation. Including equity-sensitive measures in early stages of assessment therefore seems paramount, as it would not only spotlight an important issue but also allow for more nuanced formulations of future research questions in the context of technology implementation. Cookson and Ameel argue that all cost-effectiveness analyses should incorporate equity. Overall, the outlook of the experts remains positive, and while it may take time to fully implement equity measures in routine HTAs, it is likely that it will gradually happen and the ever-expanding gap of health inequality will begin to shrink.