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Cost-effectiveness analysis with an equity approach

Ornella Moreno

Ornella Moreno Mattar
Health Administrator,
MSc in Public Policy,
health economics lead

The change of government has implied for the country a change of perspective and focus of policies, including those of the health sector.

Beyond some formal adjustments, the structural changes proposed by the current Government Plan, which will function as a roadmap for the next National Development Plan and the policies that derive from it, such as the expected health reform, are aimed at profound adjustments in terms of equality and equity.


For example, the new government's proposal addresses issues that go beyond the pandemic, for example, related to gender equity or democratization of the virtual space including telemedicine, and point 3.8 "health for life and not for business" which cites: "The health system will be public and universal, so that timely and quality access to the provision of services will not depend on the ability to pay [...]" (Government Program 2022, 2022).


Until this statement, the proposal does not become a novelty, since the reduction of inequities is the objective of many policies formulated and implemented by different governments and administrations, but whose progress is increasingly complex to achieve.


As an example, in March of this year the Ministry of Health and Social Protection launched the Health Equity Observatory, whose first report was launched last June where results are presented specifically on the health inequalities observed during the COVID pandemic. -19 (Ministry of Health and Social Protection, 2022).


Both this observatory, which has thematic lines of "Coverage, access and quality of health services", as well as the proposals currently discussed in the field of health, open the door to a discussion that has begun in England, France and other European countries on how to contribute to equity in health from the supply chain and decision-making on health technologies? And especially, one of the issues that draws attention in this line is the use of cost-effectiveness analysis to address health equity concerns.


Health equity has gained importance on the agendas of most countries in the world, however, cost-effectiveness analysis studies are still used throughout the world mainly to inform the establishment of priorities in medical care, in few countries. Sometimes they provide information on who wins and who loses with health programs or on the trade-offs between cost-effectiveness and equity in the distribution of health outcomes (Cookson, et al., 2017).


There are different approaches to address health interventions with equity, one can be to reduce social inequalities and generate financial protection against high health spending by patients, analyzing, for example, access and distribution of a technology among socioeconomic, age groups. or gender. Another way to address inequities in these analyzes is through the prioritization approach of the populations most affected by a disease, for example, due to their geographic location or their disability (Cookson, et al., 2017).


Researchers and experts in health economics have advanced in the development of tools that allow equity aspects to be included in cost-effectiveness analyses, for example, the equity impact plan (see figure 1) (Cookson, et al., 2017 ).


Figure 1. Plan of impact on equity in health



In this plane, the vertical axis shows the variation in cost-effectiveness of the intervention analyzed, while the horizontal axis shows the net impact of the program on equity in health, after taking into account the opportunity costs of the program, as well as the benefits of the program.


In Figure 1, a policy that falls into quadrant I improves both overall health and equity ("win-win"); in quadrant III, the policy hurts both (“lose-lose”). In these two cases, the impacts on health maximization and health equity go in the same direction, which facilitates decision-making.


In contrast, in the other two quadrants, the impacts on health maximization and equity are opposite. This is the case for some policies implemented by the NHS (National Health Service) of the United Kingdom, such as the cervical cancer early detection strategy, where incentives were promoted for health providers in the country. However, the low attendance of low-income women to these programs was not explored; as a result, women from lower socioeconomic levels experienced more barriers to accessing the screening program than women from middle and high socioeconomic levels (Raginel, et al., 2020)


It is worth clarifying that these methods to include equity aspects within cost-effectiveness analyzes are not yet widely used in the world, and may have some limitations in their measurement, mainly in relation to the sources of information. For this reason, currently the impact on equity can be assessed informally by the decision maker in light of disaggregated information, or through the use of formal health equity metrics that combine disaggregated information in their databases. available data.


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  • Ministry of Health and Social Protection. (September 11, 2022). SISPRO Portal > Observatories > National Observatory of Equity in Health. Retrieved from SISPRO: https://www.sispro.gov.co/observatorios/onequidadysalud/Paginas/Observatorio-Nacional-de-Equidad-en-Salud.aspx
  • Government Program 2022. (September 11, 2022). Retrieved from https://gustavopetro.co/programa-de-gobierno/.
  • Cookson R, Mirelman AJ, Griffin S, Asaria M, Dawkins B, Norheim OF. . . Culyer, A.J. (2017). Using Cost-Effectiveness Analysis to Address Health Equity Concerns. Value Health, 20(2), 206-212.
  • Raginel, T., Grandazzi, G., Launoy, G., Trocmé, M., Christophe, V., Berchi, C., & Guittet, L. (2020). Social inequalities in cervical cancer screening: a discrete choice experiment among French general practitioners and gynecologists. BMC Health Serv Res, 20, 693.


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