Equity – a blog
Ontario’s Ministry of Health and Long-Term Care (MOHLTC) has identified equity as a key component of quality care. The Ministry has developed a Health Equity Impact Assessment (HEIA) to support improved health equity, including the reduction of avoidable health disparities between population groups. HEIA also supports improved targeting of healthcare investments—the right care, at the right place, at the right time. And that is what this blog covers. Join us in the conversation.

A  Business Case for Equity in Health?

Addressing health and social inequity requires spending resources. I have often heard advocates for equity initiatives talk of the need for making the “business case” for equity interventions. The argument goes something like this: even though the intervention might cost some money up front, the downstream health effects will result in cost savings. These savings come from averting ill health and associated costs such as hospitalization. Taking a broader perspective, interventions that target the health of marginalized communities can also have other social benefits. For example, methadone maintenance therapy for people who inject opioid drugs not only improves their health but results in less criminal behaviour with associated economic savings.

Such investment-based arguments are compelling. A policy maker would conceivably have a hard time saying no to an intervention that improves health, advances health and social equity, and saves money. Furthermore, similar arguments also extend to cuts in social spending – the policy argument against a cut in a program which results in worse health, more inequity, and increased costs should be strong.

There are some striking examples of programs where economic analyses suggests that up-front interventions that have an equity focus do lead to cost savings. Examples include universal prenatal care for pregnant women (in a U.S. setting) and alcohol screening combined with brief advice in primary care settings.

Despite the appeal of such arguments, there are several reasons why it is very challenging to make such arguments:

• Counting downstream costs associated with an upstream equity intervention can be challenging. Consider, for example, an intervention which targets low literacy (or perhaps low health literacy, which has recently been associated with increased mortality). Such an intervention might target people who are still in good health – perhaps children or recent immigrants or young people living in poverty. Regardless, the time that passes between the intervention and the outcome might be very long. Furthermore, the direct association between the intervention and the health outcome might be difficult to demonstrate (how would we know that the literacy intervention improved health rather than other social determinants such as income, nutrition, or health services?). As well, the intervention might yield other benefits that are hard to quantify, such as less time receiving social assistance or better paying jobs.
• Those who pay and those who save money from an investment might not be the same. Many interventions require spending in one sector but result in benefits in another. For example, spending on primary care reform might result in fewer hospitalizations. A narrow perspective focused only on primary care costs would miss out on calculating the potential savings. Broad perspectives are thus necessary to adequately “count” all of the costs. Such considerations are even more compelling when interventions involve multiple sectors across government ministries. Consider, for example, how to count the health and non-health costs associated with a program to keep ex-convicts from re-offending. Research in “Healthin All Policy” approaches –  co-ordinated whole-of-government policy initiatives aimed to improve population health and reduce inequities – is just starting to tackle such questions.
• Even if we could count all the costs, most interventions probably do not save money. It seems that most public interventions do not save money. This is true of interventions that directly target health outcomes as well as interventions in other sectors, such as transportation and the environment. Most health-related interventions also do not save money; this is true of interventions that target treatment and those that target prevention, including so-called lifestyle interventions. This does not mean that such interventions are a bad investment. It does, however, suggest that focusing only on costs and neglecting the benefits associated with an intervention is missing an important part of the equation. It is for reasons such as this that health economists use analyses which compares costs to benefits to determine if an intervention is a good use of money rather than focusing only on interventions that result in less net costs.
• Measuring benefits is also challenging. If we are interested in both benefits and costs, the next question is how we quantify the benefits. In health economics, considerable effort has been spent on measuring quality of life and incorporating such measures alongside increased survival to yield outcome measures that can be used across interventions. But what about non-health benefits? How do we place a value on having a better education? On being out of jail? Regardless of the associated health benefits, such outcomes are valuable in their own right.
• Are we willing to pay for equity? If an intervention only improved equity but did not result in net cost savings or better health, would this be a good investment? How much would we be willing to pay for such equity improvements? That’s a very hard question to answer for many reasons, but before we can even frame the question in this way we have to both define what we mean by equity and figure out how we can measure it. There is a vigorous debate among health economists about whether we should “quantify” equity. One perspective maintains that incorporating equity concerns explicitly into economic evaluations addresses an important policy objective in a way that is defensible, transparent, and reproducible. An alternative perspective maintains that equity measurement is an important input into policy making but that no equation will be able to capture the complex considerations involved. Instead, the answer lies in careful deliberation and broad input. To date, there is no consensus and models for incorporating equity considerations are still in development.

Given all of these complexities, it seems premature to develop a template for determining the economic attractiveness of an equity intervention. Demonstrating that an intervention saves money is compelling but also sets the bar too high – most interventions will not result in net cost savings but might still represent worthwhile investments. Pluralistic and deliberative dialogue is essential when considering what we value when spending public dollars. And developing carefully considered measures of equity alongside other benefits is key to advancing the development of the much needed economic methods.

About the Author

Dr. Ahmed Bayoumi is a Scientist at the Centre for Research on Inner City Health at the Keenan Research Centre in the Li KaShing Knowledge Institute, St. Michael’s Hospital, a general internist and HIV physician at St. Michael’s Hospital, and Director of Clinical Epidemiology and Health Care Research in the Institute of Health Policy, Management and Evaluation at the University of Toronto. He holds a Canadian Institutes of Health Research / Ontario Ministry of Health and Long-term Care Chair in Applied Health Services Research and Drug Policy.

His research interests include studying how to incorporate equity concerns into resource allocation decisions.  He also studies economic evaluation, decision analysis, and quality of life assessment for HIV-related health interventions, and studies of the access to the delivery of health services, particularly to people living with HIV, injection drug users, and other marginalized populations. His work has included cost-effectiveness analyses of screening strategies for HIV, drug treatments for HIV and related conditions, and supervised injection sites for injection drug users.  He is Vice-President of the Society for Medical Decision Making.

This entry was posted on Tuesday, March 27th, 2012 at 8:31 am and is filed under Longwoods Online.