Cookson Richard, Drummond Mike, Weatherly Helen
Department of Social Policy and Social Work, and Centre for Health Economics, University of York, York, UK.
Health Econ Policy Law. 2009 Apr;4(Pt 2):231-45. doi: 10.1017/S1744133109004903. Epub 2009 Feb 16.
Health equity is one of the main avowed objectives of public health policy across the world. Yet economic evaluations in public health (like those in health care more generally) continue to focus on maximizing health gain. Health equity considerations are rarely mentioned. Health economists rely on the quasi-egalitarian value judgment that 'a QALY is a QALY'--that is QALYs are equally weighted and the same health outcome is worth the same no matter how it is achieved or to whom it accrues. This value judgment is questionable in many important circumstances in public health. For example, policy-makers may place rather little value on health outcomes achieved by infringing individual liberties or by discriminating on the basis of age, sex, or race. Furthermore, there is evidence that a majority of the general public wish to give greater weight to health gains accruing to children, the severely ill, and, to a lesser extent, the socio-economically disadvantaged. This paper outlines four approaches to explicit incorporation of equity considerations into economic evaluation in public health: (i) review of background information on equity, (ii) health inequality impact assessment, (iii) analysis of the opportunity cost of equity, and (iv) equity weighting of health outcomes. The first three approaches can readily be applied using standard methods of health technology assessment, where suitable data are available; whereas approaches for generating equity weights remain experimental. The potential benefits of considering equity are likely to be largest in cases involving: (a) interventions that target disadvantaged individuals or communities and are also relatively cost-ineffective and (b) interventions to encourage lifestyle change, which may be relatively ineffective among 'hard-to-reach' disadvantaged groups and hence may require re-design to avoid increasing health inequalities.
健康公平是全球公共卫生政策公开宣称的主要目标之一。然而，公共卫生领域的经济评估（与更广泛的医疗保健领域的评估一样）继续侧重于使健康收益最大化。很少提及健康公平方面的考虑因素。健康经济学家依赖于“一个质量调整生命年就是一个质量调整生命年”这种准平等主义的价值判断，也就是说，质量调整生命年被同等加权，无论健康结果是如何实现的或惠及何人，相同的健康结果都具有相同的价值。在公共卫生的许多重要情况下，这种价值判断是有问题的。例如，政策制定者可能对通过侵犯个人自由或基于年龄、性别或种族进行歧视而实现的健康结果评价不高。此外，有证据表明，大多数公众希望给予儿童、重症患者以及在较小程度上给予社会经济弱势群体所获得的健康收益更大的权重。本文概述了将公平考虑因素明确纳入公共卫生经济评估的四种方法：（i）审查关于公平的背景信息，（ii）健康不平等影响评估，（iii）公平的机会成本分析，以及（iv）健康结果的公平加权。前三种方法在有合适数据的情况下，可以很容易地使用标准的卫生技术评估方法来应用；而生成公平权重的方法仍处于试验阶段。在以下情况下，考虑公平的潜在益处可能最大：（a）针对弱势群体或社区的干预措施，且这些措施相对成本效益不高；（b）鼓励改变生活方式的干预措施，这类措施在“难以接触到”的弱势群体中可能相对无效，因此可能需要重新设计以避免加剧健康不平等。
