Academic Unit of Health Economics, Leeds Institute of Health Sciences, Worsley Building, Clarendon Way, Leeds LS2 9NL, UK.
Centre for Health Economics, Alcuin 'A' Block, University of York, Heslington YO10 5DD, United Kingdom.
Health Policy Plan. 2018 Apr 1;33(3):456-463. doi: 10.1093/heapol/czx175.
Reducing health inequality is a major policy concern for low- and middle-income countries (LMICs) on the path to universal health coverage. However, health inequality impacts are rarely quantified in cost-effectiveness analyses of health programmes. Distributional cost-effectiveness analysis (DCEA) is a method developed to analyse the expected social distributions of costs and health benefits, and the potential trade-offs that may exist between maximising total health and reducing health inequality. This is the first paper to show how DCEA can be applied in LMICs. Using the introduction of rotavirus vaccination in Ethiopia as an illustrative example, we analyse a hypothetical re-designed vaccination programme, which invests additional resources into vaccine delivery in rural areas, and compare this with the standard programme currently implemented in Ethiopia. We show that the re-designed programme has an incremental cost-effectiveness ratio of US$69 per health-adjusted life year (HALY) compared with the standard programme. This is potentially cost-ineffective when compared with current estimates of health opportunity cost in Ethiopia. However, rural populations are typically less wealthy than urban populations and experience poorer lifetime health. Prioritising such populations can thus be seen as being equitable. We analyse the trade-off between cost-effectiveness and equity using the Atkinson inequality aversion parameter, ε, representing the decision maker's strength of concern for reducing health inequality. We find that the more equitable programme would be considered worthwhile by a decision maker whose inequality concern is greater than ε = 5.66, which at current levels of health inequality in Ethiopia implies that health gains are weighted at least 3.86 times more highly in the poorest compared with the richest wealth quintile group. We explore the sensitivity of this conclusion to a range of assumptions and cost-per-HALY threshold values, to illustrate how DCEA can inform the thinking of decision makers and stakeholders about health equity trade-offs.
缩小健康不平等是中低收入国家（LMICs）在实现全民健康覆盖道路上面临的一个主要政策关注点。然而，在卫生计划的成本效益分析中，健康不平等的影响很少被量化。分配性成本效益分析（DCEA）是一种用于分析成本和健康效益的预期社会分配情况以及在最大化总健康和减少健康不平等之间可能存在的潜在权衡的方法。这是第一篇展示如何在 LMICs 中应用 DCEA 的论文。本文以埃塞俄比亚引入轮状病毒疫苗接种为例，分析了一个假设的重新设计的疫苗接种计划，该计划在农村地区投入额外资源用于疫苗接种，并将其与埃塞俄比亚目前实施的标准计划进行比较。结果表明，与标准计划相比，重新设计的计划每增加一个健康调整生命年（HALY）的增量成本效益比为 69 美元。与当前埃塞俄比亚健康机会成本的估计相比，这可能是成本效益不佳的。然而，农村人口通常比城市人口贫困，一生的健康状况也较差。因此，优先考虑这些人群可以被视为公平的。我们使用代表决策者对减少健康不平等关注程度的阿特金森不平等厌恶参数ε来分析成本效益与公平之间的权衡。我们发现，对于不平等关注程度大于ε=5.66 的决策者来说，更公平的计划将被认为是有价值的，而在埃塞俄比亚目前的健康不平等水平下，这意味着最贫困的五分之一财富群体的健康收益权重至少是最富有的五分之一财富群体的 3.86 倍。我们探讨了这一结论对一系列假设和每 HALY 成本阈值值的敏感性，以说明 DCEA 如何为决策者和利益相关者提供有关健康公平权衡的思路。
