This page brings together information and training materials on equity-informative research methods for quantifying the equity impacts of health policies.
If you already know which method you are interested in, click below:
The need for equity-informative research methods
Different sub-groups of the population experience different patterns of health risk and disease, exhibit different health behaviours, and live within different social and economic contexts. Consequently, well-intentioned health policies can be better for some sub-groups than others, inadvertently worsening inequalities. This is partly due to methodological approaches commonly used in health services and policy research, which focus on health outcomes for the average person rather than analysing who gains most and whether anyone loses out.
To strengthen the evidence base for tackling health inequalities, it is necessary to quantify the ‘equity impact’ of health policy decisions by modelling differences in health risks, behaviours and incentives by social group, and corresponding differences in the use, quality and outcomes of services. This requires re-engineering the common approaches used to monitor the quality of health services, evaluate the effectiveness of past policies and analyse the cost-effectiveness of proposed new policies.
Equity indicators for healthcare quality improvement
Efforts to improve quality have focused on the average patient, with improvements in equity largely a by-product of reducing variation in performance between providers. Population-wide health equity monitoring remains isolated from mainstream healthcare quality assurance. As a result, healthcare organizations remain ill-informed about the health equity impacts of their decisions – despite becoming increasingly well-informed about quality of care for the average patient. We have developed methods for monitoring equity by measuring inequality in quality in the served population and benchmarking this against equity in comparable populations. These methods have been adopted by the English NHS, and can potentially be used to integrating health equity into mainstream healthcare quality assurance in other counties.
Equity-informative effectiveness studies
Standard randomised control trials (RCTs) and quasi-experimental (QE) evaluations of health policies focus on average effects. Sub-group analysis of differences in effect by equity-relevant group is possible when sample sizes are sufficiently large, but is fraught with methodological challenges. The scientific challenges concern methods of causal inference for analysing distributional impacts and heterogeneous treatment effects, which are being developed in labour economics and elsewhere. The ethical challenges concern the selection and use of equity metrics. There are several possible measures of equity based on different value judgements, and these can lead to different conclusions of the equity impact of a policy. Assessing equity impacts therefore requires not only methodological approaches that can measure impacts for different population groups, but also a framework for choosing equity measures. Developing a framework involves exploration of the ethical implications of the methods, because equity is a complex and contested concept and behaviour is motivated by ethical norms and values, as well as rational self-interest.
Equity-informative cost-effectiveness analysis
Standard cost-effectiveness analysis focuses on total health benefits and opportunity costs. Equity-informative cost-effectiveness analysis provides additional information about the distribution of costs and benefits and about trade-offs between improving total health and reducing unfair differences in lifetime health. This includes two main kinds of analysis:
- Equity IMPACT analysis – measuring the outcomes of interventions by socioeconomic status and other aspects of social disadvantage, and producing summary measures of health equity impact.
- Equity TRADE-OFF analysis – articulating and quantifying the trade-offs between equity objectives and other policy objectives, such as improving total health.
To get a full picture of health equity impacts and trade-offs it is important to look not only at the distribution of health gains but also at the distribution of health opportunity costs – i.e. who loses out when resources are displaced from alternative uses to fund a new policy.