Table 1 Summary of methods to incorporate vertical equity into economic evaluations
| Â | Qualitative methods | Quantitative methods | |
|---|---|---|---|
| Â | Â | Outcomes-based equity weights | Cost-based equity weights |
Basis for equity adjustment | Decision-maker and/or stakeholder assessment of impact on equity | Weighted QALYs - by direct weighting or characterisation of the social welfare function | Costs weighted based on additional resources to provide improved access to health services |
When performed | Before or after calculation of cost-effectiveness ratios | Incorporation into the benefits side of cost-effectiveness ratios | Incorporation into the cost side of cost-effectiveness ratios |
Examples | Pluralistic bargaining ACE 2nd stage filters [34] | Fair innings [38] Cost-value analysis [6] Proportional shortfall [3] | Cost side equity weight described in this paper |
Main advantages of approach | Less resource intensive than quantitative methods Quick and doable with existing personnel | Explicit equity assumptions and judgements Guidance on magnitude of resource redistributions based on social welfare | Explicit equity assumptions and judgements Guidance on magnitude of resource redistributions based on solutions to inequity Equity considered in health care processes rather than outcomes Specific to context and definition of health for target group Basis of weight simple to conceptualise Comparable across different target groups |
Main limitations of approach | Equity judgements may be implicit No guidance on magnitude of redistributions | Generally do not consider equity in processes of health care delivery Not sensitive to differing preferences of target groups Assumption of proportionality between magnitude of inequity and its solutions Complex theoretical basis | Weight based on 'improved' rather than equitable access May be resource intensive to construct Dependent on a 'best practice' health service model being available for the target group May lead to perverse incentives (i.e. reward inefficiency) Untested in real policy decision contexts |