Melbourne School of Population and Global Health - Theses
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ItemA method for incorporating vertical equity for disadvantaged groups into health economic evaluations: cost-based equity weights applied to the Australian Aboriginal and Torres Strait Islander population( 2011)Health economic evaluations tend to focus on maximising efficiency, yet the need to consider societal concerns for equity for those who are disadvantaged is also an important factor in health sector resource allocation and decision-making. In this thesis, methods by which these efficiency and equity objectives can be combined within economic evaluation approaches are critically explored, and an alternative is proposed in the form of a cost-based equity weight. Based on the definition of equity ‘equal access for equal need’ and the vertical equity objective of ‘equitable access for unequal need’, it is hypothesised that a cost-based equity weight could be constructed using the ratio of the costs of delivering health interventions equitably via targeted health services for disadvantaged groups compared to delivery from mainstream ‘baseline’ health services. The construction of the weight is illustrated by its application to the Australian Aboriginal and Torres Strait Islander (or Indigenous) population as an example of a group who experience health disadvantage, with equitable primary health care delivery via Aboriginal Community Controlled Health Services (ACCHSs). This research is based within the Assessing Cost Effectiveness in Prevention (ACE-Prevention) study, which uses cost-utility analysis methods of economic evaluation and the disability-adjusted life-year (DALY) as the outcome of interest. Construction of the equity weight and its utilisation in a number of case study economic evaluations has required the development of the Indigenous Health Service Delivery (IHSD) Template to adapt cost and effectiveness evidence from the mainstream to the Indigenous setting. In addition, a decision-analytic epidemiological model of cardiovascular disease prevention has been adapted to be specific to the Indigenous population. Economic evaluation results reveal that pharmacological interventions to prevent cardiovascular disease delivered via ACCHSs produce more total health gain for the Indigenous population than delivery of these same interventions via mainstream GP services. This benefit can be attributed to improved access to these targeted services, although the greater costs associated with comprehensive health service provision makes ACCHSs appear less cost effective. A cost-based equity weight of 0.66 is calculated based on these interventions, which is the factor by which the costs of interventions delivered via ACCHSs are deflated in order to allow equitable comparison with interventions delivered via mainstream GP services. Application of this equity weight in an example significantly alters the economic evaluation results and the subsequent resource allocation recommendations that ensue. In conclusion, this thesis argues that the use of cost-based equity weighs enables economic evaluations to not only consider efficiency, but also apply equity concerns in a manner that is consistent, explicit, practical, and relevant to the target groups it endeavours to address. Therefore, the definition of efficiency used in economic evaluations is broadened to include vertical equity concepts, and results are produced that better reflect societal welfare and the needs of decision-makers.