Still waiting for the great leap forward

Now is a good time to be discussing how equity might feature more prominently in health economic evaluations given the recent publication of the report by the WHO Commission on the Social Determinants of Health and the Commission’s call to eliminate inequalities in health in a generation (Commission on the Social Determinants of Health, 2008). The lack of economic evidence is just one among many obstacles that has held back action to reduce inequalities in health (Syme, 1998; Williams, 1999). Despite the fact that most public health systems around the world have both the promotion of population health and the reduction in inequalities as twin objectives, most economic evaluations concern themselves only with the former. With this as their starting point, Cookson, Drummond, and Weatherly (hereafter CDW) examine some of the ways in which equity might be included explicitly in economic evaluations of public health interventions. CDW identify three types of equity concern that they suggest policy makers in public health might be interested in: (i) concern to reduce inequalities in health between social groups; (ii) priority given to the claim on resources from some groups – with children and the severely ill given as examples; and (iii) concern for competing ethical rules such as respect for individual liberty. There is no evidence of this tripartite concern in the WHO’s report. The Commission’s concern was on reducing type (i) inequity only, especially inequalities in health between countries but also among social groups within countries. Their recommendations emphasize the needs of children, but not because children have prior claim on resources. Instead, improving the life chances of children is an especially efficient means of reducing disparities in health. The same is true of efforts to improve access to education for young girls.