Equity in HTA: what doesn’t get measured, gets marginalised

Richard Cookson, Andrew J. Mirelman

When making recommendations about the public funding of new health technologies, policy makers typically pay close attention to quantitative evidence about the comparative effectiveness, cost effectiveness and budget impact of those technologies - what we might call "efficiency" criteria. Less attention is paid, however, to quantitative evidence about who gains and who loses from these public expenditure decisions, and whether those who gain are better or worse off than the rest of the population in terms of their health - what we might call "equity" criteria. Two studies recently published in this journal by Shmueli and colleagues suggest that this efficiency-oriented imbalance in the use of quantitative evidence may have unfortunate consequences - as the old adage goes: "what gets measured, gets done". The first study, by Shmueli, Golan, Paolucci and Mentzakis, found that health policy makers in Israel think equity considerations are just as important as efficiency considerations - at least when it comes to making hypothetical technology funding decisions in a survey. By contrast, the second study - by Shmueli alone - found that efficiency rules the roost when it comes to making real decisions about health technology funding in Israel. Both studies have limitations and potential biases, and more research is needed using qualitative methods and more nuanced survey designs to determine precisely which kinds of equity consideration decision makers think are most important and why these considerations do not appear to be given much weight in decision making. However, the basic overall finding from the two studies seems plausible and important. It suggests that health technology funding bodies need to pay closer attention to equity considerations, and to start making equity a quantitative endpoint of health technology assessment using the methods of equity-informative economic evaluation that are now available.