Making health equity count: Incorporating health equity for Māori into cost-utility analyses

Abstract

Objective The New Zealand health system has a number of objectives including reducing disparities in health for Māori and improving total population health. Despite this there are stark inequalities in health status for Māori. New tools and frameworks need to be developed to give due consideration to the impacts of health interventions on health equity as well as allowing health equity to be compared against other health system objectives and prioritisation values. This thesis aims to provide a framework to adapt standard cost-utility analysis (CUA) methods to include explicit considerations of health equity for Māori in New Zealand, which will then be tested on three case study interventions: colorectal cancer (CRC) screening, Trastuzumab treatment for female early stage breast cancer and tobacco taxation. Methods The conceptual framework for incorporating health equity in to CUAs (the framework) draws upon a literature review of existing approaches for incorporating equity in to cost-effectiveness analysis (CEA) and a definition of health equity developed for this thesis. Three are five parts to the framework. The first two parts address equitable process and the remaining three address equity of health outcomes. The five parts are: 1) non-discrimination in comparing estimates of cost-effectiveness; 2) configuring an intervention to provide equal access and quality of health care; 3) configuring an intervention to achieve equal health gains; 4) applying social values to utility measures (e.g. equity weights) and; 5) measuring the impact of an intervention on inequalities in a) disease-related health outcomes and b) overall health (as measured by quality-adjusted life expectancy (QALE)). Results The framework was used to examine the equity impacts of the three individual case study interventions, as well as providing outputs that were compared across interventions. The three case study interventions had varying impacts on health equity for Māori as measured by changes to absolute inequalities in QALE. The tobacco taxation and Trastuzumab treatment interventions reduced modelled inequalities in QALE for Māori compared to non-Māori, whereas CRC screening increased inequalities in health for Māori. All three of the case study interventions improved total population health with the tobacco taxation intervention providing the largest absolute gains in health for both Māori and non-Māori. Conclusion Improving Māori health remains a key objective of the New Zealand health system, and is an important step towards realising Māori rights to equity and supporting Māori aspirations for Tino Rangitiratanga (self-determination). CUA models are traditionally used to quantitatively assess the cost-effectiveness of interventions, but with modification can also be used to assess health equity. The framework presented in this thesis outlines an approach that can be used to assess the equity impacts of a single health intervention, and compare health interventions in a way that that is relevant to improving health equity for Māori.