Unfair Inequalities in Health and Health Care

University Paris-Descartes, CNRS, LSE and IDEP, France.
Journal of Health Economics (Impact Factor: 2.58). 09/2008; 28(1):73-90. DOI: 10.1016/j.jhealeco.2008.07.016
Source: PubMed


Inequalities in health and health care are caused by different factors. Measuring "unfair" inequalities implies that a distinction is introduced between causal variables leading to ethically legitimate inequalities and causal variables leading to ethically illegitimate inequalities. An example of the former could be life-style choices, an example of the latter is social background. We show how to derive measures of unfair inequalities in health and in health care delivery from a structural model of health care and health production: "direct unfairness", linked to the variations in medical expenditures and health in the hypothetical distribution in which all legitimate sources of variation are kept constant; "fairness gap", linked to the differences between the actual distribution and the hypothetical distribution in which all illegitimate sources of variation have been removed. These two approaches are related to the theory of fair allocation. In general they lead to different results. We propose to analyse the resulting distributions with the traditional apparatus of Lorenz curves and inequality measures. We compare our proposal to the more common approach using concentration curves and analyse the relationship with the methods of direct and indirect standardization. We discuss how inequalities in health care can be integrated in an overall evaluation of social inequality.

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    • "We can isolate this health distribution of interest by undertaking multivariate analysis on our raw health distribution, to control for 'fair' variation in health in order to leave a distribution of health reflecting only the 'unfair' variation. The adjustment process we use here has been referred to as 'direct unfairness' in the literature (Fleurbaey and Schokkaert, 2009). This 'fairness-adjusted' distribution of health is then evaluated in place of the unadjusted distribution, using the same inequality and social welfare index approaches. "
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    ABSTRACT: This paper presents an application of a new methodological framework for undertaking distributional cost-effectiveness analysis to combine the objectives of maximising health and minimising unfair variation in health when evaluating population health interventions. The National Health Service bowel cancer screening programme introduced in 2006 is expected to improve population health on average and to worsen population health inequalities associated with deprivation and ethnicity – a classic case of ‘intervention-generated inequality’. We demonstrate the distributional cost-effectiveness analysis framework by examining two redesign options for the bowel cancer screening programme: (i) the introduction of an enhanced targeted reminder aimed at increasing screening uptake in deprived and ethnically diverse neighbourhoods and (ii) the introduction of a basic universal reminder aimed at increasing screening uptake across the whole population. Our analysis indicates that the universal reminder is the strategy that maximises population health, while the targeted reminder is the screening strategy that minimises unfair variation in health. The framework is used to demonstrate how these two objectives can be traded off against each other, and how alternative social value judgements influence the assessment of which strategy is best, including judgements about which dimensions of health variation are considered unfair and judgements about societal levels of inequality aversion. © 2014 The Authors. Health Economics published by John Wiley & Sons Ltd.
    Full-text · Article · Apr 2014 · Health Economics
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    • "There is a growing literature that opposes such implicit and crude assessments of fairness and calls for more sophisticated and explicit approaches (Fleurbaey and Schokkaert 2009, 2011). This critique is largely aimed at the wide use of the Concentration index. "
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    Full-text · Article · Mar 2013 · Milbank Quarterly
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    • "Economists, practitioners and social scientists alike have long been concerned with this issue. Attempts to develop appealing measures to evaluate the health of a population abound in the literature (e.g., Pliskin et al., 1980; Torrance, 1986; Mehrez and Gafni, 1989; Wagstaff, 1991; Bleichrodt, 1995, 1997; Williams, 1997; Dolan, 1998, 2000; Murray et al., 2002; Bleichrodt et al., 2004; Guerrero and Herrero, 2005; Østerdal, 2005; Fleurbaey and Schokkaert, 2009). "
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    ABSTRACT: In this paper we explore the implications of normative principles for the evaluation of population health. We formalize those principles as axioms for social preferences over distributions of health for a given population. We single out several focal population health evaluation functions, which represent social preferences, as a result of combinations of those axioms. Our results provide new rationale for popular theories in health economics, such as the unweighted aggregation of quality-adjusted life years (QALYs) or healthy years equivalents (HYEs) and generalizations of the two, aimed to capture concerns for distributive justice, without resorting to controversial assumptions on individual preferences.
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