PHRC Phase 2 (2011-2019) projects – Cross-cutting projects

Identifying appropriate methods to incorporate concerns about health inequalities into economic evaluations of health care programmes

Lead investigator

Professor Mark Sculpher, Professor of Health Economics, Centre for Health Economics, University of York


Standard cost-effectiveness analysis (CEA) focuses on efficiency in terms of improving overall population health. However, decision makers may be concerned with reducing health inequality as well as improving health. This study aims to develop an analytical framework for quantifying concerns about health inequality within cost-effectiveness analysis of health sector programmes. Concern for health inequality may depend upon contestable beliefs and evidence about multiple and complex influences on health inequality, including the role of health care and public health interventions, as well as contestable value judgements about equity or fairness. The purpose of the framework is to provide decision makers and stakeholders with information about their health inequality concerns within the context of a deliberative decision making process, rather than to impose any particular scientific or social value judgements about health inequality.One of the most recent and comprehensive sets of guidelines for the economic evaluation of health technologies is that issued by the National Institute for Health and Clinical Excellence (NICE) in the UK. These represent state-of-the-art methods presented in terms of a 'reference case' that set out the range of methodologies deemed most appropriate when undertaking an economic evaluation.

To date, the vast majority of technologies appraised by NICE have been drugs, devices or medical procedures and there is little experience of using the same methodological standards to evaluate public health programmes. While NICE guidelines were written with no particular technology or health programme in mind, specific difficulties may arise if they are applied blindly in the evaluation of public health programmes that contain very broad costs and benefits, or to a programme directed at populations or communities rather than specific individuals. In addition, a particular feature of many public health interventions is concern with health inequalities. Standard economic evaluation methods focus on efficiency (i.e. the maximisation of health gain) rather than on equity (i.e. the distribution of health gain) and, accordingly, the evaluation of public health interventions needs to pay more attention to equity considerations.

While it is anticipated that the general principles of the NICE reference case will hold for the evaluation of public health programmes, departures from the reference case may be justifiable with respect to estimates of relative treatment (programme) effects, perspective for estimation of costs, measurement of outcomes and equity considerations.

Aims, methods and contribution

This study will explore options for how CEA can be extended appropriately and quantitatively to incorporate concerns for inequality. Drawing on the literature for measuring inequalities in, and the determinants of, health it will identify the range of existing approaches that could be applied within CEA by examining their

quantitative properties, practicality and underlying normative principles. The results will provide guidance on the alternative methods at each stage of the CEA of health care programmes for a decision maker concerned with both efficiency and inequality. Stylised examples and methodological case studies will illustrate the approach from the perspective of a UK decision maker.


  • Dr Richard Cookson
  • Dr Susan Griffin
  • Professor Karl Claxton
  • Professor Nigel Rice

Project advisor

  • Professor Tony Culyer

01/04/2011 - 31/03/2013 (24 months)

This project was conducted from 2011 to 2013 and developed the analytical framework known as "distributional cost-effectiveness analysis" (DCEA). This methods have subsequently been refined and applied in a variety of other projects, and up-to-date summary of publications and training resources in using DCEA is provided at this website: