Incorporating considerations about equity in policy briefs

1. Incorporating considerations about equity in policy briefs • What factors are likely to be associated with disadvantage? • Are there plausible reasons for anticipatingdifferencesineffectiveness? • Are therelikely to be differences in baseline conditions and absoluteeffectiveness? • Are thereimportantconsiderationsthatshould be madewhenimplementingtheoption?

2. What factors are likely to be associated with disadvantage in relation to the option being considered? Disadvantage may be related to • Economic status • Employment or occupation • Education • Place of residence • Gender • Ethnicity • Combinations of these characteristics

3. The relevance of different characteristics depends on the option of interest Theremay be goodreasons for prioritisingparticulargroups or settings generally • But for specificpolicies or programmes it is oftenimportant to considerinequities in relation to a range ofpotentiallydisadvantagedgroups or settings • Subsequentattentionshouldfocusonthosegroups or settings for whichthere is a reason to anticipatesignificantdifferentialeffects • Considerationshould be given to potentiallyimportantdifference in effectswhenthere is an associationbetweenthemechanismof action oftheoption and a particularcharacteristic

4. Economic status • Low-income populations are more likely to be responsive to changes in the prices of goods and services • Because they have less disposable income, tobacco tax increases, for example, could make such populations more likely to quit • But they would also be made more vulnerable as a result of having to spend more money on tobacco if they did not quit smoking

5. Employment or occupation • Employer-funded insurance schemes may result in differences in coverage, with less coverage being likely for those who are unemployed, self-employed or employed in small companies

6. Education • School-based programmes would be expected to differentially affect those who attend versus those who do not attend schools • Information campaigns that rely on printed materials to improve the utilisation of health services might have differential impacts on illiterate or less-educated populations

7. Place of residence • Access to care is commonly more difficult in rural areas • Any strategy, therefore, that does not take into account the need to improve the delivery of effective clinical or public health interventions is likely to be less effective in rural areas

8. Gender • Strategies for involving stakeholders in priority setting may affect women and men differently, resulting in priorities that may have different impacts on women and men

9. Ethnicity • Ethnic groups (i.e. those groups who consider themselves, or are considered by others, to share common characteristics which differentiate them from other groups in society) may have beliefs and attitudes relating to the acceptability of a particular policy or programme • Delivery strategies that do not take these perspectives into account are likely to be less effective amongst ethnic groups where an otherwise effective policy or programme might not be readily accepted

10. Questions or comments about identifying factors that are likely to be associated with disadvantage?

11. Are there plausible reasons for anticipating differences in the relative effectiveness of the option for disadvantaged groups or settings? • Evidence of the effects of options on inequities is sparse • Finding this evidence is also difficult • Publication bias may be an additional problem given that studies identifying statistically significant differences in effects are more likely to be published than those that do not

12. Systematic reviews generally tend not to provide evidence of differential effectiveness • It may be necessary to search for a widerscopeofevidencethanthattypicallyfound in systematicreviews • Suchevidencemay be needed to support or refute plausible hypothesesofdifferentialeffects, or theeffectsofpolicies or programmesonreducinginequities

13. Subgroup analyses can be misleading • Studies may be toosmall to reliablydetectdifferences in effects, resulting in false negative conclusions • Also, testing multiple hypothesesregardingfactorsthatmight moderate theeffectivenessof a policy mayresult in false positive conclusions • The resultsobserved in subgroups, for instance, maydiffer by chance from the overall effectobservedacross studies • Paradoxically, the best estimateoftheoutcomeof an option in a subgroupmay be theoverall results (acrossdifferentsubgroups) ratherthanthespecificresultsfor thesubgroupofinterest

14. Guidelines for whether to relyon an estimateofeffect for a disadvantagedsubgroup or the overall estimateofeffect • Is the magnitude of the difference important? • Is the difference between subgroups statistically significant? • Is there indirect evidence in support of the findings? • Was the analysis pre-specified or post hoc? • Are analyses looking at within-study or between-study relationships?

15. Questions or comments about plausible reasons for anticipating differences in relative effectiveness?

16. Are there likely to be different baseline conditions and absolute effectiveness? • If the relative effectiveness of an option is similar in disadvantaged settings, there may still be important differences in the absolute effect due to differences in baseline conditions • Typically, baseline risks are larger in disadvantaged populations and a larger absolute effect could therefore be expected • For example, if the relative effect of improving the delivery of artemisinin combination therapy (ACT) on mortality from malaria is the same for disadvantaged children as it is for other children, the absolute effect would be greater in disadvantaged populations that have a higher mortality rate

17. Absolute vs relative risk reduction

18. Example of a difference in baseline conditions leading to a difference in absolute effectiveness • Facility-based births can help to reduce maternal mortality • When such facilities are appropriately equipped and staffed by skilled health workers • Able to deliver effective interventions to reduce deaths from common causes of maternal deaths such as haemorrhage and eclampsia • Typically proportions of facility-based births are lower in rural areas than in urban areas due to variations in accessibility • Paying transportation costs to improve access to facilities might reduce inequities because • Payments may be more effective in rural areas where transportation costs are more of a barrier and • Due to the lower proportion of facility-based births in rural areas (which thus increases the absolute effect)

19. Questions or commentsaboutdifferences in baseline conditions and absoluteeffectiveness?

20. Are there important considerations that should be made when implementing the option? • Disadvantaged populations generally have poorer access to care and often receive poorer quality care • Consequently, programmes to improve access and the quality of care will often require implementation strategies tailored to address factors that limit access or quality in disadvantaged settings or groups • Such methods may include different delivery, financial and governance strategies, or the investment of additional resources • They may also include the provision of additional technical support to implement non-tailored strategies for such groups

21. Important considerations regarding implementation • There is a greater likelihood that disadvantaged children compared to more advantaged children will be exposed to greater health risks, have less resistance to disease, and will therefore have higher mortality rates • These inequities are compounded by reduced access to health services • Even public subsidies for health frequently benefit rich people more than poor people • Implementing interventions to reduce child mortality will not necessarily reduce these inequities and may, in some cases, even increase them • Consideration should thus be given to strategies designed to reduce inequities, such as the provision of more affordable and accessible health services

22. Strategies that target poor people versus universally implemented strategies • Situations in which targeting or universal coverage might be more appropriate include • For example, universal coverage may be a more appropriate strategy for vaccines, which are needed by everyone and which have spill-over effects • However, in order to also reduce inequities in coverage, additional targeted strategies may be needed such as those that address problems with regard to differences in health service accessibility or to a lack of demand for vaccinations in disadvantaged populations

23. Questions or comments about equity in relationship to implementing the option?

24. Conclusion • There is limited evidence of the impacts of most options on inequities • Subgroup analyses that explore whether there are different impacts on specific disadvantaged groups or settings may be misleading • Many options may, in fact, have similar relative effects in disadvantaged settings and elsewhere • However, differences in absolute effects (due to differences in baseline risks or needs) and differences in barriers to implementing them, are likely to be common • The evidence for such differences should be considered and taken into account in policy briefs

25. Monitoring and evaluation • Because the evidence is often limited, monitoring and evaluations of impacts on equity are needed to ensure that intended effects are achieved and that unintended adverse effects are avoided • To monitor or evaluate the extent to which implementing an option differentially affects disadvantaged populations • Appropriate indicators of social gradients and • Measures of change are needed

26. Questions or comments?