Beyond Averages: Integrating Health Equity into the Future of HTA – Insights from RedETSA and NICE
Jorge Ferrer , Senior Consultant at Decisive Consulting, recently attended a webinar hosted by RedETSA (the Health Technology Assessment Network of the Americas) in collaboration with the UK's National Institute for Health and Care Excellence (NICE).
The session, "Equity in Health Technology Assessment" provided a deep dive into one of the most pressing challenges facing healthcare systems globally: ensuring that advancements in health technology benefit all segments of society, not just the ‘average’ patient.
The core message was unequivocal: HTA processes conducted without an explicit equity lens risk perpetuating, and potentially widening, existing health disparities. This is particularly critical in regions like the Americas, marked by significant inequalities, where factors like socio-economic status, geography, ethnicity, and gender can heavily influence access to and outcomes from healthcare innovations.
A significant portion of the discussion focused on NICE's pioneering efforts to systematically embed equity considerations within its rigorous HTA framework. Juan Yanguela detailed their evolving approach, which moves beyond acknowledging inequities to actively analysing them:
Advancing Distributive Cost-Effectiveness Analysis (DCEA): NICE is promoting the use of DCEA methodologies. This sophisticated approach models how a technology's health gains and costs are distributed across different population subgroups (often stratified using metrics like the Index of Multiple Deprivation - IMD), rather than relying solely on population averages.
Updated Methodological Guidance: NICE is releasing clearer guidelines for incorporating equity in April 2025, following a period of public consultation. This includes specifying preferred assumptions (e.g., regarding differential uptake or opportunity costs, initially assuming equality in the base case but allowing for justified variations) and analytical approaches (currently favouring deterministic sensitivity analysis for distributional aspects due to complexity).
Informed Decision-Making: The goal is to provide committees with transparent, quantitative insights into a technology's potential impact on health inequalities. This information can then qualitatively inform deliberations, potentially justifying a higher willingness-to-pay threshold for technologies demonstrated to reduce significant, unfair health disparities.
Maintaining Universalism: Importantly, NICE's framework aims to assess equity impact before a funding recommendation. It does not currently lead to recommendations restricted solely to specific socio-economic groups, upholding the principle of universal access once a technology is approved.
For pharmaceutical companies, this evolving landscape means a greater emphasis on demonstrating not only the overall clinical and economic value of their innovations but also their impact on health equity. NICE's increased focus on DCEA and related analyses signals that manufacturers will need to proactively consider and provide evidence on how their technologies affect different patient subgroups, especially those facing significant health disparities.
This may involve generating data on differential uptake, effectiveness, and cost implications across various populations and being prepared to justify assumptions in their cost-effectiveness models.
Ultimately, a strong equity narrative could strengthen the case for a technology's value and inform pricing and access strategies that promote fairer health outcomes. Demonstrating you've addressed the equity component could potentially increase the likelihood of favourable recommendations.
Key Conference conclusions and reflections:
Equity as foundational: Addressing equity cannot be an add-on; it must be a core principle integrated throughout the HTA lifecycle, from topic selection to evidence appraisal and decision-making.
Methodological evolution: While tools like checklists and qualitative approaches are valuable (and often the starting point in many regions), the field is advancing towards more quantitative methods like DCEA where data permit.
The Data Imperative: Progress hinges on the availability of robust, disaggregated data to identify and measure disparities accurately. This remains a significant challenge globally.
Context matters: While learning from frameworks like NICE's is invaluable, implementation must be adapted to the specific context, data availability, and ethical values of each health system.
Collaboration is non-negotiable: Bridging equity gaps requires multi-stakeholder collaboration involving HTA bodies, policymakers, industry, patient groups, and healthcare providers.
For our clients, navigating the increasing focus on health equity in HTA presents both challenges and opportunities. Successfully demonstrating a technology's value now often requires robust analysis of its potential impact across diverse patient populations, going beyond traditional aggregate measures.
At Decisive, we are equipped to help clients interpret evolving requirements, develop sophisticated evidence strategies, and articulate a compelling equity narrative within their value submissions. Our goal is to partner with clients to ensure their innovations achieve fair assessment and reach the patients who can benefit, contributing to a more sustainable and equitable healthcare landscape.
This is a complex, evolving field. We welcome further discussion on how we can collectively advance health equity through thoughtful technology assessment and implementation.
Written by Jorge Ferrer
Decisive Dialogue 9th April 2025