Integrating social justice concerns into economic evaluation for healthcare and public health: A systematic review

Abstract

Social justice is the moral imperative to avoid and remediate unfair distributions of societal disadvantage. In priority setting in healthcare and public health, social justice reaches beyond fairness in the distribution of health outcomes and economic impacts to encompass fairness in the distribution of policy impacts upon other dimensions of well-being. There is an emerging awareness of the need for economic evaluation to integrate all such concerns. We performed a systematic review (1) to describe methodological solutions suitable for integrating social justice concerns into economic evaluation, and (2) to describe the challenges that those solutions face. To be included, publications must have captured fairness considerations that (a) involve cross-dimensional subjective personal life experience and (b) can be manifested at the level of subpopulations. We identified relevant publications using an electronic search in EMBASE, PubMed, EconLit, PsycInfo, Philosopher's Index, and Scopus, including publications available in English in the past 20 years. Two reviewers independently appraised candidate publications, extracted data, and synthesized findings in narrative form. Out of 2388 publications reviewed, 26 were included. Solutions sought either to incorporate relevant fairness considerations directly into economic evaluation or to report them alongside cost-effectiveness measures. The majority of reviewed solutions, if adapted to integrate social justice concerns, would require their explicit quantification. Four broad challenges related to the implementation of these solutions were identified: clarifying the normative basis; measuring and determining the relative importance of criteria representing that basis; combining the criteria; and evaluating trade-offs. All included solutions must grapple with an inherent tension: they must either face the normative and operational challenges of quantifying social justice concerns or accede to offering incomplete policy guidance. Interdisciplinary research and broader collaborations are crucial to address these challenges and to support due attention to social justice in priority setting.

Development of the WHO-INTEGRATE evidence-to-decision framework: an overview of systematic reviews of decision criteria for health decision-making

“…distribution of adverse events across all those affected by the intervention) or as an outcome (e.g. reduced health inequity several years Uptake of intervention [15,20,34,35] Magnitude of benefit/effect/impact [2,4,11,14,18,31,33,36] Additional or indirect effects [2,6,33,34] Type and composition of effect/ benefit/impact [2] Impact on mortality, survival, longevity and life expectancy [1, 2, 4, 11, 16, 19, 21, 24-26, 28, 34-36] Last chance therapies [23,24] Impact on morbidity and disability [1,2,16,35] Potential changes in health consequences [24,25] Impact on (health-related) quality of life [2,8,11,12,14,19,20,22,25,26,28,29,31,33,35,36] Impact on patient-reported outcomes [2,12,16,21,26]…”

“…Perceived priority of the problem Public perception of disease burden, disease risk or severity [15,34,35] Acceptability Acceptability in general [2,4,6,14,15,24,26,27,[34][35][36] Acceptability of cost and financial outcomes [2,14,25,26,34] Acceptability by beneficiaries Acceptability by beneficiaries: in general [2,6,8,11,15,16,26,35] Comfort, convenience and user experience [2, 11, 12, 14, 15, 20, 24-26, 31, 33, 35] Acceptability by those providing intervention Acceptability by those providing intervention [15,16,34,35] Social and cultural acceptability Social and cultural acceptability [2,4,8,9,11,15,18,21,22,25,26,[31][32][33][34]36] Ethical...…”

“…Advocacy and stakeholder (in general) interests and pressures [1,2,6,14,15,21,25,33,36] Demands, interest and pressures of the public [1,2,8,14,[24][25][26]36] Demands, interest and pressures by industry [2] Pressures, demand and interest of beneficiaries and patient representatives [2,17,20,22,25,32,33] Pressures, demand and interest of those providing intervention [2,17,20,25,26,32,33] Media attention and coverage [1,32] Societal considerations Societal needs and priority Social burden of disease (individual/population) [8,18,21,29,34,35] Social needs [24] Economic burden of disease on society (in general) [32] Social and societal impact Social impact or benefits [2, 3, 5, 6, 14, 21, 23-26, 31, 33, 35] Impact on non-health outcomes (in general) [15,18,26,…”

“…Impact on other spending/investments [2,6,14,25] Investment/start-up cost [2,22,30] Operating cost [2,30] Lifecycle cost of intervention/technology [30] Economic/financial benefits and cost-minimization potential [1,3,8,11,13,22,25,27,28,[34][35][36] Cost to/budget impact on government or society [1,2,5,18,25,26,29,33,36] Relation of cost and benefits Relation of cost and benefits [1-7, 9-16, 18-26, 28, 31-36] Financial context Appropriateness [2,14] Financial feasibility Affordability to health system Availability or lack of funds/funding [ Impact on management and organizational structure [2,8,11,25] Logistical considerations [2,15,34] Availability of, capacity of and need for monitoring, surveillance and information system [34,35] Resource considerations Availability of, capacity of and need for resources (in general) [ Donor and global interests and pressures…”

“…This is at odds with the complexity of realworld decision making, were normative and feasibility considerations may act as key drivers of decisions (e.g. infringement of population health interventions on individual rights or interactions of interventions with other components of a health system) [14,15]. The values and perceptions of different stakeholders with respect to normative and technical considerations often vary greatly both within and across societies.…”