Conflicting Values for Evaluation: Effectiveness or Equity

1. Conflicting Values for Evaluation: Effectiveness or Equity Louise Potvin Chair CHSRF/CIHR, Community Approaches and Health Inequalities, Université de Montréal 1 Seminario Brasileiro de Efetividade da Promoçao da Saude Rio de Janeiro, May 12 2005

2. Conclusions • Values of effectiveness and equity with regards to program evaluation do not necessarily go hand in hand. They can even be conflicting. • Well intentioned interventions and programs can result in inequitable situations • There should be much more concerns about equity in health promotion evaluation practices and actions should be taken to facilitate evaluations that deal with equity

3. Are health inequalities increasing? • Very difficult question to answer • Not many studies make comparisons over time • Results differ depending on • Populations studied • Periods compared • Inequality index used • Lack of individual data linking mortality or morbidity with social status • Only one recent Canadian study using aggregate data

4. Difficulty in comparing inequalities • Several indices for assessing the inequality value of a distribution and these indices are associated with normative choices • The results of the comparisons vary depending on the health indicators that are compared

5. The problem of index of inequality: Absolute or relative difference Population A Population B Mean = 20 Mean = 60 Absolute low to mean dif: 15 Relative low to mean dif: 5/20; 25% Absolute low to mean dif: 15 Relative low to mean dif: 45/60; 75% Gakidou et al., 2000

6. Measuring inequality: the problem of the index • Depending on the index, inequalities between two distributions can differ • The choice of the comparative index is crucial but is necessarily related more to normative bases than to rational processes • It is only once these normative bases have been determined that a rational comparison process can be undertaken.

7. Infant mortality per 1000 live births by income quintile in urban areas, Canada,1971-1996 Difference Q5 – Q1 (’71; ’96) : 9.8 [8.1 – 11.6] ; 2.4 [1.5 – 3.3] Ratio Q5 / Q1 (’71; ’96) : 1.97 [1.73 – 2.23] ; 1.61 [1.34 – 1.93] Wilkins, Berthelot & Ng, 2002

8. Effective interventions that increased inequalities in Canada • Smoking cessation • Number of smokers decreased by more than half in 40 years • Smokers are 4 times more numerous among people with incomplete secondary education • Infection disease • Decrease in infectious disease mortality past 50 years • Infectious disease mortality 3 times higher in lowest quintile compared to highest quintile • Health care • Decrease in lethality of most morbid conditions • Higher survival among highest socio-economic strata for most chronic conditions even with universal care coverage

9. Effectiveness hypothesis : non differential reduction of risk throughout the distribution

10. Concentration of vulnerabilities following interventions Concentration of vulnerabilities Concentration of advantages Mean effect

11. Differential effects of interventions Less vulnerable Corrective approach HealthOutcome Most vulnerable Time

12. Inequality index (absolute versus relative) and the effect on inequalities of effective interventions

13. Example of an effective intervention

14. Reduced inequalities between rich and poor, but ineffective on richer people Pr – Pp is smaller after; Pr / Pp is closer to 1 after

15. Increased inequalities between rich and poor Pr – Pp is bigger after; Pr / Pp is further from 1 after

16. Unclear case (1) Pr - Pp does not change; Pr / Pp is closer to 1 after

17. Unclear case (2) Pr – Pp is larger after; Pr / Pp does not change

18. What have we learned ? • Interventions that are equally effective in terms of improving the health of the general population can have totally different consequences in terms health inequalities between various segments of the population • Often a net effect of increasing health inequalities • Unless interaction effects are tested those inequalities will go undetected • Different inequality index lead to different conclusion

19. Two potentially conflicting health objectives • Improve the health of the general population: effectiveness of the interventions • Reduce the unjust health inequalities between various social strata: equity of the interventions

20. Four sources of inequalities in health promotion interventions • Inequalities due to planning: are intervention priorities determined with a view to the disparities between various social strata? • Inequalities due to implementation: are certain classes of people more easily reached? • Inequalities due to effects: do our interventions have different effects depending on various social factors? • Inequalities due to impacts: for equivalent effects, are the health impacts the same across the the entire population?

21. Inequalities due to planning • Requires that health indicators can be linked to social indicators of inequalities: unavailable in most countries • Requires that corrective approaches are planned taking into account the sources of health inequalities (Acheson report in UK): backlash on affirmative action and social programs • Very few studies highlighting those issues: Montreal study shows that core budget items reach higher values for more affluent areas while less areas have more renewable “program” monies

22. Inequalities due to implementation • Requires monitoring social status of program participants or beneficiaries • Very few studies for programs other than those involving the health care system • For most preventive examinations: disparities between the rich and poor in prescriptions / use • In general population programs: harder to obtain the consent of more disadvantaged parents for school programs in health education

23. Inequalities due to effects • Requires testing programs’ interaction effects • A little more knowledge • Fluoridation programs tend to reduce inequalities ( low income family children) • Promotional campaigns: • increase the disparities in awareness of CVD risk factors (income) • do not affect the disparities among risk factors (income)

24. Inequalities due to impacts • Requires testing the interactions between social determinants and risk factors • Some results of etiological studies, which have not been reproduced, lead one to conclude that certain effects do not translate in the same way into “impact” on the health of different segments of the population • Not aware of any study undertaken to examine that question

25. Actions to promote equity as a value for health interventions • Always couple reducing inequalities to improving health in health intervention objectives • Collect data that allow to estimate trends and identify major sources of health inequalities • Develop methods for assessing each of the four sources of inequalities in programs

26. Conclusions • Values of effectiveness and equity with regards to program evaluation do not necessarily go hand in hand. They can even be conflicting. • Well intentioned interventions and programs can result in inequitable situations • There should be much more concerns about equity in health promotion evaluation practices and actions should be taken to facilitate evaluations that deal with equity