Developing a National Set of Health Equity Indicators Using a Consensus Building Process

How can health technology assessment be improved to optimise access to medicines? Results from a Delphi study in Europe : Better access to medicines through HTA

INTRODUCTION

Access to medicines is a shared goal across healthcare stakeholders. Since health technology assessment (HTA) informs funding decisions, it shapes access to medicines. Despite its wide implementation, significant access variations due to HTA are observed across Europe. This paper elicited the opinions of European stakeholders on how HTA can be improved to facilitate access.

METHODS

A scoping review identified HTA features that influence access to medicines within markets and areas for improvement, while three access dimensions were identified (availability, affordability, timeliness). Using the Delphi method, we elicited the opinions of European stakeholders to validate the literature findings.

RESULTS

Nineteen participants from 14 countries participated in the Delphi panel. Thirteen HTA features that could be improved to optimise access to medicines in Europe were identified. Of these, 11 recorded a positive impact on at least one of the three access dimensions. HTA features had mostly a positive impact on timeliness and a less clear impact on affordability. 'Early scientific advice' and 'clarity in evidentiary requirements' showed a positive impact on all access dimensions. 'Established ways to deal with uncertainty during HTA' could improve medicines' availability and timeliness, while more 'reliance on real-world evidence' could expedite time to market access.

CONCLUSIONS

Our results reiterate that increased transparency during HTA and the decision-making processes is essential; the use of and reliance on new evidence generation such as real-world evidence can optimise the availability of medicines; and better collaborations between regulatory institutions within and between countries are paramount for better access to medicines.

Health Equity Impact Assessment (HEIA) reporting tool: developing a checklist for policymakers

INTRODUCTION

Health Equity Impact Assessment (HEIA) is a decision support tool that shows users how a new program, policy, or innovation affects health equity in different population groups. Various HEIA reporting and dissemination tools are available, nevertheless, a practical standard tool to present the results of HEIA in an appropriate period to policymakers is lacking. This work reports the development of a tool (a checklist) for HEIA reporting at the decision-making level, aiming to promote the application of HEIA evidence for improving health equity.

METHODS

This is a mixed-method study that was carried out over four stages in 2022-2023: 1) identifying HEIA models, checklists, and reporting instruments; 2) development of the initial HEIA reporting checklist; 3) checklist validation; and 4) piloting the checklist. We also analyzed the Face, CVR, and CVI validity of the tool.

RESULTS

We developed the initial checklist through analysis of 53 included studies and the opinions of experts. The final checklist comprised five sections: policy introduction (eight subsections), managing the HEIA of policy (seven subsections), scope of the affected population (three subsections), HEIA results (seven subsections), and recommendations (three subsections).

CONCLUSION

Needs assessment, monitoring during implementation, health impact assessment, and other tools such as monitoring outcome reports, appraisals, and checklists are all methods for assessing health equity impact. Other equity-focused indicators, such as the equity lens and equity appraisal, may have slightly different goals than the HEIA. Similarly, the formats for presenting and publishing HEIA reports might vary, depending on the target population and the importance of the report.

The COVID-19 Israeli tapestry: the intersectionality health equity challenge

BACKGROUND

COVID-19 is disproportionately affecting disadvantaged populations, with greater representation and worse outcomes in low socioeconomic and minority populations, and in persons from marginalized groups. General health care system approaches to inequity reduction (i.e., the minimization of differences in health and health care which are considered unfair or unjust), address the major social determinants of health, such as low income, ethnic affiliation or remote place of residents. Yet, to effectively reduce inequity there is a need for a multifactorial consideration of the aspects that intersect and generate significant barriers to effective care that can address the unique situations that people face due to their gender, ethnicity and socioeconomic situation.

MAIN BODY

To address the health equity challenges of diverse population groups in Israel, we propose to adopt an intersectional approach, allowing to better identify the needs and then better tailor the infection prevention and control modalities to those who need them the most. We focus on the two main ethnic - cultural-religious minority groups, that of Arab Palestinian citizens of Israel and Jewish ultra-orthodox (Haredi) communities. Additionally, we address the unique needs of persons with severe mental illness who often experience an intersection of clinical and sociodemographic risks.

CONCLUSIONS

This perspective highlights the need for responses to COVID-19, and future pandemic or global disasters, that adopt the unique lens of intersectionality and equity. This requires that the government and health system create multiple messages, interventions and policies which ensure a person and community tailored approach to meet the needs of persons from diverse linguistic, ethnic, religious, socioeconomic and cultural backgrounds. Under-investment in intersectional responses will lead to widening of gaps and a disproportionate disease and mortality burden on societies' most vulnerable groups.

Socioeconomic and ethnic disparities along five waves of the COVID-19 pandemic: Lessons we have not yet learnt

PURPOSE

The COVID-19 pandemic, now in its third year, has served as a magnifying glass, exposing the inequitable impact of the outbreak. The study aims to analyze the relationships between the socioeconomic and ethnic characteristics of the population and COVID-19 testing, infection, and vaccination throughout the first five pandemic waves.

DESIGN

A secondary analysis of an existing national database was conducted in Israel from March 2020 to May 2022. During the study period, Israel underwent 5 pandemic peaks or waves (March-April 2020, September-October 2020, January-February 2021, September 2021, and January-February 2022).

METHODS

Data on tests performed, confirmed COVID-19 cases, and uptake of vaccine doses one through four during the study period, were analyzed by the socioeconomic (SE) cluster (scale of 1 to 10) and ethnicity (Jewish, Arab, mixed Jewish- Arab ethnicity) of the residents' local authority.

RESULTS

COVID-19 testing rate gradually increased from the lowest to the highest SE clusters, with rates 3.2 times higher in the second highest, compared with the lowest cluster. People living in Jewish localities were tested twice more than those in Arab or mixed localities. The rate of confirmed cases was 1.9, 3.0, 6.3, and 4.3 times higher, respectively, among cluster 1 (the lowest) compared with cluster 9 (second highest) in the first, second, third, and fourth pandemic waves, respectively. Rates among people living in Arab or mixed localities were higher compared with those living in Jewish localities in 3 of the 5 waves. Vaccine uptake revealed a clear social gradient, with the percentage of the population being vaccinated gradually increasing from cluster 1 (the lowest) to the higher clusters. The relative difference between the lowest and highest SE clusters increased from 2.4 in the first vaccine dose to 5.5 in the third and fourth doses. Ethnic disparities also grew with vaccine dose, with a Jewish to an Arab rate ratio of 1.1, 1.2, 1.6, and 4.5 for vaccine doses 1,2,3, and 4, respectively.

CONCLUSIONS

Covering 26 consecutive months of the COVID-19 pandemic at the national level, the current study demonstrates that despite high accessibility of tests and vaccines to the entirety of the population and tailored outreach efforts, socioeconomic, and ethnic disparities not only failed to diminish, but they even widened along the five pandemic waves.

CLINICAL RELEVANCE

The pandemic exposed the vulnerability of the weakest segments of the population. Therefore, the combined action of the Ministry of Health, health providers, and local authorities is required to further adapt health messages to the cultural characteristics of diverse populations, to equip the health professionals with practical tools to promote healthy choices among the vulnerable populations, and to build communities that promote healthy lifestyles. The pandemic has highlighted the importance of reducing health disparities and building trust between vulnerable populations and the healthcare system during "normal" or routine times, to better prepare for times of emergencies, such as the current pandemic.