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«Edited by ANNE MASON Research Fellow, Centre for Health Economics University of York and ADRIAN TOWSE Director, Office of Health Economics Radcliffe ...»

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In the ESRC project on ‘Measuring preferences regarding equity and variations in health’, we explained to members of the public that there is a fiveyear difference in life expectancy at birth between men from social classes I and V. When respondents were asked in effect for the size of the WTF in order to reduce this gap in life expectancy, the median answer was 1 year. When the same respondents were told that there is the same five-year gap in life expectancy at birth between men and women, however, the median WTF was zero (Dolan et al., 2002). If the fair innings argument is valid, then shouldn’t the respondents want to make some sacrifices in efficiency in order to rectify this gap in life expectancy? Or, could it be that the fair innings argument will work across social classes (and across different ages), but not across the gender groups?

In a theoretical paper, Tsuchiya and Williams (2004) explored reasons why people’s attitude towards inequality in health might differ between the social class scenario and the gender scenario, and whether this seriously limits the applicability of the fair innings argument. The main conclusion is that if people are taking into account some notion of overall well-being that stretches beyond health and longevity, then they may think that although men have lower ELQ, they may not necessarily have a lower level of overall well-being, because of the other socio-economic advantages they have over women. If so, then men are not the relatively worse off amongst the two sexes, so it will not be equitable to give a marginal health improvement to men a higher relative weight than the same health improvement to women. This has two implications. First, it may be inappropriate to apply the fair innings argument to health across the sex groups, but that does not mean the fair innings argument cannot be applied to overall well-being across the sex groups. Second, WTF and the fair innings weights derived in the above study between the social classes may be overestimated, since those in social class V have fewer socio-economic opportunities than those in social class I, and this consideration (over and above the consideration for their poorer health) may have had a positive impact on WTF.


We see three main directions for research following from all of this. One direction is descriptive and involves collaboration with public health researchers.

Investigation into the determinants of ELQ, and the determinants of the * Women live longer than men even in societies where they are less well nourished. Would a genderless society, where sexism was overcome, be one where women lived yet longer than men? Probably not, since it seems to be that patriarchal societies are bad for men’s health and longevity as well as women’s (see for example Kawachi et al., 1999; Stanistreet et al., 2005).


variation of ELQ, are two important topics. Related to these is the measurement of inequality across different population subgroups.

Another direction involves economic theory and empirical work: the ESRC-funded project mentioned above elicited WTF independently for social class, age groups, gender and individual responsibility. Thus, public preferences support giving larger weights to those from deprived backgrounds, and those who are young, and those who have not caused their own illhealth. But what should we do about somebody who is from a deprived background and old and may have caused their own ill-health? We need to look at combinations of relevant characteristics, not just one characteristic at a time. There is a research programme, where we have one of the two major research projects, currently funded by NICE and the National Collaboration Centre for Research Methodology on ‘The relative societal value of health gains to different beneficiaries’ to explore this topic further.

The third is about expanding beyond health economics, into the economics of well-being, to explore the extent to which non-welfarism can be applied in other areas of public policy beyond health and health care. One such attempt has been discussed in our other paper at this conference on public safety. The aim there is to generate a descriptive system to capture the impact of crime on individual well-being, and to produce a population value set that goes with it. Similar attempts may be made in other areas of public policy where non-welfarist approaches may enjoy support such as social care, education, environment, and defence. This expansion will not stop at measuring and valuing well-being, but will also include the application of the fair innings weights and the derivation of distributional weights applicable to the different components of well-being, or indeed to well-being overall.


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CHAPTER 9 Equity and fairness in health and health care: looking up and extending ‘My way’ – a comment on Aki Tsuchiya and Paul Dolan’s paper... Jan Abel Olsen


I greatly enjoyed Aki and Paul’s overview of Alan’s contribution to this literature and their discussion of the fair innings argument. My discussion concentrates on the three core questions they outline, and my main points are related to the importance of acknowledging the very disparate causes of inequalities in health when we talk about equity and fairness in health and health care.

First, let me try to make my own conceptual clarifications. As opposed to the term efficiency where economists have precise definitions, different disciplines and schools of thought appear to have various definitions of equity and fairness. I will not suggest which definitions are the most precise, but rather which connotations I get – when looking up in the sky. I consider equity to deal with distributive justice, often with the aim of reducing observed inequalities among people in their possessions of particular goods (e.g. income, health, education). I consider fairness to be a wider term, related to what most people think is intuitively right or acceptable,* often with reference to particular ethical norms and/or a wide community consensus (‘empirical ethics’), and it may have connotations of procedural justice. Note also the seminal paper by Rawls (1958) entitled ‘Justice as fairness’. In the context of distributive justice, I feel that the term fairness differs from the term equity, in the sense that fairness * A paper by Kahneman et al. (1986) ‘Fairness as a constraint on profit seeking: entitlement in the market’, reports from a survey in which the various statements were labelled ‘acceptable’ versus ‘unfair’.


also includes, and refers to, the ethical justifications for accepting particular inequalities.

It appears that Aki and Paul are primarily concerned with equity rather

than fairness. The three core questions they draw up are:

1 what is equity in health care?

2 equity of what?

3 what is financial equity?

I think that (1) and (3) are intertwined in that they both deal with equity in health care. We cannot achieve equity in health care delivery, which to me means ‘equal access (or use) for equal need’ if the financial contributions from current or future users are not established completely independently of their needs for health care. This corresponds with what Alan described as the egalitarian viewpoint in his guide through the ideological jungle (Williams, 1988a), whereby health care is being distributed according to need and financed according to ability to pay. Wagstaff and van Doorslaer (2000) distinguish between divorcing payment from utilisation (delivery), and divorcing payment from ability to pay (finance).

When healthcare finance is included as a non-earmarked tax, the level of financial equity depends on the level of progressivity in income taxation – an issue of fair taxation that lies in the Treasury. Hence, Aki and Paul’s third core question – what is financial equity? – is essentially an issue that lies outside the Department of Health (at least in a UK and Norwegian context).

As to their first core question – what is equity in health care? – most authors emphasise the instrumental nature of equity in health care, as a precondition for achieving equity in health, which is the heart of their second core question.


My discussion can be summarised in a box:

Equity Fairness Health care I II Health III IV I: Equity in health care – equal access (or use) for equal need I will bypass the discussion on access versus utilisation, as both terms deal with equity in health care. For identical needs (same ill-health and same capacities to benefit), equity in health care means that people are equally entitled to, and are considered to have the same rights to, health care – completely independently of any non-medical characteristics of the recipients (e.g. most impor tantly income).This corresponds with the egalitarian camp in the jungle! In principle, the degree of various types of inequality in healthcare utilisation, or access, can be measured empirically, e.g. use of health care across social classes.

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