Inference Procedures to Quantify the Efficiency–Equality Trade-Off in Health from Stated Preferences: A Case Study in Portugal

Abstract

Objectives

This article develops two inference procedures to calculate the inequality aversion and alpha parameters of a health-related social welfare function with constant elasticity (CES-HRSWF) using stated preferences. Based on the relative concept of inequality, a range of values were proposed for the trade-offs between improving total population health and reducing health inequalities.

Methods

A self-administered questionnaire was used to collect data from a sample of 422 college students in Portugal. Respondents faced three hypothetical allocation scenarios where they needed to decide between two health programmes that assign different health gains to two anonymous sub-groups of the population and to two sub-groups identified by socioeconomic class. Combinations of the median response to these three questions were used to estimate the parameters of the CES-HRSWF.

Results

Findings suggest that the quantification of the efficiency–equality trade-off is not independent of the inference procedure used. Plausible values for the inequality aversion and for the alpha parameters were obtained ranging from 2.24 to 4.85 and from 0.5 to 0.58, respectively.

Conclusions

Respondents revealed some aversion to health inequality. However, the extent of this aversion seems to be sensitive to (1) the identification of the groups by occupation status, (2) the size of the health gain, and (3) the inference procedure used.

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Fig. 1

Notes

  1. 1.

    A reviewer cautioned that, in each version, the median responses to question 1 (Q1) and question 2 (Q2) may not be empirically correlated in the sense that they may belong to different respondents. While this behavioral hypothesis points to the development of different statistical analyses, we do not find this behavior in the current data. In fact, in version 4 (version 7) 78% (74%) of the 118 (129) participants whose response to Q1 was below or equal to the respective median response also responded below or equal to the median response to Q2 as identified in Table 2. Likewise, 79% (73%) of the 117 (130) participants whose response to Q2 was below or equal to the respective median response also responded below or equal to the median response to Q1 as identified in Table 2. This indicates a high degree of agreement between the ranking of respondents in Q1 and the ranking of respondents in Q2. Additional analysis (available upon request) confirms the statistical significance of this apparent agreement in each Version.

References

  1. 1.

    Marmot M. Social determinants of health inequalities. Lancet. 2005;365:1099–104.

    Article  PubMed  Google Scholar 

  2. 2.

    Wagstaff A. QALYs and the equity-efficiency trade-off. In: Layard A, Glaister S, editors. Cost-benefit analysis. 2nd ed. Cambridge: Cambridge University Press; 1994 [(reprinted from Journal of Health Economics, 10 (1991) 21–41, with corrections)].

    Google Scholar 

  3. 3.

    Dolan P. The measurement of individual utility and social welfare. J Health Econ. 1998;17:39–52.

    Article  PubMed  CAS  Google Scholar 

  4. 4.

    Dolan P, Tsuchiya A, Smith P, Shaw R, Williams A. Determining the parameters in a social welfare function using stated preference data: an application to health. Sheffield Health Economics Group Discussion Paper Series. Ref 02/2. Sheffield: The University of Sheffield; 2002.

  5. 5.

    Dolan P, Tsuchiya A. The social welfare function and individual responsibility: some theoretical issues and empirical evidence. J Health Econ. 2009;28(1):210–20.

    Article  PubMed  Google Scholar 

  6. 6.

    Dolan P, Tsuchiya A. Determining the parameters in a social welfare function using stated preference data: an application to health. Appl Econ. 2011;43(18):2241–50.

    Article  Google Scholar 

  7. 7.

    Edlin R, Tsuchiya A, Dolan P. Measuring the societal value of lifetime health. Sheffield Economics Research Papers. Series 2009010; 2009.

  8. 8.

    Edlin R, Tsuchiya A, Dolan P. Public preferences for responsibility versus public preferences for reducing inequalities. Health Econ. 2012;21(12):1416–26.

    Article  PubMed  Google Scholar 

  9. 9.

    Shaw R, Dolan P, Tsuchiya A, Williams A, Smith P, Burrows R. Development of a questionnaire to elicit public preferences regarding health inequalities. York: Centre for health Economics, University of York; 2001.

    Google Scholar 

  10. 10.

    Dolan P, Shaw R, Tsuchiya A, Williams A. QALY maximization and people’s preferences: a methodological review of the literature. Health Econ. 2005;14:197–208.

    Article  PubMed  Google Scholar 

  11. 11.

    Whitty J, Lancsar E, Rixon K, Golenko X, Ratcliffe J. A systematic review of stated preferences studies reporting public preferences for healthcare priority setting. Patient Patient Cent Outcomes Res. 2004;7:365–86.

    Article  Google Scholar 

  12. 12.

    Gu Y, Lancsar E, Ghijben P, Butler J, Donaldson C. Attributes and weights in health care priority setting: a systematic review of what counts and to what extent. Soc Sci Med. 2015;146:41–52.

    Article  PubMed  Google Scholar 

  13. 13.

    Pinho M, Borges A. Bedside healthcare rationing dilemmas: a survey from Portugal. Int J Hum Rights Healthc. 2015;8(4):233–46.

    Article  Google Scholar 

  14. 14.

    Pinho M, Borges A, Zahariev B. Bedside healthcare rationing dilemmas: a survey from Bulgaria and comparison with Portugal. Soc Theory Health. 2017;15(3):285–301.

    Article  Google Scholar 

  15. 15.

    Rogge J, Kittel B. Who should not be treated: public attitudes on setting health care priorities by person based criteria in 28 nations. Plos One. 2016;11(6):e0157018.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  16. 16.

    Ferreira P, Silva P. Diferenças sociais na morte: a evolução do número de óbitos na população activa Portuguesa (1981–2001). Revista Portuguesa de Saúde Pública. 2007;25(1):70–84.

    Google Scholar 

  17. 17.

    Mackenbach J, Stirbu I, Roskam A, Schaap M, Menvielle G, Leinsalu M, Kunst A. Socioeconomic inequalities in health in 22 European countries. New Engl J Med. 2008;358:2468–81.

    Article  PubMed  CAS  Google Scholar 

  18. 18.

    Volkof S, Thebaud-Mony A. Santé au travail: l’inégalité des parcours. In: Leclerc A, et al., editors. Les Inégalités socials de santé. Paris: Inserm/La Découverte; 2000.

    Google Scholar 

  19. 19.

    INE-Instituto Nacional de Estatística. Estatísticas Demográficas 2012. Lisboa; 2012.

  20. 20.

    Cuadras-Morato X, Pinto-Prades J, Abellan-Perpinan J. Equity considerations in health care: the relevance of claims. Health Econ. 2001;10(3):187–205.

    Article  PubMed  CAS  Google Scholar 

  21. 21.

    Abásolo I, Tsuchiya A. Understanding preference for egalitarian policies in health: are age and sex determinants? Appl Econ. 2008;1:1–11.

    Google Scholar 

  22. 22.

    Abásolo I, Tsuchiya A. Exploring social welfare functions and violation of monotonicity: an example from inequalities in health. J Health Econ. 2004;23:313–29.

    Article  PubMed  Google Scholar 

  23. 23.

    Abásolo I, Tsuchiya A. Is more health always better for society? Exploring public preferences that violate monotonicity. Theory Decis. 2013;74:539–63.

    Article  Google Scholar 

  24. 24.

    Mueller D. Public choice. Cambridge: Cambridge University Press; 1979.

    Google Scholar 

  25. 25.

    Dolan P, Cookson R, Ferguson B. Effect of discussion and deliberation on the public’s views of priority setting in health care: Focus group study. Br Med J. 1999;318:916–9.

    Article  CAS  Google Scholar 

  26. 26.

    Dolan P, Olsen J, Menzel P, Richardson J. An inquiry into the different perspectives that can be used when eliciting preferences in health. Health Econ. 2003;12:545–51.

    Article  PubMed  Google Scholar 

  27. 27.

    Winkelhage J, Diederich A. The relevance of personal characteristic in allocating health care resources—controversial preferences of laypersons with different educational backgrounds. Int J Environ Res Public Health. 2012;9:223–43.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Dolan P, Shaw R. A note on the relative importance that people attach to different factors when setting priorities in health care. Health Expect. 2003;6(1):53–9.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Rabin M. Psychology and economics. J Econ Lit. 1998;36(1):11–46.

    Google Scholar 

  30. 30.

    Kahneman D, Slovic P, Tversky A, editors. Judgement under uncertainty: heuristics and biases. Cambridge: Cambridge University Press; 1982.

    Google Scholar 

  31. 31.

    Lloyd A. Threats to the estimation of benefit: are preference elicitation methods accurate? Health Econ. 2003;12:393–402.

    Article  PubMed  Google Scholar 

  32. 32.

    Rowen D, Brazier J, Keetharuth A, Tsuchiya A, Mukuria C. Comparison of modes of administration and alternative formats for eliciting societal preferences for burden of illness. Appl Health Econ Health Policy. 2016;14(1):89–104.

    Article  PubMed  Google Scholar 

  33. 33.

    Dolan P, Tsuchiya A. Do NHS staff and members of the public share the same views about how to distribute health benefits? Soc Sci Med. 2007;64:2499–503.

    Article  PubMed  Google Scholar 

  34. 34.

    Robson M, Asaria M, Cookson R, Tsuchiya A, Ali S. Eliciting the level of health inequality aversion in England. Health Econ. 2017;26:1328–34.

    Article  PubMed  Google Scholar 

  35. 35.

    Asaria M, Griffin S, Cookson R, Whyte S, Tappenden P. Distributional cost-effectiveness analysis of health care programmes—a methodological case study of the UK Bowel Cancer Screening Programme. Health Econ. 2015;24:742–54.

    Article  PubMed  Google Scholar 

  36. 36.

    OCDE-Employment. 2016. http://www.oecd.org/employment/the-crisis-has-had-a-lasting-impact-on-job-quality-new-oecd-figures-show.htm.

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Data Availability Statement

Authors can confirm that all relevant data are included in the article and/or its supplementary information files. The authors declare that (the/all other) data supporting the findings of this study are available within the article (and its supplementary information files).

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Contributions

MP conceived and designed the study and drafted the first draft of the paper. AB analysed the data and reviewed and suggested the structure of the manuscript. All authors contributed critically to the revision of the manuscript for intellectual content and approved its submission for publication.

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Correspondence to Micaela Pinho.

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Micaela Pinho and Anabela Botelho disclose no receipt of any financial support for the research, authorship, and/or publication of this article.

Conflict of interest

Micaela Pinho and Anabela Botelho declare they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants before being included in the study.

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Pinho, M., Botelho, A. Inference Procedures to Quantify the Efficiency–Equality Trade-Off in Health from Stated Preferences: A Case Study in Portugal. Appl Health Econ Health Policy 16, 503–513 (2018). https://doi.org/10.1007/s40258-018-0394-6

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