Measuring aversion to health inequality in Canada: an equity-efficiency trade-off experiment

OBJECTIVESTo estimate the extent to which Canadians are averse to health inequalities, a critical component for equity-informative economic evaluations but lacking in the Canadian context. METHODSWe conducted three experiments among a representative sample of adults living in Canada to elicit value judgements about reducing income-related health inequality vs. improving population health. Each experiment compared two programs: (Experiment 1) universal and tailored vaccination; (Experiment 2) non-specific prevention programs; (Experiment 3) generic health care programs. The programs varied in terms of efficiency (additional life years), and income-related health inequality. Preferences were elicited using benefit-trade off analysis and were classified as: pro-rich (maximizing the health of individuals with the highest income); health maximizer (maximizing total health); weighted prioritarian (willing to trade some health to reduce inequalities); maximin (only improving the health of the individuals with the lowest income); and egalitarian (minimizing health inequalities). RESULTSWe recruited 1,000 participants per experiment. Preferences for the vaccination, prevention, and generic experiments were distributed as follows: pro-rich (Atkinson Index<0): 31%, 22%, and 16% respectively; health maximizers (Atkinson Index=0): 2%, 3%, and 2%, respectively; weighted prioritarians (Atkinson Index>0): 13%, 19%, and 22% respectively; maximins (Atkinson Index={infty}): 0%, 1%, and 3%, respectively; egalitarian (Atkinson Index undefined): 54%, 55%, and 57%, respectively. The median responses reflected a preference for minimizing health inequalities across the three experiments. CONCLUSIONSOur findings suggest a strong aversion to health inequality among people living in Canada with over half of respondents willing to minimize health inequalities regardless of the impact on efficiency.