The equity-effectiveness loop: An evidence-based approach to assessing the effects of programmes and policies on health equity

Description

The equity-effectiveness loop is an evidence-based approach to assessing the effects of programs and policies to determine their impact on improving health equity. The article begins with a discussion of population health, social determinants of health and health equity as a goal of population health. The authors then describe the six steps involved with the equity-effectiveness loop. Finally, the paper identifies some strengths and weaknesses of the equity-effectiveness framework.

The equity-effectiveness loop measures both the risk (burden of illness) and response (effectiveness) of public health interventions across social, demographic and geographic factors. Disadvantage may exist across the following categories (acronym PROGRESS):

• Place of residence
• Race/ethnicity
• Occupation
• Gender
• Religion
• Education
• Socioeconomic status
• Social capital

The equity-effectiveness loop requires a focus on designing, implementing and evaluating interventions that reduce health inequalities instead of simply measuring them.

Steps for Using Method/Tool

The method is broad and applicable to all public health interventions. The paper uses the example of a public health intervention involving school meals to improve nutritional status in children to demonstrate how the equity effectiveness loop can be used.

The steps of the equity-effectiveness loop are as follows:

1. Burden of illness
2. Equity effectiveness
3. Economic evaluation
4. Knowledge translation and implementation
5. Monitoring of program
6. Reassessment

The equity-effectiveness loop assesses potential for health inequities at each of the above steps, and results in an assessment of whether an intervention is likely to benefit the disadvantaged. If health disparities continue to exist after the steps of the loop are completed, the loop is reiterated. Effectiveness is estimated using a multiplicative model with the following four factors that can be lower in disadvantaged groups:

1. Diagnostic accuracy
2. Coverage/access
3. Provider compliance
4. Consumer adherence

Next, the paper discusses the contributions of the equity-effectiveness loop framework to population health. The equity-effectiveness loop:

• Promotes evaluation and re-assessment of interventions aimed at enhancing health equity;
• Reinforces the assessment of health equity and distribution of health as a goal of population health interventions;
• Emphasizes the need to assess barriers and facilitators associated with mitigating the impact of determinants of health; and
• Recognizes the importance of both downstream and upstream interventions.

The article then critiques the equity-effectiveness loop and makes suggestions in terms of situations in which it may not be applicable.