Inequality, Equity and Social Justice in Economic Evaluation of Health Technologies: Distributional and Implementation Perspectives

Abstract

Economic evaluations of health technologies are central to evidence-informed priority setting, yet conventional approaches may insufficiently represent how health gains, costs, and opportunity costs are distributed across population groups. This narrative and conceptual review synthesises methodological, ethical, health technology assessment (HTA), distributional cost-effectiveness analysis (DCEA), and implementation-science literature to examine the links among inequality, equity, distributive justice, and implementation. The synthesis shows that aggregate cost-effectiveness can coexist with unequal access, uptake, effectiveness, or displacement effects across socioeconomic, ethnic, gender, and geographic groups. DCEA offers a structured framework for quantifying these distributional consequences and the trade-offs between total health and inequality reduction, but its application depends on high-quality stratified data, consistent definitions of equity-relevant characteristics, representative clinical evidence, and appropriate real-world data. A further challenge is the persistent separation between economic evaluation and implementation: technologies judged cost-effective may fail to generate population benefit when implementation resources, contextual barriers, and distributional effects are overlooked. A phased strategy is therefore proposed to standardise equity-relevant data across clinical research, registries, administrative sources, and post-implementation monitoring. Integrating efficiency, equity, and implementation can make HTA more informative for public-health decision-making and support resource-allocation decisions that are efficient, transparent, feasible, and socially legitimate.