Value of Equity in HTA: Current Guidelines and What to Expect

The idea of “value” in health technology assessment (HTA) is shifting. Clinical and economic evidence remain the foundation of HTA; however, equity, often overlooked in the past, is becoming an increasingly important element to consider.

This article examines how current HTA guidelines address equity and what changes may be forthcoming. At Putnam, we believe that building equity into HTA in a consistent and transparent way is not only the right thing to do, but also essential for well-informed, fair policy decisions.

It is anticipated that HTA bodies will gradually shift from qualitative judgments on equity impact to quantitative methods, such as distributional cost-effectiveness analysis (DCEA). Analytical approaches evolve accordingly, and we must all remain engaged with these developments to ensure that the value of new treatments considers equity benefits, losses, and trade-offs.

Qualitative to Quantitative: How Equity is Evolving in HTA

HTA agencies review clinical and economic evidence on health interventions to assess their effectiveness, safety, affordability, and value for money. Increasingly, equity is considered for inclusion in HTA assessments as a novel element of value ¹, ensuring decisions reflect the benefits of new treatments. Most HTA guidelines already recommend some level of equity impact assessment; however, until recently, this was mostly qualitative, and did not require quantification of equity benefits or trade-offs².

In light of a recent update of the (NICE) HTA manual ^3,4 (May 2025), which explicitly advised on the application of DCEA to quantify equity impact, it is now essential to expand the methodological toolbox for economic evaluations and to closely monitor evolving recommendations across other HTA agencies.

Review of HTA Equity Guidelines

The table below summarizes the findings of a brief review of seven HTA guidelines, which explicitly outline their position on equity. The review focused on recommended approaches to equity, ranging from qualitative assessment to quantitative frameworks such as DCEA, or a combination of both.

Note: HTA guidelines that do not consider equity were excluded from this review.

Abbreviations: CADTH; Canada’s Drug and Health Technology Agency, DCEA; distributional cost-effectiveness analysis, HITAP; Health Intervention and Technology Assessment Program, ICER; Institute for Clinical and Economic Review, NICE, National Institute for Health and Care Excellence, PBAC; Pharmaceutical Benefits Advisory Committee

To date, there have been two published submissions to NICE that include an assessment of equity impact using DCEA ^{12, 13}. Both submissions were made before publication of the latest NICE guidance on equity, which indicated a distinct shift in formal practice. At the same time, discussions on approaches to incorporate equity continue to evolve across academia and industry, with increasing visibility in publications, conference debates, and expert panels. These advancements suggest that equity considerations will be gradually integrated into routine HTA in a more systematic and transparent way over time.

What Comes Next for Equity in HTA?

Within the growing methodological consensus and emerging HTA guidance on equity inclusion in assessments, it is anticipated that clear recommendations will be developed to ensure that economic evaluations provide robust evidence on the equity impact of the compared treatment strategies ^14,15.

The following developments could be expected:    

• Equity-informative methods will become broadly adopted, with agencies asking at a minimum for subgroup analysis, and likely recommending formal methodological frameworks, such as DCEA.
• Further standardization of methodology: clearer subgroup definitions, guidance on when to use aggregate versus full DCEA (with the expected preference for a full DCEA), and the choice of relevant equity measures.
• Evidence generation needs will evolve to capture subgroup-specific differences.
• Expectations on data quality will also develop, with greater emphasis on trial representativeness and targeted real-world studies to address evidence gaps for population subgroups.
• Finally, rationale and conceptualization for the equity-informative research will become more transparent, with committees documenting how equity evidence should be applied to have an impact on decision making – e.g., via the use of outcome modifiers, adapted willingness-to-pay thresholds, or equity measure thresholds.

Putnam’s Role in Advancing Equity Methods

At Putnam, we actively contribute to the advancement of equity-informative methods, including the conceptualization of the Value of Vaccination framework ^19,20, analyzes identifying challenges to incorporate robust DCEA, and suggestions for potential solutions ²¹. In addition, through publications, webinars, and conference presentations, we continue to increase awareness, share insights, and foster good practices, aiming to support the development of a consensus on a formal inclusion of equity considerations in HTA decision-making.

We’ve conducted DCEAs across a range of indications ^16-18, within the frameworks of full DCEA (based on a detailed subgroup analysis), and aggregate DCEA (simplified method used to compensate for a lack of detailed data). As the standardized approach is in development, conducting DCEA requires combining the most up-to-date knowledge base, conceptual innovation, and thoughtful interpretation of the obtained insights.

In conclusion, the way health technology assessment (HTA) evolves will play an important role in shaping a fairer healthcare system. Bringing equity into economic assessments in a structured way will be central as new quantitative methods are introduced and existing ones improve. The shift from broad, qualitative judgments to data-driven tools like Distributional Cost-Effectiveness Analysis (DCEA) reflects a growing commitment to making equity considerations more explicit and measurable in value assessment. By engaging with these changes and tracking their impact, a system can be created where new treatments prove not only their medical and economic value but also support health equity.

If you’re interested in end-to-end support for equity-informative analysis, from conceptualization and data collection to the design of appropriate model-based tools and the communication of study results, please get in touch.