Inequalities in access to healthcare: Economic evaluation in low- and middle-income countries

With the pressure on to achieve Universal Health Coverage (UHC) by 2030, international agencies have indicated that progress towards UHC can be supported by evidence from health economic evaluations. In this thesis, I aimed to investigate the extent to which standard methods of health economic evaluation provide evidence for progress towards fairer access to healthcare, and to explore the potential for expanding the scope of health economic evaluation to better address these issues. Study One is an overview of systematic reviews synthesising evidence on barriers and facilitators to healthcare access. Key themes around capacity, financial barriers and socio-cultural factors were found to impact healthcare access in different ways across contexts. Study Two is a scoping review of guidance for the conduct of health economic evaluations which finds that most guidance does not mention healthcare access or equity at all. This highlights a disparity between expectations for use of health economic evidence to support advancement towards UHC and the current methods guidance to undertake such evaluations. Studies Three and Four are case-study evaluations of surgical task-shifting for C-section in Sierra Leone. Study Three explores whether standard methods of health economic evaluation provide evidence on equity-of-access impacts; and Study Four explores how alternative approaches can be implemented to improve the evidence on equity-of-access provided. Using standard methods of health economic evaluation, it is shown that surgical task-shifting for C-section is cost-effective and improves access to C-section overall, but it does not provide evidence on equity-of-access. Using adapted methods of Distributional Cost-effectiveness Analysis implemented using a patient-level simulation model, it was also shown that surgical task-shifting for C-section was likely to improve equity-of-access. Although standard methods of health economic evaluation do not provide evidence to support UHC, they can be adapted to do so if this remains a social objective of healthcare systems.