Intended for healthcare professionals

Analysis And Comment Health policy

Applying clinical epidemiological methods to health equity: the equity effectiveness loop

BMJ 2006; 332 doi: (Published 09 February 2006) Cite this as: BMJ 2006;332:358
  1. Peter Tugwell, director (,
  2. Don de Savigny, research manager3,
  3. Gillian Hawker, associate professor4,
  4. Vivian Robinson, research associate2
  1. 1 Ottawa Health Research Institute, Institute of Population Health, University of Ottawa, 1 Stewart Street, Ottawa, ON, Canada K1N 6N5
  2. 2 Centre for Global Health, Institute of Population Health
  3. 3 International Development Research Centre, Canada/Tanzania Essential Health Interventions Project (TEHIP) Research Manager, Swiss Tropical Institute, PO Box, CH-4002 Basel, Switzerland
  4. 4 Sunnybrook and Women's College Health Sciences Centre, Women's College Campus, Toronto, ON, Canada M5S 1B2
  1. Correspondence to: P Tugwell

    Focusing on the average effects of interventions on health may miss important differences within populations. Examining these effects across gradients in wealth allows the identification of the interventions most likely to reduce health inequalities


    The world achieved impressive health gains during the 20th century.1 However, health worldwide is distributed unevenly, according to socioeconomic status.2-4 Unfair and avoidable health inequalities have been termed health inequities.5 Modern health policy must ensure that poor people are included in the benefits of development.6


    We propose the “equity effectiveness loop” framework (fig 1) to highlight equity issues inherent in assessing health needs, effectiveness, and cost effectiveness of interventions, and the development and evaluation of evidence based health policy. This framework provides a method to calculate the “equity effectiveness ratio,” which assesses the impact of various factors on the gap in the effectiveness of interventions across socioeconomic gradients. Although we illustrate the application of this approach when data are available on the economic gradient across individuals, if socialgroup attributes are also known, the approach could be applied for other equity factors as illustrated by the PROGRESS concept: place of residence; race, ethnicity, and culture; occupation; sex; religion; education; socioeconomic status; and social capital, which reflects categories across which disadvantage may exist.7 Including equity issues is an improvement on the iterative measurement loop, which focused on averages and thus ignored the distribution of health effects.8 9

    Fig 1

    Equity effectiveness loop

    Information on the distribution of both “risk” and “response” across the wealth gradient is critical for going beyond mere measurement to designing strategies to reduce the health gap between rich and poor.


    This equity effectiveness loop provides a framework for developing and evaluating population health interventions and policies that explicitly focus on narrowing the gap between rich and poor, using the best …

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