Academic journal article Bulletin of the World Health Organization

Thresholds for the Cost-Effectiveness of Interventions: Alternative Approaches/ Seuils De Rentabilite Des Interventions: Approches Alternatives/ Umbrales De la Rentabilidad De Las Intervenciones: Enfoques Alternativos

Academic journal article Bulletin of the World Health Organization

Thresholds for the Cost-Effectiveness of Interventions: Alternative Approaches/ Seuils De Rentabilite Des Interventions: Approches Alternatives/ Umbrales De la Rentabilidad De Las Intervenciones: Enfoques Alternativos

Article excerpt

Introduction

In public health, cost-effectiveness analyses compare the costs and effectiveness of two or more health interventions--with effectiveness measured in the same units. When comparing interventions, the incremental cost-effectiveness ratio (ICER) --i.e. the difference in costs divided by the difference in health effects--is often used to express the result.

Estimates of costs, health effects and ICERs provide clear guidance to policy-makers in three situations: (i) when the health-effect target is specified by policy-makers and the aim of the cost-effectiveness analysis is to minimize the expenditure needed to achieve that target; (ii) when a budget constraint is specified by policy-makers and the aim is to maximize the health benefits while keeping expenditure within budget; and (iii) when policy-makers have specified an explicit standard or threshold for what should be considered cost-effective. In all three cases, the analysts completing the cost-effectiveness analysis cannot objectively make a recommendation to policy-makers without prior decisions by policy-makers on health-effect or cost targets or thresholds. Without reference to such decisions, the cost-effectiveness analysis cannot fully orient policy-makers to the range of options that might be good investments.

For example, compared with no vaccination, routine quadrivalent human papillomavirus vaccination combined with catch-up vaccination--to protect against cervical diseases in Brazil--was found to have an ICER of 450 United States dollars (US$) per quality-adjusted life-year (QALY) gained. (1) In the United Republic of Tanzania, compared with no treatment, post-exposure prophylaxis for rabies was found to have an estimated ICER of US$ 27 per QALY gained. (2) However, how does one decide whether US$ 450 per QALY gained in Brazil or US$ 27 per QALY gained in the United Republic of Tanzania represents good use of money for the national health-care system?

Three general approaches have been used to solve this problem: (i) thresholds based on per capita national incomes; (ii) benchmark interventions and (iii) league tables. In recent years, the most common approach has involved the use of thresholds based on per capita gross domestic product (GDP). Under this approach--which has been promoted by the World Health Organization's Choosing Interventions that are Cost-Effective (WHO-CHOICE) project (3)--an intervention that, per disability-adjusted life-year (DALY) avoided, costs less than three times the national annual GDP per capita is considered cost-effective, whereas one that costs less than once the national annual GDP per capita is considered highly cost-effective.

In this article, we argue that the current thresholds based on per capita GDP have major shortcomings as guides for policy-makers, since each of the available approaches has substantial weaknesses. We then discuss that a new consensus should be reached on a process for evaluating the cost-effectiveness of health interventions that places ICERs in the context of other, local policy and programme options, including funding sources. We focus on cost-effectiveness and ignore other criteria for policy decisions, such as equity, ethics and political feasibility. We proceed from the premise that evidence-based economic evaluations are vital additions to public policy decisions--which would otherwise largely reflect political, ideological and/or bureaucratic concerns. We focus on the relative merits of different ways of distinguishing what constitutes an acceptable level of cost-effectiveness and on the limitations of the widely used national-income-based approach.

Thresholds

The most pervasive threshold was initially promoted by the Commission on Macroeconomics and Health and adopted in The world health report 2002 and by WHO-CHOICE. This threshold links per capita GDP with returns on investments in health to define the characteristics of a cost-effective and a very cost-effective intervention. …

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