Are Current Cost-Effectiveness Thresholds for Low- and Middle-Income Countries Useful? Examples from the World of Vaccines

Abstract

The World Health Organization's CHOosing Interventions that are Cost Effective (WHO-CHOICE) thresholds for averting a disability-adjusted life-year of one to three times per capita income have been widely cited and used as a measure of cost effectiveness in evaluations of vaccination for low-and middle-income countries (LMICs). These thresholds were based upon criteria set out by the WHO Commission on Macroeconomics and Health, which reflected the potential economic returns of interventions. The CHOICE project sought to evaluate a variety of health interventions at a subregional level and classify them into broad categories to help assist decision makers, but the utility of the thresholds for within-country decision making for individual interventions (given budgetary constraints) has not been adequately explored. To examine whether the 'WHO-CHOICE thresholds' reflect funding decisions, we examined the results of two recent reviews of cost-effectiveness analyses of human papillomavirus and rotavirus vaccination in LMICs, and we assessed whether the results of these studies were reflected in funding decisions for these vaccination programmes. We found that in many cases, programmes that were deemed cost effective were not subsequently implemented in the country. We consider the implications of this finding, the advantages and disadvantages of alternative methods to estimate thresholds, and how cost perspectives and the funders of healthcare may impact on these choices.

Cost-effectiveness of evolocumab in treatment of heterozygous familial hypercholesterolaemia in Bulgaria: measuring health benefit by effectively treated patient-years*

“…More often than not, the magnitude of this threshold has little or no empirical foundation; in Bulgaria, no mandatory consensus standard exists for it. On the other hand, the often adduced WHO-CHOICE threshold of 1 to 3 times GDP per capita [55], also cited by the National Council of Pricing an Reimbursement [56], has several well-acknowledged shortcomings [57,58] and is therefore contentious. Invoking thresholds that do not reflect the opportunity costs of a particular health care system is not expedient to advance the health-related well-being of the population it serves.…”

WHO guide on the economic evaluation of influenza vaccination

“…Ideally, thresholds in LMICs should be informed by the alternative ways the health resources could be allocated, as well as local budget constraints 41. As a result, it is important to consider the findings of budget impact analyses for the various influenza vaccination strategies under consideration.…”

A systematic review of health economic evaluations of vaccines in Brazil

“…19 The authors of most papers (95%) were favorable to the intervention. Since Brazil does not have a locally established cost-effectiveness threshold, we used WHO' CHOICE criteria, 11 as used by others, particularly in low-and middle-income countries, 55,56 to interpret the reviewed studies' results. In all 13 reviewed studies that reported ICERs, the vaccination program was below the threshold of cost-effectiveness (<3 GDP/ DALY).…”

“…WHO' CHOICE criteria for cost-effectiveness threshold has been discussed in the literature. 55,56 A criticism is that it "sets such a low bar for cost-effectiveness that very few interventions with evidence of efficacy can be ruled out,"…”

“…Additionally, it does not capture the affordability or sustainability of funding, nor the relative value of other interventions that compete for funding. 55,56 Recently WHO recommended not using these thresholds, alone, as a decision rule for funding decisions. 57 This systematic review identified a significant association between the conclusions of vaccines cost-effectiveness and pharmaceutical industry sponsorship (p < 0.012).…”