Which are the limits of the cost-effectiveness analysis “globally” produced by supranational organizations?
The function and structure of HTA agencies responsible for setting priorities for public spending in healthcare are strongly dependent upon the healthcare system within which they operate. Most explicitly consider cost-effectiveness evidence in their decision-making as well as evidence in the broadest sense, including so-called colloquial evidence on social values and service user perspectives.
In an interesting paper, Baltussen et al. claim that the global and supranational organizations actually ignore the local political economy of priority setting and are, therefore, unlikely to influence the actual allocation of scarce healthcare resources in low- and middle-income countries (LMICs). We agree with this perspective.
Better decisions about priorities for resource allocation, based on comparative evidence of costs and benefits, and that are feasible and implementable, are becoming increasingly possible in the current move towards universal health coverage.
In the absence of a legitimate, transparent and evidence-based priority setting process, what is going on?
Unfortunately, health systems become vulnerable to the country’s judiciary making ad hoc decisions on what the system ought to pay for individual patients, often overlooking overall budgetary and other constraints in making such decisions and the resulting impact on the availability of healthcare for the rest of the population. There has been, for example, a mushrooming of court decisions compelling the authorities to provide expensive, often unproven, treatments to specific individuals.
The increasing involvement of the courts in individual treatment decisions and national policies, prioritising human rights of individual patients over affordability for the health system and patients as a whole, can undermine well-intentioned public policy and, at worst, inject further inequalities and inefficiencies into the healthcare system.
Which is the aim of your iDSI?
Our international Decision Support Initiative (iDSI) was established to strengthen in-country institutional and technical capacity together with open participative processes for evidence-informed policy-making. It takes the form of a collaboration between local policy-makers and other stakeholders for sharing experiences, methods, and knowledge.
Is the problem too much cost-effectiveness analysis?
CEA should not be the main criterion in decision-making. Yet, as a means of systematically assessing the benefits against the cost of alternative investment options, CEA is in fact not much used by countries’ health authorities in making decisions about real-life public spending in health. But moving towards a situation where economic evidence is down-valued or even deprioritised over other socially acceptable considerations, with or without deliberation risks throwing the baby out with the bathwater.
Why do you consider global approaches to CEA context-insensitive?
Standardised cost-effectiveness decision rules arbitrarily set by global experts with no consideration of local budgetary constraints and opportunity costs – without in-country expertise for commissioning, producing and interpreting local data on costs and outcomes – may do more harm than good. CEA that is not based on local evidence is not useful and can even be harmful.
It is not possible (let alone desirable) to determine at the global level what is cost-effective or equitable or otherwise acceptable at country or regional level.
Why do you consider global approaches to CEA context-insensitive?
The first question in any respectable guidance for carrying out CEA is, rightly, something like “What is the context?” or “What is the perspective?” for this study. Criteria for setting priorities are matters of political and social judgment by those who are accountable to the citizens. Experts can help local decision-makers develop politically feasible, credible and transparent ways of making such choices.
References
– Baltussen R, Jansen MP, Mikkelsen E, et al. Priority setting for universal health coverage: we need evidence-informed deliberative processes, not just more evidence on costeffectiveness. Int J Health Policy Manag 2016;5:615.
– Chalkidou K, Li R, Culyer AJ, et al. Health technology assessment: global advocacy and local realities: comment on “Priority setting for universal health coverage: we need evidenceinformed deliberative processes, not just more evidence on cost-effectiveness”. Int J Health Policy Manag 2017;6:233.
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