title: Thresholds for the cost-effectiveness of interventions: alternative approaches.
abstract: Many countries use the cost-effectiveness thresholds recommended by the World Health Organization's Choosing Interventions that are Cost-Effective project (WHO-CHOICE) when evaluating health interventions. This project sets the threshold for cost-effectiveness as the cost of the intervention per disability-adjusted life-year (DALY) averted less than three times the country's annual gross domestic product (GDP) per capita. Highly cost-effective interventions are defined as meeting a threshold per DALY averted of once the annual GDP per capita. We argue that reliance on these thresholds reduces the value of cost-effectiveness analyses and makes such analyses too blunt to be useful for most decision-making in the field of public health. Use of these thresholds has little theoretical justification, skirts the difficult but necessary ranking of the relative values of locally-applicable interventions and omits any consideration of what is truly affordable. The WHO-CHOICE thresholds set such a low bar for cost-effectiveness that very few interventions with evidence of efficacy can be ruled out. The thresholds have little value in assessing the trade-offs that decision-makers must confront. We present alternative approaches for applying cost-effectiveness criteria to choices in the allocation of health-care resources.
authors.affiliation: Health Strategies International, 555 Fifty-ninth Street, Oakland, California, 94609, United States of America (USA).
authors.forename: Elliot
authors.initials: E
authors.lastname: Marseille
authors.affiliation: Center for Global Health and Development, Boston University, Boston, USA .
authors.forename: Bruce
authors.initials: B
authors.lastname: Larson
authors.affiliation: Division of Cardiology, San Francisco General Hospital, San Francisco, USA .
authors.forename: Dhruv S
authors.initials: DS
authors.lastname: Kazi
authors.affiliation: Institute for Health Policy Studies, University of California - San Francisco, San Francisco, USA .
authors.forename: James G
authors.initials: JG
authors.lastname: Kahn
authors.affiliation: Center for Global Health and Development, Boston University, Boston, USA .
authors.forename: Sydney
authors.initials: S
authors.lastname: Rosen
mesh_terms: D044966:Anti-Retroviral Agents / Q000191:economics / Q000627:therapeutic use; D019985:Benchmarking; D003362:Cost-Benefit Analysis / Q000379:methods*; D003906:Developing Countries; D005260:Female; D014943:Global Health; D059066:Gross Domestic Product; D015658:HIV Infections / Q000188:drug therapy; D006292:Health Priorities; D006801:Humans; D057148:Insecticide-Treated Bednets / Q000191:economics; D011247:Pregnancy; D019057:Quality-Adjusted Life Years; D013587:Syphilis / Q000175:diagnosis / Q000188:drug therapy; D014944:World Health Organization
chemical_list: D044966:Anti-Retroviral Agents