title: Hidden costs: The ethics of cost-effectiveness analyses for health interventions in resource-limited settings.
abstract: Cost-effectiveness analysis (CEA) is an increasingly appealing tool for evaluating and comparing health-related interventions in resource-limited settings. The goal is to inform decision-makers regarding the health benefits and associated costs of alternative interventions, helping guide allocation of limited resources by prioritising interventions that offer the most health for the least money. Although only one component of a more complex decision-making process, CEAs influence the distribution of health-care resources, directly influencing morbidity and mortality for the world's most vulnerable populations. However, CEA-associated measures are frequently setting-specific valuations, and CEA outcomes may violate ethical principles of equity and distributive justice. We examine the assumptions and analytical tools used in CEAs that may conflict with societal values. We then evaluate contextual features unique to resource-limited settings, including the source of health-state utilities and disability weights, implications of CEA thresholds in light of economic uncertainty, and the role of external donors. Finally, we explore opportunities to help align interpretation of CEA outcomes with values and budgetary constraints in resource-limited settings. The ethical implications of CEAs in resource-limited settings are vast. It is imperative that CEA outcome summary measures and implementation thresholds adequately reflect societal values and ethical priorities in resource-limited settings.
authors.affiliation: a Department of Health Policy and Management , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.|b Division of Infectious Diseases , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Rutstein
authors.affiliation: c Division of Global Women's Health , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.
authors.forename: Joan T
authors.initials: JT
authors.lastname: Price
authors.affiliation: d UNC Project , Lilongwe , Malawi.|f Department of Epidemiology , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.
authors.forename: Nora E
authors.initials: NE
authors.lastname: Rosenberg
authors.affiliation: e Department of Social Medicine , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.
authors.forename: Stuart M
authors.initials: SM
authors.lastname: Rennie
authors.affiliation: a Department of Health Policy and Management , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Biddle
authors.affiliation: b Division of Infectious Diseases , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.|f Department of Epidemiology , University of North Carolina-Chapel Hill , Chapel Hill , NC , USA.
authors.forename: William C
authors.initials: WC
authors.lastname: Miller
mesh_terms: D002017:Budgets; D003362:Cost-Benefit Analysis / Q000941:ethics*; D003657:Decision Making; D003695:Delivery of Health Care / Q000191:economics*; D006295:Health Resources / Q000600:supply & distribution*; D006801:Humans; D019057:Quality-Adjusted Life Years; D012935:Social Justice
keywords: Cost-effectiveness analysis; equity; ethics; resource-limited settings