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Thresholds for the cost–effectiveness of interventions: alternative approaches
Open accessAbstract
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.
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“In a separate health economics analysis (unpublished), we found that single-dose HPV vaccination with catch-up vaccination in girls aged 11–20 years could be cost-effective under the WHO recommended cost-effectiveness threshold of one-times gross domestic product per capita.”
From Evidence-based impact projections of single-dose human papillomavirus vaccination in India: a modelling study (2022) · cites this paper as [30]
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Metadata
- Authors
- Marseille, E., Larson, B., Kazi, D. S., Kahn, J. G., & Rosen, S.
- Affiliations
- Health Strategies International, 555 Fifty-ninth Street, Oakland, California, 94609, United States of America (USA).
- Boston University (US)
- San Francisco General Hospital (US)
- University of California, San Francisco (US)
- Corresponding author
- Marseille, Elliot
- Venue
- Bulletin of the World Health Organization
- Publisher
- WHO Press
- Published
- 2014-12-15
- Volume
- 93
- Issue
- 2
- Pages
- 118-124
- ISSN
- 0042-9686 (ISSN-L)
- PMC
- PMC4339959
- OpenAlex
- W2133104890
- Cited by
- 851
- References
- 42
- Citations by year
- 2026: 45 · 2025: 68 · 2024: 58 · 2023: 69 · 2022: 93 · 2021: 101 · 2020: 100 · 2019: 105 · 2018: 76 · 2017: 78 · 2016: 40 · 2015: 18
- FWCI
- 112.73
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- cc-by
- Locations
- Bulletin of the World Health Organization (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institute of Mental Health (P30MH062246)
- National Institute on Drug Abuse (R01DA015612)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Pharmaceutical Economics and Policy
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Global Health Care Issues
- Keywords
- cost-effectiveness threshold, WHO-CHOICE, disability-adjusted life years, GDP per capita, healthcare resource allocation, public health decision-making, affordability, cost-effectiveness analysis
- MeSH terms
- Cost-Benefit Analysis, Developing Countries, Female, Health Priorities, Humans, Pregnancy, Syphilis, Global Health, World Health Organization, HIV Infections, Quality-Adjusted Life Years, Benchmarking, Anti-Retroviral Agents, Insecticide-Treated Bednets, Gross Domestic Product
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