The Use of Cost-Effectiveness Thresholds for Evaluating Health Interventions in Low- and Middle-Income Countries From 2015 to 2020: A Review

Objectives: Evidence-informed priority setting, in particular cost-effectiveness analysis (CEA), can help target resources better to achieve universal health coverage. Central to the application of CEA is the use of a cost-effectiveness threshold. We add to the literature by looking at what thresholds have been used in published CEA and the proportion of interventions found to be cost-effective, by type of threshold. Methods: We identified CEA studies in low-and middle-income countries from the Global Health Cost-Effectiveness Analysis Registry that were published between January 1, 2015, and January 6, 2020. We extracted data on the country of focus, type of interventions under consideration, funder, threshold used, and recommendations. Results: A total of 230 studies with a total 713 interventions were included in this review; 1 to 3x gross domestic product (GDP) per capita was the most common type of threshold used in judging cost-effectiveness (84.3%). Approximately a third of studies (34.2%) using 1 to 3x GDP per capita applied a threshold at 3x GDP per capita. We have found that no study used locally developed thresholds. We found that 79.3% of interventions received a recommendation as "cost-effective " and that 85.9% of studies had at least 1 intervention that was considered cost-effective. The use of 1 to 3x GDP per capita led to a higher proportion of study interventions being judged as cost-effective compared with other types of thresholds. Conclusions: Despite the wide concerns about the use of 1 to 3x GDP per capita, this threshold is still widely used in the literature. Using this threshold leads to more interventions being recommended as "cost-effective. " This study further explore alternatives to the 1 to 3x GDP as a decision rule.