Cost Effectiveness in Low- and Middle-Income CountriesA Review of the Debates Surrounding Decision Rules

Cost-effectiveness analysis (CEA) is increasingly important in public health decision making, including in low- and middle-income countries. The decision makers’ valuation of a unit of health gain, or ceiling ratio (λ), is important in CEA as the relative value against which acceptability is defined, although values are usually chosen arbitrarily in practice. Reference case estimates for λ are useful to promote consistency, facilitate new developments in decision analysis, compare estimates against benefit-cost ratios from other economic sectors, and explicitly inform decisions about equity in global health budgets.