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Bull World Health Organ. 2015 Feb 1;93(2):118-24. doi: 10.2471/BLT.14.138206. Epub 2014 Dec 15.

Thresholds for the cost-effectiveness of interventions: alternative approaches.

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Health Strategies International, 555 Fifty-ninth Street, Oakland, California, 94609, United States of America (USA).
Center for Global Health and Development, Boston University, Boston, USA .
Division of Cardiology, San Francisco General Hospital, San Francisco, USA .
Institute for Health Policy Studies, University of California - San Francisco, San Francisco, USA .


in English, Arabic, Chinese, French, Russian, Spanish

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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