Use and Misuse of Cost-Effectiveness Analysis Thresholds in Low- and Middle-Income Countries: Trends in Cost-per-DALY Studies

Value Health. 2018 Jul;21(7):759-761. doi: 10.1016/j.jval.2017.12.016. Epub 2018 Feb 21.


Objectives: To determine what thresholds are most often cited in the cost-effectiveness literature for low- and middle-income countries (LMICs), given various recommendations proposed and used in the literature to date, and thereafter to assess whether studies appropriately justified their use of threshold values.

Methods: We reviewed the contents of the Tufts Medical Center Global Health Cost-Effectiveness Analysis Registry, a repository of all English language cost-per-disability-adjusted life-year averted studies indexed in PubMed. Our review included all catalogued cost-per-disability-adjusted life-year studies published from 2000 through 2015. We restricted attention to studies that investigated interventions in LMICs.

Results: Our analysis identified 381 studies (80%) focused on LMICs. Of these studies, 250 (66%) cited the World Health Organization's 1 to 3 times gross domestic product per capita threshold. A full-text review of 60 (24%) of these articles (randomly selected) revealed that none justified use of this threshold in the particular country or countries studied beyond citing (generic) guideline documents.

Conclusions: Cost-effectiveness analysis can help inform health care spending, but its value depends on incorporating assumptions that are valid for the applicable setting. Rather than rely on commonly used, generic economic thresholds, we encourage authors to use context-specific thresholds that reflect local preferences.

Keywords: DALY; LMICs; cost effectiveness; thresholds; willingness to pay.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cost-Benefit Analysis
  • Data Accuracy
  • Developing Countries / economics*
  • Disability Evaluation
  • Global Burden of Disease / economics
  • Global Burden of Disease / trends
  • Global Health / economics*
  • Global Health / trends*
  • Gross Domestic Product / trends*
  • Health Care Costs / trends*
  • Humans
  • Income / trends*
  • Life Tables*
  • Models, Economic
  • Quality-Adjusted Life Years
  • Registries
  • Research Design / trends*