The greatest happiness of the greatest number? Policy actors' perspectives on the limits of economic evaluation as a tool for informing health care coverage decisions in Thailand

BACKGROUND: This paper presents qualitative findings from an assessment of the acceptability of using economic evaluation among policy actors in Thailand. Using cost-utility data from two economic analyses a hypothetical case scenario was created in which policy actors had to choose between two competing interventions to include in a public health benefit package. The two competing interventions, laparoscopic cholecystectomy (LC) for gallbladder disease versus renal dialysis for chronic renal disease, were selected because they highlighted conflicting criteria influencing the allocation of healthcare resources. METHODS: Semi-structured interviews were conducted with 36 policy actors who play a major role in resource allocation decisions within the Thai healthcare system. These included 14 policy makers at the national level, five hospital directors, ten health professionals and seven academics. RESULTS: Twenty six out of 36 (72%) respondents were not convinced by the presentation of economic evaluation findings and chose not to support the inclusion of a proven cost-effective intervention (LC) in the benefit package due to ethical, institutional and political considerations. There were only six respondents, including three policy makers at national level, one hospital director, one health professional and one academic, (6/36, 17%) whose decisions were influenced by economic evaluation evidence. CONCLUSION: This paper illustrates limitations of using economic evaluation information in decision making priorities of health care, perceived by different policy actors. It demonstrates that the concept of maximising health utility fails to recognise other important societal values in making health resource allocation decisions.