Thresholds for the cost–effectiveness of interventions: alternative approaches

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.