Hidden costs: The ethics of cost-effectiveness analyses for health interventions in resource-limited settings

Abstract

Cost-effectiveness analysis (CEA) is an increasingly appealing tool for evaluating and comparing health-related interventions in resource-limited settings. The goal is to inform decision-makers regarding the health benefits and associated costs of alternative interventions, helping guide allocation of limited resources by prioritizing interventions that offer the most health for the least money. Although only one component of a more complex decision-making process, CEAs influence the distribution of healthcare resources, directly influencing morbidity and mortality for the world’s most vulnerable populations. However, CEA-associated measures are frequently setting-specific valuations, and CEA outcomes may violate ethical principles of equity and distributive justice. We examine the assumptions and analytical tools used in CEAs that may conflict with societal values. We then evaluate contextual features unique to resource-limited settings, including the source of health-state utilities and disability weights; implications of CEA thresholds in light of economic uncertainty; and the role of external donors. Finally, we explore opportunities to help align interpretation of CEA outcomes with values and budgetary constraints in resource-limited settings. The ethical implications of CEAs in resource-limited settings are vast. It is imperative that CEA outcome summary measures and implementation thresholds adequately reflect societal values and ethical priorities in resource-limited settings.

Cost-effectiveness analysis for decision making in health care-concept, relevance and methodological challenges

“…However, there are many limitations in the use of QALYs as outcome measurement, due to the fact that common utility weight does not consider differential in life expectancy across countries. [24][25][26] On the other hand, DALYs try to avoid these biases and is preferred over QALYs, particularly in developing countries. 24 DALYs are also not free from limitations.…”

“…22 Even if an intervention meets a CE threshold, the ICER value does not necessarily reflect the bottom line cost associated with implementation. 25 The use of WHO-recommended cost-effectiveness benchmarks of one and three times GDP per capita has been criticized by experts due to lack of theoretical or empirical basis'. 32,33 Decision rule such as willingness to pay (WTP), which assigns a monetary value to a given package of health benefits are flaunted with criticisms as these values are based on hypothetical scenarios and are mostly relevant to developed countries.…”

“…22,34 Again the categorization based on regional GDP thresholds does not consider intra-regional variations and country specific situations and their economic complexities. 25 In few countries health programmes are implemented through external support. Application of CE thresholds of health programmes may be undermined in those countries where health interventions are primarily funded by donor agencies with certain specific objectives.…”

“…37,38 In such situations, decision making for allocation of resources for new health programs should also take into consideration the role of external donors. 25 CEA is considered as an aid to decision making, not a procedure for making decision. 26 In reality, the efficiency with which we spend scarce resources is not the only criteria that need to be considered for making decisions.…”

Ethics of research methodology requires a methodology of research ethics

“…Not always recognized as having strong ethical dimensions is the method of assessment of (numbers of added) qualityadjusted life years, that represent an important component of cost-effectiveness ratios of interventions. This assessment is strongly dependent on the respondents, whether or not they are in good health, and what assumptions and methods are used [6]. The consequences can be huge in terms of recommended treatments in individual cases, guidelines and insured services.…”