What next after GDP-based cost-effectiveness thresholds?

Y-Ling Chi, Mark Blecher, Kalipso Chalkidou, Anthony Culyer, Karl Claxton, Ijeoma Edoka, Amanda Glassman, Noemi Kreif, Iain Jones, Andrew J. Mirelman, Mardiati Nadjib, Alec Morton, Ole Frithjof Nordheim, Jessica Ochalek, Shankar Prinja, Francis Ruiz, Yot Teerawattananon, Anna Vassall, Alexander Winch

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Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage.

This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.
Original languageEnglish
Article number176
Number of pages9
JournalGates Open Research
Early online date30 Nov 2020
Publication statusPublished - 3 Dec 2020


  • cost-effectiveness thresholds
  • cost effectiveness analysis
  • health opportunity cost
  • priority access


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