Using cost-effectiveness thresholds to determine value for money in low- and middle-income country healthcare systems: Are current international norms fit for purpose?

Healthcare systems in low- and middle-income countries face considerable population healthcare needs with markedly fewer resources than those in higher income countries. The way in which available resources are allocated across competing priorities has a profound effect on how much health is generated overall, who receives healthcare interventions and who goes without. Judgements about whether interventions and programmes should be regarded as cost-effective and prioritised over others should be based on an assessment of the health benefits that will be lost because the resources required will not be available to implement other effective interventions and programmes that would benefit other patients in the same or different disease areas. Unfortunately, frequently adopted international norms, in particular the cost-effectiveness thresholds recommended by the World Health Organization (WHO), are not founded on this type of assessment. Consequently current judgements about which interventions and programmes are cost-effective are often aspirational and do not reflect the reality of resource constraints. As a consequence their use is likely to reduce overall population health and exacerbate healthcare inequalities. They also fail to identify the real (and greater) value of devoting more resources to these efforts. By obscuring the true implications of current arrangements they do not contribute to greater understanding of and accountability for global and local decisions made on behalf of populations in low and middle as well as in high income countries. We illustrate these points using examples from HIV/AIDS.