MAY – JUNE 2023
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In an inequitable region with scarce resources, economic evaluation cannot be left out in coverage decisions for medications, devices and other technologies. And an equation we developed can help that process (watch video).
According to the World Health Organization (WHO), the infant mortality rate in the European Union is 3 deaths per 1.000 live births, while in Latin America and the Caribbean it is 14 per 1.000. Almost 5 times more. In absolute figures: 145.000 children under one year of age die every year in Latin America, of which 110.000 would not have died if they had been born in the European Union.
This difference in infant mortality is not due to the lack of the most innovative technologies in Latin America. Quite the opposite: it is because a large part of the population does not have access to the most basic and effective care. In many cases, health systems are letting their resources be wasted on technologies of dubious, limited or no effectiveness, although at a very high price. For example, health systems may choose to purchase high-tech equipment for the diagnosis and treatment of diseases that do not represent a high disease burden, while basic health services such as prenatal care, follow-up of diabetes or vaccination. These decisions imply that health systems will obtain fewer results than they could obtain with those same resources, which in turn implies reducing the quality of life of the population.
Many of these bad decisions, and poor health outcomes, are a consequence of ignoring economic evidence for too many years. And one of the critical parameters, which in a region as unequal as Latin America and with finite resources, is more important than ever and we cannot afford to ignore, is “cost-effectiveness,” which implies comparing the costs of a treatment or an intervention with the benefits obtained. Ultimately, cost-effectiveness seeks to maximize health benefits for each peso invested. And not only can it help identify the most effective interventions, but it can also be a key element for honest and fair price negotiation with technology and drug providers.
Obviously, this does not imply that decisions should be made solely on the basis of cost-effectiveness. There are many other dimensions, such as the magnitude of the clinical benefit, the quality of the evidence or the impact on equity, that must be a fundamental part of any decision-making process. But the other extreme is not possible either: appropriate decisions cannot be made ignoring the cost-effectiveness and opportunity cost of our choices.
One challenge is that assessing cost-effectiveness is a complex process that requires time, trained technicians, and data that are not always available in low- or middle-income countries. This situation has led to the paradox that high-income countries are the ones that take economic evidence most into account when making decisions. The results are visible. Returning to our previous example, Latin America has infant mortality rates equivalent to what European countries had more than 50 years ago.
How to overcome these barriers that hinder access to economic evidence to make decisions? In recent years, different methodologies have been developed that seek to facilitate the incorporation of economic evidence into decision-making, even when perfect information is not available for each country.
Along these lines, our IECS working group, together with Michael Drummond, from the University of York and with funds from the Inter-American Development Bank (IDB), developed a series of tools a few years ago to facilitate decision-making taking into account the economic evidence in each country (1). However, a persistent barrier to the correct assessment of economic evidence was the lack of clear cost-effectiveness thresholds. Recently our group developed and published (2) an equation that allows 174 countries to simply and directly determine cost-effectiveness thresholds to guide a more equitable allocation of health resources (watch video y publication). A contribution that has already begun to be used in countries in the region and that, we hope, will help health systems concentrate their efforts and resources on those interventions and technologies that are truly worthwhile, benefiting their populations the most.
Dr. Andrés Pichon-Riviere, director general of the IECS
References
1. Pichon-Riviere A, Drummond M, García-Marti S, Augustovski F. Application of economic evidence in health technology assessment and decision-making for the allocation of health resources in Latin America: Seven key topics and a preliminary proposal for implementation. Inter-American Development Bank (IDB). Technical Note IDB-TN-2286. July 2021. DOI http://dx.doi.org/10.18235/0003649
2. Pichon-Riviere A, Drummond M, Palacios A, Garcia-Marti S, Augustovski F. Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures. Lancet Glob Health. 2023 Jun;11(6):e833-e842. doi:10.1016/S2214-109X(23)00162-6. PMID: 37202020.
*CETQALY: cost-effectiveness threshold to gain one year of life in full health; %Δh: expected increase in health spending per capita; HEpc: health expenditure per capita; LE: life expectancy at birth; ΔLE: expected increase in life expectancy; QYr= ratio between quality-adjusted life expectancy and life expectancy measured in years; QALY: quality-adjusted life year.