Lonely at the top and stuck in the middle? The ongoing challenge of using cost-effectiveness information in priority setting : Comment on "Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden"

Financing and cost-effectiveness of emergency medical services in low- and middle-income countries

In 2023, the 76th World Health Assembly declared coordinated emergency, critical, and operative care services fundamental for comprehensive universal health coverage in low- and middle-income countries. With increasing mortality from noncommunicable diseases, an organized emergency care system has the capacity to treat a variety of conditions with a common set of resources, optimizing per-unit cost efficiency by applying economies of scope and increasing cost-effectiveness. However, the financing and cost-effectiveness of emergency medical services remain poorly understood despite affordability and financial barriers comprising some of the most significant obstacles to development. Cost-effectiveness analyses generate incremental cost-effectiveness ratios for comparison against per-capita gross domestic product thresholds to determine cost-effectiveness, promoted by the World Health Organization's Choosing Interventions that are Cost-Effective program. Incremental cost-effectiveness ratios may be used as context-specific indicators of value alongside budget impact and feasibility considerations. Currently, there are few high-quality cost-effectiveness studies of emergency care in low- and middle-income countries, demonstrating significant methodologic heterogeneity, little geographic diversity, neglecting descriptions of assumptions used in cost-effectiveness calculations and comparators used, and lacking incremental cost-effectiveness ratios for comparison. The assessment of emergency care cost-effectiveness is challenging, given the significant breadth of conditions encountered and difficulty in projecting subsequent impact. Without improved epidemiologic surveillance and data-collection infrastructure, data inputs for cost-effectiveness calculations will remain limited. Future efforts should practice standard cost-effectiveness methodologies to permit comparison of incremental cost-effectiveness ratios across interventions and settings while incorporating trauma registry data to longitudinally track patient outcomes over sufficient time horizons to determine impact. New indices that expand the scope of analysis to capture broader secondary impacts of emergency care for future cost-effectiveness studies are needed. In this article, we summarize the key steps for economic evaluations for prehospital care systems and recommend considerations for future prehospital emergency care cost-effectiveness analyses, determining the optimal structure for financing mechanisms well-suited to resource-limited settings are critical for future investigation.

Preventive health resource allocation decision-making processes and the use of economic evidence in an Australian state government—A mixed methods study

Context

Recommended best practice for resource allocation decisions by governments include a stepwise process guided by economic evidence. However, the use of economic evidence in preventive health decision-making, which often impacts on multiple sectors of government, is under-researched. This study aimed to explore the resource allocation decision-making processes for preventive health interventions in the New South Wales (NSW) Government in Australia, and specifically examined the barriers and facilitators to the use of economic evidence from the perspective of multiple government departments.

Methods

This mixed methods study was conducted using semi-structured interviews with NSW Treasury representatives (n = 4), a focus group of NSW Ministry of Health representatives (n = 9), and a quantitative questionnaire of all participants. The schedule for the interviews and focus group was based on resource allocation guidance documents from Australian government agencies. Deductive content analysis was undertaken, guided by the Multiple Streams Framework.

Findings

NSW Treasury participants believed that decision-making processes where economic efficiency was the key guiding principle was the ideal approach. However, the NSW Ministry of Health participants identified that for preventive health decision-making, economic evidence was not used to inform their own choices but was typically only used to convince other agencies of the merits of proposed initiatives when seeking approval. The key barriers to the use of economic evidence were the lack of capacity within the NSW Ministry of Health to understand and undertake economic evaluations; a lack of collaboration between NSW Treasury and preventive health decision-makers within the NSW Ministry of Health; and deficient processes and governance mechanisms that do not facilitate or incentivise effective inter-sectoral decision-making.

Conclusions

Institutional structures for resource allocation decision-making regarding preventive health result in processes that contrast with best practice recommendations. The multiple challenges to collaborative decision-making across agencies require organisational change to promote a whole-of-government approach.

Cost-effectiveness thresholds: pros and cons

Cost-effectiveness analysis is used to compare the costs and outcomes of alternative policy options. Each resulting cost-effectiveness ratio represents the magnitude of additional health gained per additional unit of resources spent. Cost-effectiveness thresholds allow cost-effectiveness ratios that represent good or very good value for money to be identified. In 2001, the World Health Organization's Commission on Macroeconomics in Health suggested cost-effectiveness thresholds based on multiples of a country's per-capita gross domestic product (GDP). In some contexts, in choosing which health interventions to fund and which not to fund, these thresholds have been used as decision rules. However, experience with the use of such GDP-based thresholds in decision-making processes at country level shows them to lack country specificity and this - in addition to uncertainty in the modelled cost-effectiveness ratios - can lead to the wrong decision on how to spend health-care resources. Cost-effectiveness information should be used alongside other considerations - e.g. budget impact and feasibility considerations - in a transparent decision-making process, rather than in isolation based on a single threshold value. Although cost-effectiveness ratios are undoubtedly informative in assessing value for money, countries should be encouraged to develop a context-specific process for decision-making that is supported by legislation, has stakeholder buy-in, for example the involvement of civil society organizations and patient groups, and is transparent, consistent and fair.