The who-choice cost-effectiveness Threshold: a Country-level analysis of changes over time


      World Health Organisation (WHO)-CHOICE promotes a threshold defined as three times (3x) gross domestic product (GDP) per capita as a guide to determining cost-effectiveness of health interventions. This analysis sought to evaluate the stability of the 3x threshold over time for different countries and the implications of this for frequency of requirements to update the threshold value.


      GDP per capita data from 2000 to 2014 were taken from the International Monetary Fund dataset and used to calculate 3x thresholds for a range of countries considered to be representative of different sizes of economies and levels of economic development. Proportional changes in the 3x threshold across the entire period and on a year-by-year basis were analyzed, and time to doubling (and increase by other magnitudes) of the initial cost-effectiveness threshold was explored.


      The 3x threshold has increased over the period 2000 to 2014 for 99% of all countries analyzed. The average proportional increase in the 3x threshold over this period varied considerably by country, with Belarus having the highest proportional increase over the entire time period (94 times). Time to doubling of the 3x threshold was highly variable (range 2.1 – 450 years [median 9.1 years]) and was as low as 2 – 3 years for a number of countries. High levels of variability were observed between countries within the same WHO country groupings.


      The results suggest that considerable proportional changes to the value of the 3x threshold are observed for a number of countries over the short-term. For some countries, the cost-effectiveness threshold would be expected to increase dramatically even over a yearly timescale. This research highlights the need for countries looking to adopt this threshold to carefully consider requirements for updating the threshold and for managing the impact of this, for instance in relation to incentives for delayed pharmaceutical entry.