Priority setting decisions in health policy are unavoidable. Priority setting has inevitable consequences in terms of foregone health benefits. Decisions can be optimized by ensuring that decision makers have clarity about both the costs and benefits of different options. The use of economic evaluation methods can provide a systematic approach to relating costs and benefits and determining the value of a policy package. In this effort, the Bill and Melinda Gates Foundation (BMGF) is one of the largest investors in economic evaluation research on health interventions in low and middle-income countries (LMICs). It funds 28% of all published cost effectiveness analyses that use the DALY outcome measure in LMIC settings. However, to date there has been substantial variation in both the approaches and methodologies used, as well as in the quality of BMGF-funded analyses. Ultimately this limits their usefulness to local policy makers, other stakeholders and BMGF. To improve on this, the BMGF involved the HITAP International Unit (HIU) in collaboration with NICE International, the University of York, the London School of Hygiene and Tropical Medicine and the University of Glasgow to review the health economic evaluations conducted in LMICs and gather information for standardizing methodology.
The Methods for Economic Evaluation Project (MEEP) focusses on the methodological aspects of a reference case, but briefly explores how the use of a reference case would reveal the social and scientific values held by the BMGF. Specifically, it looks at the development and application of a Gates Reference Case (Gates-RC) by BMGF, which presents both benefits and risks and the capacity to improve the utility of economic evaluations in informing decision-making supports its development and adoption. From then on it looks at the proposed Gates-RC and the principles it uses to guide the planning, conducting and reporting of economic evaluations.
The project aims to provide principles that align methods for economic evaluations. It also aims to synthesize methodologies that are used in economic evaluations in LMICs
11 Principles for Economic Evaluations
1. An economic evaluation should be communicated clearly and transparently to allow the decision maker(s) to interpret the methods and results.
2. The comparators against which costs and effects are measured should accurately reflect the decision problem.
3. An economic evaluation should consider all available evidence relevant to the decision problem.
4. The measure of health outcome should be appropriate to the decision problem, should capture measurements of both length of life and quality of life, and should be generalizable across disease states.
5. All differences between the intervention and the comparator in the expected resource use and costs of delivery to the target population(s) should be incorporated into the evaluation.
6. The time horizon used in an economic evaluation should be of sufficient length to capture all costs and effects relevant to the decision problem; an appropriate discount rate should be used to discount cost and effects to present values.
7. Non-health effects and costs that do not fall on the health budget that are associated with gaining or providing access to health interventions should be identified where relevant to the decision problem. All costs and effects should be disaggregated, either by sector of the economy or by who incurs them.
8. The cost and effects of the intervention on sub-populations within the decision problem should be explored and the implications appropriately characterized.
9. The uncertainty associated with an economic evaluation should be appropriately characterized.
10. The impact of implementing the intervention on health budget and on other constraints should be clearly and separately identified.
11. An economic evaluation should explore the equity implications of implementing the intervention.