Dissertation (Doctoral) The Application of Cost-effectiveness Analysis in Developing Countries


Cindy Low Gauvreau


Developing countries face imminent choices for introducing needed, effective but expensive new vaccines, given the substantial immunization resources now available from international donors. Cost-effectiveness analysis (CEA) is a tool that decision-makers can use for efficiently allocating expanding resources. However, although CEA has been increasingly applied in developing-country settings since the 1990's, its use lags behind that in industrialized countries. This thesis explored how CEA could be made more relevant for decision-making in developing countries through 1) identifying the limitations for using CEA in developing countries 2) identifying guidelines for CEA specific to developing countries 3) identifying the impact of donor funding on CEA estimation 4) identifying areas for enhancement in the 1996 "Reference Case" (a standard set of methods) recommended by the US Panel on Cost-Effectiveness in Health and Medicine, and 5) better understanding the decision-making environment in developing countries.

Focusing on pediatric immunization in developing countries, thematic analysis was used to distill key concepts from 157 documents spanning health economics, clinical epidemiology and health financing. 11 key informants, researchers active in developing countries, were also interviewed to explore the production and use of evidence in public health decision-making.

Results showed a divergence between industrialized and developing nations in the emphases of methodological difficulties, in the general application of CEA, and the types of guidelines available. Explicitly considering donor funding costs and effects highlighted the need to specify an appropriate perspective and address policy-related issues of affordability and sustainability. Key informant interviews also revealed that opinion-makers, international organizations and the presence of local vaccine manufacturing have significant influence on decision-making. It is suggested that CEA could be more useful with a broadened reference case framework that included multiple perspectives, sensitivity analysis exploring differential discount rates (upper limits exceeding 10% for costs, declining from 3% for benefits) and supplemental reports to aid decision-making (budgetary and sustainability assessments).

This study has implications for improving health outcomes globally in the context of public-private collaborative health funding. Further research could explore defining an extra-societal (multi-country) perspective to aid in efficient allocation of immunization resources among countries.


Wendy J. Ungar