Informing Decisions in Global Health: Cost Per DALY Thresholds and Health Opportunity Costs

In this policy brief, Karl Claxton and colleagues argue that the cost per DALY threshold used to judge the cost-effectiveness of an intervention should reflect evidence of the likely health opportunity costs in the settings and health care systems (HCS) in which it will be used. Heath opportunity costs are the amount of health that a HCS currently delivers with more or less resources. The effect of different levels of health care expenditure on health outcomes has been investigated in a number of published studies using country level data, many including low- and middle-income countries (LMICs). Despite the challenges of estimation, initial estimates are available for 123 countries. These need to be updated and refined as more and better data become available. Cost-effectiveness ‘thresholds’ (cost per DALY or cost per QALY) that have been recommended, or have become widely cited, are not founded on an assessment of the likely health opportunity costs. Their use is likely to reduce rather than improve health outcomes overall.