WHO-CHOICE (CHOosing Interventions that are Cost-Effective) is an initiative started by the World Health Organization in 1998 to help countries choose their healthcare priorities. It is an example of priority-setting in global health. It was one of the earliest projects to perform sectoral cost-effectiveness analyses (i.e., cost-effectiveness analyses that compare a wide range of types of spending within a sector and prioritize holistically) on a global scale. Findings from WHO-CHOICE have shaped the World Health Report of 2002, been published in the British Medical Journal in 2012, and been cited by charity evaluators and academics alongside DCP2 and the Copenhagen Consensus.
History
Launch and initial years of WHO-CHOICE In May 1998, Gro Harlem Brundtland succeeded Hiroshi Nakajima as the Director-General of the World Health Organization, and the organization was significantly restructuring as a result of the leadership change. With her election, a new program, called Choosing Interventions: Effectiveness Quality, Costs, Gender and Ethics, was launched as part of the Global Programme for Evidence on Health and Policy. The name of the program would later morph into WHO-CHOICE.
Subsequent use WHO-CHOICE was used in the World Health Report of 2002, specifically informing the recommendations in Chapter 5. Results based on WHO-CHOICE were published in a series of papers in the British Medical Journal in 2012.
Tools and methods
Adoption of sectoral CEA Prior to WHO-CHOICE, most projects that did cost-effectiveness analysis (CEA) in the real world focused on evaluating a single program or intervention, comparing it against either a fixed price threshold or an existing array of interventions with predetermined cost-effectiveness taken from the literature. However, theoretical literature on CEAs considered a broader kind of CEA called "sectoral CEA" where all programs and interventions available within a sector would be compared and cost-effectiveness priorities would be determined. Prior to WHO-CHOICE, there were only a few examples of practical implementation of sectoral CEAs: the Oregon Health Services Commission (tasked with prioritizing for Medicaid in the United States), the World Bank Health Sectors Priorities Review, and the Harvard Life Saving Project. Of these, only the World Bank's work had attempted a global comparison. In a 2000 paper discussing the WHO-CHOICE approach, Murray et al. identified four challenges to a wider application of sectoral CEA:
Resource allocation decisions affecting the entire health sector must also take into account social concerns, such as priority for the sick, reducing social inequalities in health, or the well-being of future generations. The history of the Oregon Health Services Commission provides an example of the sort of conflicts that emerge as a result of balancing all these concerns. Current CEA is too focused on the evaluation of new strategies, rather than identifying potential for efficiency improvements by reallocating within existing strategies. For all but the richest societies, the cost and time required to evaluate the large set of interventions required may be prohibitive. It is difficult to institutionalize CEA, and a number of conflicting CEA guidelines at national and regional levels have proliferated.
Use of generalized CEA (a type of sectoral CEA) based on epidemiological subregions WHO-CHOICE identified a key trade-off in sectoral CEA based on the granularity of the region at which the CEA was performed. At one extreme, sectoral CEA could be performed at the level of individual cities or districts, incorporating information about local resources, costs, and current context. At the other extreme, a single CEA could be carried out globally. Highly localized sectoral CEA would be very expensive and difficult to perform whereas global CEA would fail to take into account the huge differences between the epidemiology and resource structure of regions. WHO-CHOICE's solution was to use an intermediate level of granularity, that it called "generalized CEA" (GCEA). It argued that at this intermediate level, it could conduct CEAs more efficiently while also allowing local policymakers and agents to use its findings and further adapt them to local contexts. WHO-CHOICE has divided the world into 14 epidemiological subregions, and publishes its findings by subregion, as shown below. Each subregion is a combination of a region (a geographical region of the world) and a mortality stratum (a stratum describing the level and nature of mortality). WHO-CHOICE chose to put each country in a single mortality stratum and a single region (and therefore a single subregion) even if mortality varies widely within the country.
There are 6 regions: AFR (Africa), AMR (Americas), EMR (Middle East), EUR (Europe), SEAR (South-East Asia), and WPR (West Pacific). There are 5 mortality strata, defined as follows: A = very low rates of adult and child mortality B = low adult mortality, low child mortality C = high adult mortality, low child mortality D = high adult mortality, high child mortality E = very high adult mortality, high child mortality Although the 6 regions and 5 mortality strata could give a theoretical maximum of 6 X 5 = 30 subregions, only 14 subregions occur in practice because not every region has countries with all mortality strata. Below is the classification into subregions as of 2003.
Modifications to ICM-CEA to use null set as comparator for interventions The CEA done by WHO-CHOICE differed from the standard ICM-CEA in two important ways:
Interventions were compared against the null set of interventions, rather than the existing backdrop of interventions. This provides a complete cost-effectiveness analysis that can be adapted more easily to different subregions and different times. Results are presented in a single league table. For each set of mutually exclusive interventions (between which a selection is being made), the intervention with the lowest average cost-effectiveness with respect to the null set is presented first. If there are two or more rows, the second intervention is the one with the lowest slope with respect to the internvention with the lowest CE, and so on. Essentially, this identifies the principal components for the best intervention.
Intended usage The results that WHO-CHOICE reports are not intended to be applied literally when choosing policies or selecting interventions. This is for a few reasons:
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