Assessing Global Evidence on Cost-Effectiveness to Inform Development of Pakistan’s Essential Package of Health Services

Document Type : Original Article


1 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan

2 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

3 Health Planning, System Strengthening & Information Analysis Unit (HPSIU), Ministry of National Health Services Regulations & Coordination, Islamabad, Pakistan

4 Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands

5 Department of Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands

6 DCP3 Country Translation Project, London School of Hygiene and Tropical Medicine, London, UK


Countries designing a health benefit package (HBP) to support progress towards universal health coverage (UHC) require robust cost-effectiveness evidence. This paper reports on Pakistan’s approach to assessing the applicability of global cost-effectiveness evidence to country context as part of a HBP design process.

A seven-step process was developed and implemented with Disease Control Priority 3 (DCP3) project partners to assess the applicability of global incremental cost-effectiveness ratios (ICER) to Pakistan. First, the scope of the interventions to be assessed was defined and an independent, interdisciplinary team was formed. Second, the team familiarized itself with intervention descriptions. Third, the team identified studies from the Tufts Medical School Global Health Cost-Effectiveness Analysis (GHCEA) registry. Fourth, the team applied specific knock-out criteria to match identified studies to local intervention descriptions. Matches were then cross-checked across reviewers and further selection was made where there were multiple ICER matches. Sixth, a quality scoring system was applied to ICER values. Finally, a database was created containing all the ICER results with a justification for each decision, which was made available to decision-makers during HBP deliberation.

We found that less than 50% of the interventions in DCP3 could be supported with evidence of cost-effectiveness applicable to the country context. Out of 78 ICERs identified as applicable to Pakistan from the Tufts GH-CEA registry, only 20 ICERs were exact matches of the DCP3 Pakistan intervention descriptions and 58 were partial matches.

This paper presents the first attempt globally to use the main public GH-CEA database to estimate cost-effectiveness in the context of HBPs at a country level. This approach is a useful learning for all countries trying to develop essential packages informed by the global database on ICERs, and it will support the design of future evidence and further development of methods.


  1. Evans DB, Hsu J, Boerma T. Universal health coverage and universal access. Bull World Health Organ. 2013;91(8):546-546A. doi: 10.2471/BLT.13.125450.
  2. Woods B, Revill P, Sculpher M, Claxton K. Country-level cost-effectiveness thresholds: initial estimates and the need for further research. Value in Health. 2016;19(8):929-35. doi: 10.1016/j.jval.2016.02.017.
  3. Baltussen R, Jansen MP, Mikkelsen E, et al. Priority setting for universal health coverage: we need evidence-informed deliberative processes, not just more evidence on cost-effectiveness. Int J Health Policy Manag. 2016 Nov 1;5(11):615-618. doi: 10.15171/ijhpm.2016.83.
  4. Watkins DA, Qi J, Kawakatsu Y, Pickersgill SJ, Horton SE, Jamison DT. Resource requirements for essential universal health coverage: a modelling study based on findings from Disease Control Priorities. Lancet Glob Health. 2020;8(6):e829-e39. doi: 10.1016/S2214-109X(20)30121-2.
  5. Hutchings A, Durand MA, Grieve R, et al. Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis. BMJ. 2009;11:339:b4353. doi: 10.1136/bmj.b4353
  6. Incremental Cost-Effectiveness Ratio (ICER). 2016. Accessed November 24, 2020
  7. Goeree R, He J, O’Reilly D, Tarride J, Xie F, Lim M, Burke N. Transferability of health technology assessments and economic evaluations: a systematic review of approaches for assessment and application. Clinicoecon Outcomes Res. 2011; 3: 89-104. doi: 10.2147/CEOR.S14404
  8. Knies S, Ament AJ, Evers SM, Severens JL. The transferability of economic evaluations: testing the model of Welte. Value in Health. 2009;12(5):730-8. doi: 10.1111/j.1524-4733.2009.00525.x
  9. Glassman A, Giedion U, Smith PC, eds. What's in, what's out: designing benefits for universal health coverage. Washington, DC: Brookings Institution Press; 2017.
  10. Husereau D, Drummond M, Petrou S, et al. Consolidated health economic evaluation reporting standards (CHEERS)—explanation and elaboration: a report of the ISPOR health economic evaluation publication guidelines good reporting practices task force. Value Health. 2013;16(2):231-50. doi: 10.1016/j.jval.2013.02.002.
  11. Lewin S, Lavis JN, Oxman AD, et al. Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systematic reviews. The Lancet. 2008;372(9642):928-39. doi: 10.1016/S0140-6736(08)61403-8.
  12. Obse A, Ryan M, Heidenreich S, Normand C, Hailemariam D. Eliciting preferences for social health insurance in Ethiopia: a discrete choice experiment. Health Policy Plan. 2016;31(10):1423-1432. doi: 10.1093/heapol/czw084.
  13. Love-Koh J, Walker SM, Kataika E, et al. Economic analysis for health benefits package design. York, UK: Centre for Health Economics, University of York; 2019.

Articles in Press, Accepted Manuscript
Available Online from 07 November 2023
  • Receive Date: 03 March 2023
  • Revise Date: 27 September 2023
  • Accept Date: 06 November 2023
  • First Publish Date: 07 November 2023