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 Systems Strengthening and Information Analysis Unit (HPSIU), Ministry of National Health Services Regulations and 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 (ICERs) 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 (GH-CEA) 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 costeffectiveness 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.


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  • Receive Date: 03 March 2023
  • Revise Date: 27 September 2023
  • Accept Date: 06 November 2023
  • First Publish Date: 07 November 2023