Developing nations special issue.

This edition of PharmacoEconomics is devoted entirely to issues surrounding the use of costeffectiveness analysis (CEA) for healthcare policy decisions in developing nations. As Singer pointed out, developing nations are the areas in the world where there is the greatest need for use of CEA in healthcare decision making and yet the evidence suggests that most of these nations rarely conduct and/or use such analyses at a policy level. This is mirrored in the published literature, where it was estimated that only 7% of published CEAs in 2007 were set within a developing nation context. This special issue of PharmacoEconomics signals a start by the journal to address this disparity, with articles from Asia, Latin and South America, and Africa. Although many of the articles in this special issue of PharmacoEconomics suggest a willingness amongst policy makers to adopt CEA as part of healthcare policy decisions, there are some significant barriers. Foremost is the lack of capacity to conduct CEAs in developing nations. This not only includes lack of qualified researchers but also poor infrastructure and lack of local data. Inroads are being made in Asia, as shown by Yang, who provides an overview of the use of pharmacoeconomic evidence as part of health technology assessment (HTA) in Asia. Although the use of HTA evidence in policy making is still in its infancy in Asia, there is much interest in the methods. Yang points out that pharmaceutical manufacturers see Asia as an attractive market and this, coupled with a rising demand for healthcare in Asia, has made policy makers extremely concerned about how to best manage limited resources. Leading the way in formal use of cost-effectiveness methods are South Korea, Thailand and Taiwan. They may have impact well beyond their borders, as other countries will look to their findings to advise their own health policy decisions. However, economic evaluations in the literature have proven to be difficult to generalize or transfer to other settings. Aside from the obvious difficulties in trying to apply results from developed countries, even learning from other developing nations has proven to be a challenge. This was the finding of Augustovski et al. in their review of economic evaluations conducted in Latin America and the Caribbean. One of the greatest difficulties in using CEA for policy in developing nations is the choice of an appropriate threshold. Shillcut et al. review the different approaches. It has been common to use multiples of per-capita gross national income, and this has been endorsed by the WHO. This approach may be useful for demonstrating disparities between developed and developing nations and as a basis for seeking international aid. Yet this often fails for countries trying to make their own internal policy decisions due to excessive incremental cost when ‘cost-effective’ interventions affect a large number of people. Indeed, even interventions that have been demonstrated to be cost effective using very low thresholds that were chosen precisely because of affordability concerns, have still sometimes proven to be too expensive to implement. Shillcutt et al. argue for adoption of explicit values of lambda, using a league table approach and a context-specific budget. They believe that EDITORIAL Pharmacoeconomics 2009; 27 (11): 887-889 1170-7690/09/0011-0887/$49.95/0