# 4. The Case for a DHI Economic Evaluation Framework

## 4.1 Methods Frameworks for Economic Evaluation in Health

A methods framework guides the planning, conduct and reporting of economic evaluation and assists in maintaining a consistent approach allowing comparison of analytical results over time, and context. An economic evaluation framework builds on the concept of a reference case but is less prescriptive and accommodates a wider range of methodological options.

The World Bank has published substantively in applied benefit-cost analysis with methodological recommendations developed as early as the 1970s with subsequent methods initiatives in 1992 and 2010 [16]. The concept of a reference case was first used by the 1st US panel of cost and cost effectiveness in health care in 1996 [17]. The overarching aim was to establish a standardized methodology for the conduct of economic evaluation (in the case of the US panel, cost effectiveness analysis) as a mechanism to improve the usefulness of economic evaluation in decision making. The US panel members recognized that improving the quality of economic evaluation through methodological advancements and comprehensive guidance was insufficient, and that for economic evaluation to find a place in policy, there needed to be a degree of consistency in the analytic approach for decision makers to be able to have confidence in evidence produced and be able to compare and weigh the evidence for competing investments. The 2000s saw a proliferation of national priority setting agencies (also termed Health Technology Assessment (HTA) Agencies) that built on the reference case concept for the specification of economic evaluation that would inform investment decisions for local national health systems. A high-profile national methodology developed by the National Institute for Health and Care Excellence in England and Wales defined a series of methodological specifications for economic evaluation, including how analytical comparators were to be chosen, instruments for health-related quality of life measurement, and the management of equity and time horizon and discount rates. This enabled a level of consistency in the analytical approach used to inform investment decisions. The establishment of the Health Intervention and Technology Assessment Program (HITAP) in Thailand that was tasked with conducting economic evaluation to inform investments in the country’s health benefit package and essential drugs list highlighted the importance of rigorous economic evaluation methodology and processes as a component of a sustainable Universal Health Coverage (UHC) system. HITAP also demonstrated the applicability of this approach for a middle-income country context. The World Health Assembly Resolution 67.23 in 2014 specified the integral role of health technology assessment for countries journeying towards UHC and established a direct link between consistent methods and process when considering evidence of economic evaluation and achievement of UHC. A growing number of countries now have country-specific guidance, reference cases or frameworks for economic evaluation to inform national decision making. While these initiatives are a significant stimulus for economic evaluation methods innovation, the direct global application of these frameworks is limited, as by definition, these are developed from the perspective of a local decision maker concerned with national budgets and national population health in a particular country.

## 4.2 Existing Economic Evaluation Frameworks for Generalized Interventions

To build on the progress of national-level priority setting and economic evaluation methodology to provide a more globally focused guidance, a Bill and Melinda Gates Foundation funded workstream led by the International Decision Support Initiative (iDSI) created a generalized principle-based reference case that would have applicability to multiple