How to get cost-effectiveness analysis right? The case of vaccine economics in latin america.

Background: In middle-income countries, vaccines against pneumococcal disease, rotavirus, and human papilloma virus are in general more costly, not necessarily cost saving, and less consistently cost-effective than earlier generation vaccines against measles, diphtheria, tetanus, and pertussis. Budget impact is also substantial; public spending on vaccines in countries adopting new vaccines is, on average, double the amount of countries that have not adopted. Policymakers must weigh the costs and benefits of the adoption decision carefully, given the low coverage of other kinds of cost-effective health and nonhealth interventions in these same settings and relatively flat overall public spending on health as a share of gross domestic product (GDP) over time. Objective: This paper considers lessons learned from recent vaccine cost-effectiveness analyses and subsequent adoption decisions in Latin America a, largely under the auspices of the Pro Vac Initiative. Results: The paper illustrates how small methodological choices and seemingly minor technical limitations of cost-effectiveness models can have major implications for the studies' conclusions, potentially influencing countries' subsequent vaccine adoption decisions. Methods: We evaluate the ProVac models and technical outputs against the standards and framework set out by the International Decision Support Initiative Reference Case for economic evaluation and consider the practical effects of deviations from those standards. Conclusions: Lessons learned are discussed, including issues of appropriate comparators, GDP-based thresholds, and use of average versus incremental cost-effectiveness ratios as a convention are assessed. The article ends with recommendations for the future.