A Practical Framework for Understanding Cost-Effectiveness and Decision Risk in Health Benefits Package Design

Global cost-effectiveness evidence is often used in health benefits package (HBP) assessments but is uncertain and subject to the risk of making the wrong decision. HBP assessments use ‘adaptive’ health technology assessment (aHTA) methods, including reviews of existing cost effectiveness studies and eliciting expert opinion to expedite cost-effectiveness evaluations due to substantial time and data constraints. Using aHTA methods poses a risk of making the wrong decision. However, existing methods for assessing risk, such as value of information analysis (VOI), are time- and data-intensive. Our objectives were to develop a practical method to evaluate the risk of making the wrong decision in HBP design and to test this approach in Rwanda. We developed a heuristic framework to help decision makers determine whether aHTA methods are sufficient for decision making or de novo cost-effectiveness modelling might be needed. The framework was created by adapting the ‘Appraisal of Risk Chart’ (ARCH), which was originally designed to evaluate the risk of decision making from de novo cost-effectiveness analyses. We tested the adapted ARCH using an assessment of 136 cancer interventions in Rwanda, where each intervention was charted on the ARCH according to its risk profile. In Rwanda, 41 cancer interventions were considered low risk on the ARCH and the remainder were uncertain. We demonstrate that it is feasible to use the ARCH to determine whether aHTA methods are sufficient or more research is needed in HBP assessments.