Departures from cost-effectiveness recommendations: The impact of health system constraints on priority setting

Katharina Hauck*, Ranjeeta Thomas, Peter C. Smith

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


The methods and application of cost-effectiveness analysis have reached an advanced stage of development. Many decision makers consider cost-effectiveness analysis (CEA) to be a valid and feasible approach toward setting health priorities, and it has been extensively applied in evaluating interventions and developing evidence-based clinical guidelines. However, the recommendations arising from cost-effectiveness analysis are often not implemented as intended. A fundamental reason for the failure to implement is that CEA assumes a single constraint, in the form of the budget constraint, whereas in reality decision makers may be faced with numerous other constraints. The objective of this article is to develop a typology of constraints that may act as barriers to implementation of cost-effectiveness recommendations. Six categories of constraints are considered: the design of the health system; costs of implementing change; system interactions between interventions; uncertainty in estimates of costs and benefits; weak governance; and political constraints. Where possible—and if applicable—for each class of constraint, the article discusses ways in which these constraints can be taken into account by a decision maker wishing to pursue the principles of cost-effectiveness.

Original languageEnglish
Pages (from-to)61-70
Number of pages10
JournalHealth Systems and Reform
Issue number1
Publication statusPublished - 21 Jan 2016


  • Cost-effectiveness analysis
  • Decision making
  • Health technology assessment
  • Implementation
  • Priority setting

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