Using economic evaluation in priority setting: What do we know and what can we do?

The aim of this chapter is to examine the use of cost-effectiveness analysis (CEA) in priority setting. It provides a commentary on the evidence base and highlights two categories of barriers. These are accessibility, that is, issues of availability and understanding, and acceptability, that is, issues to do with the views, preferences and circumstances of decision-makers. The chapter then seeks to address the persistent neglect of context in explanations of the use of CEA. For example, a focus on context helps to explain the differential usage levels at national and local decision-making tiers. It is argued that not only is CEA rarely used by local decision-makers but also that the contexts in which such bodies currently operate preclude significant increases in use. By contrast, it can be seen that national bodies are more likely to operate in a political and institutional environment which facilitates and creates the demand for routine use of CEA. The chapter argues that in order for CEA to have more of an impact at local levels, analysts should better recognise and reflect the constraints in which decision-makers operate and that greater clarity is required over specific roles, responsibilities and relationships in the resource allocation process. Finally, the authors make a plea for researchers to resist simple replication of prior studies and instead to direct their energies at devising innovative ways of filling theoretical and empirical gaps in understanding across healthcare systems and contexts.