WHO-CHOICE (CHOosing Interventions that are Cost-Effective) is an initiative started by the World Health Organization in 1998 to help countries choose their healthcare priorities. [1] [2] [3] It is an example of priority-setting in global health. It was one of the earliest projects to perform sectoral cost-effectiveness analyses (i.e., cost-effectiveness analyses that compare a wide range of types of spending within a sector and prioritize holistically) on a global scale. [4] [5] [6] Findings from WHO-CHOICE have shaped the World Health Report of 2002, [7] been published in the British Medical Journal in 2012, [1] and been cited by charity evaluators and academics alongside DCP2 and the Copenhagen Consensus. [8] [9] [10]
In May 1998, Gro Harlem Brundtland succeeded Hiroshi Nakajima as the Director-General of the World Health Organization, and the organization was significantly restructuring as a result of the leadership change. With her election, a new program, called Choosing Interventions: Effectiveness Quality, Costs, Gender and Ethics, was launched as part of the Global Programme for Evidence on Health and Policy. The name of the program would later morph into WHO-CHOICE. [4]
WHO-CHOICE was used in the World Health Report of 2002, specifically informing the recommendations in Chapter 5. [7]
Results based on WHO-CHOICE were published in a series of papers in the British Medical Journal in 2012. [1] [11]
Prior to WHO-CHOICE, most projects that did cost-effectiveness analysis (CEA) in the real world focused on evaluating a single program or intervention, comparing it against either a fixed price threshold or an existing array of interventions with predetermined cost-effectiveness taken from the literature. However, theoretical literature on CEAs considered a broader kind of CEA called "sectoral CEA" where all programs and interventions available within a sector would be compared and cost-effectiveness priorities would be determined. Prior to WHO-CHOICE, there were only a few examples of practical implementation of sectoral CEAs: the Oregon Health Services Commission (tasked with prioritizing for Medicaid in the United States), the World Bank Health Sectors Priorities Review, and the Harvard Life Saving Project. Of these, only the World Bank's work had attempted a global comparison. [4] [5] In a 2000 paper discussing the WHO-CHOICE approach, Murray et al. identified four challenges to a wider application of sectoral CEA:
WHO-CHOICE identified a key trade-off in sectoral CEA based on the granularity of the region at which the CEA was performed. At one extreme, sectoral CEA could be performed at the level of individual cities or districts, incorporating information about local resources, costs, and current context. At the other extreme, a single CEA could be carried out globally. Highly localized sectoral CEA would be very expensive and difficult to perform whereas global CEA would fail to take into account the huge differences between the epidemiology and resource structure of regions. [1] [4] [6]
WHO-CHOICE's solution was to use an intermediate level of granularity, that it called "generalized CEA" (GCEA). It argued that at this intermediate level, it could conduct CEAs more efficiently while also allowing local policymakers and agents to use its findings and further adapt them to local contexts. [1] [4]
WHO-CHOICE has divided the world into 14 epidemiological subregions, and publishes its findings by subregion, as shown below. Each subregion is a combination of a region (a geographical region of the world) and a mortality stratum (a stratum describing the level and nature of mortality). WHO-CHOICE chose to put each country in a single mortality stratum and a single region (and therefore a single subregion) even if mortality varies widely within the country. [1] [5]
Although the 6 regions and 5 mortality strata could give a theoretical maximum of 6 X 5 = 30 subregions, only 14 subregions occur in practice because not every region has countries with all mortality strata.
Below is the classification into subregions as of 2003. [5]
The CEA done by WHO-CHOICE differed from the standard ICM-CEA in two important ways: [1] [4] [6]
The results that WHO-CHOICE reports are not intended to be applied literally when choosing policies or selecting interventions. This is for a few reasons: [5]
Rather, the results are intended to be used as a starting point in classifying interventions as highly cost-effective, moderately cost-effective, and cost-ineffective. With this classification in place, a more detailed and localized analysis can be done for the highly cost-effective interventions, incorporating concerns such as poverty, equity, implementation capacity, and feasibility. [5]
WHO-CHOICE lists the following tools that it uses and can provide to researchers interested in using WHO-CHOICE: [12]
This section focuses on results published by the WHO-CHOICE team or other material published by the World Health Organization relying on WHO-CHOICE data. For examples of use of WHO-CHOICE data by others, see the Reception section.
The World Health Report of 2002 relied on WHO-CHOICE. Specifically, it used the division of the world into epidemiological subregions in its analysis of health risks, and used recommendations generated by WHO-CHOICE in Chapter 5, "Some Strategies to Reduce Risk". [7] Here are the key results in the report based on WHO-CHOICE:
Risk being considered | Potential interventions | Conclusion about best intervention |
---|---|---|
Childhood undernutrition (and breastfeeding) | Complementary feeding Complementary feeding with growth monitoring and promotion |
Both interventions have identical impact, and the latter is cheaper, and more likely to be cost-effective in most regions. |
Iron deficiency | Iron fortification Iron supplementation |
Supplementation yields greater improvements in population health in subregions with high child mortality (all D and E subregions) and at all levels of coverage. On the other hand, fortification is the preferred option at low levels of resource availability, as it has lower and less sharpy increasing unit cost and does not require a visit to a provider. However, in some settings, fortification is hindered by the absence of ideal food vehicles to fortify, and supplementation could be the better approach. |
Vitamin A deficiency | Vitamin A supplementation Vitamin A fortification |
Vitamin A fortification is more cost-effective in all regions because of its lower cost. Supplementation has a higher population benefit despite the higher cost. Both interventions are cost-effective. |
Zinc deficiency | Zinc supplementation Zinc fortification |
Fortification is more cost-effective. However, it has lower total population benefit than Vitamin A supplementation in subregions where both Vitamin A deficiency and zinc deficiency are problems. |
Other individual-based interventions focusing on children under five years of age |
Oral rehydration therapy Case management of pneumonia |
Vitamin A supplementation achieves greater health effects than ORT in some areas (AMR-B, SEAR-B, WPR-B) but in others the reverse is true. Both ORT and case management of pneumonia achieve substantially greater benefits than zinc fortification and supplementation, though the latter is more cost-effective. |
Blood pressure ( hypertension) | Population wide salt reductions Individual-based hypertension treatment and education |
In all subregions, strategies to reduce blood pressure are very cost-effective. Legislation is potentially more cost-effective than voluntary agreement with industry. Strategies to reduce blood pressure by treating individuals with a blood pressure with a SBP greater than 160mmHg are the most cost-effective, and lowering the threshold to 140mmHg is not cost-effective in many subregions such as AFR-D and AMR-D. Combinations of individual treatment and population based approaches are cost-effective at the 160mmHg SBP threshold in all settings. |
Cholesterol | Population-wide health education through mass media Individual-based treatment and education |
In all subregions, population strategies to reduce cholesterol are very cost-effective, but the total impact on DALYs gained is small. Statins are low-cost and effective and thus cost-effective in all regions. |
Combined interventions to reduce the risk of cardiovascular events | Individual-based treatment and education for systolic blood pressure and cholesterol Population-wide combination of interventions to reduce hypertension and cholesterol. Absolute risk approach: focus on the absolute risks of individuals and choose medication based on that Combining population interventions and the absolute risk approach |
The absolute risk approach for a threshold of 35% is very cost-effective in all subregions. At lower thresholds, the health benefits increase but so do the costs. The threshold for cost-effectiveness can vary based on region, and can vary from 5% to 25%. |
Unsafe sex and HIV/AIDS | Population-wide mass media Voluntary counseling and testing School-based AIDS education Peer outreach for men who have sex with men Treatment of sexually transmitted infections (STI) Mother-to-child transmission (MTCT) Antiretroviral therapy (ARV) Intervention combinations |
All preventive interventions have a substantial impact on population health in the high mortality subregions. The specific intervention that is best varies with the setting. Treatment of STIs has a higher impact on population health than the other preventive interventions in all except the A subregions where peer outreach for men who have sex with men also has a substantial impact. |
Smoking | Taxation Clean indoor air laws in public places Comprehensive bans on tobacco advertising Information dissemination through health warning labels, counter-advertising, and consumer information packages. Nicotine replacement therapy |
The interventions have a larger impact in subregions with more tobacco use (AMR-B, AMR-D, EUR-B, EUR-C, SEAR-B, SEAR-D, WPR-B). If only one intervention is to be chosen, it should be taxation. |
Unsafe water, sanitation, and hygiene |
Millennium Development Goals Disinfection at point of use Improved water supply and sanitation, low technologies Improved water supply and sanitation, with disinfection at point of use Improved water supply and sanitation, high technologies |
In subregions other than EUR-A and AMR-A (where almost everybody has access to safe water and basic sanitation), the intervention that is consistently the most cost-effective is the provision of disinfection capacity at the point of use. However, the principal driver for improvement to water supplies is not health but economic development, and this should be factored into the evaluation. |
Unsafe health care injections | Decreased reuse of injected equipment without sterilization Decreased unnecessary use of injections |
Interventions were not evaluated in A subregions. In other mortality strata, reducing unnecessary use of injections has a lower total impact of health, and the impact of the interventions is additive. In approximately half the subregions (AMR-B, AMR-D, EUR-B, EUR-C), reducing reuse is also the most cost-effective intervention. In other regions (AFR-D, AFR-E, EMR-D, SEAR-B, SEAR-D, WPR-B), behavioral interventions to reduce overuse are more cost-effective, and would be done first if resources are scarce. |
The WHO-CHOICE database was one of the sources of data used for the 2009 World Health Organization costing report Constraints to Scaling Up the Health Millennium Development Goals: Costing and Financial Gap Analysis. Background Document for the Taskforce on Innovative International Financing and Health Systems (published 2010). [18] The report was a costing analysis of health system strengthening in order to meet the Millennium Development Goals by 2015, and relied on WHO-CHOICE data and published WHO-CHOICE work for some specific cost estimates. It is cited on the WHO-CHOICE website as an example of the use of WHO-CHOICE to generate Global Price Tags. [19]
In 2012, a number of papers were published in the British Medical Journal disseminating results from WHO-CHOICE. [1] [11] A discussion of the findings on the Giving What We Can blog summarized the results as follows: "countries should try to expand high-priority interventions to near-universal coverage before considering second-priority interventions on a limited scale." [1] Below are the main results:
Problem area | Conclusion | Maximum incremental cost-effectiveness ratio (cost per DALY averted in 2005 international dollars) (Africa) | Maximum incremental cost-effectiveness ratio (cost per DALY averted in 2005 international dollars) (Asia) | Intervention (Africa) | Intervention (Asia) |
---|---|---|---|---|---|
Breast cancer, cervical cancer, colorectal cancer [20] | Highly effective interventions are available; in colorectal cancer, increated overage is effective across regions | 307 | 142 | For cervical cancer: screening 50% of the target population through a single smear test at age 40, with lesion removal and treatment as required | Same as for Africa |
Cardiovascular disease, diabetes, and tobacco use [21] | Inexpensive and cost-effective interventions exist in low resource settings. These include strategies to reduce tobacco demand and retinopathy screening. | 104 | 81 | Preventive multridrug treatment for people with > 35% risk of a cardiovascular event in the following 10 years | Long term diuretic treatment after myocardial infarction patients with established heart failure |
Chronic obstructive pulmonary disease and asthma [22] | It is irreversible: current treatment options produce relatively little gains | 2686 | 2420 | Low dose inhaled corticosteroids for mild, persistent asthma | Same as for Africa |
Vision and hearing loss [23] | Vision and hearing impairment controls are generally cost effective | 16 | 14 | Treatment of chronic otitis with topical antibiotics at 50% coverage | Same as for Africa |
Neuropsychiatric conditions [24] | Highly variable cost-effectiveness across 44 assessed intervention strategies | 117 | 286 | Increased taxation on alcohol (current tax rate + 50%) | Older antiepileptic drug in primary care at 50% coverage |
Road traffic injuries [25] | 10 year transition model: 1233 | 10 year transition model: 1181 | Bicycle helmet use | Speed limits, drunk driving, seatbelt use, motorcycle helmet use |
Charity evaluator GiveWell has referenced WHO-CHOICE estimates alongside estimates from the Disease Control Priorities Project's DCP2 report, the Copenhagen Consensus, and The Lancet series on nutrition. [8] [26]
Giving What We Can, a charity evaluator and advocate of more effective giving, reviewed WHO-CHOICE's results, and emphasized that these results "should perhaps not be taken from the individual donor’s perspective, but rather from the perspective of someone who can influence the health system of that country." [1] GWWC has also referenced WHO-CHOICE and compared it with DCP2 in some of its coverage of diseases. [9]
WHO-CHOICE has also been cited alongside DCP2 and the Copenhagen Consensus in general discussions of cost-effectiveness analyses. [10]
WHO-CHOICE (CHOosing Interventions that are Cost-Effective) is an initiative started by the World Health Organization in 1998 to help countries choose their healthcare priorities. [1] [2] [3] It is an example of priority-setting in global health. It was one of the earliest projects to perform sectoral cost-effectiveness analyses (i.e., cost-effectiveness analyses that compare a wide range of types of spending within a sector and prioritize holistically) on a global scale. [4] [5] [6] Findings from WHO-CHOICE have shaped the World Health Report of 2002, [7] been published in the British Medical Journal in 2012, [1] and been cited by charity evaluators and academics alongside DCP2 and the Copenhagen Consensus. [8] [9] [10]
In May 1998, Gro Harlem Brundtland succeeded Hiroshi Nakajima as the Director-General of the World Health Organization, and the organization was significantly restructuring as a result of the leadership change. With her election, a new program, called Choosing Interventions: Effectiveness Quality, Costs, Gender and Ethics, was launched as part of the Global Programme for Evidence on Health and Policy. The name of the program would later morph into WHO-CHOICE. [4]
WHO-CHOICE was used in the World Health Report of 2002, specifically informing the recommendations in Chapter 5. [7]
Results based on WHO-CHOICE were published in a series of papers in the British Medical Journal in 2012. [1] [11]
Prior to WHO-CHOICE, most projects that did cost-effectiveness analysis (CEA) in the real world focused on evaluating a single program or intervention, comparing it against either a fixed price threshold or an existing array of interventions with predetermined cost-effectiveness taken from the literature. However, theoretical literature on CEAs considered a broader kind of CEA called "sectoral CEA" where all programs and interventions available within a sector would be compared and cost-effectiveness priorities would be determined. Prior to WHO-CHOICE, there were only a few examples of practical implementation of sectoral CEAs: the Oregon Health Services Commission (tasked with prioritizing for Medicaid in the United States), the World Bank Health Sectors Priorities Review, and the Harvard Life Saving Project. Of these, only the World Bank's work had attempted a global comparison. [4] [5] In a 2000 paper discussing the WHO-CHOICE approach, Murray et al. identified four challenges to a wider application of sectoral CEA:
WHO-CHOICE identified a key trade-off in sectoral CEA based on the granularity of the region at which the CEA was performed. At one extreme, sectoral CEA could be performed at the level of individual cities or districts, incorporating information about local resources, costs, and current context. At the other extreme, a single CEA could be carried out globally. Highly localized sectoral CEA would be very expensive and difficult to perform whereas global CEA would fail to take into account the huge differences between the epidemiology and resource structure of regions. [1] [4] [6]
WHO-CHOICE's solution was to use an intermediate level of granularity, that it called "generalized CEA" (GCEA). It argued that at this intermediate level, it could conduct CEAs more efficiently while also allowing local policymakers and agents to use its findings and further adapt them to local contexts. [1] [4]
WHO-CHOICE has divided the world into 14 epidemiological subregions, and publishes its findings by subregion, as shown below. Each subregion is a combination of a region (a geographical region of the world) and a mortality stratum (a stratum describing the level and nature of mortality). WHO-CHOICE chose to put each country in a single mortality stratum and a single region (and therefore a single subregion) even if mortality varies widely within the country. [1] [5]
Although the 6 regions and 5 mortality strata could give a theoretical maximum of 6 X 5 = 30 subregions, only 14 subregions occur in practice because not every region has countries with all mortality strata.
Below is the classification into subregions as of 2003. [5]
The CEA done by WHO-CHOICE differed from the standard ICM-CEA in two important ways: [1] [4] [6]
The results that WHO-CHOICE reports are not intended to be applied literally when choosing policies or selecting interventions. This is for a few reasons: [5]
Rather, the results are intended to be used as a starting point in classifying interventions as highly cost-effective, moderately cost-effective, and cost-ineffective. With this classification in place, a more detailed and localized analysis can be done for the highly cost-effective interventions, incorporating concerns such as poverty, equity, implementation capacity, and feasibility. [5]
WHO-CHOICE lists the following tools that it uses and can provide to researchers interested in using WHO-CHOICE: [12]
This section focuses on results published by the WHO-CHOICE team or other material published by the World Health Organization relying on WHO-CHOICE data. For examples of use of WHO-CHOICE data by others, see the Reception section.
The World Health Report of 2002 relied on WHO-CHOICE. Specifically, it used the division of the world into epidemiological subregions in its analysis of health risks, and used recommendations generated by WHO-CHOICE in Chapter 5, "Some Strategies to Reduce Risk". [7] Here are the key results in the report based on WHO-CHOICE:
Risk being considered | Potential interventions | Conclusion about best intervention |
---|---|---|
Childhood undernutrition (and breastfeeding) | Complementary feeding Complementary feeding with growth monitoring and promotion |
Both interventions have identical impact, and the latter is cheaper, and more likely to be cost-effective in most regions. |
Iron deficiency | Iron fortification Iron supplementation |
Supplementation yields greater improvements in population health in subregions with high child mortality (all D and E subregions) and at all levels of coverage. On the other hand, fortification is the preferred option at low levels of resource availability, as it has lower and less sharpy increasing unit cost and does not require a visit to a provider. However, in some settings, fortification is hindered by the absence of ideal food vehicles to fortify, and supplementation could be the better approach. |
Vitamin A deficiency | Vitamin A supplementation Vitamin A fortification |
Vitamin A fortification is more cost-effective in all regions because of its lower cost. Supplementation has a higher population benefit despite the higher cost. Both interventions are cost-effective. |
Zinc deficiency | Zinc supplementation Zinc fortification |
Fortification is more cost-effective. However, it has lower total population benefit than Vitamin A supplementation in subregions where both Vitamin A deficiency and zinc deficiency are problems. |
Other individual-based interventions focusing on children under five years of age |
Oral rehydration therapy Case management of pneumonia |
Vitamin A supplementation achieves greater health effects than ORT in some areas (AMR-B, SEAR-B, WPR-B) but in others the reverse is true. Both ORT and case management of pneumonia achieve substantially greater benefits than zinc fortification and supplementation, though the latter is more cost-effective. |
Blood pressure ( hypertension) | Population wide salt reductions Individual-based hypertension treatment and education |
In all subregions, strategies to reduce blood pressure are very cost-effective. Legislation is potentially more cost-effective than voluntary agreement with industry. Strategies to reduce blood pressure by treating individuals with a blood pressure with a SBP greater than 160mmHg are the most cost-effective, and lowering the threshold to 140mmHg is not cost-effective in many subregions such as AFR-D and AMR-D. Combinations of individual treatment and population based approaches are cost-effective at the 160mmHg SBP threshold in all settings. |
Cholesterol | Population-wide health education through mass media Individual-based treatment and education |
In all subregions, population strategies to reduce cholesterol are very cost-effective, but the total impact on DALYs gained is small. Statins are low-cost and effective and thus cost-effective in all regions. |
Combined interventions to reduce the risk of cardiovascular events | Individual-based treatment and education for systolic blood pressure and cholesterol Population-wide combination of interventions to reduce hypertension and cholesterol. Absolute risk approach: focus on the absolute risks of individuals and choose medication based on that Combining population interventions and the absolute risk approach |
The absolute risk approach for a threshold of 35% is very cost-effective in all subregions. At lower thresholds, the health benefits increase but so do the costs. The threshold for cost-effectiveness can vary based on region, and can vary from 5% to 25%. |
Unsafe sex and HIV/AIDS | Population-wide mass media Voluntary counseling and testing School-based AIDS education Peer outreach for men who have sex with men Treatment of sexually transmitted infections (STI) Mother-to-child transmission (MTCT) Antiretroviral therapy (ARV) Intervention combinations |
All preventive interventions have a substantial impact on population health in the high mortality subregions. The specific intervention that is best varies with the setting. Treatment of STIs has a higher impact on population health than the other preventive interventions in all except the A subregions where peer outreach for men who have sex with men also has a substantial impact. |
Smoking | Taxation Clean indoor air laws in public places Comprehensive bans on tobacco advertising Information dissemination through health warning labels, counter-advertising, and consumer information packages. Nicotine replacement therapy |
The interventions have a larger impact in subregions with more tobacco use (AMR-B, AMR-D, EUR-B, EUR-C, SEAR-B, SEAR-D, WPR-B). If only one intervention is to be chosen, it should be taxation. |
Unsafe water, sanitation, and hygiene |
Millennium Development Goals Disinfection at point of use Improved water supply and sanitation, low technologies Improved water supply and sanitation, with disinfection at point of use Improved water supply and sanitation, high technologies |
In subregions other than EUR-A and AMR-A (where almost everybody has access to safe water and basic sanitation), the intervention that is consistently the most cost-effective is the provision of disinfection capacity at the point of use. However, the principal driver for improvement to water supplies is not health but economic development, and this should be factored into the evaluation. |
Unsafe health care injections | Decreased reuse of injected equipment without sterilization Decreased unnecessary use of injections |
Interventions were not evaluated in A subregions. In other mortality strata, reducing unnecessary use of injections has a lower total impact of health, and the impact of the interventions is additive. In approximately half the subregions (AMR-B, AMR-D, EUR-B, EUR-C), reducing reuse is also the most cost-effective intervention. In other regions (AFR-D, AFR-E, EMR-D, SEAR-B, SEAR-D, WPR-B), behavioral interventions to reduce overuse are more cost-effective, and would be done first if resources are scarce. |
The WHO-CHOICE database was one of the sources of data used for the 2009 World Health Organization costing report Constraints to Scaling Up the Health Millennium Development Goals: Costing and Financial Gap Analysis. Background Document for the Taskforce on Innovative International Financing and Health Systems (published 2010). [18] The report was a costing analysis of health system strengthening in order to meet the Millennium Development Goals by 2015, and relied on WHO-CHOICE data and published WHO-CHOICE work for some specific cost estimates. It is cited on the WHO-CHOICE website as an example of the use of WHO-CHOICE to generate Global Price Tags. [19]
In 2012, a number of papers were published in the British Medical Journal disseminating results from WHO-CHOICE. [1] [11] A discussion of the findings on the Giving What We Can blog summarized the results as follows: "countries should try to expand high-priority interventions to near-universal coverage before considering second-priority interventions on a limited scale." [1] Below are the main results:
Problem area | Conclusion | Maximum incremental cost-effectiveness ratio (cost per DALY averted in 2005 international dollars) (Africa) | Maximum incremental cost-effectiveness ratio (cost per DALY averted in 2005 international dollars) (Asia) | Intervention (Africa) | Intervention (Asia) |
---|---|---|---|---|---|
Breast cancer, cervical cancer, colorectal cancer [20] | Highly effective interventions are available; in colorectal cancer, increated overage is effective across regions | 307 | 142 | For cervical cancer: screening 50% of the target population through a single smear test at age 40, with lesion removal and treatment as required | Same as for Africa |
Cardiovascular disease, diabetes, and tobacco use [21] | Inexpensive and cost-effective interventions exist in low resource settings. These include strategies to reduce tobacco demand and retinopathy screening. | 104 | 81 | Preventive multridrug treatment for people with > 35% risk of a cardiovascular event in the following 10 years | Long term diuretic treatment after myocardial infarction patients with established heart failure |
Chronic obstructive pulmonary disease and asthma [22] | It is irreversible: current treatment options produce relatively little gains | 2686 | 2420 | Low dose inhaled corticosteroids for mild, persistent asthma | Same as for Africa |
Vision and hearing loss [23] | Vision and hearing impairment controls are generally cost effective | 16 | 14 | Treatment of chronic otitis with topical antibiotics at 50% coverage | Same as for Africa |
Neuropsychiatric conditions [24] | Highly variable cost-effectiveness across 44 assessed intervention strategies | 117 | 286 | Increased taxation on alcohol (current tax rate + 50%) | Older antiepileptic drug in primary care at 50% coverage |
Road traffic injuries [25] | 10 year transition model: 1233 | 10 year transition model: 1181 | Bicycle helmet use | Speed limits, drunk driving, seatbelt use, motorcycle helmet use |
Charity evaluator GiveWell has referenced WHO-CHOICE estimates alongside estimates from the Disease Control Priorities Project's DCP2 report, the Copenhagen Consensus, and The Lancet series on nutrition. [8] [26]
Giving What We Can, a charity evaluator and advocate of more effective giving, reviewed WHO-CHOICE's results, and emphasized that these results "should perhaps not be taken from the individual donor’s perspective, but rather from the perspective of someone who can influence the health system of that country." [1] GWWC has also referenced WHO-CHOICE and compared it with DCP2 in some of its coverage of diseases. [9]
WHO-CHOICE has also been cited alongside DCP2 and the Copenhagen Consensus in general discussions of cost-effectiveness analyses. [10]