Abstract
Introduction: Cost-effectiveness (CE) thresholds have been applied in health technology assessment (HTA) processes for decades. In Brazil, although the HTA process has been effectively implemented since 2011 (2006, if we count CITEC), decisions were being made without defining this parameter. Usually, the threshold of 3 times the gross domestic product (GDP) per capita was recommended, following the recommendation of the World Health Organization. However, until 2022 there was no national threshold appropriately defined for the country's reality. In 2022, the Ministry of Health's recommendation of R$40,000 (or 1 time the GDP per capita of that year) was released. In this paper, we present evidence-based questions about how this threshold may be below what is necessary to allow the implementation of technological innovations in the Brazilian public health system. Methods: A systematic search was conducted in open databases (Google Scholar and Pubmed) on CE thresholds in countries with internationally defined and recognized HTA processes. In addition to this search, additional information was sought in the agencies' own public domains for validation. Once located, the thresholds were extracted in dollars, reais (exchange rate of R$ 5.35 applied) and GDP per capita. In addition, the current GDP per capita of the countries was validated on the World Bank website. No thresholds for specific diseases or age groups were considered. Results: EC thresholds were located for: United States (US$50,000), United Kingdom (£20,000 to 30,000 = US$25,000 to 37,700), Canada (US$50,000), Chile (US$23,300), Colombia (US$6,000), Mexico (US$11,000) and Brazil (US$8,000). According to the most recent estimates from the World Bank (2022), these values represent in terms of GDP per capita: United States: 65%; United Kingdom: 82%; Canada: 90%; Chile: 1; Colombia: 1; Mexico: 1 and Brazil: 1. Discussion and conclusions: Brazil, as a developing country, already has an automatic adjustment of the EC threshold values, since Brazilian GDP per capita is about 8.5 times lower than that of the United States and 5 times lower than that of the United Kingdom. In addition, the threshold proposed for Brazil is 6.7 times lower than the American one and 5 times lower than the English one. Furthermore, our GDP per capita is lower than the Latin American average (US$ 9,747), and lower than that of Chile and Mexico, which are given as examples. Among the countries selected for this analysis, the Brazilian threshold is close to that of Colombia, which has a very different health system when compared to Brazil. Approximately 75% of CONITEC's incorporations might not have occurred if the threshold of 1 GDP per capita had been used. It is known that the CE threshold is only one of the factors taken into consideration in the decision, but we believe that this reduction from 3 to 1 GDP per capita could be an obstacle to access to innovative technologies in the SUS.
