Abstract
Background and Rationale
The cost-effectiveness threshold (CET) is a policy-level decision-making tool used as a benchmark for
interpreting health economic evaluations. In Thailand, this approach has been integrated into the
consideration of benefit package inclusion under the Universal Health Coverage (UHC) and the development
of the National List of Essential Medicines (NLEM). However, there has been no qualitative study on the use
and evolution of CET in Thailand.
Objectives
This study aims to explore the origins, utilisation, challenges, and limitations of CET, as well as the
monitoring and evaluation processes associated with CET-based policies. Additionally, it examines the
characteristics of medicines subjected to cost-effectiveness analysis during different CET periods, the
changes in CET, and the resulting impacts within the scope of the development of Thailand’s NLEM.
Methods
This study employed qualitative research methods to review events related to the use and evolution of
CET in policy decision-making, focusing on explanatory insights. Data collection methods included literature
and document review, focus-group discussions, in-depth interviews and stakeholder meetings.
The data analysis consisted of:
1) Categorisation – Organising information from meeting minutes using content analysis.
2) Thematic analysis – Identifying key themes from focus-group discussions and in-depth interviews
with stakeholders both within and outside the NLEM Subcommittee and relevant working groups.
3) Triangulation – Cross-validating information obtained from meeting minutes, focus-group
discussions, and in-depth interviews, supplemented by literature and other relevant documents.
4) Chronological and comparative analysis – Sequencing events and comparing data across different
processes.
In addition, preliminary findings were presented in the stakeholder meetings to gather feedback and refine
policy recommendations.
Findings
The official use of CET in Thailand began in 2008, with an initial reference range of 1–3 times the gross
domestic product (GDP) per capita, following the widely understood recommendation of the World Health
Organization. In 2009, research indicated that the Thai population's willingness to pay (WTP) for healthcare
was approximately 100,000 THB per quality-adjusted life year (QALY), equivalent to 1 GDP per capita. In
2011, the GDP-based reference for CET was replaced with gross national income (GNI) per capita, which
amounted to 117,442 THB. Subsequently, in 2012, the NLEM Subcommittee approved a CET of 120,000
THB per QALY, as proposed by the health economics working group. This was later revised to 160,000 THB
per QALY in 2013, based on 1.2 GNI per capita (Atlas Method) and aligned with WTP research findings, which
estimated 156,000 THB per QALY.
Thailand has primarily determined CET using two key approaches: referencing macroeconomic indicators
(GDP/GNI per capita) and assessing the population’s willingness to pay. The practical application of CET
generally aligns with its nature as a single numerical value with a clear threshold for categorisation (costeffective or not cost-effective). This has provided a standardised benchmark for medicine evaluation.
However, its limitations and challenges depend on contextual factors, such as the stringency of decisionmakers, the quality of cost-effectiveness studies, and the management of different health funds.
Despite CET being one of the criteria used in NLEM decision-making, no formal or routine monitoring and
evaluation processes for its application have been established. Previous assessments have focused on
access to Category E(2) medicines and appropriate prescribing practices according to prescribing guidelines.
In 2 0 2 1 and 2 0 2 3, impact assessments of CET adjustments were conducted, revealing that CET changes
had no influence on medicine pricing proposed for cost-effectiveness evaluation. This was due to marketdriven pricing strategies determined at a global level. Likewise, changes in CET did not affect the NLEM
Subcommittee’s decision-making, as multiple factors, including technical, ethical, and political
considerations, were taken into account.
Discussions within the Subcommittee have also explored the development of an affordability threshold or
a budget impact ceiling. However, such efforts have not been successfully implemented due to various
challenges, including the lack of academic research on appropriate threshold-setting methods and
differences in budget allocation mechanisms across Thailand’s public health insurance schemes. Since
2 0 2 1, cost-effectiveness evaluations have increasingly focused on specific medicine categories, such as
treatments for rare diseases and personalised medicines, which present both methodological and political
challenges. As NLEM development is expected to become more complex, the Subcommittee has discussed
a new CET of 5 0 0,0 0 0 THB per QALY for high-cost, life-saving medicines with no alternative treatments.
However, this CET has not yet been formally adopted and remains an issue requiring further monitoring
and evaluation.
Conclusion and Discussion
Findings from this study indicate that the concepts and processes of NLEM development have evolved over
time. However, the use of scientific evidence, cost-effectiveness considerations, and financial feasibility—
practices that have been in place for over a decade—are likely to remain fundamental principles. This is
especially relevant in the current era, where pharmaceutical technologies and innovations are becoming
increasingly complex.
