In this Insights Article we delve into the crucial aspect of conducting health economic evaluations in LMICs – low and middle-income countries. The primary objective is to illustrate the vital role such evaluations play in health policy decision-making, while also acknowledging the challenges often encountered due to constraints such as limited resources, data scarcity, and underdeveloped capacities. The goal is to identify the most cost-effective health interventions that can contribute to achieving universal health coverage (UHC), especially within the realms of growing international collaboration, knowledge sharing, and capacity building.
Below we explore specific challenges faced by LMICs, including unique economic, political, and demographic factors, along with strategies to overcome them. The article highlights innovative approaches to address data scarcity and capacity constraints, and underscores the importance of integrating local stakeholder preferences into decision-making processes. Moreover, it outlines the concerted efforts of international bodies such as the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the Health Technology Assessment international (HTAi) in enhancing health outcomes research and prioritising health interventions. The final section of the article focuses on initiatives like the Global Economic Analysis and Research (GEAR), and tools like Plant-A-Tree that are instrumental in supporting health economists in LMICs.
Challenges and Opportunities for Health Economics and Outcomes Research (HEOR)
LMICs face unique challenges that must be addressed to maximise the benefits of HEOR. The economy of LMICs are often stagnant, with a low gross national product and difficulty competing with high-income countries (HIC). Political instability and unethical practices in elections further contribute to a sense of insufficiency and instability among the population. The demography of LMIC is also unpredictable, with high international migration, an increasing middle-income population, and a growing elderly population.
The burden of non-communicable diseases like diabetes, cancer, and obesity is expected to continue to rise in LMICs. In 2020, these diseases accounted for 80% of the global burden of disease and 70% of deaths, with the majority of the burden and death in LMICs. The increasing urbanisation trend and sedentary lifestyle factors only exacerbate this problem.
One of the challenges of conducting economic evaluations in LMICs is incorporating health system capacity constraints into the analysis. Health systems in LMICs often lack the resources and infrastructure to support the implementation of certain interventions, which can affect the cost-effectiveness of those interventions. For example, a highly effective intervention that requires expensive equipment or specialised personnel may not be cost-effective in a LMIC where those resources are scarce. Therefore, economic evaluations in LMICs should consider the feasibility of implementing interventions in the local context.
Another challenge of conducting economic evaluations in LMICs is data scarcity. Data on costs and health outcomes are often incomplete or unavailable in LMICs, which can make it difficult to accurately estimate the cost-effectiveness of interventions. To address this challenge, researchers in LMICs have developed innovative methods for estimating costs, such as using proxy indicators or conducting micro-costing studies. These methods can help improve the accuracy of cost estimates and make economic evaluations more feasible in LMICs.
Despite these challenges, there are many opportunities for conducting economic evaluations in LMICs. One opportunity is the growing interest in promoting universal health coverage in LMICs. The aim of UHC is to ensure that all individuals have access to essential health services without suffering financial hardship. Economic evaluations can play a critical role in informing the selection of interventions that are most cost-effective and contribute to achieving UHC. Another opportunity is the increasing collaboration and mutual learning between HICs and LMICs. Researchers working in HICs may find approaches developed in LMICs to incorporate health system capacity constraints increasingly relevant as greater demands are placed on HIC health systems.
Addressing Capacity Constraints and Incorporating Local Stakeholders’ Preferences in Economic Evaluations
Capacity constraints are another challenge to conducting economic evaluations in LMICs as they often lack the trained personnel and resources necessary to conduct economic evaluations. To address this challenge, there is a need for investment in training programs for researchers and policymakers in LMICs. These programs should focus on study design, data collection and analysis for economic evaluations, and should be tailored to the specific challenges faced in LMICs. On-the-job training and mentoring of economic evaluation researchers are also important to improve the quality of evaluations.
HEOR can help address these challenges by providing evidence-based information to guide priority setting, strategic planning, and cost minimisation approaches to enhance the sustainability of the health care system. This can include evaluating the cost-effectiveness of different interventions and treatments, assessing the impact of health policies, and identifying areas where resources can be best allocated to improve health outcomes. 
In addition to these challenges, there is also a need to incorporate local stakeholders’ preferences into the decision-making process. Local stakeholders – such as patients, healthcare providers, and policymakers – have unique perspectives on the costs and benefits of health interventions. Incorporating their preferences into economic evaluations can help ensure that the interventions selected are acceptable and feasible in the local context. This can be achieved through stakeholder engagement activities, such as focus groups and surveys, which can provide valuable insights into the local context and inform the decision-making process. 
Advancing Economic Evaluations and Institutionalising Priority Setting
There is a need for further methodological development and investment to support economic evaluations in LMICs. Novel methods are required to integrate heterogeneity in epidemiology, demography, and unit costs across diverse settings in an expedient and informative way. Further investment in large-scale costing studies and analysis of cost functions will also be required to inform assessments of the costs of scaling up interventions and the generalisability of unit costs across settings. Funders have a role to play in providing methodological funding streams and requiring economic evaluations to be included in major trials and other evaluations.
Institutionalising priority setting through health technology assessment (HTA) is also important in LMICs. HTA can help ensure that interventions are selected based on their cost-effectiveness and feasibility in the local context. National agencies have already begun to institutionalise priority setting through HTA. However, in low-income settings where capacity is more constrained, intermediate steps might include fostering opportunities for assessing transferability of evidence and use of evidence produced regionally.
Regional Insights: MENA and Sub-Saharan Africa
Strengthening Healthcare Decision Making in the Middle East and North Africa
ISPOR has committed to LMICs and is reflected in its robust portfolio of activities, which includes the ISPOR Arabic Network, eight regional chapters, numerous educational webinars and trainings, grants and funding for educational activities, and much more. These programs focus on capacity building, research, and advocacy to ensure that HEOR is integrated into healthcare decision making.
The Middle East and North Africa (MENA) region is one of the regions where ISPOR has a strong presence. The region faces significant disparities in healthcare access and outcomes, which have been exacerbated by the COVID-19 pandemic. ISPOR’s MENA programs aim to strengthen healthcare decision making in the region through the ISPOR Arabic Network, regional chapters, and educational activities. For example, the ISPOR Jordan Chapter is strengthening HTA capacity in the country through trainings. The ISPOR Lebanon Chapter is contributing to the development of economic evaluation guidelines for Lebanon and conducting a survey investigating the knowledge and awareness of payers and patient advocacy groups about the HTA process in Lebanon. The ISPOR Arabic Network also conducts research with regional decision makers on their top priorities and challenges for the future.
Advancing Health Outcomes and HEOR Development in Sub-Saharan Africa
Sub-Saharan Africa faces challenges such as limited resources for public healthcare financing, high out-of-pocket expenditure, lack of data, insufficient capacity, and high disease burdens for both infectious and noncommunicable diseases. However, there are also signs of progress, such as the strong commitment of some countries to establish universal healthcare and the recent establishment of the Africa Medicines Agency. The development of HEOR will be critical in building capacity and improving health outcomes in the region. ISPOR supports the development of HEOR in Sub-Saharan Africa through educational and research activities, as well as collaborations between countries and organisations. Recent activities include collaborations on pressing research topics, institutionalisation of HTA in Ghana, and input into national guidelines for rapid-evidence review mechanisms in South Africa.
Improving global healthcare decision making requires involvement and buy-in from a diverse range of perspectives, including researchers, regulators, policymakers, payers, healthcare providers, industry members, and patients. ISPOR’s LMIC programs foster engagement across these various stakeholder groups to integrate knowledge, build leadership, and empower people to carry the Society’s mission forward in their own arenas. ISPOR HTA Roundtables provide a platform for technology assessors, private and public payers, regulators, and patients to discuss, debate, and share issues relating to HTA. 
Patient and Citizen Involvement (HTAi Project)
HTAi launched a project that aims to explore the importance of patient and citizen involvement in LMIC settings, where access to quality and affordable healthcare can be a challenge. The Patient and Citizen Involvement Interest Group’s (PCIG) project will collaborate with LMIC stakeholders to define LMIC-specific needs for patient involvement to develop and adapt guidance and tools to support patient and citizen involvement in healthcare decision-making. The project is designed for HTA units in emerging economies and the patient and public in these countries. The project will explore the current situation in pilot LMIC countries and develop a landscape analysis for LMICs, while adapting existing tools or developing new ones as needed. The questionnaire was piloted in the first set of countries (Brazil, Indonesia, Nigeria, and South Africa). 
GEAR: A Unique Information Hub for Health Economists in LMICs
The GEAR initiative aims to address the gap in capacity for health economists in LMICs by providing reliable and up-to-date information to researchers, academics, and ministry of health employees. The website is updated regularly with new methodological standards and mind maps to address contextual problems and other issues identified by users. To overcome the problem of limited internet access in LMICs, the International Decision Support Initiative (iDSI) is considering solutions such as providing downloadable mind maps and minimising bandwidth requirements for viewing the website. Collaborations with international and regional professional associations and global initiatives have been established to ensure the relevance of the site to its intended users. By providing good quality support in economic evaluation to a global audience, the GEAR website hopes to foster high-quality research and facilitate better decision making in healthcare in LMICs.
Plant-A-Tree is an open-source Microsoft Excel Add-In that allows for the creation of unlimited branches (nodes) in decision trees for economic evaluations or any decision problem. It is particularly useful for those still conceptualising or visualising their decision problem and all the possible outcomes and sources of costs. Plant-A-Tree presents both costs and outcomes together in a single tree (spreadsheet), making it easy for users to compare and calculate final outcomes. It was developed to meet the needs of researchers in LMICs where access to modeling tools is limited. It was developed by the Saw Swee Hock School of Public Health at the National University of Singapore (NUS) and Health Intervention and Technology Assessment Program (HITAP) with support from the iDSI. 
Health economics is not neutral and policy prescriptions are often underpinned by ideological positions. It is unfortunate that much of the health economics research in LMICs has been driven by external agencies, reflecting policy trends in HICs. Governments in LMICs need to take greater ownership of the research agenda and invest in domestic capacity to provide informed input into health systems development. Promising signs include the creation of national research funds in countries like Thailand and Kenya. As countries grow richer, it is crucial that they invest in building their own research capacity for long-term success. 
Conducting economic evaluations in LMICs is challenging due to limited resources, capacity constraints, and the need to incorporate local stakeholders’ preferences. However, innovative methods and investment in training programs can help improve the accuracy and feasibility of economic evaluations in LMICs.
Institutionalising priority setting through HTA is important in LMICs to ensure that interventions are selected based on their cost-effectiveness and feasibility in the local context. ISPOR and HTAi support the development of HEOR through educational and research activities, as well as collaborations between countries and organisations.
The GEAR initiative and Plant-A-Tree are examples of tools that can support health economists in LMICs by providing reliable and up-to-date information and modeling tools. However, it is important for governments in LMICs to take greater ownership of the research agenda and invest in domestic capacity to provide informed input into health systems development.
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