Alireza Mosavi Jarrahi

Standardizing Cost-Effectiveness Evidence for Cancer Prevention: A Case Study Analysis of HPV Vaccination

Cervical cancer remains a leading cause of cancer mortality worldwide, with over 85% of deaths occurring in low- and middle-income countries (LMICs) where resources are scarce. A fundamental challenge in global health policy is comparing economic evaluations across these diverse settings, as traditional Incremental Cost-Effectiveness Ratios (ICERs) are constrained by different currencies, price levels, and willingness-to-pay (WTP) thresholds. To address this, we propose a standardized Cost-Effectiveness Ratio (CER), calculated as the ICER divided by the country-specific WTP threshold, creating a unitless, income-adjusted metric. We conducted a rapid review of HPV vaccination economic evaluations published between 2022 and 2025. Employing a case study approach, we extracted original ICERs and WTP thresholds from diverse countries. All monetary values were converted to 2024 US Dollars using transparent exchange rates, with a critical handling of the Thailand WTP threshold to ensure it was based on the original Thai Baht value from the publication before conversion to USD to ensure analytical integrity. The CER was then calculated to facilitate direct comparison. The CER provides a powerful lens for interpreting value. Our case study reveals that a vaccination strategy in China (CER=0.0002) is dramatically more favourable than one in Japan (CER=0.20), a finding obscured by absolute costs. Furthermore, the CER shows that programs in Thailand and the Philippines offer over twice the relative economic value of Japan's program. It also enables nuanced comparisons, such as between single-dose and two-dose regimens, revealing comparable value for money in lower-middle-income settings. The CER is a simple yet powerful tool that transforms incomparable data into a standardized metric. For international funders like Gavi and national policymakers, it provides robust evidence to prioritize investments in LMICs, where the return on investment is highest. By reframing the economic question from "can we afford it?" to "how can we afford not to?", the CER promotes health equity and strengthens the case for accelerating global HPV vaccination efforts.