When is elimination of an infectious disease cost-effective? An analytical framework to guide elimination priorities

Elimination targets for infectious diseases are increasingly common in global health, yet the economic rationale for pursuing elimination is often assumed rather than rigorously assessed. Existing evaluations frequently emphasise future cost savings or broader economic benefits while overlooking health opportunity costs-the health that could have been gained had resources been allocated elsewhere. This study aimed to develop an analytical framework to investigate when disease elimination generates positive net health benefit (NHB) and to illustrate how key factors interact to shape this assessment.

We constructed a generalisable analytical framework incorporating ten factors related to intervention and disease costs, intrinsic disease/intervention characteristics, and stakeholder viewpoints and evaluation parameters. The framework was applied to create an exemplar model that showed how these factors jointly influence the NHB of achieving elimination. This was evaluated across wide parameter ranges informed by the literature, using different cost-effectiveness thresholds, discount rates, and time horizons.

The framework revealed distinct regions of parameter space in which elimination yield positive NHB. The cost-effectiveness threshold, discount rates, disease burden, and intervention impact were strong determinants of NHB. In particular, lower thresholds, higher discount rates, and shorter time horizons reduced the likelihood that elimination would generate positive NHB. The framework also showed that elimination may be cost-effective in some settings but not in others, even for the same disease, due to differences in costs, burden, and opportunity costs.

Disease elimination is not always a good investment; its value depends on the interplay between disease characteristics, programme costs, and the health opportunity costs of resource use. The proposed framework provides a transparent, health opportunity cost-based structure for evaluating elimination strategies and supports more robust, context-specific priority-setting on elimination targets in global health.