Global Mapping of National Health Economic Evaluation Guidelines: Evidence from 40 Countries

Health economic evaluation (HEE) guidelines play an important role in health technology assessment (HTA) by supporting the consistent and transparent use of economic evidence in decision making. As countries continue updating their guidelines, substantial methodological variation persists. This review aimed to provide an updated global comparison of national HEE guidelines. National HEE guidelines were identified from the ISPOR and GEAR repositories and supplemented by hand-searching and searches of governmental and institutional sources. Two reviewers independently extracted data across 23 methodological domains, including analytical perspective, comparators, cost categories, outcome measures, modeling, discounting, evidence synthesis, and uncertainty analysis. Forty national guidelines were identified (25 high-income countries, 9 upper-middle-income countries, and 6 lower-middle-income countries). Most guidelines had been updated between 2015 and 2025. Forty-eight percent were recommendatory, 43% mandatory, and 10% voluntary. Cost-utility analysis was preferred in 48% of guidelines, and quality-adjusted life-years (QALYs) were recommended in 53%. Systematic review and the use of real-world evidence was commonly emphasized. Discount rates ranged from 1.5 to 5%, largely reflecting national economic conditions. Nearly all guidelines required clear reporting of assumptions, parameter values, and sensitivity analyses. Variation remained in preferred perspectives, comparator selection, inclusion of indirect costs, and utility measurement methods. This review provides an updated global overview of national HEE guidelines, highlighting areas of convergence in analytical methods, evidence requirements, and approaches to uncertainty. Persistent differences across countries and income settings underscore the need for context-specific but methodologically robust guidance to support HTA and healthcare decision making.