Uncertainty in Economic Evaluation: A Pragmatic Guide for Health Technology Assessment (HTA) Agencies in Resource-Constrained Settings.

Understanding the financial and health consequences if economic evaluation assumptions prove incorrect is essential for managing the risk associated with benefit package decisions, particularly in resource-constrained and overburdened healthcare systems. Yet these are also the settings that face the greatest challenges in conducting comprehensive uncertainty analysis, owing to a range of factors including limited skilled staff, data constraints, and short timelines to generate evidence in time to influence policy. This paper takes a pragmatic approach to support health technology assessment agencies in these settings to generate policy-relevant uncertainty analysis, drawing on good practice literature and the authors' collective experience conducting economic evaluation for policy across resource-constrained settings. For each step of the economic evaluation process, we outline the main sources of uncertainty, principles for deciding which uncertainty analysis to prioritise, and approaches to overcome some of the common challenges faced when dealing with constrained timelines, data, and skilled staff. The overarching goal is to support better-informed decisions, by targeting uncertainty analysis to factors that actually affect decisions and by effectively communicating this decision-relevant uncertainty to policymakers.