, Volume 34, Issue 4, pp 323–329 | Cite as

Should the Lambda (λ) Remain Silent?

  • Hossein Haji Ali AfzaliEmail author
  • Jonathan Karnon
  • Mark Sculpher


When making decisions regarding the funding of new health technologies (e.g. pharmaceuticals), a key consideration should be the opportunity cost associated with a positive funding decision in terms of other patients’ health. Lambda (λ) is a term that has been used to refer to a maximum acceptable value (cost-effectiveness threshold) for the incremental cost-effectiveness ratio (ICER) of a new technology, which should reflect the opportunity cost of funding decisions.

In 2006, Gafni and Birch [1] discussed the ‘silence of the λ’ with respect to the justification of its numerical value within the decision-making process. They noted that the use of threshold values, which do not represent the true opportunity cost of new and generally more expensive technologies, can lead to increased health expenditures with little evidence of increases in population health.

In this commentary, we interpret the ‘silence of the λ′ with respect to the lack of explicit recognition of the use...


Opportunity Cost Budget Impact Sofosbuvir Ruxolitinib Funding Decision 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Hossein Haji Ali Afzali, Jonathan Karnon and Mark Sculpher conceptualized the manuscript and prepared the final draft. They share full responsibility for its content. Hossein Haji Ali Afzali is the overall guarantor.

Compliance with Ethical Standards


No sources of funding were used to prepare this manuscript.

Conflicts of interest

Hossein Haji Ali Afzali is a member of the ESC of the MSAC. Jonathan Karnon has served as a member of the ESC of the PBAC since 2009. Mark Sculpher has been a member of various NICE advisory committees and was co-author of the University of York’s research on the NHS cost-effectiveness threshold.


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Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Hossein Haji Ali Afzali
    • 1
    Email author
  • Jonathan Karnon
    • 1
  • Mark Sculpher
    • 2
  1. 1.School of Public HealthUniversity of AdelaideAdelaideAustralia
  2. 2.Centre for Health EconomicsUniversity of YorkYorkUK

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