Beyond cost-effectiveness: a reflective commentary on adapting global health technology assessment for equity considerations in South Africa and other LMICs

Abstract

This commentary critiques the global transplantation of Health Technology Assessment (HTA) frameworks grounded in cost-effectiveness analysis (CEA) and cost-utility analysis (CUA), highlighting their potential misalignment with the ethical and historical realities of LMICs such as South Africa. We introduce utilitarian principlism, a hybrid ethical framework that combines utilitarian efficiency with the normative safeguards of principlism to enable context-sensitive health priority-setting. Drawing on two recent empirical studies done by the authors (currently under review), we show that internationally developed EQ-5D value sets used to compute CEA locally in South Africa correlate poorly with patient-reported health status in South Africa and that sociodemographic variables significantly influence patient-perceived health scores necessitating a deep understanding of South African history to adequately make ethical and fair healthcare policy decisions. We argue that while locally derived utility weights are necessary for more accurate local CEA analysis, use of metrics like CEA alone in contexts like South Africa fails to address systemic inequity in the population. Instead, we propose a Multi-Criteria Decision Analysis (MCDA) framework to integrate CEA determined by using locally derived value sets with ethical and contextual considerations. We therefore recommend four policy shifts: (1) ethical adaptation of economic methods; (2) localisation of HTA methods and value sets; (3); contextualisation of global HTA guidance and (4) a move away from cost efficacy only metrics and adoption of MCDA approaches. This approach advances a model of contextual fairness and ethical pluralism, enabling LMICs to build HTA systems that reflect their own moral, historical, and public health priorities, offering a principled, equitable path forward for value-based healthcare reform.

Introduction

HTAs are increasingly used to guide funding decisions globally since utilising HTA measures such as CEA and CUA promises a more impartial allocation of healthcare resources focusing on efficiency considerations [1]. However, HTA is best understood as a broader process that incorporates multiple forms of evidence, not as a single methodological tool [1]. Even in high-income countries, cost-effectiveness analysis is not applied in isolation. For instance, the Canadian Drug Expert Committee considers unmet need, efficacy, safety, budget impact, and patient perspectives alongside cost-effectiveness [2], while the UK, Denmark and USA incorporate broader social and ethical factors within appraisal processes [3]. However, in LMIC contexts HTA may prioritise CEA/CUA due to donor or institutional pressures. As the application of HTAs extends into LMICs, deeper questions arise about what constitutes fairness and equity, who decides, and under what ethical conditions?

In many LMICs, including South Africa, where legacies of apartheid and colonialism have created stark inequities in health access and outcomes, importing value frameworks from high-income countries (HICs) may inadvertently entrench disadvantage [4]. This can occur through favouring interventions that produce the greatest aggregate health gains while overlooking historically marginalised groups whose healthcare needs are more complex and costly [5, 6]. In South Africa, equity cannot be divorced from its historical context. Under apartheid, certain demographic groups within the South African population were systematically denied access to quality healthcare, resulting in lasting disparities in disease burden and infrastructure [4, 5]. Primary care and associated initiatives (such as vaccination programmes), while efficient on a population level, may therefore disproportionately benefit already well-served or urban populations, including historically privileged groups [4]. Achieving true equity as opposed to generalised equality may therefore require prioritising interventions that redress past injustices even if such interventions appear inefficient in cost-effectiveness terms [7].

This commentary engages with broader ethical literature to propose a more context-sensitive framework for defining HTA guidelines in the LMIC context. The concept of utilitarian principlism is introduced and defined as a hybrid ethical framework that integrates the efficiency goals of utilitarianism with the normative safeguards of principlism to support context-sensitive, equitable decision-making in health policy. We propose a pragmatic approach to HTA in South Africa and other LMICs that balances cost-effectiveness with fairness by introducing a tailored MCDA framework to be supported by four key policy recommendations for more context-appropriate adoption. In doing so, we offer a practical path forward for LMICs like South Africa seeking to localise HTA without sacrificing justice, fairness and equity considerations necessary when considering socioeconomic disparities created by systemic inequality in these markets.

Value-based care and its discontents

At its core, value-based healthcare links resource allocation to measurable improvements in health [8]. This shift has catalysed the development of HTA agencies worldwide, supported by global donors and health financing institutions [9]. Yet the reliance on metrics like CEA or CUA analysis reflects a distinctly utilitarian ethic, where the goal is to maximise aggregate health gains regardless of underlying distribution of the population or systemic inequity [7].

Efficiency, in these contexts, can mask a failure of fairness and true equity without contextual understanding. Without tools that explicitly surface structural inequities, health systems risk enshrining injustice under the guise of a mathematically robust HTA framework.

The ethical shift: from utilitarianism to utilitarian principlism

Global health ethics has increasingly embraced utilitarianism, an approach focused on maximising overall health benefit, often measured in life years or aggregate population outcomes [10]. Principlism, on the other hand, rests on four cornerstones: autonomy (respecting individual choice), beneficence (doing good), non-maleficence (avoiding harm), and justice (fairness and equity) [11]. As HTA practices are adopted across LMICs, achieving the right balance between maximizing overall health benefits and principilism will be key in ensuring system inequity is appropriately allowed for.

We therefore propose an alternative lens: a term we coin Utilitarian Principlism. This hybrid model acknowledges the need for efficiency in resource-scarce settings but insists on embedding justice, proportionality, and contextual relevance into decision-making. While bearing resemblance to hybrid frameworks such as Daniels’ Accountability for Reasonableness and Sen’s Capability Approach, utilitarian principlism differs in that it explicitly integrates economic efficiency with the four principles of principlism within a single evaluative structure [12, 13]. In contrast, Accountability for Reasonableness emphasises procedural fairness, and the Capability Approach prioritises expansion of human freedoms over aggregate efficiency. Our proposal aims to operationalise ethical pluralism within HTA decision-making while retaining cost-effectiveness as one, but not the only, criterion. Our proposal does not reject economic evaluation but it repositions it within a broader ethical landscape necessary for robust decision making in settings like South Africa. We also recognise that the integration of principlism into HTA will be shaped by institutional capacity, governance structures, and political will. These factors may constrain the extent to which principlism can be operationalised, even where the ethical rationale is clear.

While introducing broader considerations may be ambitious in contexts where HTA systems are still being implemented, we argue that embedding ethical safeguards early can help avoid entrenching inequitable practices that may be harder to reform later.

Empirical case studies: misalignment of utility metrics and the role of socioeconomic context in South Africa

Two recent studies by the authors (currently under peer review) empirically demonstrate the limitations of using international value sets in South African CEA and of assuming population homogeneity. Together, they demonstrate the need for locally derived utility weights and a contextually grounded, equity-oriented approach to HTA (these findings should be regarded as provisional, as both studies are currently under peer review). While not definitive, these studies indicate the types of empirical challenges that arise when international value sets are applied in South Africa. Importantly, these findings align with earlier published work by Jelsma and Ferguson (2004), which also demonstrated that sociodemographic and cultural diversity significantly influenced self-reported health-related quality of life in South Africa [14]. This corroboration suggests that the misalignment between international value sets and local health perceptions is not unique to our dataset, but reflects a broader and persistent challenge.

In the first study, 148 patients with stage IV non-small cell lung cancer were assessed using the EQ-5D-5 L instrument and a visual analogue scale (VAS) to capture patient-perceived health status [15]. Utility scores were derived using both UK and Zimbabwe crosswalk value sets as these two international value sets are sometimes used in HTA in South Africa as proxies given the absence of a South African-specific utility weight [14]. While the correlation between UK and Zimbabwe utility scores was extremely high (r = 0.958), correlations between patient-reported VAS scores and the UK and Zimbabwe utility scores were only modest and negative (r = − 0.518 for UK, − 0.466 for Zimbabwe). These results suggest that although UK and Zimbabwe utility scores produce internally consistent utility estimates, they both fail to reflect the lived health perceptions of a set of South African patients.

Building on this, a second study employed a Generalised Linear Modelling approach to explore predictors of VAS scores in the same patient cohort [16]. This analysis found that incorporating demographic variables that capture historical inequities significantly improved model fit and explained variation in self-reported health beyond what could be attributed to health state classification alone. This model therefore offers a more context-sensitive alternative to relying on internationally derived utility weights, particularly relevant in settings where local tariffs are unavailable and VAS scores are often used as proxies for health utility. By accounting for demographic heterogeneity within South Africa, the model highlights the limitations of applying a single standard value set in South Africa.

Taken together, these studies highlight a deeper structural problem with using existing CEA and CUA analyses in isolation: LMICs remain epistemically dependent on utility metrics derived from populations that are likely to be demographically and socioeconomically different, with limited applicability to their own citizens. This is not merely a methodological gap, but a systemic flaw where value is defined through the lens of others, distorting local HTA decisions and undermining legitimacy. Addressing this misalignment requires more than recalibrating value sets; it requires a rethinking of how value is conceptualised, contextualised, and validated in diverse policy environments.

While some health economists might argue that developing local EQ-5D-5 L value sets may resolve these limitations, practical and infrastructural challenges in countries like South Africa complicate this path. Developing robust, population-representative utility weights requires substantial investment in research infrastructure, technical expertise, and sustained funding which is often scarce in LMICs [6]. Moreover, South Africa’s own population is not demographically homogenous as is demonstrated by the second empirical study under review; historical divisions along racial, linguistic, and socio-economic lines create significant intra-country variability in health status, perceptions and values. Designing a single, representative national value set under such conditions is not only logistically difficult, but ethically fraught, as it risks flattening differences that are essential to address in the pursuit of true equity.

Contextual equity and the limits of numerical proxies

Alternative models of health from non-Western paradigms offer useful correctives. Ubuntu in sub-Saharan Africa, for instance, defines health as relational harmony, not just physiological wellbeing [17, 18]. The Andean cosmovisión conceptualises wellness as balance with nature and community [19, 20]. These holistic views challenge the abstraction of health into cardinal utilities and demand a richer engagement with local values.

For South Africa, the most salient equity dimensions include race, socioeconomic status, geography (urban versus rural access), and gender, all of which continue to be associated with differential health outcomes [21]. These factors are directly linked to the legacies of apartheid and colonialism, which left stark disparities in infrastructure, income, and life expectancy. Incorporating these dimensions into HTA requires tools that can capture not only aggregate health gains but also distributional effects across these subgroups.

We argue for the adoption of contextualised fairness, a principle that foregrounds local history, ethics, and social realities in defining value. Rather than applying cost-effectiveness thresholds uniformly and in isolation to guide funding decisions, contextualised fairness encourages deliberation about which interventions promote not just health gain, but social repair.

Enacting ethical pluralism through MCDA

Ethical pluralism is the view that there is more than one valid moral principle or ethical framework that can guide human behaviour, and that these principles may sometimes conflict without one being universally superior to the others [22]. One promising vehicle for implementing contextualised fairness is MCDA. MCDA frameworks allow decision-makers to incorporate diverse considerations such as unmet need, disease severity, strategic public health goals, and social vulnerability alongside cost-effectiveness [23]. It is important to note, however, that MCDA should not be reduced to a purely quantitative scoring exercise. As Baltussen et al. (2019) argue, the value of MCDA lies in supporting structured deliberation, transparency, and stakeholder input, rather than mechanical application of weights and scores [24]. International experience (such is in the Netherlands, UK, and Ghana) shows that deliberative MCDA approaches can embed ethical and contextual considerations without overcomplicating or obscuring the decision-making process [25]. We therefore position MCDA as a deliberative framework consistent with utilitarian principlism, rather than a narrow technocratic tool. Trade-offs are made explicit rather than assumed, creating space for deliberation and stakeholder input. Importantly, CEA is retained but should be based on locally derived value sets and repositioned as one criterion among many to address population heterogeneity. This approach recognises both the strengths and limitations of pure health economic evaluation and ensures that no single metric becomes dominant in line with a utilitarian principlism approach.

Internationally, similar MCDA-like approaches have been adopted in LMICs such as Ghana, Indonesia, and Thailand to reflect local values and health priorities [23]. While not always labelled as “utilitarian principlism,” these approaches share the ethos of balancing efficiency with fairness in complex, resource-constrained environments. The absence of consensus on a single methodological framework underscores the importance of flexibility. LMICs can therefore adapt a range of pluralistic approaches that align with their local values and constraints, rather than committing one dominant model.

In the South African context, MCDA could be operationalised through criteria that reflect both global best practice and local priorities. Criteria should be informed by international best practice approaches to designing MCDAs but adapted to South African circumstances. These include clinical effectiveness [26], disease burden and severity [27], equity and fairness [28], budget impact [28], societal values [27], innovation [29], and cost-effectiveness [30]. Incorporating such criteria would require stakeholder involvement extending beyond technical experts to include patient groups, civil society, and provincial health authorities, reflecting South Africa’s diverse and divided society [25]. Inevitably, trade-offs will arise. For example, prioritising interventions that advance equity goals may appear less efficient in cost-effectiveness terms. Making these trade-offs explicit through structured deliberation is essential to ensuring transparency and legitimacy.

We note that a limitation of this approach is the potential for conflicts to arise between the principles such as autonomy vs. beneficence. It may also lead to inconsistencies in decision making over time. This therefore requires a participative approach such as community engagement platforms to inform priority setting as is done in certain LMIC contexts [31].

Policy recommendations

For LMICs to reshape HTA guidelines in a way that reflects their own ethical and historical contexts, we recommend four key policy shifts:

1. Ethical adaptation of methodology: As methods evolve, so must ethical frameworks. Utilitarian principlism provides a structure for embracing efficiency when needed, but never at the cost of fairness, equity or transparency.

2. Localisation of HTA: Rather than importing HIC frameworks wholesale, LMICs should adapt HTA tools to reflect local moral, political, and cultural priorities. We note that South Africa already has HTA guidelines which include provisions for patient values, preferences, and acceptability 1. However, these provisions remain relatively underdeveloped in practice, and institutionalisation of HTA is still at an early stage. Our proposal for utilitarian principlism is not intended to replace existing guidelines, but to provide a conceptual scaffold that can strengthen and extend them as national health insurance (NHI) reforms progress. This includes developing local utility weights reflective of the population, stakeholder engagement processes, and constitutional alignments. The generalized linear model developed by the authors in the second empirical study described above provides one option.

3. Contextualising global guidance: Donors and global HTA agencies can support local capacity-building. This means funding empirical work in LMICs, encouraging ethical debate, and legitimising local definitions of value.

4. Moving from solely efficacy-based metrics to adoption of MCDA approaches: CEA and CUA analysis should be treated as informative, not definitive. Where statistical proxies diverge from patient perspectives or reinforce inequity, decision-makers should have ethical latitude to choose otherwise.

Conclusion

This commentary advances two central arguments in the ongoing debate around equitable health priority-setting in LMICs. First, there is a fundamental need for locally derived utility weights. Evidence from the authors’ recent study of stage IV lung cancer patients in South Africa shows that internationally developed utility scales (such as the UK and Zimbabwe EQ-5D value sets) correlate poorly with patient-reported health status measured via VAS. This misalignment is not a trivial technical issue but instead it reflects a deeper structural inequity, whereby LMICs are compelled to base resource allocation on foreign metrics that fail to capture local realities. A second study by the authors further underscores that socio-demographic variables are statistically significant predictors of perceived health. These findings imply that even locally derived utility weights will need to account for profound population heterogeneity rooted in historical inequality. However, developing such granular value sets is often prohibitively costly and complex, particularly in diverse, resource-constrained settings like South Africa. Moreover, the scarcity of disaggregated data on health inequalities and subgroup differences poses a practical limitation to implementing more equity-sensitive HTA. Building data infrastructure and governance systems that enable such analyses will be essential if contextualised approaches are to move from principle to practice.

Secondly, cost-effectiveness should not be treated as a standalone proxy for value. The demonstrated variation in patient-perceived health across demographic lines illustrates that clinical metrics alone cannot capture what matters most to patients. In this context, MCDA offers a compelling solution. MCDA provides a structured framework to integrate efficiency with justice, equity, and contextual relevance. It enables policymakers to make transparent, contestable trade-offs between competing priorities, rather than defaulting to CEA as a dominant criterion.

As South Africa moves toward implementing NHI and more formalised HTA processes, this pluralistic, context-sensitive approach becomes not just desirable but necessary. LMICs have an opportunity to lead by building models that reflect their unique ethical, historical, and demographic contexts rather than by mimicking existing global frameworks. By combining rigorous economic evaluation with grounded ethical reasoning, countries like South Africa can shape a more legitimate, equitable, and locally resonant path forward in value-based healthcare.

South Africa’s experience also resonates with broader LMIC debates. Ghana, for example, has pioneered deliberative MCDA approaches to reflect local priorities; Thailand has embedded social values and severity criteria into HTA; and India has grappled with incorporating equity considerations within a fragmented health financing landscape [23]. By situating South Africa within this comparative landscape, we underscore that the challenges of contextualising HTA are shared across LMICs, though the solutions must be locally adapted.

We acknowledge the limitations of this commentary, including reliance on provisional empirical findings, the scarcity of disaggregated data, and the influence of institutional and political constraints on the adoption of ethical frameworks. We also note that proposals such as utilitarian principlism and MCDA risk adding complexity if not implemented carefully. These limitations notwithstanding, we believe that our recommendations contribute meaningfully to ongoing debates about context-sensitive HTA in South Africa and other LMICs.

Author contributions

Conceptualization, C.S. and R.H.; methodology, C.S.; validation, R.H.; formal analysis, C.S.; investigation, C.S.; resources, C.S.; data curation, C.S.; writing: original draft preparation, C.S.; writing: review and editing, C.S. and R.H.; supervision, R.H.; project administration, R.H. All authors have read and agreed to the published version of the manuscript.

Funding

No funding received.

Data availability

Data sharing is not applicable to this article as no data were created or analysed in this study.

Declarations

Ethics approval and consent to participate

Not applicable.

Disclosure

Not applicable.

Paper context

Main findings: Traditional approaches to health economics that prioritise efficiency fail to capture ethical and contextual nuances relevant to resource-limited settings.

Added knowledge: This paper introduces the concept of utilitarian principlism to guide equitable healthcare decision-making in contexts of scarcity and historical inequality and provides four key policy recommendations to aid adoption of global HTA frameworks in LMICs.

Global health impact for policy and action: Reframing health economics through an ethically pluralistic lens offers a more equity based, context-appropriate framework for healthcare prioritisation in low- and middle-income countries.

Competing interests

The authors declare no competing interests.