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

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. 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. 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 ^{Footnote 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. 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. 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.