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.