In the evolving landscape of global health, the traditional frameworks used to evaluate medical interventions—primarily cost-effectiveness analyses—are increasingly being recognized as insufficient in addressing the multifaceted realities faced by low- and middle-income countries (LMICs). A groundbreaking commentary by Siriram and Harris, published in the International Journal for Equity in Health, delves into the pressing need to adapt health technology assessments (HTAs) to better embrace equity considerations, particularly within the South African context and similar LMIC settings. This insightful reflection challenges the conventional paradigms and urges a critical rethinking of how health priorities are set in resource-limited environments.
Health technology assessment, a multidisciplinary process designed to evaluate the social, economic, organizational, and ethical issues of a health intervention or health technology, has long been dominated by cost-effectiveness metrics. These metrics predominantly focus on maximizing health outcomes per unit of cost, often neglecting how benefits and burdens are distributed across different social groups. The commentary posits that this focus inadequately captures the complexities of health inequities prevalent in LMICs, where socioeconomic disparities and historical injustices severely affect health access and outcomes. By sidelining equity, traditional HTAs risk inadvertently perpetuating systemic health disparities.
The authors underscore South Africa as a poignant case study, given its stark socio-economic gradients and a legacy deeply imprinted by apartheid-era inequalities. This context illustrates vividly how cost-effectiveness-driven decisions can fall short when applied to heterogeneous populations with divergent health risks and access profiles. In countries like South Africa, health technologies or interventions that appear cost-effective on average may, in practice, exacerbate inequities by privileging already advantaged groups. Thus, the need arises for HTAs that are sensitive to equity concerns and capable of informing policies that promote both efficiency and fairness.
One of the central technical challenges addressed is the operationalization of equity within HTA frameworks. Equity, as a normative concept, is multifaceted—encompassing dimensions such as socioeconomic status, geographic location, gender, ethnicity, and disability. Integrating these into quantitative models requires metrics that reflect distributional impacts rather than aggregate benefits alone. Siriram and Harris advocate for incorporating equity weights in decision analytic models to better capture trade-offs between efficiency and fairness. These weights adjust the value attributed to health gains depending on who benefits, prioritizing disadvantaged populations where necessary.
The commentary further critiques the prevalence of utilitarian approaches that dominate global HTA practices. Utilitarianism, with its focus on aggregate utility maximization, may overlook concerns around fairness and justice, which are central to equitable healthcare provision. The authors argue for a pluralistic ethical framework in HTA processes that can reconcile efficiency with equity. This calls for methodologies that incorporate stakeholder engagement and deliberative processes, ensuring that diverse societal values inform health priority setting.
Data limitations present another formidable obstacle in adequately addressing equity. In many LMICs, robust disaggregated data on health outcomes and determinants are scarce or incomplete. This gap constrains the ability of modelers to reliably estimate how interventions affect different social strata. Siriram and Harris emphasize the need for investments in health information systems that capture granular equity-relevant data. Enhanced data capabilities enable more precise modeling of the differential impacts of technologies among subpopulations, thereby improving the evidence base for equitable policymaking.
A critical dimension of this equity-focused HTA adaptation concerns the integration of social determinants of health. Factors such as education, housing, nutrition, and employment significantly influence health outcomes, yet traditional HTA models seldom account for these complexities. The commentary advocates for interdisciplinary approaches that blend clinical outcomes with social science insights, enabling a more holistic assessment of intervention impacts beyond the health sector. Such incorporation is vital for addressing root causes of disparities rather than merely managing their clinical manifestations.
Policy implications of shifting HTA paradigms towards equity are profound. Allocating healthcare resources with an equity lens may require sacrificing some aggregate health gains to improve outcomes in marginalized groups. This deliberate trade-off challenges policymakers and health economists who are accustomed to efficiency-driven metrics. However, the authors argue convincingly that sustainable health improvements in LMICs hinge on inclusive approaches that rectify entrenched inequities rather than perpetuate them under the guise of cost-effectiveness.
Siriram and Harris also discuss the practicality of implementing equity-inclusive HTAs in LMIC settings. They caution that resource constraints and capacity limitations complicate the adoption of more complex assessment frameworks. Nonetheless, they highlight innovative approaches emerging from South Africa and other LMICs where local adaptations of HTA methodologies incorporate equity considerations within existing institutional contexts. These case examples demonstrate that with political will and stakeholder engagement, it is feasible to embed equity into HTA processes even where resources are limited.
The commentary further addresses the global health governance landscape and the role of international organizations in promoting equity-oriented HTA practices. It calls on entities such as the World Health Organization and development partners to support capacity-building and knowledge sharing that prioritize equitable evaluation frameworks. Such support is essential to harmonize efforts across countries and prevent the marginalization of equity perspectives in global policy dialogues dominated by economic efficiency narratives.
Siriram and Harris also touch on the ethical imperative of equity in health technologies during pandemics and public health emergencies. The COVID-19 pandemic exposed widespread disparities in access to vaccines and therapeutics, highlighting the limitations of conventional HTA processes under crisis conditions. Incorporating equity considerations into emergency health technology assessments can guide more just and effective resource allocation when time and stakes are high.
Moreover, the authors stress that equity-adapted HTAs must remain context-specific, tailored to the unique social, cultural, and epidemiological realities of each country. This implies that standardized global guidelines need flexible frameworks accommodating local priority settings and equity notions. Successful integration of equity into HTA is not a one-size-fits-all endeavor but a nuanced process guided by local expertise and inclusive consultation.
Finally, the article ends on a visionary note, calling on researchers, policymakers, and practitioners to co-create the next generation of HTA methodologies with equity at their core. By moving beyond the narrow confines of cost-effectiveness, health technology assessments in LMICs can become powerful tools for social justice, ultimately contributing to healthier, fairer societies. This transformative agenda resonates strongly in an era where the global health community increasingly recognizes that efficiency divorced from equity risks deepening rather than closing gaps in health outcomes worldwide.
Subject of Research:
Adapting global health technology assessment frameworks to integrate equity considerations in low- and middle-income countries, focusing on the South African context.
Article Title:
Beyond cost-effectiveness: a reflective commentary on adapting global health technology assessment for equity considerations in South Africa and other LMICs.
Article References:
Siriram, C., Harris, R. Beyond cost-effectiveness: a reflective commentary on adapting global health technology assessment for equity considerations in South Africa and other LMICs. Int J Equity Health 24, 316 (2025). https://doi.org/10.1186/s12939-025-02676-z
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