This commentary, Beyond cost-effectiveness: a reflective commentary on adapting global health technology assessment for equity considerations in South Africa and other LMICs, published in the International Journal for Equity in Health on 14 November 2025, examines the limits of applying global HTA frameworks—especially cost-effectiveness analysis—in low- and middle-income countries.
Authored by Chantel Siriram and Roseanne Harris, the paper argues that traditional CEA and CUA methods often fail to reflect the ethical, social and historical realities of contexts like South Africa. Drawing on two empirical studies by the authors, it shows that internationally developed EQ-5D value sets correlate poorly with South African patients’ reported health status and are strongly influenced by sociodemographic factors, underscoring the need for locally derived utility weights. The authors propose utilitarian principlism, a hybrid ethical framework that blends efficiency with principled safeguards, and call for four policy shifts: adapting economic methods ethically, localising HTA tools, contextualising global guidance, and adopting multi-criteria decision analysis (MCDA). Their approach charts a fairer, more context-sensitive path for value-based healthcare reform in LMICs.