From Cost-Effectiveness to Legitimacy: A Systematic Review of Governance in Essential Medicines and Diagnostics Priority Setting in sub-Saharan Africa
1
Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
2
Division of Health Systems and Public Health, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
3
Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
4
Department of Internal Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
5
Department of Surgery, Nelson R Mandela School of Medicine, College of Health Sciences, Durban, South Africa
6
Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
BACKGROUND:
Constrained resources necessitate difficult and often politically mediated decisions about funding essential medicines and diagnostics. Explicit priority setting is essential for equitable and sustainable Universal Health Coverage (UHC), and COVID-19 exposed the limitations of implicit rationing, accelerating interest in evidence-informed deliberative processes. In sub-Saharan Africa (SSA), priority-setting activity has expanded, but remains constrained by limited technical capacity, fragmented governance, donor influence, and weak institutionalisation of Health Technology Assessment (HTA). This review assessed how explicit frameworks have been applied to primary healthcare (PHC) essential medicines and diagnostics selection in SSA.
METHODS:
We conducted a systematic review of priority-setting applications informing the selection of essential medicines and diagnostics in SSA. We searched bibliographic databases and grey literature from January 2000 to July 2025. Information was extracted in duplicate and synthesised thematically. We assessed implementation fidelity using Carroll’s framework and appraised reporting quality using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. Policy uptake was explored through ministry and guideline repositories.
RESULTS:
Across 84 studies, cost-effectiveness analysis dominated (n=59), while deliberative approaches were uncommon (Multicriteria Decision Analysis, n=3; Accountability for Reasonableness, n=1). Evaluations were largely externally led, with SSA-based first/senior authorship in 30% and funding predominantly international. Most analyses were model-based (71%), but advanced dynamic/microsimulation modelling was uncommon, and 68% relied on secondary data. Ministries of Health participated in only 7%, and stakeholder engagement was seldom reported (6%). The integration of equity considerations, implementation capacity, and financial sustainability into decision-making remained uneven. Policy uptake was evident in 36 studies, but limited by donor dependence, fragmented governance, and weak HTA institutionalisation.
CONCLUSIONS:
Priority setting for essential medicines and diagnostics in SSA remains institutionally fragile. Strengthening ministry stewardship, domestic technical analytic capacity, deliberative processes, and systematic integration of equity, affordability, and feasibility criteria will promote sustainable and accountable progress towards UHC. PROSPERO: CRD420251129191.
Constrained resources necessitate difficult and often politically mediated decisions about funding essential medicines and diagnostics. Explicit priority setting is essential for equitable and sustainable Universal Health Coverage (UHC), and COVID-19 exposed the limitations of implicit rationing, accelerating interest in evidence-informed deliberative processes. In sub-Saharan Africa (SSA), priority-setting activity has expanded, but remains constrained by limited technical capacity, fragmented governance, donor influence, and weak institutionalisation of Health Technology Assessment (HTA). This review assessed how explicit frameworks have been applied to primary healthcare (PHC) essential medicines and diagnostics selection in SSA.
METHODS:
We conducted a systematic review of priority-setting applications informing the selection of essential medicines and diagnostics in SSA. We searched bibliographic databases and grey literature from January 2000 to July 2025. Information was extracted in duplicate and synthesised thematically. We assessed implementation fidelity using Carroll’s framework and appraised reporting quality using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. Policy uptake was explored through ministry and guideline repositories.
RESULTS:
Across 84 studies, cost-effectiveness analysis dominated (n=59), while deliberative approaches were uncommon (Multicriteria Decision Analysis, n=3; Accountability for Reasonableness, n=1). Evaluations were largely externally led, with SSA-based first/senior authorship in 30% and funding predominantly international. Most analyses were model-based (71%), but advanced dynamic/microsimulation modelling was uncommon, and 68% relied on secondary data. Ministries of Health participated in only 7%, and stakeholder engagement was seldom reported (6%). The integration of equity considerations, implementation capacity, and financial sustainability into decision-making remained uneven. Policy uptake was evident in 36 studies, but limited by donor dependence, fragmented governance, and weak HTA institutionalisation.
CONCLUSIONS:
Priority setting for essential medicines and diagnostics in SSA remains institutionally fragile. Strengthening ministry stewardship, domestic technical analytic capacity, deliberative processes, and systematic integration of equity, affordability, and feasibility criteria will promote sustainable and accountable progress towards UHC. PROSPERO: CRD420251129191.
| eISSN: | 2654-1459 |
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