Health Without Borders: Governance, Equity, and Priority Setting for Essential Medicines and Diagnostics in sub-Saharan Africa – A Systematic Review
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:
Health Without Borders requires priority-setting that promotes equitable, inclusive, and sustainable resource allocation. In sub-Saharan Africa (SSA), limited resources, cross-border health challenges, and donor financing complicate trade-offs in selecting essential medicines and diagnostics for primary healthcare (PHC). Health Technology Assessment (HTA), Multi-Criteria Decision Analysis (MCDA), and procedural justice approaches may strengthen transparency and accountability, but their role in SSA is poorly documented.
METHODS:
We systematically reviewed empirical applications of explicit priority-setting and economic evaluations for selecting PHC essential medicines and diagnostics in SSA. Bibliographic databases and grey literature were searched from January 2000 to 8 July 2025. Information was extracted in duplicate and analysed thematically. Carroll’s framework was used to assess implementation fidelity against global standards for HTA, MCDA, Accountability for Reasonableness (A4R), and Evidence and Values: Impact on Decision-Making. We appraised reporting quality using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist and explored policy uptake through ministry repositories.
RESULTS:
In 84 included studies, cost-effectiveness analysis predominated (n=59); deliberative approaches were rarely applied (MCDA, n=3; A4R, n=1; Program Budgeting and Marginal Analysis, n=0). Few studies used primary data; 68% relied on secondary sources. Among studies reporting cost-effectiveness thresholds (55%), gross domestic product–based rules were frequently used (57%). Ministries of Health participated in 7% of evaluations, and stakeholder engagement was mentioned in 6%. Equity, feasibility and budget impact were rarely addressed. Governance fragmentation and donor dependence constrained decision uptake, but deliberative participation in some cases suggested potential for more responsive and regionally coherent Universal Health Coverage (UHC).
CONCLUSIONS:
Evidence-informed priority-setting tools have been used inconsistently to guide essential medicine and diagnostic selection in SSA. Strengthening domestic capacity and integrating equity, affordability, and feasibility criteria in ministry-led deliberative processes may foster legitimate, sustainable resource allocation, supporting the extension of UHC to marginalised and mobile populations. PROSPERO registration: CRD420251129191.
Health Without Borders requires priority-setting that promotes equitable, inclusive, and sustainable resource allocation. In sub-Saharan Africa (SSA), limited resources, cross-border health challenges, and donor financing complicate trade-offs in selecting essential medicines and diagnostics for primary healthcare (PHC). Health Technology Assessment (HTA), Multi-Criteria Decision Analysis (MCDA), and procedural justice approaches may strengthen transparency and accountability, but their role in SSA is poorly documented.
METHODS:
We systematically reviewed empirical applications of explicit priority-setting and economic evaluations for selecting PHC essential medicines and diagnostics in SSA. Bibliographic databases and grey literature were searched from January 2000 to 8 July 2025. Information was extracted in duplicate and analysed thematically. Carroll’s framework was used to assess implementation fidelity against global standards for HTA, MCDA, Accountability for Reasonableness (A4R), and Evidence and Values: Impact on Decision-Making. We appraised reporting quality using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist and explored policy uptake through ministry repositories.
RESULTS:
In 84 included studies, cost-effectiveness analysis predominated (n=59); deliberative approaches were rarely applied (MCDA, n=3; A4R, n=1; Program Budgeting and Marginal Analysis, n=0). Few studies used primary data; 68% relied on secondary sources. Among studies reporting cost-effectiveness thresholds (55%), gross domestic product–based rules were frequently used (57%). Ministries of Health participated in 7% of evaluations, and stakeholder engagement was mentioned in 6%. Equity, feasibility and budget impact were rarely addressed. Governance fragmentation and donor dependence constrained decision uptake, but deliberative participation in some cases suggested potential for more responsive and regionally coherent Universal Health Coverage (UHC).
CONCLUSIONS:
Evidence-informed priority-setting tools have been used inconsistently to guide essential medicine and diagnostic selection in SSA. Strengthening domestic capacity and integrating equity, affordability, and feasibility criteria in ministry-led deliberative processes may foster legitimate, sustainable resource allocation, supporting the extension of UHC to marginalised and mobile populations. PROSPERO registration: CRD420251129191.
| eISSN: | 2654-1459 |
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