Why a framework?

South Africa’s population has multiple diverse health needs. There are many challenging decisions about what health services and health interventions will or will not be covered by the National Health Insurance with a limited budget.
Why a framework?

This priority-setting for health raises many ethical questions about how to use scarce resources. Decision-makers must balance the needs of individuals with the broader health needs of the population, accounting for equity considerations and the many ways that health interventions impact other aspects of wellbeing.

An ethics framework can help navigate these challenging decisions and trade-offs, providing a method and structure for exploring morally relevant ethics considerations associated with a decision, not just focusing on cost effectiveness.


A diverse stakeholder working group developed this Framework in South Africa, supported by an international and in-country research team. The Framework was then tested in 3 provinces in South Africa.


An Ethical Framework with 12 domains. Each domain has an explanation several questions to guide the decision-making process. The Framework was designed to apply after a health intervention is proposed for inclusion or prioritisation and selected for review. It lays out a set of morally relevant considerations to inform the types of evidence that are gathered and guide discussions and deliberations during the appraisal. In line with good practices for evidence-informed decision-making, those using the framework should search for the best available evidence for each domain, assessing the rigour, quality, and relevance of the data to the South African setting, while recognizing that there may be limited or different types of evidence for different kinds of morally relevant considerations.


The SAVE-UHC approach consisted of two phases. In Phase I, the research team convened and facilitated a national multi-stakeholder working group to develop a provisional ethics framework through a collaborative, engagement-driven process. In Phase II, the research team refined the model framework by piloting it through three simulated HTA appraisal committee meetings. Each simulated committee reviewed two case studies of sample health interventions: opioid substitution therapy and either a novel contraceptive implant or seasonal influenza immunization for children under five.

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