A Structured MCDA‐Based Decision Framework for Funding Decisions in South Africa: An Illustrative Case Study

Health technology assessment (HTA) in South Africa operates in the absence of formal, nationally adopted health economic guidelines, creating challenges for consistent and transparent healthcare funding decisions. While international frameworks provide useful reference points, their direct application may be inappropriate in a highly unequal, resource‐constrained setting characterised by a dual public‐private healthcare system. This paper proposes a structured decision‐support framework for health technology funding decisions in South Africa that integrates international best practices with contextual considerations relevant to the local health system. The framework addresses three key limitations of conventional cost‐effectiveness approaches: the subjectivity inherent in quality‐adjusted life year (QALY) measurement, the limited consideration of affordability and budget constraints, and the incomplete inclusion of treatment pathway costs. A normative reference‐case multi‐criteria decision analysis (MCDA) framework was developed through a structured four‐stage process involving a targeted review of international HTA and MCDA frameworks, contextual adaptation to the South African setting, and the identification, grouping, and weighting of decision criteria using explicit normative judgement. The resulting framework incorporates clinical effectiveness, disease burden and severity, equity and fairness, budget impact, societal acceptance, innovation, and cost‐effectiveness within a transparent decision‐making structure. An illustrative application using advanced non‐small cell lung cancer demonstrates how funding recommendations may differ when broader value considerations are incorporated alongside conventional incremental cost‐effectiveness ratio (ICER) estimates. The framework makes explicit the value judgements that underpin healthcare funding decisions and provides a transparent reference case for examining the implications of alternative weighting assumptions through scenario and sensitivity analyses. While not intended as a prescriptive national guideline, the framework offers a practical foundation for structured, context‐sensitive decision‐making and contributes to ongoing discussions regarding equitable priority setting in South Africa and other upper‐middle‐income countries facing similar health system constraints.