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Public Health: The Forgotten Dimension of Health Technology Assessment

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19 August 2026

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21 August 2026

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Abstract
Rationale. Health technology assessment (HTA) is the principal instrument wealthy health systems use to decide what to fund, and it measures the health a technology adds for treated patients rigorously. Yet population-health considerations—disease burden, prevention, externalities such as herd protection, fairness between groups, and democratically chosen priorities—are weakly built into how HTA judges value. Aims and objectives. To specify the nature of this gap and to offer a conceptual framework that clarifies it: to distinguish three paradigms of value assessment (clinical, cost-effectiveness and public-health HTA), and to separate two frequently conflated ideas—respecting public-health priorities versus yielding to political pressure. Method. A conceptual analysis informed by a narrative reading of HTA methodological guidance and the health-economics, public-health and priority-setting literatures. Results. First, contemporary HTA clusters around two paradigms—clinical assessment and cost-effectiveness assessment—while a population-health paradigm is named but instantiated in no major agency’s reference case. Second, public-health objectives (burden, prevention, transmission externalities, distribution, priorities) are only partially operationalised—acknowledged but rarely weighed in the formal value calculation. Third, the three-paradigm model shows the gap is systematic, not incidental: today’s methods ask “does it help the patient?” and “how much health per euro?”, seldom “how do we improve population health, fairly?”. Fourth, the gap is tractable—the necessary instruments exist and are compatible with opportunity cost, and two common objections (that QALYs already capture population value, and that priorities equal interference) do not withstand scrutiny. Conclusion. A public-health-informed HTA—explicit disease-burden assessment, transmission modelling, transparent treatment of priorities and formal equity analysis—could better align appraisal with population health, fairly distributed. We call on EUPHA and HTAi to convene a joint working group.
Keywords: 
technology assessment
;  
biomedical
;  
public health
;  
population health
;  
quality-adjusted life years
;  
cost of illness
;  
health priorities
;  
health equity
Subject: 
Public Health and Healthcare  -   Public Health and Health Services

Introduction

Every health system has to choose. Budgets are limited, new treatments are expensive, and a euro spent on one thing cannot be spent on another. Over the past forty years, most wealthy countries have built a formal way of making these choices, called health technology assessment, or HTA [1,2]. Its job is to tell decision-makers how well a new treatment works, what it costs, and whether it is worth funding [3]. As medicine advances and prices climb, HTA has become the gatekeeper that decides which treatments a health system will pay for [4].
HTA does one thing extremely well. It measures, with real rigour, how much health a treatment adds for the patient who receives it, and what that health gain costs. The trouble is that public health asks a different kind of question. Public health is about the health of whole populations, how common and how damaging a disease is, whether illness can be prevented, whether the benefits and burdens are shared fairly, and what goals a society has chosen for itself [5,6]. These are not the same as the questions HTA is built to answer, and the gap between them matters for real decisions [7].
It would be easy to overstate the problem, so let us be precise. We are not claiming that HTA ignores public health; it plainly does not. Our argument is narrower and, we think, more useful: HTA has no agreed, transparent method for letting population-health goals count in its judgment of what a treatment is worth. The burden a disease places on society, the value of preventing it, fairness between groups, and the priorities a country has openly set tend to sit outside the formal calculation, mentioned, perhaps, but not measured or weighed in a consistent way.
This article is a conceptual analysis. We first define our terms in plain language. We then offer a simple lens, three different questions HTA can ask, that organises the rest of the argument. We use vaccines as the clearest worked example, look briefly at France’s attempt to score public-health value, give QALYs a fair hearing, take the objections to our argument seriously, and separate two ideas that are often confused: respecting public-health priorities versus bowing to political pressure. We keep the discipline of opportunity cost in view throughout, and close with practical reforms.

Methods

This is a conceptual analysis rather than an empirical study; it generates no primary data. Our approach had three components. First, we undertook a purposive, narrative reading of the methodological guidance and reference cases of major HTA bodies, including the English National Institute for Health and Care Excellence, Germany’s IQWiG, France’s Haute Autorité de Santé, and the European Union’s Joint Clinical Assessment,to characterise how each defines and operationalises value [18,19,20,28]. Second, we read across the health-economics literature on cost-effectiveness, opportunity cost and the QALY, and the public-health, priority-setting and equity literatures, to identify which population-health considerations these traditions make explicit and which they leave implicit [6,32,34,41]. Third, from this reading we synthesised a conceptual typology, three paradigms of value assessment, and used it as an analytical lens to locate where population-health objectives enter, or fail to enter, appraisal. The analysis is interpretive rather than a systematic review; it yields a set of conceptual findings, stated explicitly in the next section and developed in those that follow, and these are offered to be tested against empirical practice.

Results

The analysis yields four conceptual findings, stated here and developed in the sections that follow.
Finding 1: contemporary HTA clusters around two paradigms. Across the major systems, value is operationalised either as clinical added benefit assessed at the level of the individual patient, the European Union’s Joint Clinical Assessment, Germany’s IQWiG and the French clinical-benefit appraisal [19,20,28], or as a cost per aggregate health gain, expressed in quality-adjusted life years (QALYs), as at NICE, CADTH and the PBAC [10,18,32]. A population-health paradigm is named in policy language and in the modern definition of HTA [3], but it is instantiated in no major agency’s reference case.
Finding 2: public-health objectives are only partially operationalised. Within these two paradigms, disease burden, prevention, transmission externalities such as herd protection, distributional fairness and democratically chosen priorities are routinely acknowledged but seldom enter the formal calculation of value in a consistent, transparent and weighted way [6,41]. Aggregate QALYs capture part of population value, but not burden, externalities, distribution or priorities [32].
Finding 3: the three-paradigm model reveals a systematic gap. Set side by side (Table 1), the paradigms show that contemporary methods reliably answer two questions, “does this help the patient?” and “how much cost a unit of health gain QALY?” but rarely the third, “how do we improve the health of the whole population, fairly?”. The omission is therefore structural, a property of the prevailing methodological architecture, rather than an oversight in particular appraisals.
Finding 4: the gap is methodologically tractable. The instruments required to operationalise the third paradigm already exist, standardized burden metrics [36,39], dynamic transmission models [8,22,40], multi-criteria decision analysis [48], and distributional and extended cost-effectiveness analysis [45,46], and each is compatible with the discipline of opportunity cost [34]. Two recurrent objections do not survive analysis: that aggregate QALYs already capture population value [32], and that honoring democratically chosen priorities is equivalent to political interference [44,47].

What We Mean by Public Health, Population Health and HTA

Because so much turns on words, we state ours plainly. By public health we mean the long-standing idea that it is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society [5]. By population health we mean the health outcomes of a group of people, including how those outcomes are distributed within the group [43]; a definition that deliberately puts the spread of health, not just the total, at the centre [50]. And by HTA we mean the structured, multidisciplinary process that uses explicit methods to judge the value of a health technology [3]. Our point is not that HTA never looks at populations, its economic models are built on populations, but that several core public-health ideas are only weakly built into how it decides what a technology is worth.

Three Different Questions HTA Can Ask

The clearest way to see the gap is to notice that “HTA” is not one thing. Underneath the label sit at least three different ways of judging value, each answering a different question.
Clinical HTA asks: does this help the patient in front of us? This is the tradition of the European Joint Clinical Assessment, of Germany’s IQWiG, and of the clinical-benefit ratings in France [19,20]. The unit of analysis is the individual patient, and the ethical instinct is a duty of care to that person. Public health is largely absent here, simply because the patient, not the population, is what is being measured.
Cost-effectiveness HTA asks: how much cost a unit of health gain? This is the tradition of NICE in England, of CADTH in Canada and PBAC in Australia [18]. The goal is to get the most health out of a fixed budget, which is a genuinely population-level objective. But,and this is the crucial point; maximizing total health is not the same as pursuing public health. A pure value-for-money calculation can conclude that money invested elsewhere would generate more health and so decline to back treatment for a condition a country has named a national priority [10]. That is not irrational; it is simply optimizing a different goal.
Public-health HTA asks: how do we improve the health of the whole population, fairly? This is the approach we argue is missing. Here, value for money still matters, a great deal—but it becomes one consideration among several, alongside the burden of disease, prevention, fairness, protection that spreads through a community, and democratically chosen priorities [41,48]. The three are summarized in Table 1.
One caution is worth stating up front, because it is easy to overreach. It would be wrong to say that cost-effectiveness HTA “is not population health.” It is a population-based framework, and a powerful one. The fairer statement is this: cost-effectiveness HTA maximises the total amount of health produced under budget constraint, whereas public-health policy pursues a broader set of aims, burden, prevention, fairness, resilience and chosen priorities, that include, but go beyond, simply producing the most health [44,48]. That formulation respects what economic evaluation does well while showing where it stops short.

What Today’s HTA Captures Well, and What Slips Through

Most HTA today sits in the first two columns of Table 1. Effectiveness is judged mainly through clinical trials that measure outcomes for individual patients, such as how long a treatment delays a disease or relieves symptoms [16]. Cost is then weighed against the health gained, usually in QALYs, quality-adjusted life years, where a year in full health counts as one and a year in poorer health counts as less [17]. This is careful, useful work. But several things that matter to public health tend to slip through:
How common and how damaging the disease is. Appraisals rarely weigh how many people a condition affects, or how much it shortens and worsens lives across a population, what specialists measure in DALYs, a yardstick of total burden [21]. A treatment for a disease affecting millions can be judged in exactly the same way as one for a rare condition.
Protection that spreads. For infections, treating or vaccinating one person can protect many others by slowing the spread, “herd protection.” Standard methods usually count only the benefit to the person treated, missing the wider gain [22,23].
What the country has chosen as a priority. Governments openly name priorities, cancer screening, heart-disease prevention, antimicrobial resistance, childhood vaccination [25]. HTA usually works without formal reference to them.
Fairness. A treatment that would narrow the health gap between rich and poor, or between regions, gets no special credit for doing so [26].
Prevention. Preventing illness pays off slowly, and standard methods discount benefits that arrive years later, which quietly penalizes prevention against treatments that act now [27].

Vaccines: The Clearest Example

Vaccines are where the gap between “helping the patient” and “helping the population” is widest, which makes them a kind of natural experiment for the limits of patient-centred HTA. Take vaccination against human papillomavirus (HPV), given mostly to adolescents to prevent cervical and other cancers decades later. Almost everything that standard appraisal handles awkwardly is present at once.
First, the benefit to any single vaccinated person is modest and uncertain, most would never have developed cancer anyway—yet the benefit across a whole population is large, because a small risk removed from millions adds up. Second, the payoff is delayed by twenty or thirty years, so discounting shrinks it on paper [11,27]. Third, vaccinating enough people reduces how much the virus circulates, protecting even the unvaccinated, a spillover that patient-level methods miss entirely [23]. Fourth, the disease it prevents is a recognized population burden and, in many countries, a named public-health priority.
Judged only as “how much health does this buy for the person vaccinated, soon, at what cost,” HPV vaccination looks far weaker than it is. Judged as “how much disease does this remove from the population over a generation, and how fairly,” it looks very strong. This is why several jurisdictions assess vaccines through separate immunization advisory groups rather than ordinary HTA [24] ,or on the top of HTA, and why a growing literature argues that the full value of vaccination, including its broader social and economic effects, is systematically understated by conventional methods [13,49]. The vaccine case does not require a special pleading; it simply shows, in one concrete example, every dimension this analysis argues HTA should learn to weigh [31].

France’s Attempt: The “Public-Health Interest” Rating

France is unusual in trying to score public-health value directly. Its Transparency Commission gives each product a rating called Intérêt de Santé Publique (ISP), or “public-health interest,” on a five-point scale [28]. At first glance this looks like exactly the integration we are calling for. On closer inspection it falls short, and it is worth saying why, while being clear that a full verdict would need a systematic study of how the rating has been used over time. We offer the following as a reasoned critique to be tested, not a settled finding.
Three limits stand out. The rating leans on judgement rather than on standard burden measures such as DALYs, so two conditions can be scored very differently without a transparent basis [21,29]. It does not systematically capture spillovers such as reduced transmission or the population value of prevention [31]. And, most importantly, the ISP carries little formal weight in the decision: it is deliberative, can in specific cases open a route to funding outside the standard hospital tariff and so widen access, but does not directly drive the price [28,29]. The lesson is not that France was wrong to try, its very existence shows the idea is workable, but that adding a public-health label is not the same as building public health into the decision.

A Fair Word for QALYs

A common defense of current methods is that QALYs already capture population benefit, because they add up health gains across everyone treated. That is true, and we should concede it plainly: adding up QALYs across a population is, by definition, a population measure [32]. Our argument is the more specific one, that this total, on its own, leaves out things public health cares about: how big the underlying burden is, the protection that spreads through a community, the value of prevention, how fairly health is shared, and a country’s chosen priorities.
Consider burden. A treatment giving 100 quality-adjusted years to 100 people with a rare disease is scored exactly like one giving 100 such years to 100 people with a common, high-burden disease [35]. From a population view these differ, because tackling a widespread disease can shift a nation’s health far more. But we should be honest that this is a value judgement, not a fact: it does not automatically follow that commoner diseases deserve priority, and societies rightly also value treating rare and severe conditions [35]. The defensible claim is therefore the modest one, burden should count, openly and consistently, rather than being left to a footnote [6,37]. Standardised burden data already exist to make that possible [36,39]; HTA simply makes little systematic use of them.

Why HTA Has Kept Public Health at a Distance

There are real reasons HTA has avoided formal public-health criteria, and a fair argument has to meet them. We find them serious but not decisive.
“They are different jobs.” HTA judges technologies; public-health governance acts on populations through programs and regulation. True,but a technology’s population effects are exactly what an honest assessment of its value should not leave out by design.
“Burden is already handled elsewhere.” Prevalence shows up in budget calculations, and burden shapes politics before HTA begins. But budget impact is about affordability, not value, and the upstream handling of burden is precisely the vague, unweighted treatment we are criticising.
“It threatens independence.” Bringing in government goals risks politicising a process meant to be evidence-based. This is the most important objection, and we devote the next section to it. In short, it can be met by letting priorities enter as open, reasoned inputs subject to public justification, rather than by shutting them out [44].
“Priorities change; methods must be stable.” Public-health priorities shift, while HTA needs consistent methods. Yet stable methods are quite compatible with openly documented priority inputs that are updated periodically, just as cost-effectiveness thresholds are themselves revised over time.
“Some decisions belong to ministries.” Some choices do belong to government rather than HTA. That is reasonable for program-level decisions; it is far weaker as a reason to strip the population effects out of the appraisal of a specific technology.

Public-Health Priorities Are Not Political Meddling

The objection about independence deserves a careful answer, because the two ideas it runs together are in fact opposites. A health minister telephoning an agency to demand that a particular drug be reimbursed is improper political interference: it is product-specific, serves a particular interest, and threatens the very independence that makes HTA trustworthy. A government deciding, through democratic institutions, that Alzheimer’s disease, obesity, antimicrobial resistance or childhood vaccination are national priorities is something altogether different. It is the legitimate expression of what a society has chosen for itself. Table 2 sets out the contrast.
The implication is straightforward. HTA’s independence should protect the assessment of evidence from lobbying and product-specific pressure. It should not mean isolation from the public-health priorities a country has democratically set. Once a society has decided, through legitimate processes, that a health challenge is a national priority, it is reasonable to expect its public institutions, HTA agencies included, to pull in the same direction. The alternative is a system in which each agency optimizes its own narrow objective while the country, collectively, fails to meet the goals it has chosen [44,47].
This is also why public priorities are best understood not as interference but as one of several legitimate dimensions of social value, precisely the kind of value that structured multi-criteria approaches are designed to weigh openly alongside cost-effectiveness, rather than in place of it [48]. And it answers the independence objection in the right way: not by smuggling politics into the evidence, but by making the choice of priorities explicit, reasoned and open to challenge, in line with well-established accounts of fair and legitimate priority-setting [44,47].

The Hard Constraint: Opportunity Cost

None of this suspends the most important discipline in HTA. In a fixed budget, paying for one treatment means not paying for something else, and that something else also produces health. This is opportunity cost: the health quietly given up elsewhere whenever money is spent here. Cost-effectiveness thresholds exist to represent it [10]. There is good evidence that the real opportunity cost of NHS spending may be higher than the threshold often used, meaning that funding very expensive treatments can sometimes remove more health from other patients than it adds [34]. Any reform that ignored this would do harm [42].
This cuts both ways, and honesty requires saying so. It tempers any call to fund something simply because it addresses a big disease or a stated priority: displacement is real, and good intentions do not make it disappear. But the same logic strengthens the case for measuring prevention, spillovers and fairness properly, because each of them changes where health is gained and lost across the population. Public-health value and opportunity cost are not enemies. A public-health-minded appraisal that ignored displacement would be just as incomplete as the patient-centred one it seeks to improve.

What a Public-Health-Informed HTA Could Look Like

The goal is not to replace cost-effectiveness analysis but to widen the lens, carefully and within the limits above. Four practical steps would move HTA toward the third column of Table 1.
Weigh disease burden openly. Each appraisal could include a clear, standardized statement of how much disease a technology addresses, using established burden data [36,39]. The aim is to make burden a visible, documented input, not an automatic multiplier.
Model the spread of infection. For infectious diseases, appraisals should use models that capture herd protection and prevented onward transmission, including effects on antimicrobial resistance [22,40], developed with infectious-disease specialists [8].
Treat government priorities transparently. Agencies could consider, openly and with reasons, whether a technology serves a democratically chosen priority, as an explicit and revisable input, governed by the conditions of publicity, relevance, appeal and enforcement that define fair priority-setting [44,47], and weighed using multi-criteria methods rather than hidden in a footnote [48].
Assess fairness directly. Equity can be measured rather than merely invoked. Distributional cost-effectiveness analysis estimates how a technology changes health gaps between groups [45], while extended cost-effectiveness analysis also captures financial-protection effects [46]. These methods weaken the claim that fairness cannot be assessed rigorously.

Discussion

Read together, these strands point to a single conclusion: the limitation of contemporary HTA is methodological, not attitudinal. HTA does not lack concern for populations; it lacks an agreed, transparent and reproducible way of letting population-health objectives count in its verdict on value. While in France, Italy and Spain Burden of illness is part of the HTA assessment and NICE adopted severity as a modifier criteria this is going in the right direction but remain poorly standardized. Public health priorities are also implicitly considered as it was reported that NICE had a threshold for oncology technologies higher than non oncology ones. The three-paradigm lens makes the consequences visible. A system anchored in the first two questions, does this help the patient, and how much health do we buy per euro, will systematically under-weight burden, prevention, transmission externalities, distribution and democratically chosen priorities, not by intent but by construction. The practical implication is that the necessary tools already largely exist, burden metrics, dynamic transmission models, multi-criteria frameworks, and distributional and extended cost-effectiveness analysis [22,36,45,46,48]—and the task is to integrate them, openly and proportionately, rather than to invent a new discipline.
Limitations. This is a conceptual contribution and carries the limits of that genre. The reading of agency methods was purposive rather than systematic, and was concentrated on European and Anglophone systems; other jurisdictions may distribute these questions differently. The three-paradigm typology is a clarifying lens, not a scoring algorithm, and is offered as a hypothesis to be refined. Crucially, the framework now requires empirical testing, for example, structured comparison of how named agencies treat burden, externalities and equity in real appraisals, and pilot work to establish how the proposed reforms would behave under a fixed budget. We regard these as the natural next steps rather than weaknesses of the argument.

Conclusions

Public health remains the forgotten dimension of HTA, not because HTA ignores populations, but because it lacks an agreed, transparent way to weigh what public health values most. Seeing HTA as three possible questions—help the patient, buy the most health, or improve population health fairly, makes the gap easy to name: today’s methods rarely ask the third. France’s public-health rating shows that a label alone is not enough [28,29]; vaccines show, in one concrete case, everything that a fuller approach would need to weigh [13,49].
We have tried to argue this at a defensible strength. Aggregate QALYs are a real population measure, but not the whole of public-health value [32]; disease burden should count, but not automatically override [35]; and respecting a country’s democratic priorities is the opposite of bowing to lobbying [44,47]. Above all, any reform must respect opportunity cost, because widening what we measure cannot mean ignoring what is displaced [34,42]. Pursued in this measured way—through open burden assessment, transmission modelling, transparent treatment of priorities, and direct measurement of fairness [22,36,45,48]—HTA could finally deliver on its own promise: to spend a health system’s money so as to improve the health of the whole population, fairly, and not merely to optimise outcomes one patient at a time. We call on EUPHA (the European Public Health Association) and HTAi (Health Technology Assessment international) to convene a joint working group on the public-health dimension of HTA.

Funding/Acknowledgements

The authors received no specific funding for this work

Conflict of Interest Statement

Mondher Toumi is a consultant to the pharmaceutical industry, public health organisations and health authorities, and declares none for this project. Anna Kapuśniak, Emilia Strycharz-Angrecka and Mairem El Haj are employees of Clever-Access — a consulting company in the field of life sciences. All other authors have no conflict of interest to declare.

Ethics Statement

This article is a conceptual analysis and does not involve human participants, identifiable human data, or animals. Institutional review board approval and informed consent were therefore not required.

Data availability Statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

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Table 1. Three ways of judging the value of a health technology. Cost-effectiveness HTA is already population-based, but it pursues total health rather than the wider set of public-health goals.
Table 1. Three ways of judging the value of a health technology. Cost-effectiveness HTA is already population-based, but it pursues total health rather than the wider set of public-health goals.
Clinical HTA Cost-effectiveness HTA Public-health HTA
Typical examples EU Joint Clinical Assessment; IQWiG; French clinical-benefit ratings NICE; CADTH; PBAC The approach this paper argues for
Core question Does this help the patient? How much for a unit of health gain in QALY How do we improve population health, fairly?
Main unit The individual patient Total health gained (population QALYs) Population health, and how it is shared
Ethical leaning Duty to the individual (deontological) Greatest total health (utilitarian) Broader public-health ethics
Disease burden Limited role Indirect role Explicit role
Prevention Weakly represented Partly represented Central
Fairness / equity Limited Optional Explicit
Government priorities Absent Usually absent Explicit
Spillovers (e.g. herd protection) Rarely included Sometimes included Core consideration
Table 2. Resisting lobbying and respecting democratic priorities are not in tension; they pull in opposite directions.
Table 2. Resisting lobbying and respecting democratic priorities are not in tension; they pull in opposite directions.
Political pressure — illegitimate in appraisal Public-health priority — a legitimate input
Lobbying for a specific product A democratic mandate
Aimed at one product or company Aimed at the whole population
Often short-term Long-term
Serves particular interests Serves collective interests
Threatens HTA’s independence Defines the goals the system exists to serve
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