Public Health: The Forgotten Dimension of Health Technology Assessment

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. Methods 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 “how much 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.