Applications of GRADE-Adolopment in South African health policy: Assessing affordability in South Africa’s GRADE-Adolopment processes
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Background. South Africa’s (SA) progress toward universal health coverage (UHC) is marked by efforts to prioritise primary healthcare and improve access to cost-effective and affordable health services. Central to this reform is the adoption of evidence-based processes, such as Health Technology Assessment (HTA) and the GRADE-Adolopment approach, which support the contextualisation of global clinical guidelines through local epidemiological, health system, and cost data. Despite progress in considering clinical effectiveness and cost-effectiveness, explicit integration of affordability and equity considerations remains limited. This review assessed SA case studies applying the GRADE-Adolopment and Evidence-to-Decision (EtD) frameworks to evaluate how affordability, particularly through budget impact analysis (BIA), has been addressed.
Methods. We conducted a review of both published and grey literature from 2015 to May 30 2025, searching PubMed, Scopus, and the websites of the SA National Department of Health and the Council for Medical Schemes, using terms such as ‘GRADE,’ ‘Adolopment,’ ‘South Africa,’ ‘guidelines,’ and ‘affordability.’ Eligible studies included those applying the GRADE or Evidence-to-Decision (EtD) frameworks in the development of guidelines or policies in South Africa. We extracted data on the use of GRADE, EtD domains, and affordability frameworks (including cost-effectiveness analysis, budget impact analysis, equity trade-offs, resource mapping, and feasibility), assessing their impact on policy through comparative analysis. Additionally, we performed inductive thematic analysis to synthesise cross-cutting lessons and barriers related to the integration of affordability within decision-making processes.
Results. Across six SA case studies, the integration of affordability assessments within GRADE-Adolopment processes varied considerably. National initiatives demonstrated structured approaches, consistently applying cost-effectiveness and budget impact analyses in guideline development. In contrast, subnational or project-based adaptations often addressed affordability reactively, due to limited data and health economics capacity. Key themes included the reactive nature of affordability considerations, the enabling role of centralised decision-making structures, and challenges from inadequate data and technical expertise. Several case studies highlighted the importance of using transparent, context-specific EtD frameworks to support consistent, equitable, and feasible policy decisions in resource-constrained settings.
Conclusion. Affordability was inconsistently integrated into the guideline development processes, with structured assessments more common in nationally led initiatives. Conversely, reactive and informal approaches dominated at subnational levels. Given fiscal constraints, tools such as league tables and expansion pathways could be more effective in prioritising affordable, high-impact interventions. Institutionalising such approaches and strengthening local capacity will support sustainable, evidence-based policy under SA’s National Health Insurance.
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