An Original Theoretical Framework for Universal Health Coverage-Oriented Medical Technology Assessment in Sub-Saharan African Health Systems

Universal health coverage goals require that medical technology adoption decisions explicitly consider equity, access, and population health impact dimensions that are absent from conventional health technology assessment frameworks originally developed for insurance-payer decision-making in high-income countries. Existing adaptations of HTA for low and middle-income country contexts address some limitations but do not provide a theoretically coherent framework grounded in the specific structural, ethical, and epidemiological conditions of sub-Saharan African health systems. This dissertation makes an original theoretical contribution by developing a universal health coverage-oriented medical technology assessment framework specifically designed for sub-Saharan African health systems, with the Nigerian Federal Ministry of Health technology coverage decision context as the primary empirical grounding. The theoretical framework is constructed through a three-stage process: a critical epistemological analysis of the foundational assumptions of conventional HTA theory identifying assumptions incompatible with sub-Saharan African health system contexts; a normative theory development stage drawing on distributive justice theory, capabilities approach philosophy, and complexity systems thinking to specify the value principles appropriate for sub-Saharan African technology assessment; and an operationalization stage translating normative principles into a practical multi-criteria decision analysis methodology. The framework specifies seven assessment dimensions with theoretically derived weighting provisions for equity correction, burden-of-disease priority alignment, and health system strengthening impact. Application of the framework to five technology coverage decisions pending before the Nigerian Health Insurance Authority demonstrates substantially different and theoretically more defensible technology ranking outcomes than conventional cost-effectiveness analysis alone. The framework offers an original theoretical contribution to global health technology assessment theory. Keywords: health technology assessment, universal health coverage, sub-Saharan Africa, equity, Nigeria.