Health technology assessment (HTA) processes typically combine both evidence and values in order to inform decisions about relative value. Health-economic evaluation and other economic evidence are thought by many to be important for such processes, but there is typically tension between the information offered by health-economic assessment, and the context-specific interpretation of such information. This study reviews the meaning, and interpretation, of ‘health-economic evaluation’ aimed at informing HTA processes. One central aim is to answer the question: “Can health-economic evaluation provide a representation of ‘value for money’ for HTA?”

A seminal article was used as a starting point and then a variety of search techniques, including bi-directional citation searching, were used to obtain evidence relating to the study objective. A critical review is undertaken spanning the last fifty years of health-economic evaluation, which provides perspective on the balance between more context-independent assessments and the context-specific interpretation of those assessments.

Although health-economic evaluation can legitimately be undertaken in a variety of ways, we find that processes of ‘valuation’ are fundamental to all approaches to economic evaluation in practice. Values influence how these economic value frameworks tend to be operationalized, promoted and understood. Our critical review provides those interested in prioritization with a timely reminder that health-economic evaluation should be thought of as largely context- and content -specific.

Health-economic evaluation can typically only offer a truncated representation of ‘value for money’ to HTA processes. In answer to the question posed above, this study finds that health-economic evaluation will typically not provide a full assessment of ‘value for money’. Therefore, it should always be accompanied by an assessment of its qualities: what is covered in the analysis, how well what is covered is measured or analysed, and what is left out. Humility about what health-economic evaluation can offer would seem useful, especially given that other elements of value exist, such as the potential harms and benefits of medical-industry profits and environmental sustainability.

Proceeding from a basic concept underpinning economic evaluation, opportunity cost, this study aims to explain how different approaches to economics diverge quite dramatically in their ideas of what constitutes appropriate valuation, both in principle and practice. Because the concept of opportunity cost does not inherently specify how valuation should be undertaken or specify how appropriate any economic value framework (EVF) might be, the three main economics-based approaches to providing evidence about value for health technology assessment are described.

This paper describes how the three main EVFs—namely, the extra-welfarist, welfarist, and classical—are most typically understood, applied, and promoted. It then provides clarification and assessment of related concepts and terminology.

Although EVFs differ, certain underlying characteristics of valuation were identified as fundamental to all approaches to economic evaluation in practice. The study also suggests that some of the rhetoric and terms employed in relation to the extra-welfarist approach are not wholly justified and, further, that only the welfarist approach ensures adherence to welfare-economic principles. Finally, deliberative analysis, especially when connected with a classical economic approach, can serve as a useful supplement to other analytical approaches.

All three approaches to economic evaluation have something to offer assessment processes, but they all display limitations too. Therefore, the author concludes that the language of economic evaluation should be used with sufficient humility to prevent overselling of EVFs, especially with regard to the qualities of evidence they provide for priority setting processes.