Beyond cost-effectiveness: Reframing the value of essential nursing care in healthcare priority-setting

Cost-effectiveness analysis (CEA) has become a dominant framework for healthcare priority-setting, offering policymakers a standardized way to compare costs with expected health gains under conditions of scarcity. Yet its dominance raises ethical and conceptual problems when applied to forms of care that are relational, continuous, preventive, and foundational to human wellbeing. Essential nursing care is often difficult to represent through the outcome metrics that CEA privileges, particularly in critical care, chronic illness management, palliative care, gerontological care, and end-of-life care. Drawing on feminist political economy, care ethics, health justice, and the capabilities approach, this discursive paper argues that essential nursing care should not be treated primarily as a discretionary investment whose legitimacy depends on economic efficiency. Rather, it should be understood as a human rights-based ethical commitment necessary for safe, dignified, equitable, and humane healthcare. The paper shows how prevailing evaluative frameworks may systematically undervalue nursing work by privileging what is most easily measured over what is morally and clinically indispensable. It then considers rights-based, capabilities-based, and deliberative approaches to priority-setting as more ethically adequate ways of recognizing the value of essential nursing care. The paper contributes to nursing ethics by arguing that essential nursing care should be recognized not only as a contributor to measurable outcomes, but also as a moral condition of dignity, safety, non-abandonment, and justice within healthcare systems.