In an environment where debates about tertiary care viability in South Africa are characterised more by stridency than logic, it is refreshing to encounter positive suggestions such as those from Kenyon et al. (1) They suggested that scrutiny of expensive new medications and technologies by a NICE-like body would lead to appropriate rationing. NICE refers to the UK’s National Institute of Health and Clinical Excellence, a government-funded but politically independent body tasked with evaluating the clinical efficacy and cost-effectiveness of medicines and health devices. Its efficacy in improving quality of care and resource allocation is still unclear, and similar attempts in the United States have failed because of the political sensitivity of perceived rationing in that country. (2) The proposal to establish a similar unit in South Africa appeared unduly optimistic to Taylor, (3) who observed correctly that setting cost-effectiveness thresholds is not a rationing strategy in the absence of a concurrent mechanism and commitment to forego established expenditure on other less cost-effective items. (This is an issue which has not yet been resolved by the United Kingdom’s NICE.) She also observed that cost-effectiveness analysis is time-consuming, extremely resource-intensive, and arguably not easy to perform on a large scale in South Africa at present. Further local debate on this matter has been reported recently in the Journal of the Colleges of Medicine of South Africa, where Price (4) argues that there are many more societal advantages to tertiary care than those measured by cost per patient benefited. His example of society’s assumed willingness to pay for the assurance of availability of renal replacement therapy highlights the quandary faced by funders–while each individual tertiary component may seem a reasonable purchase, it is the composite of many such items that proves less easy to justify.