The characterization of efficiency in this article verges on being a straw man. Efficiency is concerned with maximizing the desired output from a given budget. For healthcare systems equity in healthcare provision, however defined, is an integral component of the outcome which the system seeks to maximize. Changes to these domains of output have opportunity costs in the same way as changes in the health gain domains can impact these domains. By putting cost and outcome into a single efficiency domain, the framework described above promotes opacity in decision-making on equity effectiveness trade-offs. In addition, the statement that something can be cost effective but unaffordable demonstrates a failure to understand the concept of cost effectiveness. The appropriate threshold for determining cost effectiveness is determined by budget impact and the efficiency of the current portfolio of healthcare provided. In fairness to the authors, both of these misunderstandings are frequently shared by decision makers who profess to use cost effectiveness analysis to promote efficient resource allocation.