HTA as a Policy Tool: Balancing Cost, Access, and Equity

Healthcare systems around the world are grappling with the same challenge: how to deliver the best possible care to populations with finite resources. Budgets are not limitless, yet the demand for life-saving medicines, cutting-edge technologies, and innovative therapies keeps rising. Against this backdrop, Health Technology Assessment (HTA) has emerged as one of the most powerful policy tools governments can use to to guide evidence-based, equitable, and sustainable decisions.

At its core, HTA is more than a technical evaluation of cost-effectiveness, it is a balancing act between cost, access, and equity. Different governments use HTA to navigate these trade-offs in ways that reflect their health system goals, political priorities, and societal values.

What is HTA and Why Does it Matter?

HTA is a multidisciplinary process that evaluates the clinical, economic, social, and ethical dimensions of a health technology. It helps policymakers decide whether a new medicine, medical device, diagnostic tool, or intervention provides sufficient value to warrant public investment.

At its core, HTA asks critical questions:

• Does the technology improve health outcomes compared to existing alternatives?

• Is it cost-effective in relation to the health gains it delivers?

• Will it advance, or undermine, equity in access to care?

By answering these questions, HTA gives governments a framework for making transparent, evidence-based choices that ensures that limited health budgets are spent where they deliver the most benefit, improving health outcomes, and protecting systems from unsustainable spending.

Global Perspectives: How Governments Use HTA

1. The United Kingdom – Setting a Global Benchmark

The UK’s National Institute for Health and Care Excellence (NICE) is often regarded as a good benchmark for HTA. NICE assesses new medicines, devices, and interventions against a cost-effectiveness threshold (often expressed in cost per quality-adjusted life year, or QALY). This ensures that the National Health Service (NHS) invests in technologies that offer good value for money. While NICE has been criticized for sometimes delaying access to innovative therapies, its approach provides transparency and predictability for both industry and patients and ensures that NHS resources are distributed equitably, preventing overspending in one area at the expense of other services.

2. Germany – Balancing Speed with Value

Germany’s system, led by the Institute for Quality and Efficiency in Health Care (IQWiG), allows new medicines immediate market entry but requires manufacturers to demonstrate added benefit compared to existing alternatives. This creates early patient access while linking pricing to demonstrated value. It is a model that combines responsiveness with fiscal discipline. If no added benefit is demonstrated, the product is often subject to reference pricing, which can limit reimbursement.

3. Thailand – Embedding Equity in HTA

Middle-income countries like Thailand have pioneered the use of HTA to achieve universal health coverage (UHC) with limited resources. Thailand’s Health Intervention and Technology Assessment Program (HITAP) explicitly integrates equity concerns, ensuring decisions consider cost-effectiveness and the needs of marginalized populations. This has enabled the country to expand access to essential medicines and vaccines without overwhelming the national budget.

4. South Africa – Institutionalising HTA for Sustainability

South Africa is developing HTA capacity in preparation for National Health Insurance (NHI) implementation. Through embedding formal guidelines for pharmacoeconomic submissions, the government aims to create a transparent and consistent system that supports fair resource allocation, critical in a context of inequality and competing priorities.

5. Canada: Balancing Federal and Provincial Priorities

Canada uses a coordinated HTA approach through the Canadian Agency for Drugs and Technologies in Health (CADTH), which provides guidance to provincial health systems. This decentralization acknowledges regional health needs while maintaining national consistency. It also illustrates how HTA can adapt to federated systems where healthcare delivery is shared across multiple levels of government. Though CADTH guides provinces, Quebec, the largest province in Canada, has its own HTA body, the Institut national d'excellence en santé et en services sociaux (INESSS).

The Policy Trade-Offs

While HTA has proven to be an essential tool, its use also highlights difficult trade-offs:

• Cost vs. Access: Strict cost-effectiveness thresholds may delay or deny access to high-cost, cutting-edge therapies, especially for rare diseases.

  
  

• Efficiency vs. Equity: What is cost-effective at the population level may not always address the needs of vulnerable groups.

  
  

• Short-Term vs. Long-Term Value: Some innovations may not look cost-effective immediately but could deliver system-wide savings or transformative health outcomes over time.

Governments must therefore use HTA not in isolation, but as part of broader policy frameworks that include risk-sharing agreements, managed entry schemes, and patient engagement.

The Way Forward

As healthcare challenges intensify, the role of HTA will only grow. For low- and middle-income countries (LMICs), institutionalising HTA offers a pathway to maximise scarce resources while advancing toward universal health coverage. For high-income countries, it provides discipline against unsustainable spending while supporting innovation.

Crucially, the future of HTA lies in making the process more inclusive and adaptive, incorporating real-world evidence, listening to patient voices, and considering long-term system benefits. By doing so, governments can strike a more humane balance between cost, access, and equity.