Introduction
Health technology assessment (HTA) emphasizes explicit methods, transparency, and the aim of informing decision making to promote equitable, efficient, and high-quality health systems (Reference O’Rourke, Oortwijn and Schuller1). Its promise is powerful: rigorous evaluation of clinical effectiveness and broader impacts to guide which health technologies should be funded and for whom. Yet as health systems grapple with growing inequities, eroding public trust, democratic backsliding, and a rapidly evolving technological landscape, HTA must confront more searching questions: whose values does it serve, and whose does it leave behind? These questions were at the heart of the Plenary Three session at the HTAi 2025 Annual Meeting, held in Buenos Aires, Argentina (14–18 June 2025), where the global HTA community explored the conceptualization and use of next-generation evidence in HTA (2). While Plenary One discussed a general redefinition of HTA’s role (Reference Oortwijn, Dabak, Ryan, Glaetzer and Pichon-Riviere3) and Plenary Two explored the methods needed for HTA to respond effectively to emerging innovations and evolving health system needs (Reference Richardson, Augustovski, Pegg, Seck, Kar and Goettsch4), Plenary Three concluded the discourse with a critical examination of stakeholder participation entitled “How Can We Use HTA to Achieve More Transparent, Equitable and Fair Health Systems?”
The session brought together panelists representing distinct stakeholder categories: a patient advocate from a lower-middle-income country (KAV), a global health and gender equity researcher (EC), a health policy practitioner and former health minister (AR), an industry representative (VG), and two facilitators from the HTA research community (CG and IL). Their perspectives, together with audience polling on perceived shortcomings and priorities for change, offered a rare multistakeholder panorama of HTA’s unfinished agenda.
This perspective synthesizes the key arguments advanced in the plenary discussion and situates them within the broader literature on HTA equity, transparency, and trust (Reference Pearson-Stuttard, Richardson, Griffin, Lübker and Duffield5–Reference Trowman, Migliore and Ollendorf7). HTA has made genuine progress in recent decades in standardizing methods and expanding its reach into LMICs (Reference Siriram and Harris8;Reference Migliore, Jameleddine and Single9). Yet, technical progress is not the same as justice. A technically flawless evaluation can be profoundly unjust if it systematically excludes the voices, data, and lived realities of those it purports to serve. In this article, the authors argue that the HTA community must embrace a broader mandate that treats transparency, equity, and trust not as optional enhancements, but as foundational values.
HTA in the mirror: persistent gaps between aspiration and practice
The plenary opened with an audience poll inviting participants to name, in one to three words, where HTA is falling short. The prevalent responses (trust, equity, transparency, representation, rare diseases, adaptability, misinformation, real patient-centricity, and democracy) were striking in their breadth and consistency. They speak to a gap not primarily technical, but social and political.
Transparency as a two-way obligation
Panelists highlighted that transparency in HTA remains insufficient and unevenly distributed. From the perspective of patient advocates, HTA processes often function as black boxes: submissions are made, recommendations are issued, but the reasoning connecting patient-submitted evidence to final decisions is rarely made explicit. It was remarked that, when an HTA body produces only an incremental cost-effectiveness ratio or a binary coverage decision without explaining the deliberative pathway, it fails manufacturers and patients alike. Such questions as what evidence was weighted, how, and why often remain unanswered. But transparency also has a political dimension. It was noted that, in some countries, current political environments are actively working to diminish transparency, bypass evidence, and undermine trust in public institutions, a hostile context that HTA bodies cannot ignore and from which they are not insulated.
Equity as a contested, context-dependent concept
The HTA community is challenged to abandon a single, universally applied definition of equity, as it conflicts with contextual reality. In high-income countries, equity debates tend to focus on access across socioeconomic groups, insurance status, and disability categories. In lower-middle-income settings, the issues tend to be more structural: rural – urban divides, gender and caregiver burden, colonial legacies, fragmentation of the health system, and grinding poverty. Also, indigenous populations and rural communities are often functionally excluded, not necessarily through explicit policy but through the absence of connectivity, the requirement for in-person participation, and the dominance of urban, educated voices. Similarly, patients struggle with medical jargon, and few patient groups possess the organizational capacity or secretariats needed to participate meaningfully in HTA consultation processes. Whose equity is being assessed? When HTA bodies define value without asking this question explicitly, they risk cementing the inequities they profess to address. As a panelist bluntly noted, a technically flawless HTA can be profoundly unjust.
Trust: the currency HTA cannot afford to lose
Trust was perhaps the most frequently invoked theme across the session. Evidence generators and decision makers inhabit distinct worlds: they come from largely separate professional cultures, communicate in different registers, and respond to different incentives. Evidence alone does not persuade; compelling narratives do. Without deliberate efforts to bridge this communication gap, HTA bodies risk producing technically sound but politically irrelevant assessments. Decision making that favors a treatment that benefits only a small patient population at a cost comparable to what could fund an entire national immunization program calls attention to the need for transparent deliberation about opportunity costs, cost-effectiveness, budget impact, and the drive for equity. Indeed, innovations that do not achieve conventional incremental cost-effectiveness thresholds may be prioritized on equity grounds, but doing so without transparent public reasoning can induce criticism and erode health system trust.
Pathways forward: opening the black box
While recognizing these challenges, the panelists cited progress and the way forward. They identified concrete recommendations and pointed to emerging institutional models that demonstrate that more transparent, equitable, and trustworthy HTA is achievable.
Canada’s Drug Agency (CDA-AMC, formerly CADTH) and Québec’s Institute of Economic and Social Studies (INESSS) were highlighted as leading examples of transparency in practice (10;11). Both agencies have moved beyond allowing patients to submit standardized forms to actively involving patients and caregivers in HTA deliberations.
Other than gathering patient input through formal submission process, both agencies have citizens on their permanent deliberation committees; CDA-AMC can also include a patient (or caregiver) with lived experience who can present to the committee for complex submissions, has a patient representative on its board of directors, and has published public-friendly method guides explaining what types of evidence are reviewed, how evidence is assessed, and how value is appraised across multiple domains. Further, information that can be redacted in reports is now carefully limited to genuinely commercially sensitive material, increasing the transparency of HTA recommendations to the public. These and related approaches can be readily implemented globally.
In England, the National Institute for Health and Care Excellence (NICE) has undertaken a strategic review of its patient and public involvement and engagement program, leading to plans to strengthen patient evidence collection, feedback loops, and the role of lay members throughout the appraisal process (Reference Rasburn, Crosbie and Fitzpatrick12). These developments reflect a recognition that involvement cannot be a tick-box exercise; patients who contribute to HTA processes must receive feedback on what happened with their input.
The Philippines experience offers a model for countries building HTA capacity within fragmented health systems. Under their Universal Health Care Act, all health technologies funded by the government should undergo HTA, which is defined as a systematic evaluation of the social, economic, organizational, and ethical impact of health-related technologies and interventions, using a multidisciplinary process, to improve health outcomes (13).
A challenge that remains inadequately addressed in most HTA frameworks is the consideration of patient-valued outcomes that fall outside conventional clinical endpoints. Such aspects as autonomy, social participation, and caregiver relief are not well captured by quality-adjusted life years (QALYs). The Health Economics Methods Advisory (HEMA), a recent joint initiative convened in February 2025 by the Institute for Clinical and Economic Review (ICER), the NICE, and the CDA-AMC, was highlighted. HEMA’s first research project explicitly addresses the question of which benefits, including novel elements such as the “value of hope,” may be appropriate to include in HTA economic evaluations (14). This collaborative, independent effort to evolve methodology while maintaining rigor signals that leading HTA bodies are willing to examine their frameworks critically and in dialogue with international partners.
Discussion
The picture that emerges from this multistakeholder dialogue is an HTA field that is genuinely committed to the values of transparency, equity, and trust but that has yet to build the institutional infrastructure or methodological consensus needed to deliver consistently on those values. Several cross-cutting themes merit further reflection.
First, equity is not a single variable. Equity debates are fundamentally context-dependent, shaped by the structural determinants of each health system. This does not argue against global standards, but for global standards that are flexible enough to be applied in heterogeneous contexts. The aspiration expressed during the session, “harmonize the principle, localize the application,” points to a productive direction that the HTA community is beginning to operationalize.
Second, the science-policy interface requires deliberate investment. HTA bodies that limit their communication to technical reports are more likely to find their work ignored or misrepresented in policy debates. The evidence on effective evidence-to-policy communication is clear: narratives matter, stakeholder relationships matter, and timing matters (Reference Barreto, de Melo and da Silva15). HTA bodies that invest in policy engagement capacity, not just analytical capacity, will have greater real-world impact.
Third, industry has a role and a responsibility, including to its own benefit. The plenary did not frame industry as an antagonist. Rather, it was acknowledged that manufacturers can contribute meaningfully to transparency as well as to scientific advancement by engaging patients early in clinical trial design, by incorporating patient-relevant endpoints, and by providing research and development cost data in jurisdictions where transparency regulations require it. When industry engages with HTA bodies to understand what evidence to expect and how to evaluate it, the entire system benefits.
Fourth, the issue of “epistemic diversity” has received insufficient attention in the formal discourse of HTA and concerns the evidence base itself. When findings of even technically rigorous assessments are based on data generated in narrowly defined patient populations and then generalized to broader, diverse populations, clinical relevance is eroded, outcomes are suboptimal, and often-ignored patient groups are again disadvantaged. This is not a call to abandon rigor; rather, it is a call to interrogate what counts as adequate evidence for fairness in context.
Finally, this plenary illustrated that HTA’s greatest asset may not be its methods, but its capacity and commitment to convene patients, clinicians, policy makers, researchers, and manufacturers around shared problems. If HTA bodies use that convening power to interrogate their own assumptions, to invite challenge from those left behind, and to build coalitions for fairer systems, they have the potential to be not only gatekeepers, but guardians of justice.
Conclusion
The discussion during Plenary Three at the HTAi Annual Meeting 2025 confirmed that the field is at a pivotal moment. The ingredients for more than just HTA are available: participatory frameworks, methodological innovations, cross-sector collaborations, and committed advocates. When the audience was asked the closing question, “What could we use to improve transparency, equity, and trust?” the answers were “inclusion,” “support,” “honesty,” “embrace innovation,” “collaboration,” “clear methodology,” “connection,” “listening to patients,” and “multistakeholder engagement.” The collective will aims to redesign HTA so that it looks different in the mirror, more inclusive in who shapes it, more transparent in how it works, and more equitable in whom it ultimately serves.
Acknowledgments
The authors would like to thank the audience of Plenary Three for providing active contributions during the session. The authors would like to extend their gratitude to HTAi and its staff for providing financial and administrative support to organize the event.
Funding statement
No specific grants from funding agencies in the public, commercial, or not-for-profit sectors were received for this work.
Competing interests
KAV has received speaker honoraria and educational grants from Boehringer Ingelheim, Takeda, Johnson & Johnson, United Laboratories, International Myeloma Foundation, and IASO BioTechnology. She has received support for attending meetings and/or travel from AstraZeneca, Boehringer Ingelheim, Takeda, and International Council for Health Outcomes. She has also leadership or fiduciary role in the Philippine Tuberculosis Society, UP College of Public Health Program on Health Equity, British Medical Journal, Patients for Patient Safety Observatory, MyeSPEAK Phils, and Alyansa Para sa Kalusugan. VG is an employee of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ, USA, who may own stock and/or hold stock options in Merck & Co., Inc., Rahway, NJ, USA. AM has a contract with HTAi as a Manager of Scientific Initiatives. The views expressed in this manuscript represent the authors’ personal positions and do not necessarily represent the official positions of the institutions to which they are affiliated.
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