All health systems are challenged by finite resources to address unlimited demand for services. In many countries priority-setting and resource-allocation decision-making has been inconsistent and unstructured. In these cases, the lack of coherence between limitless promise and limited resources leads to implicit and covert rationing through waiting lines, low quality, inequities, and other mechanisms. Over the past decades, different countries have established specialized health technology assessment (HTA) organizations aimed at better informing health care policies and clinical practice. Although the first technology assessment institution, although not exclusively health related, was the Office for Technology Assessment (OTA) in the U.S. in the 1970s, HTA is not yet current nationwide practice. Nevertheless, there are more than fifty agencies in operation in over thirty countries to assist systematic priority setting, especially in high income countries. The cases of Ukraine, Colombia and U.S. represent different features of the need for systematic priority setting. Ukraine is moving from National essential medicines lists (EML) to more dynamic HTA use to update its publicly funded benefits package; Colombia established a few years ago nationwide HTA, but is currently attempting to use HTA for Pricing and Reimbursement since healthcare coverage is so heavily contested by judicialization. Nevertheless, even in countries where formal HTA activities are ongoing, and in most low and middle income countries, rationing still occurs as an ad hoc, haphazard series of non-transparent choices that reflect the competing interests of governments, payers and other stakeholders. Henceforth, there is the opportunity to closely review why the state of development for HTA varies so much according to setting.

Retrospective policy analysis considering common motivators for the implementation of HTA; the agenda setting model of the three streams (problems, policy and politics) for policy action ; and qualitative approaches for the inception of HTA are being used in these three cases.

Through a qualitative approach, ten “drivers” previously emerged with the ability to help or hinder HTA development in Colombia were used to assess the difference of HTA development in the USA and Ukraine (i.e. availability and quality of data, implementation strategy, cultural aspects, local capacity, financial support, policy/political support, globalization, stakeholder pressure, health system context, and usefulness perception). Policy/political and financial support, stakeholder pressure, cultural aspects and health system context were the most prominent drivers to induce or prevent institutional development of HTA in different countries.

Common motivators, similar drivers and context specific characteristics are all influential for the implementation of HTA at the national level. Policy/political and financial support, stakeholder pressure, cultural aspects and health system context preliminarily seemed the most prominent drivers to induce or prevent institutional development of HTA in different countries. Henceforth, methods and processes matter, as well as the political economy for HTA. Further research is needed to test these preliminary findings.