From willingness to pay to health system affordability: new realities in health technology assessment

Abstract

Health technology assessment (HTA) worldwide has entered a period of significant change. This was the theme of the 2026 HTAi Global Policy Forum. The current challenge is considered through the health technology trilemma, which brings together the financial sustainability of the health system, value-creating innovation and equity of access. What is new is not the growth in expenditure itself, which historically became one of the drivers of HTA, but the simultaneous intensification of processes that alter the balance between all three elements of the trilemma. Opportunities to increase health budgets are shrinking amid competition from other public priorities. Multi-million technologies for small patient groups are entering the market at the same time as interventions for common diseases with large target populations. Decisions are being made within shorter timeframes on the basis of less mature evidence, disparities in access persist, the cost of evidence generation is rising and political pressure is increasing. Under these conditions the focus shifts from whether the system is willing to pay to whether it is able to fund a technology at the required scale and within the required timeframe. Ability to pay does not replace cost-effectiveness and budget impact analysis; rather, it requires more precise definition of target patient groups, uptake volumes and rates, the distribution of expenditure over time and the consequences of uncertainty. Retaining previous approaches increases the risk of politicized and non-transparent decisions, court-enforced access, displacement of other types of care and loss of the role of HTA in evidence-based resource allocation. Eight key signals and conclusions of the forum are presented, aimed at preserving the legitimacy of HTA, supporting value-creating innovation, making priorities and opportunity costs explicit, addressing equity in practice and reducing low-value care. Russian examples demonstrate the limitations of current regulation in funding technologies with multiple indications and an evidence base that is still being formed.