The study, led by Lapad Pongcharoenyong and colleagues at the Health Intervention and Technology Assessment Program Foundation in Thailand, known as HITAP, with collaborators from the Access and Delivery Partnership hosted by the United Nations Development Programme, documents and analyzes the full portfolio of HTA capacity-strengthening activities carried out between 2010 and mid-2025. The scale of the enterprise is striking. The researchers identified 278 separate capacity-strengthening activities spanning 25 countries, the overwhelming majority of them in Asia and a smaller but growing subset in Africa. Using internal documentation, the team categorized each initiative and then complemented the documentary record with key informant interviews involving senior HTA decision-makers from seven countries who had direct experience working with HITAP. Those interviews were analyzed thematically to understand not just what was done, but what actually changed as a result.

To make sense of hundreds of heterogeneous activities, the researchers turned to a conceptual tool called the INNE framework, which distinguishes four levels at which capacity must develop: the Individual level, covering the skills and knowledge of analysts and decision-makers; the Node level, referring to the institutions and organizational units where HTA work is anchored; the Network level, encompassing the relationships and communities of practice that connect practitioners within and across borders; and the Environment level, capturing the broader political, regulatory and financial conditions that determine whether technical analysis can actually influence policy. This multi-level lens matters because, as the study makes clear, training a statistician to build a cost-effectiveness model accomplishes little if there is no institutional home for the work, no legislative mandate for its use, and no network of peers to review and refine it.

The quantitative results reveal a geography and a philosophy of engagement. Of the 278 activities, 151 took place with partners in Asia, while activities with African countries involved 11 nations, of which only 3 had what the researchers classify as programmatic engagements, totaling 30 activities. That word “programmatic” is doing heavy analytical work in the paper. Roughly 128 of the initiatives were programmatic, meaning they were designed as sustained, multi-year partnerships with defined objectives, rather than one-off workshops or ad hoc consultancies. The distinction proved consequential. Programmatic engagements, the evidence suggests, are far more likely to produce durable institutional change, because they allow trust to accumulate, allow methods to be adapted to local epidemiology and budget realities, and allow the inevitable political setbacks of health policy reform to be weathered rather than fatal.

The content of the activities also tells a story. Knowledge sharing accounted for 26 percent of all initiatives, making it the single most common activity type, followed closely by research and project collaborations at 21 percent. In African engagements, by contrast, advising and mentoring dominated, comprising 30 percent of activities. The authors read this asymmetry candidly: in Asia, where HTA institutions in many countries have matured over the past two decades, collaboration has shifted toward co-production of research and shared learning between roughly equal partners. In Africa, where the field is younger in many national contexts, the work remains more advisory, reflecting a genuine gap in institutional infrastructure that external partnerships have only begun to close. The study does not treat this as a failure of African health systems but as a roadmap for the kind of sustained, long-horizon investment that Asia’s experience suggests is necessary.

One of the more intriguing temporal findings concerns the aftermath of the COVID-19 pandemic. Analysis of annual activity frequency shows that from 2022 onward, multi-country engagements increased noticeably, with collaborative activities transitioning to include larger numbers of countries within a single event. The pandemic, which devastated in-person technical cooperation in 2020 and 2021, appears to have left behind a changed format: once virtual and hybrid meeting technologies normalized, convening analysts from a dozen nations simultaneously became cheaper and more routine than bilateral engagements ever were. Whether this consolidation of geography comes at the cost of the deep, country-specific tailoring that programmatic work requires is a question the authors raise implicitly, and it is one that global health funders would do well to watch closely.

What did fifteen years of partnership actually produce? The interview data offer a layered answer. At the most visible level, collaborations generated concrete artifacts: national HTA guidelines, peer-reviewed publications, dedicated HTA units within ministries of health, a Memorandum of Understanding formalizing institutional cooperation, and in some cases regulatory and legislative reforms. Participants reported that the work raised awareness and recognition of HTA among key stakeholders, including policy-makers who might otherwise never have encountered the concept, and strengthened technical capacity not only within ministries of health but within partner organizations and universities. Crucially, informants described changes at all four INNE levels, from individual analysts gaining modeling skills to environmental shifts in how health budgets are justified. That breadth, the authors argue, is precisely the point: capacity that exists only in individuals evaporates when those individuals change jobs, while capacity embedded in institutions and enabling environments persists across political cycles.

The study is refreshingly honest about the limitations of its own model. Only three African countries achieved programmatic engagement over fifteen years, a pace that would leave the continent’s HTA needs unmet for generations at current rates. The authors acknowledge that the field must accelerate, and they point to the mechanics of how that might happen. Contextual adaptation emerges as the non-negotiable core: methods and institutional designs transplanted wholesale from high-income settings, such as the appraisal models of England’s National Institute for Health and Care Excellence, routinely fail when local data are sparse, budgets are small, and the political economy of pharmaceutical pricing differs fundamentally. What transfers instead is methodological discipline, priority-setting frameworks, and the hard-won institutional wisdom of how to make evidence survive contact with politics. The paper argues that a multi-pronged approach, deliberately combining individual training, institutional anchoring, network building and environmental reform, and emphasizing joint initiatives across countries, is what ensures HTA remains relevant and responsive as priorities evolve.

There is also a macroeconomic argument threaded through the findings that explains why this work matters far beyond the technical community. Universal health coverage, the commitment that every person should obtain needed health services without financial hardship, is a stated goal of virtually every government in the world, yet the fiscal space to pursue it is finite everywhere and brutally constrained in low- and middle-income countries. HTA is, in essence, the technology for allocating that finite space rationally, and countries without it are left making purchasing decisions at the mercy of information asymmetries that historically favor manufacturers. The study’s conclusion that these collaborations “will shape the next decades” is not rhetorical inflation; as more low- and middle-income countries establish national health insurance schemes and negotiate with global pharmaceutical markets, the presence or absence of domestic analytical capacity will directly determine how much health their health budgets buy.

For the broader scientific and policy audience, the paper is also a methodological contribution to the emerging science of capacity development itself. Efforts to strengthen research and policy institutions in low- and middle-income countries have often been evaluated anecdotally, through counts of trainees or workshops, metrics that reveal little about durability or influence. By systematically coding fifteen years of activity against an explicit framework and triangulating with decision-maker testimony, the HITAP team has produced something rare: an empirically grounded theory of how institutional capability in health policy actually accumulates. The answer they offer is patient, relational and unglamorous, built on decades-long commitments, mutual adaptation, and the recognition that the goal is not to export expertise but to cultivate the conditions in which local expertise becomes authoritative. As pressures on global health funding intensify, that distinction between exporting and cultivating may prove to be the study’s most important message of all.