National HTA system in Canada: From system analysis and understanding to system strengthening.

Health Technology Assessment (HTA) has played a critical role in guiding evidence-based decision-making in Canada's healthcare system; however, its current structure and processes face several limitations that reduce its effectiveness and responsiveness. To effectively address these challenges, there is a clear need for a comprehensive framework that outlines the key components of Canada's HTA system-including its conceptual foundations, policy environment, structural organization, governance models, institutional capacities, implementation pathways, and integration into decision-making processes. Such a framework would support more coordinated, transparent, and responsive HTA practices across jurisdictions. Using a systems thinking and analytical approach, the study aims to comprehensively analyze the components of the national HTA system in Canada. The study was conducted between 3rd May 2021 and 22nd April 2022, selectively recruiting experts and organizations involved in HTA. Seven national HTA experts participated in virtual In-Depth Interviews (IDIs) to understand HTA from a policy perspective, and ten HTA-associated organizations from the Canadian governmental and non-governmental sectors completed one electronic institutional survey to understand HTA from a technical perspective. Findings indicate a high level of literacy/understanding and perceived applicability of HTA, though challenges exist in governance, legislation, and decentralized coordination. While there's general support for HTA, concerns arise regarding the extent of HTA report utilization and the need for a more cohesive national HTA approach. Capacity-wise, sustainable funding exists, but challenges include varying assessment coverage and the lack of harmonized guidelines resulting from a decentralized structure revealed within provinces. Qualitative findings revealed a decentralized structure with provincial-level HTA bodies, limited national coordination, and inconsistent integration into decision-making. Experts emphasized the need for standardized guidelines, improved capacity, and stronger national oversight to enhance the utilization of HTA. This study proposes advancing national coordination and developing standardized HTA guidelines to address fragmentation. It also recommends investing in capacity-building, training, and sustainable funding to strengthen HTA implementation. In conclusion, this study generates evidence of the strengths of the Canadian HTA system, as well as the presence of significant legislative, structural, policy, and capacity-related challenges. Despite the available funding, human resources, and capacity, and the active role of the Canadian Agency for Drugs and Technologies in Health (CADTH), establishing national HTA frameworks and strategies is a priority. This strategy, along with reinforcing provincial and federal stakeholder engagement, improving adoption pathways of HTA recommendations, and adapting HTA methodologies for more flexible and timely evaluations, can strengthen the Canadian HTA system.