Abstract for: Systems Dynamics for challenges to Universal healthcare in a Southeast Asian Country

Health technology assessment (HTA) was mandated to support evidence-based decision making for universal healthcare in Country X. However, the HTA system faced persistent challenges over time. Despite process reforms at the HTA agency, backlog of technologies continued to grow, and outputs failed to meet stakeholder expectations for policy making, reducing confidence in HTA, and leading to weakening of HTA mandate. A systems dynamics approach was used to examine feedback structures influencing HTA performance in Country X, combining literature review and stakeholder interviews, mapped to existing frameworks for evaluation of health systems. Causal loop diagrams were developed from data sources and validated through stakeholder workshops. Archetypes were identified to explain recurring system behaviours and to reveal leverage points to strengthen the perceived value of HTA. Analysis revealed interlinked archetypes driving HTA system performance. Fragmented, siloed workflows across agencies led to duplicated processes and delays, while policy misalignment reduced the relevance and perceived utility of HTA. Data and human resource constraints further limited capacity. Efforts to increase capacity through external assessors failed to yield expected gains, and attempts to bypass HTA weakened incentives for long-term improvements of the HTA system. HTA system performance is shaped by cross-agency feedback dynamics, rather than by individual agency capacity. In this study, systems dynamics enabled discourse among stakeholders with differeing perspectives in a politically sensitive context. Stakeholder validation workshops and follow-up discussions on solutions were particularly helpful for supporting alignment on shared priorities and coordinated actions to support performance of the HTA system.