OBJECTIVES : Countries new to technology assessment often experience difficulties with aligning their processes to achieve public health, sustainability, and equity. We aimed to disentangle the interdependencies of those processes and their potential impact on system objectives for new medicines in Malta’s public healthcare services.

METHODS : We used a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis to identify internal and external factors influencing the objectives of the Maltese reimbursement system. Policy documents and semi-structured interviews (N=33) with policymakers, representatives of healthcare providers, patients, and industry, guided by the Hutton Framework, informed our analysis.

RESULTS : Assessors provide cost-effectiveness information but lack expertise to comprehend cost-effectiveness evidence and to address transferability issues. Consequently, the role of cost-effectiveness is challenged by both appraisal committees, with members also unexperienced in cost-effectiveness, limiting possible gains in public health and sustainability. Challenges with pricing of new medicines and volume estimates limit efficient procurement and reliable decision-making based on budget impact. This can result in budgetary issues and/or under- or overstock of medicines impacting public health and sustainability goals. The processes’ set-up does not support timely evaluation resulting in delayed access. At appraisal, both committees fail to appraise new medicines on a regular basis due to competing responsibilities, and lack of well-defined criteria and budget resulting in backlogged medicines. Consequently, industry remains uninformed for significant time about the evaluation outcome potentially negatively affecting submission rates.

CONCLUSIONS : Our study unravels the processes’ interdependencies and their potential for impacting system objectives. Although systems differ, process weaknesses, such as the lack of efficiency and quality can be generalized to various jurisdictions, especially when new to technology assessment. By tackling those weaknesses, systems might achieve system goals more efficiently and effectively.