OBJECTIVES:   Assessment of health technology (HTA), including pharmaceuticals, devices, procedures and organizational systems plays an increasingly important role in health care systems by providing structured, evidence-based input to policymaking. HTA is firmly established in Europe, North America and Australasia, and is growing rapidly in Asia and Latin America. We investigated the organisation and influence of HTA in middle-income countries on real decision-making over pharamceutical budgets.  METHODS:   We selected middle-income countries where HTA activities are establihsed to some extent: Argentina, Brazil, China, Colombia, Israel, Mexico, Philippines, Korea, Taiwan, Thailand, and Turkey. We collected and reviewed relevant information to describe the health care and reimbursement systems and how HTA relates to coverage decision making of pharmaceuticals using a common template. The country profiles were supplemented by information from a structured web-survey among professionals working in public and private health insurance, industry, regulatory authorities, ministries of health, academic units or HTA agencies. RESULTS:   The use and implementation of HTA recommendations in reimbursement decision-making is still in its early stages. We found that in South Korea, Taiwan, Brasil and Mexico HTA was more developed, with guidelines for manufacturers submissions,  a link to the pricing of new treatments and some requirement for data to be adapted for local costs epidemiology. CONCLUSIONS: The study provides evidence of the development of HTA in coverage decision making in middle-income countries. Increased health care spending and the resulting access to modern technology give a strong impetus to HTA. The assessment and regulation of pharmaceuticals are advanced in relation to other technologies. HTA is developing with uneven speed in middle-income countries; many countries are building on the organisational and methodological experience from established HTA agencies in Europe, Australia and Canada.