OBJECTIVES:  Health Technology Assessment is a decision making and policy formulation tool in the health sector. The purpose of this study was to examine and compare selected European countries with different maturity in the use of HTA. METHODS:  Countries were selected on the basis of long established HTA institutions (Group A: England, Germany, France, Sweden) and comparatively recent established HTA (Group B: Poland, Romania, Hungary, Romania). A systematic literature review was performed and collected information was reviewed by two independent researchers. Comparative analysis of HTA organizations in the respective countries was carried out based on the analytical framework by Hutton et al (2006). RESULTS:  In Group A countries, the assessment is done by independent HTA institutions with specific guidelines; criteria used include effectiveness, safety, and economic data. They critically appraise local data with emphasis on relative effectiveness and the therapeutic added value based on the optimal treatment/ comparator. The main objective of HTA in this group of countries is equal access to care, and assessing value for money. Group B countries have established HTA agencies with formal procedures, however they differ in the way HTA is organized and the extent it influences decision making. They generally follow the standards of other more mature HTA organizations and often consult the decisions of more developed countries; however the transferability of HTA results across different countries is an important limitation. Effectiveness, safety and therapeutic added value are the key criteria but considerable emphasis is also given on the budget impact of new therapies. CONCLUSIONS: HTA is widely used for assessing new technologies for the benefit of patients, and as a cost estimation tool for state budgets. HTA organizations have been established and developed dynamically in high income countries, but also in countries with limited resources, with distinctive operational characteristics and priorities.