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This perspective synthesizes Plenary Three of the HTAi 2025 Annual Meeting, which examined how HTA can contribute to more transparent, equitable, and fair health systems. Drawing on multistakeholder perspectives from patient advocacy, global health equity, health policy, industry, and HTA research, this article argues that transparency, equity, and trust must be treated as foundational principles rather than optional enhancements. It highlights persistent challenges, including opaque deliberation, context-dependent definitions of equity, limited feedback to patient contributors, and evidence bases that insufficiently reflect diverse populations. Emerging practices from leading HTA bodies illustrate practical pathways forward. The article concludes that HTA\u2019s convening power can help transform it from a technical gatekeeper into a guardian of fairer health systems across diverse contexts.<\/jats:p>","DOI":"10.1017\/s0266462326104152","type":"journal-article","created":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T11:11:25Z","timestamp":1790593885000},"source":"Crossref","is-referenced-by-count":0,"title":["Holding up the mirror: how can HTA achieve more transparent, equitable, and fair health systems?"],"prefix":"10.1017","volume":"42","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7459-4994","authenticated-orcid":false,"given":"Clifford","family":"Goodman","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/04f45q833","id-type":"ROR","asserted-by":"publisher"}],"name":"Consultant, Health Care Technology & Policy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9600-1419","authenticated-orcid":false,"given":"Iga","family":"Lipska","sequence":"additional","affiliation":[{"name":"Institute for Health Policy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen","family":"Alparce-Villanueva","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emilia","family":"Caro","sequence":"additional","affiliation":[{"name":"Women in Global Health (WGH)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adolfo","family":"Rubinstein","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/02nvt4474","id-type":"ROR","asserted-by":"publisher"}],"name":"Institute for Clinical Effectiveness and Health Policy (IECS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Virginie","family":"Giroux","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/00rz3ed53","id-type":"ROR","asserted-by":"publisher"}],"name":"MSD"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1984-0803","authenticated-orcid":false,"given":"Antonio","family":"Migliore","sequence":"additional","affiliation":[{"name":"Health Technology Assessment International"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"56","published-online":{"date-parts":[[2026,9,28]]},"reference":[{"key":"S0266462326104152_r9","doi-asserted-by":"publisher","DOI":"10.1017\/S0266462326103663"},{"key":"S0266462326104152_r6","doi-asserted-by":"publisher","DOI":"10.1017\/S0266462322000198"},{"key":"S0266462326104152_r8","doi-asserted-by":"publisher","DOI":"10.1186\/s12939-025-02676-z"},{"key":"S0266462326104152_r11","unstructured":"11. 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