Health technology assessment (HTA) is increasingly used to guide coverage and pricing decisions, but many countries lack formal HTA agencies or rely on fragmented processes. This study aims to compare institutional and procedural features of selected HTA agencies and to derive policy options for establishing, institutionalising, or reforming HTA in diverse health systems. Using the World Health Organization’s five-component institutionalisation framework, researchers completed a comparative narrative review of ten HTA systems. Thirtyfive structural and procedural elements were extracted and synthesised into five analytical modules covering governance, assessment methods, institutional roles, lifecycle integration, and stakeholder engagement to enable structured cross-country comparison. HTA functions, authority, and processes varied widely. Independent agencies undertook broader mandates, whereas ministry-based units were more closely linked to reimbursement and policy implementation. Assessment relied on hybrid internal-external evidence review models, followed by formal appraisal or deliberation in all systems. Binding coverage outcomes were observed in England, France, Germany, and Brazil, although the legal force and implementation pathway differed across agencies. Pricing negotiation arrangements differed but were commonly linked to appraisal outputs. Horizon scanning, early scientific advice, and disinvestment mechanisms were unevenly implemented, while few systems employed lifecycle-oriented practices. HTA systems differ widely in governance, scope, and authority, and these differences shape their influence on pricing and reimbursement policies. Strengthening statutory integration, analytical capacity, and transparent engagement, especially where HTA is emergent or fragmented, is essential for legitimacy and sustainability. This study offers transferable options for settings without formal HTA agencies and may guide reforms towards sustainable and equitable health system goals. Keywords: Health technology assessment, Institutional governance, Coverage and pricing, Lifecycle management, Stakeholder engagement