Ongoing improvement of participatory health technology assessment in Brazil’s SUS: 10 lessons from Conitec’s (2012–2025) policy implementation evolution (case) study

Brazil’s National Committee for Health Technology Incorporation (Conitec) has progressively expanded mechanisms for public and patient participation in health technology assessment (HTA) decision-making within the Unified Health System (SUS) since the 2010 National Policy for Health Technology Management. From 2012 until 2017, social participation was formally limited to public consultations, National Health Council representation and public hearings. The Department of Management and Incorporation of Health Technologies (DGITS)—Conitec's Executive Secretariat—initiated serial evidence-informed actions to expand social participation typologies and integrate qualitative evidence into HTA. Evidence on how participatory HTA is institutionalized in low- and middle-income country (LMIC) universal health coverage (UHC) settings remains limited. We conducted an implementation science type 2 hybrid effectiveness case study examining the co-production (January 2017–June 2020) and implementation (July/2020–December/2025) of evidence-informed actions to improve social participation in Conitec’s HTA processes. Data sources included participant observation notes, focus group transcripts ( n = 11 facilitators, November 2017), written and visual materials from 2017 and 2019 stakeholder events, a qualitative evidence synthesis, policy documents, legislative instruments and implementation monitoring reports. We analysed data via a grounded-theory-inspired analysis triangulated with critical discourse analysis and an adapted theory of institutional change framework to systematically identify facilitators, barriers and outcomes to actions, simultaneously evaluating effectiveness and implementation feasibility. Key outcomes included: experienced qualitative researchers into DGITS (2020); patient testimonials in Conitec Committees’ meetings (2020); systematic qualitative analysis of 178 public consultation contributions(2021); initial qualitative evidence synthesis in HTA reports (2022); judiciary representations without voting rights (2022); and a rotating civil society organization (CSO) membership with voting rights (2025). Crucial facilitators included: legislative reform, institutional leadership, interinstitutional collaboration and investment in qualitative expertise. Persistent barriers comprised: digital inequities, HTA literacy gaps and risks of unaccountable influence in Conitec Committees’ deliberations. Our case study on this 2012–2025 policy implementation evolution underlines that an institutional culture shift towards inclusive, evidence-informed HTA within a LMIC/UHC setting requires clear legal frameworks and sustained investment in information strategies and qualitative analytical capacity as preconditions for transparency, accountability and ongoing co-production of context-specific impact indicators. The Brazilian experience highlights opportunities and tensions involved in embedding participatory practices within evidence-informed health policy systems.