Thanks to the work of the global scientific community, the body of evidence on effective and cost-effective health interventions is regularly updated. A key feature of PBF/P4P programs is that one can introduce new indicators, remove redundant ones and thus generally adapt the reward structure on the basis of new evidence at global and country levels. In an ideal “strategic purchasing” system, such updating of interventions of focus would be done regularly. In practice however, this does not seem to be done enough. Health Technology Assessment (HTA) is the gold standard of cost effectiveness assessment for countries to ensure allocative efficiency of health budget and therefore strategic purchasing of key interventions and services.