The agencies involved in the assessment and prioritisation of medicines for public subsidy purposes in Australia, England and Wales, and New Zealand are compared in terms of their processes; ultimate decision-maker and political involvement in decisions; price-setting processes; decision criteria and inclusion of economic assessment of cost-effectiveness; provision for the rule of rescue and separate treatment of potentially life-saving medicines and cancer drugs; levels of access; extent of consumer participation in processes and decisions; and provision for appeal from decisions. All countries face the key challenge of expanding access to important new treatments, while maintaining cost-effectiveness as a key criterion for public funding and safeguarding the affordability and sustainability of their programs into the future. New Zealand's model may have led to a greater focus on cost-containment and overall affordability than those of the other two agencies. Despite controversial decisions that have led on occasion to disappointment and challenge, the Australian and New Zealand agencies have survived and appear to have managed to date to maintain public and political support. By contrast, the United Kingdom's National Institute for Healthcare and Clinical Excellence is facing major changes to its role that could see it become more of an advisory organisation.