Assessing the development of health technology assessment in Iran: a policy analysis using Kingdon’s Multiple streams framework: a qualitative study | BMC Public Health

The findings of this study shed light on the challenges and opportunities surrounding the development of HTA in Iran, using Kingdon’s Multiple Streams Framework to analyze the issue. Based on the analysis of the participant quotes and the concepts of Kingdon’s Multiple Streams Framework, the development of HTA in Iran appears to be on the agenda, but not yet fully implemented or prioritized at the necessary levels. The findings demonstrate that Iran, like many other countries, faces significant challenges in fully developing HTA, but also has key opportunities to leverage for progress.

Problem stream

The rising costs of healthcare, particularly concerning imported medical technologies, have become a significant issue in Iran, mirroring global concerns about the efficiency of healthcare resource allocation. As highlighted by the participants in our study, these financial pressures are amplified in countries with resource constraints, where the need to optimize healthcare spending is critical. For instance, countries like Brazil, South Africa, and China have faced similar challenges, leading to the recognition of HTA as a vital tool for addressing inefficiencies and ensuring cost-effectiveness in healthcare [26, 27].

In South Africa, the implementation of HTA has helped tackle disparities in access to essential medical technologies, especially in the context of selecting medications for the National Essential Medicines List. The institutionalization of HTA in South Africa has been a strategic response to resource constraints, facilitating the cost-effective selection of medicines [27]. While this approach has yielded positive results, our study found that Iran faces more significant structural barriers, primarily due to economic sanctions and political dynamics. Unlike South Africa, which has successfully integrated HTA into its policy frameworks, Iran’s progress has been hindered by these unique contextual challenges [28].

China, similarly, has recognized the importance of HTA as a response to rising healthcare costs and an aging population. In contrast to Iran, China has successfully used HTA to inform national policies such as the National Reimbursement Drug List (NRDL), which has been central to making evidence-based decisions on which technologies to include in their health insurance system [29]. While both countries share common challenges, China’s more centralized, top-down approach to HTA implementation contrasts sharply with Iran’s fragmented healthcare system, providing valuable insights into the role of political landscapes in shaping HTA effectiveness [30].

The Covid-19 pandemic has further highlighted the urgency of integrating HTA into healthcare systems. In countries like the UK and Germany, HTA played a central role in managing the crisis and ensuring cost-effective responses to the pandemic [31]. However, in Iran, the pandemic has acted more as a catalyst for discussion about HTA rather than as a prompt for immediate policy reform. This suggests that while there is an increasing recognition of HTA’s potential, its adoption in Iran remains slow, hindered by structural and political challenges.

Policy stream

While HTA has been a topic of academic discussion in Iran for several years, it has yet to be integrated into formal health policy. The gap between theoretical discussions and policy action on HTA, as identified by Iranian participants, is not unique to Iran. This gap between theoretical discourse and actual policy action is a common challenge in many countries, where the transition from academic knowledge to policy implementation is slow. This gap was especially evident in the case of South Africa, where although HTA was discussed extensively, the implementation of policy frameworks was delayed due to political resistance [28].

The technical feasibility of implementing HTA in Iran, given the existing infrastructure in universities and research centers, is promising. However, the findings underscore the need for political will to overcome the resistance from private sector actors, particularly medical equipment suppliers, who may view HTA as a threat to their business interests. This dynamic illustrates a broader tension between public health objectives and private sector interests, a challenge well-documented in the health policy literature. However, unlike in Turkey and India, where bureaucratic resistance has been identified as a significant barrier, our findings suggest that in Iran, political and sectoral resistance are the primary factors preventing HTA from moving into policy [32, 33].

Countries like India and Turkey have also struggled with moving HTA from academic discussions to formal policy adoption [33, 34]. In India, despite the existence of academic research on HTA, the institutionalization of HTA into the health ministry’s decision-making processes has faced delays due to bureaucratic resistance and lack of coordination between stakeholders [33]. Similarly, Turkey’s HTA development has been slow, with political challenges and private-sector opposition hampering progress [34]. However, other countries have managed to overcome these barriers. For instance, Thailand’s Health Intervention and Technology Assessment Program (HITAP) offers a model where HTA was successfully integrated into national policy by securing strong political backing and aligning the process with national health goals [35]. Iran could learn from Thailand’s success in securing political buy-in, particularly in light of recent government reforms that align more closely with healthcare efficiency. The experience of Thailand demonstrates the importance of political will and strategic advocacy, which are crucial factors also emphasized by participants in Iran.

Politics stream

The political environment in Iran appears increasingly conducive to the adoption of HTA, with a growing emphasis on healthcare efficiency and transparency. As highlighted by participants, the increasing political interest in efficiency and accountability in healthcare could create a supportive environment for HTA adoption shortly [36].

The alignment of HTA with broader political goals of improving resource allocation and government accountability presents a significant opportunity for its development [37]. However, the findings also highlight the need for sustained advocacy to maintain momentum, particularly in light of recent leadership changes in the Ministry of Health.

A comparison with countries like Chile and Mexico is useful here. In these nations, political shifts have created both challenges and opportunities for HTA adoption [3]. In Chile, HTA was integrated into broader healthcare reforms aimed at improving resource allocation, and in Mexico, similar reforms have recently started to bear fruit [38].

In Indonesia, the establishment of the Indonesian Health Technology Assessment Committee (InaHTAC) in 2014 was a response to the need for greater transparency and accountability in healthcare spending [39]. Iran’s context, marked by political shifts, highlights the importance of advocacy in ensuring HTA’s place on the political agenda.

Policy window and entrepreneurs

The identification of the Covid-19 pandemic and healthcare shortages as potential focusing events presents a key opportunity for advancing HTA in Iran. As the findings suggest, these crises have exposed vulnerabilities in the healthcare system, making the adoption of evidence-based decision-making frameworks more pressing. Our study found that while the pandemic presented opportunities for advancing HTA, it also emphasized the need for specific policy entrepreneurs who can push the agenda forward [40].

In the UK, the pandemic accelerated the role of HTA in evaluating new treatments and vaccines, reinforcing the importance of evidence-based decision-making [41]. In Germany, the Institute for Quality and Efficiency in Health Care (IQWiG) played a central role in assessing new medical technologies during the pandemic, demonstrating the value of HTA in crises [42].

The role of policy entrepreneurs, as highlighted in this study, is critical to pushing HTA forward. These individuals, whether in the Ministry of Health or academic institutions, are well-positioned to champion HTA, but they require more visibility and institutional support. This is especially evident in the case of Taiwan, where HTA faced initial resistance but was gradually integrated into the National Health Insurance system due to strategic efforts by policy entrepreneurs [43].

This aligns with Kingdon’s theory, which emphasizes the importance of policy entrepreneurs in coupling the streams and seizing the policy window when it arises. The active role of these entrepreneurs in shaping the HTA agenda is essential for advancing its implementation in Iran. This finding aligns with other countries’ experiences, such as Australia, where policy entrepreneurs played a significant role in pushing for the establishment of the Australian Medical Services Advisory Committee (MSAC), which now oversees HTA activities [44].

Limitations

While this study provides valuable insights, its limitations must be acknowledged. The sample size, while sufficient for qualitative analysis, is relatively small and may not fully capture the diversity of perspectives among all relevant stakeholders in Iran’s healthcare system. The small sample size could limit the generalizability of the findings to the broader population of healthcare professionals and policymakers in Iran. Additionally, potential biases in participant selection could affect the representation of certain stakeholder groups, particularly those with less visibility or influence in the decision-making process. For instance, the inclusion of primarily academic or governmental stakeholders may not adequately represent the perspectives of private sector actors or marginalized communities.

Furthermore, while Kingdon’s Multiple Streams Framework provides a useful lens for understanding policy development, future research could explore other theoretical models to provide a more comprehensive analysis. Additionally, the focus on a single country case study limits the ability to compare findings across different healthcare systems or policy contexts. Further research is also needed to examine the specific steps required to integrate HTA into Iran’s healthcare system and the potential challenges that may arise during its implementation.

Implications of developing HTA in Iran

Developing an HTA process in Iran carries significant implications for the population, the healthcare system, and the policy landscape. These implications can play a pivotal role in advancing the effectiveness, equity, and sustainability of healthcare delivery in the country.

Impact on population

The development of HTA in Iran can ensure that the population benefits from evidence-based, cost-effective healthcare interventions. By prioritizing the adoption of technologies that provide the most benefit in terms of health outcomes relative to costs, HTA can enhance access to essential treatments and services for all segments of the population. This will not only improve the quality of care but also address existing health disparities by making healthcare more equitable, especially for marginalized or underserved groups.

Impact on healthcare system

Integrating HTA into Iran’s healthcare system will help optimize resource allocation, reduce inefficiencies, and improve the overall performance of the system. As healthcare costs continue to rise, HTA will enable policymakers to make informed decisions about which health technologies and interventions should be funded, thereby avoiding unnecessary expenditures on ineffective or low-priority treatments. This can result in better utilization of available resources, ensuring that Iran’s healthcare system remains both financially sustainable and capable of providing high-quality care.

Impact on policy

HTA has the potential to transform health policy decision-making in Iran by promoting evidence-based policymaking. It can provide policymakers with the necessary data to make informed choices on health technology adoption, reimbursement policies, and the design of national healthcare programs. In the long term, this can lead to more transparent and accountable decision-making processes, increasing public trust in the healthcare system. Furthermore, the development of HTA could contribute to Iran’s efforts to integrate with global health standards, improving its positioning in international health forums.

Developing a formal HTA process in Iran would not only enhance the efficiency and effectiveness of healthcare delivery but also align the country’s health policies with global best practices, ensuring that the healthcare system can meet the evolving needs of its population.

To synthesize the key recommendations derived from our analysis, we have developed a one-page diagram, presented in Supplementary 2, that outlines actionable strategies for advancing HTA in Iran. This diagram integrates the study’s recommendations with examples of best practices from established HTA agencies worldwide, such as the National Institute for Health and Care Excellence (NICE) in the United Kingdom, the Institute for Quality and Efficiency in Health Care (IQWiG) in Germany, and the Canadian Agency for Drugs and Technologies in Health (CADTH] in Canada, the Medical Services Advisory Committee (MSAC) in Australia and the Tandvårds-Läkemedelförmånsverket (TLV) in Sweden. These global examples highlight successful approaches to HTA implementation, providing inspiration and practical guidance for the Iranian context. The visual representation aims to clarify the recommendations and their implications for policymakers, healthcare professionals, and researchers, emphasizing their potential to improve evidence-based decision-making, resource allocation, and health outcomes in Iran.