Original Articlehttp://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)

Iran University of Medical Sciences

____________________________________________________________________________________________________________________1. Assistant Professor, National Institute for Health Research -General Director of Health Technology Assessment, Standardization and TariffDepartment, Deputy of curative affairs, MOHME, Tehran, Iran. arolyaee@yahoo.com2. (Corresponding author) MSc, MPH, PhD Candidate of Health Service Management, Medical science school, Science and Research Branch,Islamic Azad University, Tehran, Iran,shiladoaee@live.com3. PhD Candidate of Health Service Management, School of Management and Economics, Science and Research Branch, Islamic Azad Univer-sity, Tehran, Iran. mobinreza@yahoo.com4. MSc in Health Care Administration, Deputy of curative affairs, MOHME, Tehran, Iran. merciful.2008@yahoo.com5. BSc in Health Care Administration, Department of Payment and Financing System, National Institute for Health Research, Tehran Universityof Medical Sciences, Tehran, Iran. aboeep@yahoo.com6. Associate Professor, Tehran University of Medical Sciences, Tehran, Iran. emami_r@health.gov.ir

Health technology assessment in Iran: challenges and views

Alireza Olyaeemanesh1, Shila Doaee2, Mohammadreza Mobinizadeh3, Mina Nedjati4Parisa Aboee5, Seyed Hassan Emami-Razavi6

Received: 29 May 2013 Accepted: 7 April 2014 Published: 29 December 2014

AbstractBackground: Various decisions have been made on technology application at all levels of the health system in

different countries around the world. Health technology assessment is considered as one of the best scientifictools at the service of policy- makers. This study attempts to investigate the current challenges of Iran’s healthtechnology assessment and provide appropriate strategies to establish and institutionalize this program.

Methods: This study was carried out in two independent phases. In the first, electronic databases such as Med-line (via Pub Med) and Scientific Information Database (SID) were searched to provide a list of challenges ofIran’s health technology assessment. The views and opinions of the experts and practitioners on HTA challengeswere studied through a questionnaire in the second phase which was then analyzed by SPSS Software version16. This has been an observational and analytical study with a thematic analysis.

Results: In the first phase, seven papers were retrieved; from which, twenty- two HTA challenges in Iran wereextracted by the researchers; and they were used as the base for designing a structured questionnaire of the se-cond phase. The views of the experts on the challenges of health technology assessment were categorized asfollows: organizational culture, stewardship, stakeholders, health system management, infrastructures and exter-nal pressures which were mentioned in more than 60% of the cases and were also common in the views.

Conclusion: The identification and prioritization of HTA challenges which were approved by those expertsinvolved in the strategic planning of the Department of Health Technology Assessment will be a step forward inthe promotion of an evidence- based policy- making and in the production of comprehensive scientific evi-dence.

Keywords: Evidence Based Policy Making, HTA, Challenges, Iran.

Cite this article as: Olyaeemanesh A, Doaee Sh, Mobinizadeh M, Nedjati M, Aboee P, Emami-Razavi S.H. Health technology assessmentin Iran: challenges and views. Med J Islam Repub Iran 2014 (29 December). Vol. 28:157.

IntroductionVarious decisions are made on using

technology at all levels of the health systemin every country which usually include co-ordinating complicated medical issues withmatters related to patients, organizational,economic and moral factors. Also, provid-ing appropriate inputs for health policy-makers which depend on interactions, workdivision and cooperation among the health

experts, decision makers and practitionersis of prime importance. These decisionsshould be based on documented principlesin which all the conditions and results ofthe decisions are systematically explainedby scientific methods (1, 2). Although theconcept of health technology assessment(HTA) is increasingly expanding in the in-dustrialized world, particularly in Europe,and it has also been institutionalized in

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HTA challenges in Iran

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Northern America, it has not yet been fullyinstitutionalized in developing and Asiancountries due to such factors as lack ofawareness, lack of epidemiologic data andlack of a relationship between research ef-forts (3). This study aimed to help the Ira-nian health policy- makers to design andimplement the HTA program by investigat-ing its current challenges in the country.

MethodsThis study was carried out in two phases:

the study phase and the polling phase. Inthe first phase, the sources were investigat-ed from the database of Medline (via Pub-Med) from 2000 to November 2011; theScientific Information Database (SID) wasalso searched by the key term of ‘HealthTechnology Assessment’ up to 2011 in or-der to obtain the Persian papers; two Per-sian papers were obtained. Manual searchwas also done through contacting the in-formants as well as using the Google searchengine; 3 papers were retrieved; overall, 24papers were collected. After studying theabstracts and eliminating irrelevant or re-peated cases, 7 papers were finally selected.

The second phase included the polling ofinformants, managers and experts of healthtechnology assessment in Iran. It should benoted that a minority of the participantswere some members of the scientificcommittee of the health technologyassessment (12 individuals) who

participated in this phase through astructured questionnaire designed by theauthors for the purpose of data collection.All challenges extracted from the phase 1were classified in a table, and theparticipants were asked to state their viewsbased on the Likert scale. In addition, theywere asked to state the reason for theirviews and solutions for the challenges aswell as other challenges not mentioned inthe questionnaire (in the form of openquestion based on the Likert scale). Datawere analyzed by SPSS 16 software, andthe scores given to views of the experts onthe current challenges were prioritized; andthen their reasons and solutions weresummarized.

ResultsTwenty- two HTA challenges which were

regarded as the most basic problemsencountered by the health system’s officialswere specified from the 7 selected papersand were then used for designing thequestionnaire and collecting data in thesecond phase. The findings of the secondphase, which were collected through asemi-structured questionnaire and includedthe views of the experts on both HTA andits specified challenges, suggest that theparticipants had relatively the same viewson the mentioned challenges. Stronglyagreeing views of the informants on thechallenges are given in Fig. 1.

Table 1. Search Strategy in Pub Med DatabaseNo. Key Term The Number of Papers1 HTA 19562 (HTA) OR Health Technology Assessment 139083 ((HTA) OR Health Technology Assessment) AND Iran 19

Table 2. Papers used in the studyNo. Author/Publication Date Title1 Farnoodi S/2009(1) Presenting a Framework for Evaluation of health Technologies in

health and Medical System of Iran; Case Study: Robolens Robot2 Sivalal S/2009(2) Health technology assessment in the Asia Pacific region3 Palesh M/2010(3) We noticed that suddenly the country has become full of MRI". Policy

makers' views on diffusion and use of health technologies in Iran.4 Larijani B/2000 (4) Prioritized list of health services in the Islamic Republic of Iran.5 Marzban S/2007(5) A summary of HCTM report in Iran6 Hosseini A/2007(6) HTA Policy Paper7 NaserHamzeKhanloo M/2010(7) Role and Necessity of Health Technology Assessment (HTA) in

Health System

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As demonstrated in the diagram, amongthe 22 mentioned challenges, the partici-pants reached the highest consensus aboutthe factors in the area of health systemmanagement (57.1%); they also stronglyagreed on important factors (42.85%) suchas stewardship, stakeholders, infrastruc-tures, external pressures, lack of coordina-tion at the policy making level and lack ofsystematic structure for decision- making inthe health system organization. However,

only 14.28% of the participants stronglyagreed on such challenges as the involve-ment of partner organizations with unrelat-ed tasks, dependence of HTA activities onperiodic meetings, being passive to newtechnologies, lack of experts in the field,lack of feasibility studies in the process ofHTA application and dependence HTA oninvestors and importers. The Department ofHealth Technology Assessment, the mainorganization responsible for HTA in Iran,

Fig.1. Informants with strongly agreeing views on the mentioned challenges regarding health technology assessment

Table 3. The 22 investigated challenges in this researchLack of feasibility studies in the process of HTAapplication

MLack of integration with the country's macroeco-nomic policy

A

Lack of experts in the fieldNInvolvement of partner organizations with unrelat-ed tasks

B

Lack of coordination with the HTA process at thepolicy- making level

OLack of HTA activity in academic unitsC

Inadequate understanding of policy makers withthe HTA process

PLack of a local model for the arrangement of relat-ed organizations

D

Lack of a comprehensive (systematic) evidencebased system

QOrganizational culture related factorsE

Influence of the investor and importer manner onthe HTA process in Iran

RStewardship factors such as lack of a clear bounda-ry between the public and private sectors, reluc-tance to develop the private sector and ambiguousconnection to the global structure

F

Dependence of HTA activities on periodic meet-ings

SLack of a common understanding between thestakeholders and not using the potential of all thestakeholders

G

Being passive to new technologiesTFactors related to the management of the healthsystem such as senior executives’ lack of under-standing of the establishment needs in such a struc-ture

H

Lack of legal protection in the upstream docu-mentation such as in Fifth Development Plan

UFactors related to infrastructures such as lack ofexperts and lack of academic centers for trainingthe infrastructures of health technology assessment

I

Allocation of insufficient resourcesVExternal pressuresKLack of planning for academic training of theinvolved experts

WInsufficient application of a comprehensive frame-work in the HTA system

L

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has introduced three main challenges in thisfield as follows: the lack of legal supportfor HTA in the legal documentation of thenational health system, insufficient re-source allocation and the lack of academiccourses for the involved experts; the viewsof the experts are presented in the follow-ing diagram:

The findings of this study imply that ahigh percentage of the expert participantshad the same view on the three factorsmentioned by the HTA department. At thesame time, they mentioned the followingfactors as the challenges affecting HTA:lack of sufficient scientific capacity in theHTA subject at universities, lack of interac-tion between public and private sectors re-garding HTA, conflict of interest, lack of anational organization for evidence qualitycontrol, limited access to databases, lack ofa clear policy- making structure, lack offundamental macro strategies for managingthe health and education sector, weaknessof intersectional organizations of the healthsystem and lack of an integrated, perfect,evidence based structure in the health sys-tem of Iran.

DiscussionConsidering the increasing importance of

evidence based policy- making, the healthsystem authorities and decision makershave focused on the production of scientificand comprehensive evidences. In recentdecades, budget constraints and the needfor the effective application of health tech-nology have doubled the necessity for theirassessment and prioritization. Thus, by ac-knowledging the emphasis of World Health

Organization (WHO) on HTA and its keyrole in the promotion of evidence basedpolicy- making, many countries such asIran, which follow the health reformingprogram, pay a particular attention to HTA,the selection and application of appropriatetechnology within the framework of mana-gerial and political strategies and attempt todevelop HTA through government support.In addition, the accurate identification ofthe current challenges and obstacles as wellas their prioritization may lead to the ad-vancement of the health system reforms.Thus, studying the challenges of HTA notonly helps planning the needed reforms, itcan also bring about an efficient allocationof health technologies despite resource dis-tribution. For this purpose, such factors ashealth system management, stewardship,stakeholders, infrastructures, external pres-sures, lack of coordination at policy- mak-ing level, lack of a comprehensive systemfor decision- making in the health system,lack of legal support for HTA in the legaldocumentation of the national health sys-tem, insufficient resource allocation andlack of planning for academic training ofthe experts involved in the program wereidentified as the main obstacles and havebeen considered in the priorities of the pro-grams of the Department of Health Tech-nology Assessment. Although the men-tioned challenges were classified into twogroups, stewardship and management, weattempted to study the challenges separate-ly regardless of their classification. In sup-porting the challenges investigated in thisstudy, Palesh (2010) introduced lack ofneed assessment in the process of technolo-

Fig.2. Views of the experts about the challenges recognized by the HTA office

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gy application, lack of coordination at thepolicy making- level, lack of experts in thefield and propaganda by importers and pro-ducers of the health technologies as the bar-riers to the application of the health tech-nology assessment in Iran (4). However,Sivalal stated that the lack of technical andexpert forces is one of the main problems inthe application of health technology as-sessment in Asian countries including Iran(3). Additionally, Hosseini (2007) men-tioned the followings as the main challeng-es of health technology assessment: lack ofcompetence and expert labor force, con-stant specialized personnel shift from onefield to another, lack of academic centersfor training infrastructures of health policymaking, health economics such as HTA,lack of appropriate training of managersand experts in various sections, lack of ex-perienced advisors in the field (5). Similar-ly, although South Korea has initiated HTAactivities since 1990, enabling human re-sources was one of the main challenges ofthe health system of this country in2009(6). Although HTA has not long en-tered into the health arena In Iran, noticea-ble actions have been done by the Depart-ment of Health Technology Assessment,Standardization and Tariff Department,main of which is the establishment of theHTA major at the master level. TehranUniversity of Medical Sciences in collabo-ration with the professors in this field trainsmany students annually in this major.Moreover, the return of HTA graduates andother related majors such as health policy-making from abroad universities has con-tributed to the strength and improvement ofIran’s health technology assessment pro-gram. However, considering the currentneed of the health system, the emphasis hascontinuously been on the fact that HTA ac-ademic training can guarantee the applica-tion of this interdisciplinary knowledge andmay improve the objectives of HTA.Hence, in order to increase the currentknowledge of HTA, the department ofHealth Technology Assessment and Stand-ardization and Tariff Department have tak-

en two essential steps including holdingshort-term HTA courses and preparingtraining packages to accomplish consistentand structured training courses.

The key role of the policy- makers in theestablishment and institutionalization ofHTA is undeniable and should not be un-derestimated. As mentioned, lack of coor-dination at the policy- making level in thehealth system was put at the second rate ofimportance (42.85%), and inadequate un-derstanding of the HTA process by the pol-icy- makers was placed at the third rate ofimportance. Sivalal has noted that there isno longer a need for convincing the policy-makers and top level decision makers aboutthe importance of HTA in Asian countriesincluding Iran (3). However, Hosseini(2007) stated that the followings are themain barriers and problems of HTA: noserious attempt at higher levels of man-agement, inadequate political support, lackof attitude and belief in the macro level andlack of understanding of the establishmentneeds in such a structure in senior execu-tives (5). Palesh (2010) has also argued thatalthough the policy- makers agree withHTA, it seems that they do not have a per-fect knowledge of it (4). In a study bySampietro entitled as ‘HTA History inSpain’, it was revealed that the policy-makers’ poor awareness of HTA preventsthem from providing adequate and fixedresources for it (8). In a study by Pichonand Colleagues entitled as ‘Facilitators andBarriers for International Collaboration’ inLatin America, Little government supportand funding and limited resources were in-troduced as the main problems againstHTA (9). Investigating the health technolo-gy assessment development in China, Chenet al. (2009) found that the distribution andpromotion of HTA theories and methods inthat country is under the influence of suchchallenges as coordination and cooperationof policy- makers, and they also maintainedthat although the policy- makers may havesome knowledge of HTA, they do not use itin practice (10). Investigating HTA historyin Japan, Hisachi noted that health policy-

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making in Japan is based on the traditionalconsensus approach and that institutionali-zation in health policies is fully based onthe individual’s opinion and depends on theopinion of the health system’s leaders.Thus, it appears that the application andcoordination of health technology assess-ment are considered two HTA challengesamong policy- makers in Japan (11). Re-cently, it seems that health policy- makersin Iran have gained a relatively positive at-titude toward health technology assessmentand have done the necessary efforts for itsestablishment; and finally, it can be saidthat the formal structure of HTA at themacro level has been established in theMinistry of Health and Medical Education.

The second most important challenge in-vestigated in this study was the lack of sys-tematic and comprehensive evidence basedsystem in the national health system.Marzban (2007) found that health technol-ogy related policies at the Health Ministryare not the integrated parts of the overallhealth policies of the country (Iran). He de-fined a national health technology assess-ment program with the initiation of pre-evaluation activities at the university leveland then considered the complete activitiesof the health technology assessment in anational agency. In addition, he acknowl-edged the necessity of observing nationalstrategic programs and national health sys-tem priorities in allocating technologies todevelop an effective pattern. He considereddesigning a model for health- centered or-ganizations and their role in supplying anddemanding the evaluation necessary forhealth technologies (12). HamzeKhanloo(2010) supported these findings and notedthat such factors as the lack of systematicstructure for health decision- making, de-pendency on investors and importers, de-pendency on periodic meetings and beingpassive to new technologies are the mainbarriers of application of HTA (13). There-fore, necessary and important efforts havebeen done or are in the evolution stage inthe Department of Health Technology As-sessment and Standardization and Tariff

Department. Projects in cooperation withmedical universities of the country aimingat developing a local model for the struc-ture and process of health technology as-sessment is among such efforts. In addition,designing a systematic structure for the co-operation of research centers in universitiesof medical sciences in the country was de-veloped by the help of one of the universityprofessors (Dr. Yazdani) in order to pro-vide structured, consistent and purposefulrelationship between universities and highrank authorities of the health system. In thisstructure, the method of health technologyassessment codification and medical guide-lines (from the horizon scanning stage forhealth technologies to pre-assessment,quick review of health technology assess-ment and a complete technology review)have been explained in detail which is nowin its initial stages of implementation.Therefore, relying on scientific and re-search centers and universities of the coun-try has made it possible to produce a list ofnew technologies to utilize the country'shealth technology assessment forknowledge production. It seems that man-agement practices can eliminate and solvesuch problems as lack of integration withnational macro policies, involvement ofpartner organizations with unrelated tasks,lack of HTA activity in academic units,lack of a local model for the arrangement ofrelated organizations, dependency of HTAactivities on periodic meetings, lack of acomprehensive and systematic structure ofan effective evidence, dependency on theinvestors and importers and being passiveto new technologies and the insufficientapplication of a comprehensive frameworkin the HTA system. By considering therunning programs and challenges of thisfield, the Department of Health TechnologyAssessment is going to promote and ad-vance plans for health technology assess-ment in the national health system.

ConclusionIt seems that by the appropriate use of

HTA horizon scanning, the Department of

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Health Technology Assessment has beenable to collect relevant data and desiredpriorities to localize HTA in an appropriatestructure and manage it properly. In con-clusion, the transformation of the resultsreported from the HTA projects into poli-cies will help produce practical knowledgeproduct and will also improve evidencebased policy- making. However, the mainfactors within the stewardship area shouldnot be underestimated.

The support of the relevant legislatorsfrom HTA and the macro statutes of thehealth system including the High Councilof Health decisions and Insurance SupremeCouncil legislations will warrant the pro-duction of scientific evidence on healthtechnology assessment. Also, empoweringthe HTA experts and technical officers willimprove the HTA process in the health sys-tem of Iran.

AcknowledgementsOur thanks go to all the professors and

scholars who sincerely helped us in thisstudy.

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