The participants in this study included 14 males and 4 females, with an average age of 42.35 ± 7.30 years and an average work experience of 16.65 ± 4.97 years. A total of 12 interviews were conducted virtually, while 6 were conducted in person. A summary of participant characteristics, including roles, years of experience, and sectors, is provided in Table 1.

In this study, 14 sub-themes emerged across seven main themes, highlighting the barriers to developing HTA in Iran. Figure 1 illustrates the key themes and their corresponding sub-theme. The seven themes were policy and governance, economic and financial, human resource and expertise, cultural and social, technical and infrastructure, collaborative and communication, and political issues. Through the analysis of participant interviews, seven overarching themes emerged, each capturing key barriers related to the development of HTA in Iran. These themes, along with their sub-themes and associated participant quotes, provide a comprehensive understanding of the multifaceted challenges hindering the advancement of HTA in the country.

Themes and sub-themes emerging from the analysis

The policy and governance theme highlighted significant challenges associated with legal, regulatory, and leadership frameworks in HTA. Participants consistently mentioned the lack of comprehensive legal and regulatory frameworks.

Many interviewees pointed out the absence of clear regulations and laws, which hinders the full integration of HTA into decision-making processes:

“The existing regulations for HTA do not fully cover our needs, and we need more up-to-date legal frameworks. For example, there are no clear guidelines on how to prioritize health technologies or how to allocate resources based on HTA findings. This creates confusion and delays in decision-making.” (P4, P11, P15, P18).

In addition, there was a misalignment between health policies and HTA needs, with several respondents expressing concern that current health policies do not prioritize HTA:

“Our current health policies do not align with the actual needs of HTA. Higher-level policies are more focused on other issues, and HTA is often overlooked. For instance, when new technologies are introduced, there is no systematic process to evaluate their cost-effectiveness or long-term impact on the health system.” (P1, P16, P19).

A recurring issue was the weak monitoring and evaluation mechanisms. The lack of mechanisms to track HTA implementation and its impact on policy decisions was frequently mentioned:

“Currently, there is no specific system in place to track and monitor the implementation of HTA. Without proper monitoring, it is difficult to assess whether HTA recommendations are being followed or if they are having the intended impact on health outcomes.” (P4, P9, P12, P14, P15).

Economic constraints were a pervasive concern. Under the economic and financial theme, participants emphasized the budget constraints and resource allocation issues that limit the effectiveness of HTA. A lack of financial resources was repeatedly identified as a primary obstacle:

“The budget allocated for HTA is very limited, and this has prevented us from properly evaluating all technologies. For example, we often have to prioritize only a few technologies due to financial constraints, leaving many others unevaluated and potentially harmful or ineffective.” (P3, P5, P8, P9, P11).

Another significant challenge was the economic pressures and justification of new technologies. Participants described difficulties in justifying the cost-effectiveness of new technologies, which complicates the decision-making process:

“Many new technologies are challenging in terms of cost-effectiveness. We cannot always find a financial justification for their adoption in the health system. For instance, some technologies are expensive but offer only marginal benefits, making it hard to justify their use given our limited resources.” (P7, P12, P14, P15).

The human resource and expertise theme revealed a shortage of skilled professionals, with participants noting the limited availability of individuals with sufficient expertise in HTA:

“One of our main problems is the shortage of experienced and skilled professionals in HTA. For example, we have very few people who are trained in advanced methods of economic evaluation or data analysis, which are critical for conducting high-quality HTAs.” (P1, P6, P9, P11, P16, P17, P18).

There was also considerable resistance to organizational changes from both staff and management, which further complicated the adoption of HTA:

“Any change related to technology or structure is met with negative reactions, which slows down the progress of HTA. For instance, when we tried to introduce new evaluation tools, many staff members were reluctant to adopt them, citing a lack of training or fear of increased workload.” (P5, P7, P9, P14).

Participants highlighted the cultural and social challenges, particularly the lack of public awareness and acceptance of HTA. The lack of awareness among healthcare professionals and the public often prevents the effective use of HTA:

“Many people, including healthcare staff, have no awareness of HTA. This lack of recognition prevents the use of this important tool. For example, when we present HTA findings to policymakers, they often do not understand the value of the data or how it can inform their decisions.” (P3, P8, P11, P15).

Moreover, ethical and social concerns related to patient rights and data privacy were frequently raised. One participant voiced concerns about inequitable access to health technologies:

“Some patients cannot access these technologies due to financial or geographical issues, which undermines their rights. For instance, patients in rural areas often miss out on advanced treatments because the infrastructure and resources are concentrated in urban centers.” (P2, P7, P18).

A recurrent issue under the technical and infrastructure theme was the weak technology and data infrastructure. Many participants expressed concerns over the inadequate infrastructure for data collection and analysis:

“We really need more advanced infrastructure for data collection and analysis. Without this infrastructure, HTA cannot be properly conducted. For example, we often struggle to access reliable data on patient outcomes or costs, which limits the accuracy of our evaluations.” (P5, P9, P11, P14, P18).

Additionally, the complexity of HTA methods and evaluation tools was a significant barrier, with many interviewees struggling to use existing tools effectively:

“The tools required for evaluating health technologies are very complex. Many staff members cannot use these tools properly due to insufficient training. For instance, some of the software used for economic modeling is highly specialized, and without proper training, it is difficult to generate reliable results.” (P3, P8, P17).

The collaborative and communication theme highlighted the weak inter-organizational collaboration between key stakeholders, including government institutions, universities, and the private sector. Participants lamented the lack of interaction, which they felt undermined the effectiveness of HTA:

“There is almost no interaction between government agencies, universities, and the private sector in the field of HTA. For example, when we conduct evaluations, we often do not have access to data or expertise from other sectors, which limits the comprehensiveness of our assessments.” (P6, P9).

Limited stakeholder engagement was another significant issue, with participants noting the low involvement of patients, healthcare workers, and policymakers:

“In the HTA process, key stakeholders like patients and healthcare staff do not actively participate. This issue leads to final results that are less reflective of actual needs. For instance, when patients are not consulted, we may overlook important factors such as quality of life or patient preferences in our evaluations.” (P10, P13, P16).

Finally, the political theme captured the political interference in health decision-making, where decisions on health technologies were often influenced by political interests rather than evidence-based evaluations:

“Sometimes decisions regarding the selection of health technologies are influenced by politicians, without considering the actual needs of the health system. For example, a new technology may be adopted because it is supported by a powerful political figure, even if the evidence shows that it is not cost-effective or beneficial for patients.” (P5, P9, P13, P14).

Participants also noted the challenge of policy instability, with frequent changes in health policies leading to uncertainty and inconsistent decision-making:

“Frequent changes in health policies and a lack of long-term stability undermine the effectiveness of health interventions. For instance, a policy that supports HTA one year may be completely abandoned the next, leaving us with no clear direction or resources to continue our work.” (P6, P11, P16).