Analysing the development of health technology assessment in Iran: a policy perspective based on the five control knobs framework

Health Technology Assessment (HTA) is increasingly recognized as a vital instrument for evidence-informed policymaking, especially in resource-limited health systems. Although HTA was introduced in Iran over a decade ago, its integration into national decision-making processes remains limited. This study aims to examine the challenges associated with the development and implementation of HTA in Iran, using a comprehensive policy analysis framework. A qualitative policy analysis was conducted using the five control knobs framework, encompassing financing, payment, organization, regulation and behaviour. Data were collected through semi-structured interviews with 25 key informants, including health policymakers, academic experts and healthcare professionals, selected via purposive and snowball sampling. Interviews were audio-recorded, transcribed and analysed thematically using MAXQDA version 10 software. Thematic coding was guided by the five dimensions of the analytical framework to ensure systematic categorization and interpretation. The analysis revealed multiple, interrelated barriers to HTA development in Iran. Financially, there is no dedicated budget for HTA activities, and limited incentives exist for private sector engagement. In the payment dimension, the weak integration of HTA findings into coverage and pricing decisions reduces its practical impact. Organizationally, fragmented governance and poor coordination amongst stakeholders hinder HTA institutionalization. Regulatory gaps, including the absence of binding legislation and susceptibility to political pressures, were also identified. Finally, limited awareness and resistance to HTA amongst healthcare providers and decision-makers were key behavioural challenges. Despite these barriers, opportunities exist in the form of growing demand for cost-effectiveness data and increased academic capacity in HTA. HTA development in Iran is impeded by systemic challenges across policy domains. Overcoming these barriers requires coordinated efforts to institutionalize HTA through sustainable financing, legal mandates, intersectoral collaboration and stakeholder capacity-building. These actions are essential for strengthening evidence-informed policymaking and improving the efficiency and equity of health services in Iran.