Once upon a time… The rise and use of HTA throughout the world

Once upon a time, in a different place and time, at the foot of a hill, lays a town called Washington DC. The people of Washington DC lived very well; they all had lots of money and excellent health. Then, one day, everything changed. A plague of very different types of health care technologies emerged everywhere. Suddenly, more and more new health technologies were being used without accurately knowing about their safety and efficacy and which drew resources from public and private funds. As decisions had to be made as soundly as possible, one day the mayor of Washington DC decided to summon all citizens and said to them: «I offer ten gold pieces, free of tax, to anybody who can guide us» (1). A strange voice came from the back of the crowd. «I know a book that can help on that. It is from 1972 and is called Effectiveness and Efficiency, and its author is Archie Cochrane. In this book it is said that on health care technologies sound and evidence-based decisions have to be made, and to achieve this, good randomized controlled trials have to be set up» (2). The mayor of the city was listening attentively to the man, and decided to design a plan. An organization would be established to provide relevant and valuable guidance. And that was how the Office of Health Technology Assessment (OTA), under the USA Health Care Financing administration, was created in 1976. From then, lots of health technology assessment instruments have been developed. OTA began to play the instrument. The people of Washington had never heard such a tune: «The validity of technologies should be assessed by considering many different types of evidence, not only RCT, but always looking at the quality of the information available, the economic impact of the decision and the context where decisions have to be made». With all this information decision-makers will be helped. The strange music filled every corner of the town, and the mayor and the citizens enjoyed the music very much, so they decided to create the first national public program in HTA without a doubt. The National Center for Health Care Technologies was created in 1980 with the remit to inform Medicare on the introduction and spreading of health technologies by systematically reviewing them (3).

But the music was so powerful, sound and wise that other countries also wanted something alike. The music easily crossed the sea and arrived at Spri (i.e. Swedish Planning and Rationalization Institute for Health Services). The first European conference on HTA was held (1979), and relevant guests and close relatives were invited to the event (4). Nordic countries have always been close, so to make a collaborative effort the Nordic Evaluation of Medical Technology (NEMT) was created (1980), being the Hospital Institute of Denmark, Finland, Norway and Spri its members.

Closely in time, a voice claim «vive la France». The mayor of the city of Paris didn’t want to fall behind, so CEDIT (Committee for the Assessment and Diffusion of Health Technologies under the Paris Hospitals) was set up (1982) (5). While other countries talked about that, the Health Insurance Council of Netherlands also took the HTA flag (1985). Decisions were recommended to be made on safety and efficacy, and cost-effectiveness had to be the base (6). As the government in Sweden heavily bet for HTA the Swedish Agency for HTA (i.e. SBU) was created (1987) (4). And that was when ANDEM was set up by France (ie. National Agency for Medical Assessment, 1989). Catalonia (Spain) also let the HTA music play, so a Program for the Assessment of big ticket Technologies was created (1988) (7).

However, more and more health technologies – generally expensive – were being introduced into the European health markets. From north to south, health care systems were facing hard times. «Can we afford all that?» was this claim frequently raised. Eventually, the 80’s witnessed the birth of the HTA star in Europe, and the 90’s its raising. The light of the baby HTA star was consolidated and its music was heard in Europe and worldwide. Two important actions contributed to the 90’s rise: the creation of the International Society of Health Technology Assessment in Health Care (ISTAHC) and its Journal (1985) (3).

Since the early 90’s up to now, the HTA music has been heard all across Europe. Thus, Sweden was closely followed by France, the Netherlands and Catalonia (Spain); almost all Western European countries created National HTA agencies, as the UK National Coordinating Center for HTA in 1993 and NICE in 1999; HAS in France; GBA-2000 and IQWiG in Germany in 2004; CVZ in the Netherlands in 2000; and SMM the Norwegian HTA Center in 1998 -currently NOKC. Regional agencies were also created as the Region of Emilia Romana in Italy in 2000 and Osteba in the Basque Country, Spain, in 1992. Moreover, Eastern European countries also institutionalized HTA programs (e.g. Hungary (8) and Poland (9)). The European Union helped a lot to strengthen all these initiatives. Since 1994, the EU has funded several HTA collaborative projects among different European HTA organizations (10), leading to the European Network of Health Technology Assessment Agencies (EUnetHTA) (www.eunethta.org). Additionally, different types of networks sustain and promote the use and development of HTA in Europe. For example, apart from the pan-European network of agencies (EUnetHTA), there are further scientific networks such as CEESTAHC, the Scientific Association of HTA for Eastern European countries (www.ceestahc.org), and national scientific networks such as the Dutch Association for HTA (6) and the Italian Scientific Association for HTA (SIHTA) (www.sihta.org).

After all this time, a new meeting with health technology stakeholders was held.

• Why the HTA music is being followed everywhere? A scientist said.

• Because I have to do my best to take care of patients and citizens with the funds and HTA instruments available. This way, I can base my decisions on reliable evidence and information. A policy decision-maker said (11).

• But the same can be done by Evidence-Based Medicine (EBM). A clinician said

• Yes, EBM is needed but it is not enough for my final say, I need further information that should be country-based. The politician said.

• But an overly cautious interpretation of evidence and other information can frustrate innovation. A representative from the industry said.

• Yes, I agree, I need new discoveries and treatments for my strange disease. A patient also said.

• Maybe, but an overly optimistic interpretation can lead to waste resources. A hospital manager said.

• Alright, but we can also give guidance on how to introduce new health technologies without compromising the budget of a country or hospital. A HTA scientist said.

After listening to all these arguments, the group of stakeholders wondered whether a new approach to international interaction in the field of HTA more in keeping with the current times was needed. This viewpoint was shared by a group of HTA professionals who were members of the ISTAHC board at that time, so this Society was re-funded (2003) and re-named as Health Technology Assessment International (HTAi) (www.htai.org). HTAi arose as a neutral open space for all those having some interest in health technologies, as well as for those who design, assess, use and decide to pay or not for health technologies. A space for cross-fertilization among scientists and professionals, a dynamic and interactive place to make HTA methods and health policies evolve, so that valuable innovative health technologies are promoted and obsolete health technologies are recalled. In its eight years of life, HTAi has greatly contributed to the spread of HTA around the world; through its Policy Forum, it has also provided guidance on and helped to evaluate the establishment of new health technology policies in different health care systems.

The HTA music is now heard everywhere. In Asia there are 18 countries (over 47) with HTA activities, from which nine have established HTA units (12). After a long time trying to set up stable HTA programs, they have finally taken off in Latin American countries. Most of the countries in this area have initiatives in the field of HTA, some of them at Ministry level. Following the geographical collaborations between Mercosur and the Andino Treaty, a pan-Latin American HTA network has been recently created which is called REDETSA (2011) (13).

The music of HTA is nowadays a «global hit parade». But further lyrics to this music should be added. For a healthy evolution, fitness to societal changes and interactions, both with other scientific disciplines and public and private HTA initiatives, should be made (14). Among the principles that should guide this new rise of a collaborative and modern HTA effort worldwide are the promotion of common goals, mutual trust, and a fluent communication and meaningful dialog among the interested parties. All this should lead to an enlightened decision-making focused on the public interest (15). But that is another story.

And so it was, and so it is, that this real tale has reached its end.