Background and introduction

The Middle East and North Africa (MENA) region includes nineteen countries (according to the United Nations) with ~500 million people and significant within-region economic differences, ranging from a sociodemographic index of 0.4 (Yemen) to 0.88 (United Arab Emirates) (Reference Khedhiri1). Across MENA, shift in regional burden of disease landscape linked with aging populations and lifestyle factors (e.g., rise in noncommunicable diseases such as 143 percent projected increase in the incidence of cancers in Gulf Cluster Countries by 2040), rising healthcare costs, increasing access to innovative technologies, and the imperative to achieve universal health coverage (UHC) (included mandatory health insurance) are placing greater pressure on health systems to allocate resources more efficiently and transparently (Reference Khedhiri1–4).

These challenges highlight the importance of health technology assessment (HTA), a multidisciplinary process that uses explicit methods to determine the value of health technologies, with the purpose of informing decision-making to promote an equitable, efficient, and high-quality health system (Reference O’Rourke, Oortwijn and Schuller5). HTA institutionalization varies considerably across the MENA region, ranging from more established arrangements (e.g., Tunisia’s National Authority for Assessment and Accreditation in Healthcare, INEAS), to systems that are still consolidating mandates, methods, and workforce capacity (Reference Jameleddine, Migliore and Single6–Reference Hannawi, Ojeil and Alnaqbi10). A recent literature review concluded that only three countries (Tunisia, Saudi Arabia, and Egypt) have established formal HTA bodies with explicit legislation and integrated pricing/reimbursement mechanisms; two countries (Jordan and United Arab Emirates) employ decentralized institutional-level HTA approaches; and six countries (Qatar, Kuwait, Lebanon, Algeria, Morocco, and Oman) remain in emerging phases with HTA activities primarily confined to research and policy analysis without formal decision-making integration (Reference Al-Jedai, Almudaihem, Hamad, Felfel Ep Ghodhbane and Kluszczynski11).

HTA collaboration has emerged as a growing priority, driven by uneven capacity, shared health challenges, and inefficient duplicated efforts. In a context like this, it is important to assume that collaboration should be understood as a means to strengthen national systems and not to replace them.

This Perspective article is part of a broader, evolving regional conversation, building directly on the discussion initiated at the HTAi MENA Regional Meeting held in Tunis, Tunisia, in September 2025, co-organized with INEAS, which brought together delegates from 28 countries and produced a shared set of strategic recommendations for sustainable HTA development in the region (e.g., HTAi’s support in connecting MENA actors to global conversations) (Reference Migliore, Jameleddine and Single12). It also draws on emerging insights from the HTAi Policy Dialogue for MENA, an initiative involving experts from 12 MENA countries that documented priorities and preferred forms of cooperation (Reference Jameleddine, Migliore and Single6).

The insights informing this Perspective article were drawn from a panel discussion co-organized by HTAi and the ISPOR UAE Chapter during the ISPOR UAE Chapter Conference, held in Abu Dhabi in January 2026.

Structure of the session

The panel brought together HTA experts, policy makers, and health system stakeholders from across the MENA region and internationally (Supplementary Table S1). The panel structure was framed to contrast MENA realities with European Union (EU) experience to extract transferable lessons, while explicitly avoiding direct transposition of solutions and focused on translating these foundations into a more granular discussion of feasibility, governance prerequisites, and pragmatic entry points for collaboration. Discussions were exploratory and reflective rather than technical, focusing on two guiding questions: what success in regional HTA collaboration might look like and which conditions are necessary to move from aspiration to action. The session was not intended to produce formal policy recommendations. Rather, it aimed to generate a shared understanding of the opportunities and constraints that characterize the MENA context.

EU and MENA: Similarities and differences

Both the EU and MENA contexts share fundamental pressures driving interest in HTA collaboration: rising costs of health innovation, increasing demand for transparency and accountability in coverage decisions, varied capabilities across national HTA efforts and recognition that duplicating HTA efforts across jurisdictions is inefficient and costly (Reference Vella Bonanno, Bucsics and Simoens13;Reference Imaz-Iglesia, Belorgey and Charokopou14). In both settings, the ambition is to improve evidence quality, increase predictability for technology developers, and optimize resource use, without any aim to centralize decision making. These shared drivers were evident in the HTAi MENA Regional Meeting, where participants across countries consistently identified resource optimization, structured decision rules, and access to innovative technologies as the primary motivations for investing in HTA (Reference Migliore, Jameleddine and Single12).

However, the structural and institutional differences between the two regions are substantial and must not be underestimated. The EU’s trajectory toward formal HTA collaboration has received substantial support from the European commission through over more than two decades of voluntary, project-based cooperation prior to the introduction of a binding legal framework: Regulation (EU) 2021/2282 (also known as EU HTAR) (15).

In MENA, no equivalent supranational legal or institutional structures exist, nor is there a common economic or political framework comparable to the EU Treaties. Formal initiatives exist, such as the Gulf Health Council, a collaborative platform that aims to promote public health and develop healthcare systems in the Gulf Cooperation Council countries, but these have limited geographic coverage. The heterogeneity within MENA, spanning high-income Gulf states, lower-middle-income economies, and widely varying stages of health system maturity, is considerably broader than variation within the EU (Reference Fasseeh, Karam and Jameleddine16). This is compounded by fragmented governance arrangements and, in several settings, weak or unclear institutional mandates for HTA. These challenges have been extensively documented in the HTAi Policy Dialogue survey, where limited legal and institutional frameworks ranked among the most significant barriers to HTA progress across the region (Reference Jameleddine, Migliore and Single6). These structural differences imply that any realistic model of HTA collaboration in MENA must be far looser and more flexible than what has been achieved in Europe. Alignment should focus on transferable HTA components, such as methodological guidance, evidence expectations, and capacity-building approaches, rather than on context-specific elements such as pricing thresholds or reimbursement decisions.

How the EU HTA Regulation can show the path

European collaboration on HTA evolved over 27 years through four distinct phases. The EUR-ASSESS project (1994–1996), HTA-Europe (1997), and ECHTA/ECAHI (2000–2002) established foundational coordination methods across all 15 EU member states. The EUnetHTA project (2006–2008) formalized a network, followed by three Joint Actions: JA1 (2010–2012), JA2 (2012–2015), and JA3 (2016–2021), with JA3 involving 80+ organizations and a €20+ million budget, producing 43 relative effectiveness assessments (Reference Vella Bonanno, Bucsics and Simoens13;Reference Willemsen, Ettinger and Helmink17).

The Cross-Border Healthcare Directive (2011/24/EU) provided the legal foundation for voluntary cooperation, leading to the HTA Network establishment (2013/329/EU). EU Cooperation on HTA policy options were evaluated in 2017 in terms of impact and feasibility; and the EU HTA Regulation (2021/2282) was formally adopted in December 2021, establishing a binding legal framework for joint clinical assessments (its scope expands gradually, covering all medicinal products and selected medical devices and IVDs by 2030), joint scientific consultations, and emerging technology identification (Reference Vella Bonanno, Bucsics and Simoens13;18;Reference Ivo, Rodrigues, Couto and Cossito19). Figure 1 summarizes the lessons learned on this journey.

Figure 1.

Lessons learned on the European Union health technology assessment cooperation journey.

Figure 1. Long description

At the center is a light blue semi-circle containing the text E U H T A Cooperation Journey: Lessons learned. Surrounding this core are five distinct segments arranged in an arch, each containing a blue circular icon and descriptive text.

Moving clockwise from the bottom-left:

1. The first segment features an icon of three people and the text: Building culture with a step-by-step approach to facilitate broader adoption.

2. The second segment features a calculator icon and the text: Designing right governance and financial support models.

3. The third segment, at the top center, features a speech bubble icon and the text: Engaging with broader stakeholders, including decision makers, clinicians and patients.

4. The fourth segment features an icon of a person next to a document and the text: Developing capacity for right workforce through training programs.

5. The fifth segment, at the bottom-right, features a telescope icon and the text: Supporting a learning system and staying adaptive.

Enabling conditions for HTA collaboration in MENA

Early and feasible entry points

The panel identified pragmatic starting points for collaboration that carry low political risk while offering tangible value. These include: (i) Alignment of countries with similar HTA maturity, recognizing that collaboration is most productive when partners share comparable institutional foundations as mismatched capacity levels risk placing disproportionate burdens on less developed systems and can undermine the mutual trust that sustained cooperation requires; (ii) Clinical evidence generation initiatives, which offer an immediately actionable and politically neutral entry point, as jointly defining the evidence needed to support coverage decisions reduces duplication for technology developers and improves the quality and local relevance of data available to all participating countries; (iii) Horizon scanning initiatives and early engagement with technology developers, which allow countries to pool intelligence on emerging technologies before individual assessment processes begin, enabling a more coordinated and anticipatory approach to coverage planning; and (iv) Agreement on common elements of HTA submissions, a practical step that does not require harmonization of decision making but can meaningfully reduce the duplicative burden on both submitters and assessors by establishing shared expectations around the structure and content of evidence packages.

The panel also agreed that the role of international organizations in facilitating this agenda is central. As a neutral, multistakeholder convener focused on the governance, use, and institutionalization of HTA at health system and policy levels, HTAi is positioned to sustain the multi-stakeholder dialogue needed during the transition time, from concept to implementation, where mandates are interpreted, methods localized, and trade-offs managed. HTAi can operationalize peer-to-peer mentorship across the region, pairing mature programs with emerging ones to co-develop topic-specific methods and share tools and processes. The ISPOR UAE Chapter can contribute with methodological expertise in health economics and outcomes research, a core technical component of any solid HTA framework, through its professional networks and educational resources.

Discussion and conclusions

Meaningful HTA collaboration in MENA is both necessary and feasible, but only if it respects the heterogeneity of the region and the primacy of national sovereignty in health policy decisions.

The central argument that emerged from the panel at the ISPOR UAE Chapter Conference 2026, co-organized by HTAi and the ISPOR UAE Chapter, is that collaboration should be incremental, trust-based, and focused on high-value, transferable components rather than on premature institutional alignment. There is a clear willingness to move from aspirations to structured actions, but where to start? A structured regional agenda should be grounded in a dialogue which, if from one side is driven by local needs and sustained stakeholder engagement, from the other is mediated and supported by international players. Despite the region-wide recognition that governance consolidation must precede more advanced forms of cooperation (Reference Jameleddine, Migliore and Single6), establishing formal legal frameworks across all countries will take time. A sequenced approach, in terms of collaborating countries, technologies assessed, and specific HTA components, can support long-term convergence without forcing artificial alignment at too early a stage. Crucially, the purpose of regional collaboration is not to harmonize processes for their own sake, but to strengthen national decision making to improve access to health technologies. The earliest and most tangible returns of this investment are not necessarily immediate budgetary savings or measurable health gains, but stronger governance: clearer decision rules, greater transparency, and enhanced accountability, the institutional foundations on which more advanced collaboration can be built.

However, designing effective HTA collaboration requires more than goodwill. The 2024 HTAi Global Policy Forum drew a clear distinction between collaboration (intensive, goal-directed work toward a shared outcome) and coordination (e.g., information exchange) that is often conflated with it (Reference Trowman, Migliore and Ollendorf21). The Forum agreed that purpose definition, governance, partner identification, and role delineation are critically essential, as well as resources in terms of time, people, and finances. For MENA, these lessons suggest a disciplined approach: rather than attempting to design a regional architecture from scratch, countries should identify specific, bounded activities where the conditions for success are already in place and ensure that enthusiasm for cooperation is matched by realistic planning and secured resources.

The EU experience demonstrates that what appears today as an ambitious regulatory framework was, not long ago, a set of voluntary pilot projects built on personal relationships and shared frustration with duplication. The same trajectory is available to the MENA region, on its own terms and at its own pace. The time has come for stakeholders to move from conceptual discussion to concrete pilots that can generate visible value and begin to build the trust that sustained collaboration requires.

Limitations

This Perspective article reflects the views expressed during a specific panel discussion and may not capture the full diversity of country contexts or stakeholder perspectives across the MENA region. It is a conceptual contribution and does not evaluate existing collaboration initiatives or provide an empirical assessment of the feasibility or potential impact of the approaches proposed.