Dear Editor,

We read with great interest the recent article by Jameleddine et al., Policy dialogue on health technology assessment in Middle East and North Africa: reporting from an HTAi initiative (Reference Jameleddine, Migliore and Single1). The authors should be commended for facilitating an important regional discussion on the development of health technology assessment (HTA) across the Middle East and North Africa (MENA). Comparative assessments of HTA systems are essential for informing regional collaboration and identifying priorities for capacity building.

However, we wish to comment on the classification of Iran’s HTA status as “Incomplete” in Table 1 of the article. This classification cites our recent study published in BMC Public Health, yet we believe that our findings have been interpreted more broadly than the evidence supports (Reference Behzadifar, Shahabi and Bakhtiari2).

Our study was designed to examine the policy institutionalization of HTA using Kingdon’s Multiple Streams Framework. It did not aim to classify the maturity of the Iranian HTA system, nor did it propose categories such as “complete,” “incomplete,” or “institutionalized.” Rather, our principal conclusion was that although HTA has become established as an institutional and technical function within Iran’s Ministry of Health and Medical Education, its routine incorporation into national policy decisions remains incomplete because the necessary legal, political, and governance conditions have not yet fully converged.

This distinction is fundamental.

A conclusion that HTA has not yet been fully integrated into policy making should not be interpreted as evidence that the HTA system itself is incomplete. These statements refer to two different dimensions of health system development. The former reflects the extent to which HTA evidence is utilized in decision making, whereas the latter implies a judgment regarding the existence or maturity of the HTA system itself.

Indeed, our study documented that Iran has possessed many core elements of an operational HTA system for more than a decade, including a dedicated HTA office within the Ministry of Health and Medical Education, established methodological capacity, trained human resources, postgraduate educational programs, and the routine production of HTA reports. The principal barriers identified were related to governance, legal authority, financing, and policy uptake—not to the existence of HTA infrastructure.

Interestingly, the methodology of the regional article itself supports this distinction. The authors explicitly acknowledge that survey responses regarding HTA institutionalization were inconsistent because definitions of institutionalization were not provided. Consequently, these responses were excluded from the analysis, and the final classification of countries was developed through literature searches and discussions among the authoring group. This indicates that the labels presented in Table 1 represent the authors’ interpretation rather than standardized or validated classifications.

For this reason, we respectfully suggest that the designation “Incomplete” may inadvertently oversimplify the status of HTA in Iran and blur the distinction between HTA establishment, HTA institutionalization, and HTA implementation. These concepts describe different stages of health system development and should not be used interchangeably.

A country may have an established HTA organization, technical expertise, trained professionals, methodological guidelines, and a sustained history of HTA production while simultaneously lacking full integration of HTA into reimbursement and policy decisions. Such a system is more appropriately described as “partially institutionalized,” “developing,” “emerging,” or “established but not yet fully institutionalized” rather than simply “Incomplete.”

This distinction is not merely semantic. Regional comparative studies are increasingly used by policy makers, international organizations, and development partners to evaluate institutional readiness and identify opportunities for investment and collaboration. Therefore, classification terminology should accurately reflect the different dimensions of HTA system development and avoid unintentionally underestimating countries that have already established substantial institutional capacity.

We fully appreciate the authors’ valuable contribution to advancing HTA dialogue across the MENA region. Our intention is not to challenge the overall conclusions of the article but rather to encourage greater conceptual precision in describing national HTA systems. We believe that distinguishing between establishment, institutionalization, and implementation would strengthen future comparative analyses and provide a more accurate representation of countries progressing through different stages of HTA development.