History of health technology assessment: a commentary.

I have long felt the need for documentation on the global development—I could probably pin it to the moment I was visiting health technology assessment (HTA) institutions in the United States in 1995, and was looking forward to a trip to the Office of Technology Assessment, only to be told it had just been shut. Instead, I visited the Office of Health Technology Assessment in Washington. In addition, I have observed that some regular attendees of annual meetings of International Society of Technology Assessment in Health Care (ISTAHC) and then Health Technology Assessment International (HTAi), have been slowly dropping out, so that a lot of the history as well as their valuable experiences and expertise have been lost. To be fair, studies have been written about specific HTA institutions, programs, countries, and even regions. Attempts have also been made to chart the history of HTA, but these have, however, fizzled out. Why is this important? Going back to my personal experience, when I first set out to establish HTA in Malaysia, I was plagued with several questions—apart from the obvious one about what HTA really meant, there were others like what organization structure should it have, what should be the work process, how could HTA be used, to name a few. I needed to know what the options were, for example, in coming up with an organizational structure, and to understand these options I would need to look at organizational models in other countries— should it be a national office with regional offices like the Canadian model, or a fully public agency but not within the department of health, like the Swedish model, or an almost independent agency like the Catalan agency in Barcelona. In the absence of a detailed account with the information I sought, I actually had to physically visit various agencies to study their organizational structure, work process, and application, to hear of the challenges they faced, and to learn from their experiences of what could work and what may not. So it is wonderful that the International Journal of Technology Assessment in Health Care, specifically Egon Jonsson, has taken the initiative to commission an issue of the Journal on the history of HTA. David Banta deserves special commendation for taking on this Herculean task, but I cannot think of a more appropriate person for this job, given that Banta has been involved in HTA programs of so many countries around the world. It will probably give them feeling of déjà vu when going through some of the country and regional reports. HTA has made considerable progress since its introduction more than 30 years ago. As has been repeatedly pointed out, whereas HTA has been well established in the developed countries, less developed countries have not been as successful in this area. The irony of it is it is these economies that need HTA most, in their struggles to maximize the scarce resources that are available to provide healthcare services to their populations. From the United States, it has spread almost all over the world, taking firm root in Europe and Canada. It has moved gradually into Asia and South America, but there are some glaring gaps. There is virtually no HTA in Africa, whereas in countries in the Middle East, there has been some progress. In a sense, this has also mirrored the spread of research initiatives. A few decades ago, almost all research seemed to be confined to North America and Europe. In a sense, it probably had to do with the state of development of these countries (in comparison to less developed ones), which brought with it a lack of importance of scientific methodology, the need for research evidence in decision making, and indeed the philosophy of the evidence based approach in policy and decision making. It has often struck me that, while in the legal area the use of evidence has been long established, in that previous cases and precedents are used in coming to decisions, no such philosophy exists in the health sector. English law, for example, has been a basis for legal system in many countries, especially in those that were British colonies, such as India, Malaysia, and Australia. If we compare this with the health sector, although health systems have some similarities to the English system in Canada and Australia for instance, countries such as India and Malaysia have evolved totally different systems. So with increasing development, research