Introduction
Health systems across the Middle East and North Africa (MENA) face a complex and interrelated set of challenges, including rising healthcare costs, an increasing burden of chronic disease, fragmentation of health system governance, workforce constraints, and, in several settings, political instability and conflict (1). Rapid demographic and epidemiological transitions further amplify pressures on already heterogeneous health systems, increasing the demand for structured, evidence-informed decision-making to ensure efficiency, equity, and resilience. While interest in health technology assessment (HTA) is growing, many countries in the region continue to rely on unstructured or ad hoc evaluation processes (Reference Mirelman, Goel and Edejer2). HTA is a multidisciplinary process that employs explicit, systematic methods to assess the value of health technologies throughout their lifecycle, thereby supporting the equitable and efficient allocation of limited resources (Reference O’Rourke, Oortwijn and Schuller3). Its increasing prominence in low-, middle-, and high-income settings reflects its relevance for achieving universal health coverage (UHC) and sustainable health system financing (Reference Guzman, Fan and Baker4;5). Across the MENA region, HTA is increasingly recognized as a critical governance tool in response to variable institutional capacity and wide disparities in access to health technologies that make explicit prioritization mechanisms necessary to support equitable coverage decisions and strengthen accountability within health governance structures. In this context, the Health Technology Assessment International (HTAi) MENA Regional Meeting, held in Tunis on 24–25 September 2025 and organized in partnership with the Tunisian National Authority for Assessment and Accreditation in Healthcare (INEAS), provided a neutral platform for dialogue among policymakers, practitioners, academia, industry, and civil society. The event took place at a moment of significant transition, as several MENA countries are moving from exploratory or ad hoc HTA activities toward more formalized institutional arrangements. The meeting theme, “Advancing HTA in the MENA Region: Promoting Equity, Efficiency, and Innovation in Healthcare,” reflected a shared regional ambition to embed evidence-informed decision-making within health governance structures. Synthesizing insights from this regional dialogue provides a timely perspective on shared challenges, emerging implementation models, and strategic inflection points shaping the next phase of HTA development in the region.
Meeting structure
The two-day meeting brought together 173 delegates from 28 countries, including representatives from government agencies, HTA bodies, academia, industry, and civil society. Proceedings included a keynote address, three main sessions, and three educational workshops designed to explore the technical, institutional, and political dimensions of HTA development through a collaborative approach. Readers are invited to consult the event agenda, which includes a synopsis of the three workshops and the list of speakers, not included in this article (6).
Lessons learned for advancing HTA in the MENA region
HTA institutionalization requires political anchoring and pragmatism
A consistent message across country experiences was that successful HTA implementation depends on more than technical capacity alone. Political commitment, legislative backing, and sustainable financing mechanisms are foundational prerequisites. Countries at different stages of HTA maturity reported that unclear mandates, fragmented legal frameworks, and reliance on ad hoc funding undermine continuity and policy relevance. At the same time, participants emphasized the importance of “pragmatic HTA”: flexible, context-sensitive approaches that balance methodological rigor with timeliness and feasibility. International experience shared during the meeting highlighted that overly complex or data-intensive processes risk marginalization if they fail to align with real-world policy cycles. Incremental implementation, starting with priority technologies and progressively expanding scope, was repeatedly identified as a viable pathway for countries with limited resources.
Capacity building and data infrastructure are persistent bottlenecks
Across the region, shortages of trained human resources and limited access to high-quality local data remain critical constraints. Participants noted gaps in formal HTA education and limited opportunities for applied, on-the-job learning. Weak health information systems, including incomplete registries and underdeveloped electronic health records compound these challenges. The discussions underscored that capacity building must extend beyond analysts to include policymakers, clinicians, and other stakeholders involved in decision-making. Without a shared understanding of HTA principles and limitations, even technically sound assessments may fail to influence policy. Cross-country mentorship, regional training programs, and collaboration with academic institutions were widely viewed as cost-effective strategies to accelerate skills development and methodological consistency.
Broadening the scope beyond pharmaceuticals is both necessary and complex
While pharmaceuticals remain the dominant focus of HTA activities worldwide, there was a strong consensus that confining assessments solely to medicines significantly restricts the systemic impact of HTA and limits its ability to deliver meaningful health gains across the broader health system. Participants highlighted growing interest in assessing medical devices, diagnostics, digital health solutions, artificial intelligence-based technologies, and public health interventions. However, evaluating nonpharmaceutical technologies presents distinct methodological and organizational challenges. Rapid innovation cycles, limited clinical evidence at launch, and significant organizational implications require adapted frameworks that consider, for instance, safety, usability, lifecycle costs, and system impact. Experiences shared during the meeting reinforced that expanding HTA scope should be gradual and aligned with national priorities and available expertise.
HTA must be integrated within broader health governance ecosystems
Another recurring lesson was that HTA delivers value only when clearly linked to downstream decisions on pricing, reimbursement, procurement, and benefit design. Participants cautioned against treating HTA as an isolated technical function. Instead, HTA should be embedded within broader governance ecosystems that connect regulation, assessment, purchasing, and service delivery. Discussions on access to medicines further highlighted the need to balance innovation with affordability and financial sustainability. While legislative and resource contexts differ across countries, structural barriers are often similar.
Strategic recommendations for sustainable HTA growth in MENA
Drawing on these lessons, several strategic priorities emerge for fostering sustainable HTA development across the region:
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■ Strengthen institutionalization and governance – Establish clear legal mandates, independent governance structures with dedicated resources, and predictable financing mechanisms that anchor HTA within national decision-making processes.
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■ Invest in comprehensive capacity building – Develop coordinated education and training strategies that target analysts, policymakers, clinicians, and other stakeholders, combining formal education with practical, mentored experience.
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■ Improve data infrastructure and access – Strengthen health information systems, registries, and data-sharing mechanisms to support locally relevant assessments and reduce reliance on external evidence alone.
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■ Promote inclusive stakeholder engagement – Engage patients, clinicians, industry, and policymakers early and transparently to improve the relevance, acceptability, and uptake of HTA recommendations.
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■ Encourage regional collaboration and alignment – Leverage cross-country cooperation, shared methodological guidance, and joint training initiatives to reduce duplication of effort and accelerate learning across different HTA maturity levels.
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■ Capitalize on the outputs of the European Joint Clinical Assessments to inform HTA in the MENA region, to reduce duplication of effort, enhancing process efficiency, and building systematically on evidence and assessments already generated in other jurisdictions.
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■ Integrate HTA into policy and financing decisions – Explicitly link HTA outputs to procurement, reimbursement, and benefit-package design to ensure assessments translate into tangible system-level impact.
Discussion and conclusions
While many of the challenges identified during the meeting mirror those observed in other emerging HTA settings, discussions highlighted several constraints that are particularly salient in the MENA context. These included fragmented healthcare systems, weak data infrastructures, noninteroperable data systems across payers and providers, limited transparency regarding decision-making mechanisms, and heavy reliance on coverage and pricing decisions from other contexts. Participants emphasized that these factors complicate the conduct of HTA and the full transition to evidence-informed priority setting, underscoring the need for regionally adapted approaches rather than direct transplantation of models from other settings. The discussions during the event echoed a pattern now visible across multiple MENA settings: institutionalization succeeds when countries pair clear mandates with pragmatic, stepwise methods, consistent stakeholder engagement, and deliberate capacity building. Recent work in the United Arab Emirates reached nearly identical conclusions, calling for a nationally coordinated HTA function, ring-fenced public financing for appraisals, expansion of graduate and postgraduate training, and a widening of the remit beyond pharmaceuticals to include devices and public-health interventions (Reference Alnaqbi, Elshamy and Gebran7). Egypt’s reform pathway likewise shows that legal scaffolding alone is not sufficient: early investments in awareness, skills, and transparent processes are needed to translate statutory intent into routine practice and to build trust among decision-makers and market actors (Reference Pinilla-Domínguez, Chalkidou and Akeel8). Algeria’s roadmap adds further weight to these points, recommending a tailored implementation plan grounded in local resources, governance realities, and an explicit education strategy to make HTA outputs policy-relevant and timely (Reference Hedibel, Ghanassi and El-Fass9). Experience from middle-income settings shows that the earliest and most tangible returns of HTA are not necessarily immediate budgetary savings or health gains, but stronger governance: clearer decision rules, greater transparency, and enhanced accountability. Over time, these institutional improvements create the conditions for more sustainable fiscal and health outcomes (Reference Fasseeh, Elezbawy and Gamal10). Country practice illustrates how this evolution occurs in reality. In Tunisia, HTA of innovative medicines is undertaken to guide uptake and coverage decisions and facilitate the move toward value-based pricing arrangements. This experience highlights how structured, methodologically robust evaluations can be embedded within procurement and coverage processes, ensuring that resource allocation is grounded in explicit value considerations rather than implicit or ad hoc criteria (Reference Jameleddine, Harzallah and Grati11). In the UAE, recent work to develop locally appropriate cost-effectiveness thresholds and decision tools shows how methods can be adapted to national preferences while remaining anchored in international standards (Reference Aldallal, Alnaqbi and Elshamy12). In Oman, the adoption of formal HTA methodological guidelines illustrates how international standards can be embedded within national decision-making. By linking clinical value, cost–utility analysis, budget impact assessment, and transparency requirements, the framework supports more consistent and evidence-based coverage decisions (Reference Wani, Alsabti and Allamki13) while the first national health economic evaluation guideline to standardize methods and support evidence-based healthcare decisions have recently been released in Lebanon, with the aim to improve transparency and resource allocation (Reference Daccache, Rizk, Hiligsmann, Evers and Karam14). These experiences mirror the meeting’s emphasis on HTA frameworks where processes are rigorous yet proportionate, fast enough for policy windows, and connected to budgeting and benefit-design levers. Against this backdrop, participants perceived HTAi as uniquely positioned to accelerate the next phase. First, as a neutral convener, HTAi can sustain a safe, multi-stakeholder dialogue that keeps political and technical actors aligned during the “messy middle” of implementation – where mandates are interpreted, methods localized, and trade-offs managed. Second, HTAi’s Interest Groups (Reference Migliore, Vicari, Valiotis and Single15) and Policy Forums can operationalize peer-to-peer mentorship across the region, pairing mature programs with emerging ones to codevelop topic-specific methods and to share submission templates, appraisal checklists, and deliberative processes. Finally, by connecting MENA actors to global conversations on value frameworks and lifecycle HTA, HTAi can help ensure regional methods keep pace with evolving practices while remaining context-sensitive. In sum, the Tunis meeting did more than catalogue needs; it clarified a shared playbook now visible across the MENA region: build capacity, codify transparent methods, broaden scope, and tie HTA outputs to procurement and reimbursement. HTAi is continuing this discussion with HTA experts from the different countries in the format of a Policy Dialogue, which is intended to underscore the significance of collaboration and cocreation among stakeholders, providing a “safe space” that encourages participants to discuss and subsequently collaborate to ensure that HTA is a fully functional and integral component of their healthcare decision-making (Reference Migliore, Vicari, Turk and Sucu16). The output of the HTAi Policy Dialogue for MENA will be the focus of another publication, which is currently in preparation.
Limitations
This perspective draws on synthesized insights from a regional meeting and does not claim to represent consensus views of all participants or countries in the MENA region. Some countries were not represented, and variation in HTA maturity may limit generalizability. Nonetheless, the lessons and recommendations outlined here provide a qualitative foundation to inform strategic planning and dialogue on HTA institutionalization across the region.
Acknowledgments
The HTAi Regional Meeting in the Middle East & North Africa 2025 was made possible thanks to the endorsement of the HTAi Board of Directors and their decision to invest unrestricted HTAi reserves as the primary funding source for the meeting. Support was received from the National Authority for Assessment and Accreditation in Healthcare (INEAS), Tunisia, and the following sponsors: Clever Access, Roche and SEPHIRE. A special acknowledgment goes to the Tunisian Ministry of Health, INAHTA, WHO and all the moderators, speakers and sponsors. Full list can be accessed from the HTAi website (6).
Funding statement
No funding was received for the development of this manuscript.
Competing interests
The authors declare no competing financial or personal interests related to this work.
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