Abstract
BACKGROUND: Health technology assessment (HTA) is a critical tool for evidence-based decision-making in healthcare systems, yet its implementation in low- and middle-income countries such as Iran remains understudied. This study examines the political dynamics of HTA implementation in Iran, focussing on the roles, interests and interactions of key stakeholders. By addressing the gap in understanding the political challenges and opportunities associated with HTA implementation, this study aims to provide actionable insights for policymakers and practitioners. METHODS: A qualitative study design was employed, using in-depth semi-structured interviews with 19 stakeholders from 6 categories: interest groups, political leaders, donors, financial decision-makers, beneficiaries and bureaucracies. Participants were selected through purposive sampling to ensure representation across sectors. Data were analysed using thematic analysis, guided by the political analysis framework of Campos and Reich. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigour. RESULTS: The findings reveal significant barriers to HTA implementation in Iran, including limited political will, competing priorities, inter-agency coordination challenges and concerns about equity and access. Interest groups, such as physicians and pharmacists, expressed concerns about restricted clinical autonomy and limited access to innovative treatments. Political leaders emphasized the difficulty of prioritizing HTA amidst competing healthcare and economic issues, whilst donors highlighted the need for alignment with national priorities and long-term sustainability. Financial decision-makers acknowledged the potential of HTA to improve resource allocation but raised concerns about budgetary constraints. Beneficiaries stressed the importance of transparency and inclusion, and bureaucrats underscored the need for stronger leadership and capacity building. CONCLUSIONS: The study underscores the importance of strong political leadership, stakeholder engagement and institutional capacity building for successful HTA implementation in Iran. Practical steps include strengthening inter-agency coordination mechanisms, ensuring transparent and inclusive decision-making processes, aligning donor support with national health priorities and investing in training programs to build technical capacity within government agencies. By addressing these challenges, policymakers can enhance the integration of HTA into the health system, ensuring efficient and equitable resource allocation.