For the past several years, we have discussed the idea of producing a publication on the history of health technology assessment (HTA). It seemed important to us to develop this history now, while those who lived it can give their own accounts. An exception is Seymour Perry, the first president of ISTAHC and the Director of the first national public program in HTA, the U.S. National Center for Health Care Technology (NCHCT). See the In Memoriam in this issue.

Technology is generally defined as “science or knowledge applied to a definite purpose.” Technology assessment has been defined as a form of policy research that examines short- and long-term consequences (for example, societal, economic, ethical, legal) of the application of technology. The goal of technology assessment was said to be to provide policy makers with information on policy alternatives. Health technology assessment (HTA) grew out of this field and was developed in the U.S. Office of Technology Assessment (OTA). However, the OTA was closed in 1995. The links between technology assessment and health technology assessment were more-or-less lost after the dissolution of OTA, and few workers in the field of HTA seem familiar with the roots of the field in the more general and social-oriented technology assessment.

Health technology assessment (HTA) (1), also known as healthcare technology assessment or medical technology assessment, is a form of policy research that systematically examines short- and long-term consequences of the application of a health technology, a set of related technologies, or an issue related to technology. The goal of HTA is to provide input to decision making in policy and practice. The essential properties of HTA are this orientation to decision making and its multidisciplinary and comprehensive nature.

The 1970s and early 1980s was the period in which high technology medicine became dominant. It had begun in the late 1950s with the introduction of effective artificial respiratory technology. This gave physicians, patients, and families the hope that the threats to fundamental life processes such as breathing could be countered by technology, and the dilemma of both meeting its costs and the ethical challenges of how to remove it when its use no longer produced benefits.

The International Society for Technology Assessment in Health Care (ISTAHC) was formed in 1985. It grew out of the increasing awareness of the international dimensions of health technology assessment (HTA) and the need for new communication methods at the international level. The main function of ISTAHC was to present an annual conference, which gradually grew in size, and also to generally improve in quality from to year. ISTAHC overextended itself financially early in the first decade of the 2000s and had to cease its existence. A new society, Health Technology Assessment international (HTAi), based on many of the same ideas and people, grew up beginning in the year 2003. The two societies have played a large role in making the field of HTA visible to people around the world and providing a forum for discussion on the methods and role of HTA.

Objectives: To describe the development of the International Network of Agencies for Health Technology Assessment (INAHTA) and its activities.

Methods: Review of literature material and other documents produced by or relating to INAHTA.

Results: INAHTA includes organizations that provide health technology assessment (HTA) advice to governments and receive most of their funding from public sources. In early 2009, there were forty-six members from twenty-seven countries, including both national and regional agencies. Interaction with other organizations includes links to Health Technology Assessment International (HTAi), the European Union Network for Health Technology Assessment (EUnetHTA), PAHO (the Pan American Health Organization, and the World Health Organization (WHO). An important feature of INAHTA is the routine interaction of its members with public sector decision makers. Output from the network has included guidelines and frameworks on HTA, reports of surveys, and joint projects.

Conclusions: INAHTA has developed as a global point of contact and information for those with interests in HTA.

The U.S. Congressional Office of Technology Assessment (OTA) established a health program in 1975. During the next few years, OTA's health program published a series of reports dealing with different aspects of health technology assessment (HTA) in some depth. The key report in this series concerned the efficacy and safety of health technology, which in many ways played a ground-breaking role. It pointed out the pervasive lack of accessible information on efficacy and safety, despite more-than-adequate methods of assessment. It also pointed to many problems that resulted from this lack, and the limited use of such information in clinical practice and policy making. It promoted synthesis of existing literature as a practical method of assessment. Other key reports developed other aspects of HTA, including cost-effectiveness. These reports are generally considered to have shaped the field of HTA at least into the 1990s. OTA also pioneered the use of HTA in determining what preventive services to cover in public healthcare programs.

Objectives: To describe and explore the reasons for the current health technology assessment (HTA) landscape in the United States.

Methods: Relying on multiple historical literature and other documents as well as drawing on personal experiences and observations, we describe, evaluate, and explain the evolving and dynamic HTA-related evidence landscape.

Results: The present HTA-related landscape is a product of a dynamic, somewhat turbulent path in the United States. Many early aggressive federal efforts beginning in the 1970s were rejected in the 1980s only to be revived by the mid-1990s and continue to strengthen today, likely due to diffusing private sector political opposition from de-linking HTA from policy decisions (e.g., coverage, clinical guidelines) and omitting economic evaluation. Meanwhile, private sector HTA efforts have remained active during the entire period.

Conclusions: The current HTA-related landscape is at least as dynamic as it has been at any point in its turbulent 30-year history and is likely to continue as health reform in the US is debated once again.

Sweden has a long history of using data as a basis to form policies in many sectors of society. The very first documented efforts to collect data and use some kind of evidence to judge health care began 350 years ago in Sweden. In 1663, the Swedish Collegium Medicorum (re-named Collegium Medicum in 1688) was established; initially to distinguish quackery from medicine, to develop a pharmacopoeia, to control the trade of poisonous drugs, and banish all swindlers who “grease people with their fake, fraudulent, and harmful medicaments”(12;20;25;26).

Canada's health system is a unique combination of public financing and private provision. With the significant government role in financing health services, health technology assessment (HTA) has found a ready audience as a form of policy research. In addition, Canada has been a leader in HTA and is entering a phase of deepening and maturation of HTA activities. The relative absence of dramatic change in the overall health system, coupled with public faith in the Canadian approach has been favorable to HTA's development in Canada. Emerging issues, beyond the demographic and economic pressures facing all Organisation for Economic Co-operation and Development health systems, include the convergence of assessment modalities and organizations for drug and nondrug technologies, increasing public concerns about the viability of Canada's approach to healthcare services, and the transition of HTA from an activity targeting macro-level policy makers to a management tool for healthcare facilities and providers.

Objectives: To describe the development and application of health technology assessment (HTA) in Australia.

Methods: Review of relevant literature and other documents related to HTA in Australia.

Results: Most HTA activity in Australia has been associated with provision of advice for the two national subsidy programs, Medicare, and the Pharmaceutical Benefits Scheme (PBS). National advisory bodies established by the federal government have had a prominent role. Assessments from the advisory bodies have had a major influence on decisions related to Medicare and the PBS, and in some other areas. Technologies without links to the national subsidy schemes, and those that are widely distributed, have been less well covered by HTA. To some extent these are addressed by evaluations supported by state governments, but details of approaches taken are not readily available.

Conclusions: HTA in Australia now has a long history and is well established as a source of advice to health decision makers. Challenges remain in extending the scope of assessments, developing more transparent approaches in some areas, and consistently applying appropriate standards.

This study summarizes the experience with health technology assessment (HTA) at the European level. Geographically, Europe includes approximately fifty countries with a total of approximately 730 million people. Politically, twenty-seven of these countries (500 million people) have come together in the European Union. The executive branch of the European Union is named the European Commission, which supports several activities, including research, all over Europe and in many other parts of the world. The European Commission has promoted HTA by several policy positions and has funded a series of projects aimed at strengthening HTA in Europe. Around fifteen of the European countries now have formal national programs on HTA and some also have regional public programs. All countries that are members of the European Union and do not have a national approach to HTA have an interest in becoming more involved. The HTA projects sponsored by the European Commission have focused on networking and collaboration among established agencies and institutions for HTA, however, also on capacity building, support, and facilitation in creating mechanisms for HTA in European countries that still do not have any program in the field.

Objectives: The aim of this article is to describe and analyze the stages toward recognition and implementation of health technology assessment (HTA).

Methods: System analysis of structures and institutions and their use of HTA.

Results: Austria is a latecomer in implementing evaluations/HTA as decision support. It can to a certain degree absorb the increasing international knowledge. Austria had a long time to observe the successes and failures of HTA in other countries and to learn from other countries. The implementation of HTA within the Austrian healthcare system ran through stages of uptake: starting 1989 with a systematic review on international activities, first international networking and collaboration since 1991, proposed assessments until the late 1990s, followed by reactive assessments on demand mostly on high volume and costly technologies since then. Since 2000, HTA is used on a regular basis for investment and reimbursement decisions by several players, namely the Ministry of Health, the Social Insurance and hospital cooperations. In 2006, the Austrian HTA-institute was founded.

Conclusions: It took approximately 15 years from first research activities in HTA to an institutionalization. HTA in Austria is not only product- but also process-oriented: The actual production of assessments for decision support is as important as the structuring and accompanying of the process of decisions making. In addition, shaping the public understanding of science (characterized by the intrinsic belief that all new medical interventions provide added value to the healthcare system) is part of Austrian HTA.

Objectives: This paper gives an overview of health technology assessment (HTA) in Belgium.

Methods: The information included in the overview is based on legal documents and publicly available year reports of the Belgian Health Care Knowledge Centre (KCE).

Results: Belgium has a relatively young history in HTA. The principle of evidence-based medicine (EBM) was introduced in the drug reimbursement procedure in 2001, with the establishment of the Drug Reimbursement Committee (DRC). The DRC assesses the efficacy, safety, convenience, applicability, and effectiveness of a drug relative to existing treatment alternatives. For some drugs, relative cost-effectiveness is also evaluated. The activities of the DRC can, therefore, be considered to be the first official HTA activities in Belgium. Later, in 2003, KCE was established. Its mission was to perform policy preparing research in the healthcare and health insurance sector and to give advice to policy makers about how they can obtain an efficient allocation of limited healthcare resources that optimizes the quality and accessibility of health care. This broad mission has been operationalized by activities in three domains of research: HTA, health services research, and good clinical practice. KCE is independent from the policy maker. Its HTAs contain policy recommendations that may inform policy decisions but are not binding.

Conclusions: Although the Belgian history of HTA is relatively short, its foundations are strong and the impact of HTA increasing. Nevertheless KCE has many challenges for the future, including continued quality assurance, further development of international collaboration, and further development of methodological guidance for HTA.

Objectives: The current and past situation of health technology assessment (HTA) in Catalonia is presented in this study.

Methods: The approach used here is a historical review of facts and landmarks.

Results: Spain has undergone radical change in many aspects, but the changes in healthcare provision have been major indeed. Catalonia has had the ability to benefit from these changes and has been able to build upon professionals' experience and expertise to development a consistent HTA network and continuous evaluation paradigm. The early involvement of the Catalan Agency for Health Technology Assessment (CAHTA) in several relevant HTA international initiatives and the relationship of CAHTA and Research with other HTA agencies in Spain is also stressed.

Conclusions: HTA is currently of common use in Catalonia for decision making at different levels. Now emphasis has to be put on the coming challenges that the HTA community will have to face in the coming years: uncontrolled demand, capacity scarcity, a rapidly evolving knowledge frontier, and insufficient input from the economic sphere into evaluations.

Objectives: The mainly tax-paid healthcare system in Denmark is decentralized with three defined policy and management levels. Health technology assessment (HTA) as a concept was introduced in the beginning of the 1980s. Significant implementation only happened when the first national strategy for HTA was developed by relevant stakeholders and issued as an official document in 1996. The introduction and the further development are described.

Methods: The Danish Institute for HTA was established in the National Board of Health in 1997 with responsibility for coordination and production of HTA. A local government reform from 2007 provides several new challenges to HTA and its coordination.

Results: An external evaluation in 2003 indicated that HTA was widely disseminated and that HTA results were benefitting political, administrative, and clinical decision making at all levels of the healthcare system.

Conclusions: The first national strategy for HTA, the broad HTA model covering four elements: Technology (clinical aspects), Patient, Organization, and Economy, and the development and introduction of mini-HTA as a tool for HTA-related activities in institutions and municipalities are major contributions to international HTA.

Since the 1990s, health policy makers in Finland have been supportive of evidence-based medicine and approaches to implement its results. The Finnish Office for Health Technology Assessment (Finohta) has grown from a small start in 1995 to a medium-sized health technology assessment (HTA) agency, with special responsibility in providing assessments to underpin national policies in screening. External evaluations enhanced the rapid growth. In the Finnish environment, decision making on health technologies is extremely decentralized, so Finohta has developed some practical tools for implementing HTA findings. The Managed Uptake of Medical Methods program links the hospital districts to agree on introduction of technologies. The Ohtanen database provides Finnish-language summaries of major assessments made in other countries.

Objectives: The aim of this study was to describe the history of health technology assessment (HTA) in France.

Methods: The approach was a descriptive review done by people who have been very much involved in this history.

Results: The interest in HTA and evaluation as a tool for health decision making goes back to the 1970s in France. During the 1980s, there were several attempts to develop a national HTA agency, which finally came to fruition with the development of the Agence Nationale de l'Evaluation Medicale (ANDEM) in 1989. ANDEM's main success, perhaps, was in making HTA known in France by developing its own assessments, writing and validating appropriate methodologies for assessing medical technology and medical practices, and by organizing in France the development of programs of consensus development conferences, which the ANDEM either organized itself or supported and validated. In the mid-1990s, the mandate of ANDEM was extended to hospital accreditation and the agency's name was changed to Agence Nationale d'Accreditation et d'Evaluation en Sante (ANAES). Finally, in 2005, the National Authority for Health (HAS) was formed to consolidate efforts to centralize the programs of HTA, aiming at helping decision making regarding reimbursement and pricing, in one agency and to define the optimal use of health technology in France.

Conclusions: HTA has become a strong influence in the healthcare system in France. These developments may be considered rather typical of the approach to public policy questions in France, where regulation is more in use than in other countries (at least in the healthcare field). At the same time, this approach has made lobbying and other attempts to influence decisions common as well, so one might say that HTA is more politicized than in some other countries in Europe.

Objectives: To provide an overview of the development of health technology assessment (HTA) in Germany since the 1990s.

Methods: Analysis of key documents (e.g. literature, laws, and other official documentation) and personal experiences.

Results: Health technology assessment (HTA) entered the political agenda in Germany only in the mid-1990s, basically as the result of a top-down approach toward more efficiency in health care, but with a strong impetus of an evidence-based medicine movement. Accordingly, HTA became part of several healthcare reform laws since 1997, which led to the establishment of the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWiG) in 2004. This tandem construction aims at using evidence in decision-making processes for coverage and other decisions.

Conclusions: These developments have led to a considerable impact of HTA in Germany. In addition, a broad spectrum of activities at universities and in other organizations, such as the German Institute for Medical Documentation and Information (DIMDI), can be observed that contribute to both teaching and research in HTA. German researchers in the field of HTA are actively involved in international projects, such as EUNetHTA, and contribute to scientific conferences and journals.

In Hungary, the history of the health technology assessment (HTA) dates back to 1993 when HTA and related activities started by professional initiatives. The legal background, institutionalization, and training capacities were created between 1998 and 2004. The main challenges for HTA in Hungary are partly similar to the ones in countries with a developed economy; no question it is time for cost-effectiveness. However, there are very important differences as well, that is why transferability and adaptability issues have to be considered. This article describes the characteristic features of the Hungarian healthcare system, the history and the current role of HTA, and the most important challenges.