Establishing health technology assessment (HTA) in middle-income countries: a comparative analysis of the path towards institutionalisation in Thailand and the Philippines

This thesis examines the process of establishing HTA in two middle-income countries, Thailand and the Philippines. It conceptualises HTA establishment as involving decisions in relation to creating HTA organisations, developing processes and the methods used for analysing and appraising evidence, and embedding HTA in existing decision-making and governance structures. These elements make up the path towards institutionalisation. A comparative case study design with a pragmatic constructivist approach was chosen to allow for a rich description of the process of institutionalisation. The two case countries were selected based on their similarity with regard to their early interest in HTA, but differences regarding the degree to which HTA has been institutionalised at the time of the study. The analysis of the process of institutionalisation was informed by interviews with key policy actors and documentary review. The conceptual perspectives chosen for the analysis of HTA institutionalisation focus on ideas, interests and institutions. This study found that HTA advocates organised in policy networks, of which senior civil servants were important members, were key to initiating the process of establishing HTA. The rules of the administrative systems, which provide civil servants with varying degrees of independence, determined the way in which HTA organisations were established. The development of HTA processes was largely influenced by the existing rules for making coverage decisions. HTA processes and methods were not directly copied from other countries but were developed in each country and adjusted over time. The interests of some policy actors opposed to HTA seemed to undermine institutionalisation at different points in time. However, this thesis also found examples in which opposition to the results of HTA strengthened its development in the long term. How HTA processes operated was influenced by other aspects of health systems governance, especially mechanisms for procurement and reimbursement, as well as the long-term evolution of the heath system, which explained and structured power struggles between policy actors.