HEALTH TECHNOLOGY ASSESSMENT AS A VALUABLE FRAMEWORK FOR STEERING DECISION-MAKING IN PUBLIC HEALTH

Health Technology Assessment (HTA) is a formal, systematic, and transparent process that accomplishes a multidimensional, multidisciplinary, and multistakeholder evaluation of the direct and indirect effects of a health technology and determines its value compared to existing alternatives. The evidence provided by HTA informs decision-making to promote quality improvement and sustainability in the health system [1,2]. The key common features of HTA and PH were identified [3] to be the interdisciplinarity of activities, the variety of methods to produce evidence, and the primary purpose of moving from research to practice. The increasing burden of chronic conditions, as well as populations ageing, and the relentless technological innovation whose implications are complex to assess, as in the case of artificial intelligence or genomic technologies, are burning trends generating the need to bridge HTA and PH [3]. In this environment of mounting pressure on health systems, decision-makers at all levels, generally encumbered by resource constraints, express demands for information on the effects of investing or disinvesting in technologies for health. Nevertheless, systematically addressing such demands requires an adequate human and organizational capacity for HTA [4]. In this light, PH policies and programs could benefit from the findings provided by HTA in countries where the bodies performing HTA activities are linked to the responsible governmental policy-making organs [4]. Institutionalized HTA processes indeed facilitate the generation and gathering of evidence to support informed decisions in all fields of health, including PH [5]. Policies, programs, and interventions aimed at prospectively reducing the burden of diseases, such as those based on community-based prevention, can be subject to HTA, whether we aim to prevent communicable diseases, such as HIV infections in at-risk populations [6], or non-communicable ones, for which physical activity interventions may be studied [7]. Examples of PH interventions undergone HTA involve physical activity promotion for diabetes and falls prevention, self-help groups and psychological interventions for fetal alcohol syndrome and child obesity, and community pharmacy interventions for smoking cessation [8]. The assessments take the form of reports, which can be classified according to their increasing comprehensiveness and scientific robustness in Rapid Reviews, Mini-HTAs, and HTA Reports [8]. Early HTAs should also be mentioned, used to inform industry and other stakeholders about the potential value of technologies in development, not yet applied (i.e., pre-marketing) [9]; Horizon Scanning, on the other hand, is used to identify, filtrate, and assess the future impact of new or emergent technologies and new applications of affirmed ones [10]. As Early HTAs are designed to evaluate health technologies even before they are brought into existence, they can support time-sensitive decisions, as in PH emergencies [11]. Taking the COVID-19 pandemic as an example, using HTA, the uncertainty attached to interventions with significant financial and/or social implications such as mass vaccination campaigns [12] and masking mandates [13] could be quantified and considered as a factor in the assessment processes, allowing for multi-disciplinary considerations. Appropriately executed HTAs [14] can help prioritize funding of interventions that demonstrate the highest value, and defund those with the lowest. Transparency, accountability, reproducibility, and systematicity are factors of HTA processes which legitimize decisions and potentially instill public trust, especially in instances where participatory approaches are adopted, and every stakeholder is involved in a process of consensus-building. In Countries whose constitutions hold the safeguarding of health as a fundamental principle and embrace solidarity in benefit-sharing in their social welfare vision, HTA serves the purpose of PH not only by guiding community-based prevention strategies, but also curative (diagnostic and/or therapeutic), rehabilitative, and palliative interventions. These technologies are prioritized according to the perspective of providing value-based health care for all [15]. In fact, PH and healthcare, despite having formally distinct sets of roles and responsibilities, they share a common objective, namely addressing health threats [16]. To underline the relevance of all the components of healthcare for a sustainable publicly financed healthcare system, and the importance of empowering HTA within the organizational structures of States (institutionalization), the World Health Organization recently released an operational, step-by-step guide listing and explaining the requirements for a fruitful institutionalization of HTA mechanisms [17], to effectively connect the world of research to that of policy-making for applying evidence-informed decisions in healthcare. This form of institutional mobilization for public health purposes is in line with the current supranational approach enacted in the European Union (EU). Infact, given the naturally disambiguous meaning of HTA for decision-makers, its self-evident necessity, and its overall utility, it was decided that that an infrastructural collaborative system for HTA activities was to be put in place at the EU level [18]. The current aim is to increase the efficiency of those HTA processes which generate knowledge with higher generalizability, namely that pertaining to the so-called clinical domains of effectiveness, safety, technical and epidemiological characteristics of technologies. As for the so-called non-clinical domains of HTA evidence, those of economic, ethical, organizational, societal, and legal aspects, it is up to the single States to produce assessments, the reason being that these aspects are context- dependent, thus far less generalizable than clinical aspects. These insights allow to increase the magnitude of public health benefits driven by HTA, envisioning it as a tool not only for comprehensive technical evaluations of public health interventions, but also as a framework for the governance of all the healthcare choices in a publicly-funded healthcare system.