Problem structuring in Health Technology Assessment. An argumentative approach to increase its usefulness.

This thesis addresses the problem of the limited impact of Health Technology Assessment (HTA) research on health policy and clinical practice. HTA is a type of policy research that aims to provide information concerning medical technologies in order to support health care decision making. Although, in many cases, HTAs appear to affect health care decisions, their actual contribution has been frequently debated. My hypothesis is that HTAs do not sufficiently answer the questions deemed important by their potential users, namely policy makers and health care professionals. Evaluation is usually restricted to assessing whether a specific programme or intervention has, or has not, fulfilled the programme objectives. The main problem is that such evaluations fail to take into account the underlying assumptions and normative values which influence the evaluation of specific interventions. In this thesis, I will further explore this hypothesis by reporting on a number of case studies. Analyses of the case studies indicated that policy makers, researchers, and policy's target populations defined the problems for which solutions were sought differently and therefore used different criteria to assess the intervention in question. This was insufficiently acknowledged. As a result, the problem definitions shifted during the research project and the implementation of subsequent policy measures failed. In essence, the research conducted answered the wrong question. By applying an interactive methodology, it is possible to pay attention to diversity in perspectives and situations. Interactive problem structuring led to different outcomes (in terms of relevant interventions and research questions) as compared to a more traditional approach. Conventional HTA methods need to be embedded in a more problem based approach, whereby an extensive process of problem analysis must take place prior to the design of research projects