Health system stewardship in Iran: Far from perfect! (original) (raw)
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Journal of Research & Health, 2022
Background: The health system of each country are required to achieve the goals based on appropriate frameworks. Assessment of health system performance provides an opportunity to address the main mission through recognizing new needs and resolving existing gaps. This review study aims to investigate Iran's health system performance in achieving its goals based on the World Health Organization (WHO)'s conceptual framework. Methods: This scoping review was conducted based on Arksey and O'Malley's methodological framework. A search in international databases including Web of Science, Scopus, PubMed/ Medline and in national databases such as SID, MagIran and IranDoc was conducted using the keywords "health system, Iran", "disease burden", "responsiveness" and "financial contribution", which were used in both English and Persian separately for each variables of health promotion, responsiveness, and fair financial contribution. Retrieved articles were analyzed using qualitative synthesis method. Results: Data extracted from articles categorized into the three groups of "Health" (with subcategories of epidemiologic and demographic transitions), "Responsiveness" and "Fair financing and financial risk protection". Synthesis of data revealed that the profiles of diseases has been changed over recent decades in Iran, which has resulted in epidemiologic and demographic transitions. In terms of responsiveness, services provided by the health system had not fulfilled patients' expectations. Regarding fair financial contribution, synthesis of data showed that people had faced high health costs, with a high amount of out-of-pocket payment. Conclusion: Iran's health system has not yet achieved the goals recommended by the World Health Organization. Fundamental reforming is required in the health system of this country.
Space or no space for managing public hospitals; a qualitative study of hospital autonomy in Iran
The International Journal of Health Planning and Management, 2010
hospitals can be defined as a continuum that covers four organizational modalities: (1) budgetary hospitals: administrative units dependent on a higher authority of a regional or national government; (2) autonomous hospitals: 'making managers manage' (Harding and Preker, 2000, p. 14) by granting more responsibility and accountability and exposing hospitals to the market; (3) corporatized hospitals: mimicking the decision-making structure of private corporations while ownership remains with the government; and (4) privatized hospitals, i.e. freestanding organizations owned by private entities (either for or not-for-profit). On the basis of this framework, five organizational elements-see below-are critical in granting diverse levels of autonomy to public hospitals. These are summarized here as: decision rights; market exposure; residual claimant; accountability mechanism; and, the hospital's social functions. These features should be fit into different organizational reform modalities. Overview of the Iranian health system Iran is a lower middle-income country with a population of over 70 millions (World Bank, 2007). Total expenditure on health in 2005 is estimated to be over 6% of GDP, and general government expenditure on health is about 52% of total health expenditure (WHO, 2007). The health system in Iran is organized into three levels. Specialty and super-specialty healthcare services (upper level) are mainly located in big cities. The other levels (district general hospitals and primary healthcare networks) are predominantly in small towns, semi-urban, rural, and remote areas (Regional Health Systems Observatory, 2002). Health system reform in Iran The legislation for structure and duties of Ministry of Health and Medical Education (MOHME) was approved in 1988. Accordingly, faculties of medical sciences were Figure 1. Organizational modalitis
2018
The operational management of healthcare services is expected to directly touch patient experiences. Iranian Ministry of Health and Medical Education (MoHME) for the first time, as such, has sought to improve the operational management of healthcare delivery within a reform agenda by setting benchmarks for 'number of visit per hour' and waiting time in outpatient clinics of about 700 affiliated hospitals. As a new initiative, it has faced with mixed reactions and various doubts have been cast on its successful implementation. This manuscript aims to shed some light on the operational challenges of the initiative and the requirements of its successful implementation.
A model of healthcare decentralization for Iran
2018
Background: As one of the key aspects of policymaking in healthcare, making reforms has long been considered as a significant subject by many countries, and governments have paid close attention to the important role of implementing efficient reforms in their health systems. In Iran, healthcare policy is highly centralized and decision makers have always been seeking for solutions to improve equality and productivity. The aim of this research was to identify the affecting factors in this area of policy making and to develop a model of healthcare decentralization for Iran. Methods: In this study, in order to design a theoretical and feasible model of decentralization for healthcare, a descriptive-survey approach was used and qualitative research methods were employed. In the first phase, we used meta-synthesis and at the second stage, data were analyzed through thematic analysis. Results: We initially reviewed 31 remarkable studies in the field of healthcare decentralization. Then, nine studies were selected as the final selection to carry out meta-synthesis analysis. After the final prerequisite factors for a successful decentralization in healthcare were extracted and categorized, a questionnaire was designed based on these factors to conduct interviews. Thematic analysis was used to analyze data from interviews with 15 healthcare experts and decision makers including former and current executive managers at the ministry of Health and Medical Education. Conclusion: We identified the main factors of decentralization in the process of health policy making. Based on these, we created a model of decentralization comprised of 12 stages, considering the main aspects of healthcare decentralization.
So Near, So Far: Four Decades of Health Policy Reforms in Iran, Achievements and Challenges
2019
The Islamic revolution of 1979 in Iran emphasized social justice as a pillar for development. The fundamental steps towards universal equitable access to high-quality healthcare services began with the creation of the Ministry of Health and Medical Education (MoHME) and the nationwide establishment of primary healthcare (PHC) network in 1985. Now, in the 40th anniversary of the Islamic revolution, the history of health system development in Iran is characterized by constant policy changes; i.e. structural and procedural transformations. Ever since and despite the imposed 8-year war with Iraq and continuous unfair sanctions against the country, noticeable progress has been achieved in the health system that has led to better population health including among others: self-sufficiency in training health workforce; advances in public health and medical sciences; establishment and expansion of health facilities within the hard-to-reach areas aiming to enhance equity in access to needed h...
Exploring Current Iran’s Primary Healthcare System: Challenges and Solutions
2020
Background: Since 1980s, establishing Primary Healthcare (PHC) network in Iran to promote health care delivery and population’s health, the PHC system has experienced various achievements and changes. This study aimed to explore current PHC in Iran focusing on challenges and solutions.Methods: Documentary review and interviews were used to collect qualitative data. The interviews were conducted with 26 stakeholders in various levels of the health system including health policymakers, academics, health managers and staffs are expert in public health and the PHC. National upstream documents including the Five Year Development Plans, General Health Policies, and the Iran’s 20 year national vision were reviewed. Data analysis was done using deductive content analysis assisted by MAXQDA 12 software. Results: Although Iranian PHC has enjoyed significant successes, it does not match with the changing populations’ health needs especially during the last years. The current workforce cannot r...
Primary Health Care Research & Development, 2018
Background: New public management (NPM) was developed as a management reform to improve the efficiency and effectiveness in public organizations, especially in health sector. Using the features of private sector management, the managers of health organizations may try to implement the elements of NPM with the hope to improve the performance of their systems. Aims: Our aim in the present study was to identify the elements and infrastructures suitable for implementing NPM in the Iranian health complex. Method: In this qualitative study with conventional content analysis approach, we tried to explore the NPM elements and infrastructures in Iranian public health sector. A series of semi-structured interviews (n = 48) were conducted in 2016 with a managers in public and private health complex. Three focus group discussions with nine faculty members were also conducted. A data collection form was used to collect the demographic characteristics and perspectives of the participants. Findings: From the perspective of managers, managerialism, decentralization, using market mechanism, performance management, customer orientation and performance budgeting were the main elements of NPM in the Iranian context. The most important infrastructures for implementing this reform were as follows: education and training, information technology, the proper use of human resources, decision support systems, top management commitment, organizational culture, flexibility of rules, rehabilitating of the aging infrastructures, and expanding the coverage of services. Conclusion: The NPM was generally identified to be an effective replacement for the traditional administration method. These reforms may be helpful in strengthening the public health complex and the management capacity, as well. NPM also seems to be useful in interacting the public health sector with the private sector in terms of personnel and resources, performance, reward structure, and methods of doing business.
Health Sector Evolution Plan in Iran; Equity and Sustainability Concerns
2015
In 2014, a series of reforms, called as the Health Sector Evolution Plan (HSEP), was launched in the health system of Iran in a stepwise process. HSEP was mainly based on the fifth 5-year health development national strategies (2011-2016). It included different interventions to: increase population coverage of basic health insurance, increase quality of care in the Ministry of Health and Medical Education (MoHME) affiliated hospitals, reduce out-of-pocket (OOP) payments for inpatient services, increase quality of primary healthcare, launch updated relative value units (RVUs) of clinical services, and update tariffs to more realistic values. The reforms resulted in extensive social reaction and different professional feedback. The official monitoring program shows general public satisfaction. However, there are some concerns for sustainability of the programs and equity of financing. Securing financial sources and fairness of the financial contribution to the new programs are the main concerns of policy-makers. Healthcare providers’ concerns (as powerful and influential stakeholders) potentially threat the sustainability and efficiency of HSEP. Previous experiences on extending health insurance coverage show that they can lead to a regressive healthcare financing and threat financial equity. To secure financial sources and to increase fairness, the contributions of people to new interventions should be progressive by their income and wealth. A specific progressive tax would be the best source, however, since it is not immediately feasible, a stepwise increase in the progressivity of financing must be followed. Technical concerns of healthcare providers (such as nonplausible RVUs for specific procedures or nonefficient insurance-provider processes) should be addressed through proper revision(s) while nontechnical concerns (which are derived from conflicting interests) must be responded through clarification and providing transparent information. The requirements of HSEP and especially the key element of progressive tax should be considered properly in the coming sixth national development plan (2016-2021).
Iranian Success Story: The Development of Iran's Public Health System
Iran 1400 Project, 2020
In this article, Shideh Rezaie traces back the first organization for managing public health in Iran to 1904. Rezaei presents a well-documented history of institutions of public health along with the number of medical schools, hospitals, physicians and nurses in Iran. The formation of public health policy and the process through which these policies were implemented are presented here. Rezaei devotes a considerable portion of her research on the creation and the expansion of the public health networks and their missions throughout Iran's modern history. She, indeed, goes beyond mere history of these institutions and policies and provides a detailed explanation of specific procedures and processes combined with an astute evaluation of them.
A decentralization model for healthcare system in Iran
2018
Background: As one of the key aspects of policymaking in healthcare, making reforms has long been considered as a significant subject by many countries, and governments have paid close attention to the important role of implementing efficient reforms in their health systems. In Iran, healthcare policy is highly centralized and decision makers have always been seeking for solutions to improve equality and productivity. The aim of this research was to identify the affecting factors in this area of policymaking and to develop a model of healthcare decentralization for Iran. Methods: In this study, in order to design a theoretical and feasible model of decentralization for healthcare, a descriptive-survey approach was used and qualitative research methods were employed. In the first phase, we used meta-synthesis and at the second stage, data were analyzed through thematic analysis. Results: We initially reviewed 31 remarkable studies in the field of healthcare decentralization. Then, nine studies were selected as the final selection to carry out meta-synthesis analysis. After the final prerequisite factors for a successful decentralization in healthcare were extracted and categorized, a questionnaire was designed based on these factors to conduct interviews. Thematic analysis was used to analyze data from interviews with 15 healthcare experts and decision makers including former and current executive managers at the ministry of Health and Medical Education. Conclusion: We identified the main factors of decentralization in the process of health policymaking. Based on these, we created a model of decentralization comprised of 12 stages, considering the main aspects of healthcare decentralization.