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Kabir MJ, Moeini S, Heidari A. Strategies for improving the financing of family medicine program: Evidence from Iran. Health Sci Rep 2024; 7:e1813. [PMID: 38204751 PMCID: PMC10776829 DOI: 10.1002/hsr2.1813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 11/26/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
Background and Aims The impact of health financing on the performance of the entire health system, including access, quality, and efficiency of healthcare, has been emphasized in the Astana Declaration, and the need to strengthen primary healthcare (PHC) and policy integration has been emphasized. After about two decades, the family medicine (FM) program in Iran is still facing great challenges. The aim of this study is to explore strategies for strengthening financing of the FM program in Iran, a vital component of PHC. Methods A qualitative study was conducted in 2021. Purposeful sampling was used to select 34 policymakers, managers, and experts from various levels of the Ministry of Health, Iran universities of medical sciences, plan and budget organization of Iran, and health insurance organization in Iran. Thirty-four semistructured interviews were conducted to collect data, which were analyzed by content analysis. Results Through the analysis of interviews, our study has identified five strategies (identification and management of sustainable resources, pooling of sustainable resources, modeling of service provision, payment system model and its implementation process, and FM management structure), and 13 actions for strengthening financing of the FM program in Iran. Conclusion Our study has identified five strategies and 13 actions for strengthening the financing of the FM program in Iran. These strategies and actions should be considered by policymakers during the review of the FM program in Iran. Without implementation of the suggested strategies and action, allocated resources may be wasted.
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Affiliation(s)
- Mohammad Javad Kabir
- Health Management and Social Development Research CenterGolestan University of Medical SciencesGorganIran
| | - Sajad Moeini
- Department of Health Services Management, School of Health Management & Information SciencesIran University of Medical SciencesTehranIran
| | - Alireza Heidari
- Health Management and Social Development Research CenterGolestan University of Medical SciencesGorganIran
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Heidarzadeh A, Hedayati B, Sirous S, Huntington MK, Alvandi M, Arabi A, Farrokhi B, Nojomi M, Noori Hekmat S, Mirkazemi R. Financial challenges in the family physician programme in Iran: A systematic review of qualitative research. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2023; 18:59. [PMID: 38026574 PMCID: PMC10664759 DOI: 10.51866/rv.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Introduction The family physician programme (FPP) was implemented nearly two decades ago as a major health reform. Since the health system and FPP function in a rapidly changing social and economic environment, successful expansion of the programme requires a detailed analysis of its multiple major challenges, including the crucial aspect of its funding system. This systematic review aimed to assess the challenges in the FPP relative to its financing. Method All published articles related to the FPP in Iran were included in this study. In particular, original qualitative studies published in English or Persian from 2011 to 2021 were included. In January 2022, international credible scholarly databases and Persian databases were searched. All selected articles were carefully studied, and the data were extracted using the sample, phenomenon of interest, design, evaluation and research type technique. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in preparing the study report. Results Among 491 articles retrieved from the search strategy, 50 met the inclusion criteria after their titles and abstracts were screened. Twenty-nine studies were excluded after their full texts were reviewed. A total of 11 eligible empirical studies were finally included. Based on the results, six broad categories (budget and funding, insurance system, tariffs, payments, accountability and injustice) were identified as financial challenges. Conclusion This study identified the challenges associated with financing among family physicians, and the results could provide guidance for policy-making in the expansion of the FPP.
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Affiliation(s)
- Abtin Heidarzadeh
- MD, MPH, Medical Education Research Center, Department of Community and Family Medicine. School of Medicine. Guilan University of Medical Sciences, Rasht, Iran
| | - Bita Hedayati
- MPH, Research Department, Farzanegan Nik Andish Institute for the Development of Knowledge and Technology, Tehran, Iran
| | - Shadrokh Sirous
- MD, National Professional Officer and Unit Head, Universal Health Coverage/Health System, WHO Representative Office, Tehran, Iran
| | - Mark K Huntington
- MD, PhD, FAAFP Professor, Director, Sioux Falls, Family Medicine Residency program and founding Director, Pierre Rural, Family Medicine Residency program, University of South Dakota Sanford, School of Medicine, Vermillion, United States
| | - Mehdi Alvandi
- MD, Department of Public Administration, Faculty of Management, University of Tehran, Tehran, Iran
| | - Alireza Arabi
- Family Physician Specialist, National Center for Health Insurance, Research, Tehran, Iran
| | - Babak Farrokhi
- MD, MPH, Executive Deputy, National Director for Family Medicine, Undersecretary for Health Affairs, Health Network Administration Center, Ministry of Health and Medical Education, Tehran, Iran
| | - Marzieh Nojomi
- MD, MPH, Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine. School of Medicine. Iran University of Medical Sciences, Tehran, Iran
| | - Somayeh Noori Hekmat
- PhD, Associate Professor of Health Services Management, Leadership and Management in Medical Education Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Roksana Mirkazemi
- BSc, MSc, PhD, Founder and Managing Director of Farzanegan Nik Andish Institute for the Development of Knowledge and Technology, Tehran, Iran.
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Burns D, Hamblin K, Fisher DU, Goodlad C. Is it time for job quality? Conceptualising temporal arrangements in new models of homecare. SOCIOLOGY OF HEALTH & ILLNESS 2023; 45:1541-1559. [PMID: 37191249 DOI: 10.1111/1467-9566.13650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/11/2023] [Indexed: 05/17/2023]
Abstract
Time is a key organising principle in the formal provision of care to older people in their own homes. It is used when delivering homecare services, calculating fees and care staff's pay entitlement. Research in the UK highlights how the predominant service model of compartmentalising care into pre-defined tasks, delivered in strictly scheduled time-based units, offers poor quality jobs, characterised by low pay, insecure and tightly controlled work. Our case study research of 'new models' of homecare however, found variation in the way time measures were operationalised. Drawing from Thompson's (1967, Past & Present, 38, 56-97) conceptualisation of clock-time (where care work is controlled by external measures of time) and nature's time (where care work is performed through internal notions of time) as a lens, we examine how service delivery models and job quality are temporally connected through homecare work. Through our analysis, we exemplify how the use of strict time-based measures can limit care work according to nature's time. We also consider the potential of ambitemporality-the accommodation of clock and nature's time-in organising service delivery as a means of enriching job quality. Finally, we discuss the pertinent implications of conceiving job quality in homecare work through a temporal lens.
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Affiliation(s)
- Diane Burns
- Sheffield University Management School, University of Sheffield, Sheffield, UK
| | - Kate Hamblin
- Centre for International Research on Care, Labour and Equalities (CIRCLE), University of Sheffield, Sheffield, UK
| | | | - Cate Goodlad
- Sheffield University Management School, University of Sheffield, Sheffield, UK
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Alaref M, Al-Abdulla O, Al Zoubi Z, Al Khalil M, Ekzayez A. Health system governance assessment in protracted crisis settings: Northwest Syria. Health Res Policy Syst 2023; 21:88. [PMID: 37649119 PMCID: PMC10466772 DOI: 10.1186/s12961-023-01042-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Since the withdrawal of government forces from Northwest Syria due to the conflict, several national initiatives have aimed to create alternative governance approaches to replace the central governmental system. One of the recent initiatives was the formulation of so-called 'Central Bodies' as institutional governance structures responsible for thematic planning and service provision; for example, the referral unit is responsible for planning and delivering medical referral services. However, the governance and administrative rules of procedures of these bodies could be immature or unsystematic. Assessing the governance of this approach cannot be condoned, especially with the urgent need for a methodical approach to strategic planning, achieving strategic humanitarian objectives, and efficiently utilizing available resources. Multiple governance assessment frameworks have been developed. However, none were created to be applied in protracted humanitarian settings. This research aims to assess the extent to which the existing health governance structure (central bodies) was capable of performing the governance functions in the absence of a legitimate government in Northwest Syria. METHODS AND MATERIALS A governance assessment framework was adopted after an extensive literature review and group discussions. Four principles for the governance assessment framework were identified; legitimacy, accountability and transparency, effectiveness and efficiency, and strategic vision. Focus Group Discussions were held to assess the levels of the selected principles on the governance thermometer scale. Qualitative and quantitative data were analyzed using NVivo 12 and SPSS 22 software programs, respectively. RESULTS The level of the four principles on the governance thermometer scale was between the lowest and middle quintiles; 'very poor or inactive' and 'fair and requires improvement', respectively. The results indicate that the governance approach of Central Bodies in NWS is underdeveloped and summons comprehensive systematic development. The poor internal mechanisms, poor planning and coordination, and the absence of strategic vision were among the most frequent challenges to developing the approach. CONCLUSION Humanitarian actors and donors should pay more attention to health governance approaches and tools in protracted crises. The central bodies must improve coordination with the stakeholders and, most importantly, strategic planning. Establishing or utilizing an independent planning committee, with financial and administrative independence, is crucial to maintain and improving contextual governance mechanisms in Northwest Syria.
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Affiliation(s)
- Maher Alaref
- Research for Health System Strengthening in Northern Syria (R4HSSS), Union for Medical and Relief Organizations, Incili Pinar MAH, 27090, Gaziantep, Turkey.
- Strategic Research Center (ÖZ SRC), Gaziantep, Turkey.
| | | | - Zedoun Al Zoubi
- Research for Health System Strengthening in Northern Syria (R4HSSS), Union for Medical and Relief Organizations, Incili Pinar MAH, 27090, Gaziantep, Turkey
| | - Munzer Al Khalil
- Research for Health System Strengthening in Northern Syria (R4HSSS), Union for Medical and Relief Organizations, Incili Pinar MAH, 27090, Gaziantep, Turkey
- Syria Public Health Network, London, UK
| | - Abdulkarim Ekzayez
- Syria Public Health Network, London, UK
- The Centre for Conflict & Health Research (CCHR), King's College London, London, UK
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Abstract
AIM The aim of this paper is to introduce the experience of applying public-private partnership (PPP) in providing primary health care (PHC) in East Azerbaijan Province (EAP), Iran. BACKGROUND Moving toward the Universal Health Coverage (UHC) involves using of all health-related resources. Certainly, one of the key strategies for achieving UHC is PPP. Since 2015, a PPP in PHC policy has begun in EAP as a major strategy for strengthening the health system and achieving UHC. METHODS In this case study, data were collected through interviews with stakeholders, document analysis, reviewing of health indexes and published studies. The data were analyzed using content analysis. FINDING PPP in PHC policy was designed and implemented in EAP with the aim of social justice, strengthening the health system and achieving UHC in the framework of health complexes (HCs). HCs provide a defined service package according to the contract. The reimbursement method is a combination of per capita, fee for services and bonus methods. Part of the payments is fixed and the other part is based on the pay for quality system and paid according to the results of monitoring and evaluation. According to the study results, the most important strength of the plan is to improve access to services, especially in marginalized areas. The main weakness is not providing infrastructures before the implementation of the plan, and the most important challenges are financial, political and organizational unsustainability and, sometimes, poor cooperation by the other organizations. The findings show that PPP in PHC in EAP is an effective strategy to provide social justice, implement family practice and achieve UHC.
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Killie P, Jakobsen R, Sørensen KE, Debesay J. A qualitative study of purchaser unit employees’ experiences of patient pathways from specialist healthcare to primary healthcare in Norway. INTERNATIONAL JOURNAL OF CARE COORDINATION 2022. [DOI: 10.1177/20534345221124711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Understanding the purchaser–provider split model in the patient pathway is important. The purchaser is a key player in managing the flow between specialist and municipal healthcare services. A smoother patient transfer has been a priority in Norway, but also challenging. Accordingly, this study aims to describe and explain how the purchasers operate as liaisons during patient transfers from specialist to primary healthcare services. Methods Eleven interviews were conducted with employees at purchaser units in primary healthcare in Norway. The interviewees’ professional backgrounds were in nursing and physiotherapy, as well as casework, and management. The interviews took place in 2018–2019 and analyzed with Graneheim and Lundman's content analysis strategy. Results The interviewees’ views reflected the changes they experienced in the wake of healthcare reforms in specialist healthcare services and municipal healthcare institutions. Three themes emerged from the analyses: (1) increased efficiency requirements after the Coordination Reform, (2) better reporting systems and the need for role clarifications in contact with hospitals, and (3) the need for good assessments for safe transfer to the municipality. Discussion Purchaser unit employees’ experiences with patient pathways point towards a need for certain changes. There is a need for increased efficiency requirements for purchasing units, even with new electronic tools, as well as a growing need for better reporting systems and a common understanding between the service levels about what patients can expect in the municipalities.
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Affiliation(s)
- Paul Killie
- Department of Nursing and Health Sciences, University of South-Eastern Norway, Kongsberg, Norway
| | - Rita Jakobsen
- Department of Nursing, Lovisenberg Diaconal University College, Oslo, Norway
| | | | - Jonas Debesay
- Department of Nursing, Oslo Metropolitan University, Oslo, Norway
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Doshmangir L, Doshmangir P, Beyrami HJ, Alizadeh G, Gordeev VS. Policy options to reduce patient visits in specialized service centers: A case study in speciality and subspeciality clinics in Iran. WORLD MEDICAL & HEALTH POLICY 2022. [DOI: 10.1002/wmh3.541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Leila Doshmangir
- Department of Health Policy & Management, Tabriz Health Services Management Research Center, School of Management & Medical Informatics Tabriz University of Medical Sciences Tabriz Iran
- Social Determinants of Health Research Center Tabriz University of Medical Sciences Tabriz Iran
| | | | - Hossein Jabbari Beyrami
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute Tabriz University of Medical Sciences Tabriz Iran
| | - Gisoo Alizadeh
- Department of Health Policy & Management, Tabriz Health Services Management Research Center, School of Management & Medical Informatics Tabriz University of Medical Sciences Tabriz Iran
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A dominance approach to analyze the incidence of catastrophic health expenditures in Iran. Soc Sci Med 2021; 285:114022. [PMID: 34384625 DOI: 10.1016/j.socscimed.2021.114022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 11/22/2022]
Abstract
Financial protection is a health system goal for all countries. Assessing progress on this relies on measuring the incidence of catastrophic health expenditures (proportion of the population whose out-of-pocket (OOP) payments for health surpass a certain threshold of household resources). Standard approaches rely on selective thresholds, however this masks varying intensities of financial hardship and poses a measurement challenge as incidence is sensitive to the choice of the threshold. We address this problem by applying the dominance approach, which tests differences in catastrophic incidence curves over a continuous range of thresholds. Iran is an interesting country for empirical application of the dominance approach given its historically high reliance on OOP payments to finance its health system and its commitment to improving financial protection through several national health policies over the last two decades. Using data from annual Household Income and Expenditure Surveys from 2005 to 2017 (sample size: 26,851-39,088 households), incidence was analyzed following this novel approach. Distribution of incidence across socio-economic status was also analyzed by estimating concentration indices and across health services or products by estimating average shares of each item. Results showed that over time catastrophic health expenditures increased for thresholds lower than 25% and decreased for thresholds higher than 35%. Catastrophic health expenditures were more equally distributed across income levels at lower thresholds, becoming concentrated amongst the rich as the threshold rose. Medicines represented the largest share of catastrophic spending for the poorest; medicines, dentistry, inpatient and ancillary services for the richest. This is the first study to apply dominance methods to analyze catastrophic health expenditures in a country over time. The analysis provides a nuanced picture of who incurs catastrophic health expenditures, to what extent hardship is experienced and what were the drivers of these expenditures - thus providing a better basis for policy responses.
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Ghiasvand H, Mohamadi E, Olyaeemanesh A, Kiani MM, Armoon B, Takian A. Health equity in Iran: A systematic review. Med J Islam Repub Iran 2021; 35:51. [PMID: 34268239 PMCID: PMC8271272 DOI: 10.47176/mjiri.35.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Health inequities are among debatable and challenging aspects of health systems. Achieving equity through social determinants of health approach has been mentioned in most upstream national plans and acts in Iran. This paper reports the findings of a systematic review of the current synthesized evidence on health equity in Iran.
Methods: This is a narrative systematic review. The relevant concepts and terminology in health equity was found through MeSH. We retrieved the relevant studies from PubMed/MedLine, Social Sciences Database, and Google Scholar in English, plus the Jihad University Database (SID), and Google Scholar in Farsi databases from 1979 until the end of January 2018. The retrieved evidence has been assessed primarily based on PICOS criteria and then Ottawa-Newcastle Scale, and CASP for qualitative studies. We used PRISMA flow diagram and a narrative approach for synthesizing the evidence.
Results: We retrieved 172 455 studies. Following the primary and quality appraisal process, 114 studies were entered in the final phase of the analysis. The main part (approximately 95%) of the final phase included cross-sectional studies that had been analyzed through current descriptive inequality analysis indicators, analytical regression, or decomposition-based approaches. The studies were categorized within 3 main groups: health outcomes (40.3%), health utilization (32%), and health expenditures (27%).
Conclusion: As a part of understanding the current situation of health equity in the policymakers’ need to refer the retrieved evidence in this study, they need more inputs specially regarding the social determinants of health approach. It seems that health equity research plan in Iran needs to be redirected in new paths that give appropriate weights to biological, gene-based, environmental and contextbased, economic, social, and political aspects of health as well. We advocate addressing the aspects of Social Determinant of Health (SDH) in analyzing health inequalities.
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Affiliation(s)
- Hesam Ghiasvand
- Health Economics Group, Medical School, Institute of Health Researches, South Cloister Building, University of Exeter, United Kingdom
| | - Efat Mohamadi
- Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Olyaeemanesh
- National Institute of Health Research, Tehran University of Medical Sciences (TUMS), Tehran, Iran.,Department of Management and Health Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Kiani
- Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran.,Department of Global Health & Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Armoon
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Amirhossein Takian
- Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran.,Department of Management and Health Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Global Health & Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Doshmangir L, Bazyar M, Rashidian A, Gordeev VS. Iran health insurance system in transition: equity concerns and steps to achieve universal health coverage. Int J Equity Health 2021; 20:37. [PMID: 33446202 PMCID: PMC7807408 DOI: 10.1186/s12939-020-01372-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/26/2020] [Indexed: 01/29/2023] Open
Abstract
Background Equity, efficiency, sustainability, acceptability to clients and providers, and quality are the cornerstones of universal health coverage (UHC). No country has a single way to achieve efficient UHC. In this study, we documented the Iranian health insurance reforms, focusing on how and why certain policies were introduced and implemented, and which challenges remain to keep a sustainable UHC. Methods This retrospective policy analysis used three sources of data: a comprehensive and chronological scoping review of literature, interviews with Iran health insurance policy actors and stakeholders, and a review of published and unpublished official documents and local media. All data were analysed using thematic content analysis. Results Health insurance reforms, especially health transformation plan (HTP) in 2014, helped to progress towards UHC and health equity by expanding population coverage, a benefits package, and enhancing financial protection. However, several challenges can jeopardize sustaining this progress. There is a lack of suitable mechanisms to collect contributions from those without a regular income. The compulsory health insurance coverage law is not implemented in full. A substantial gap between private and public medical tariffs leads to high out-of-pocket health expenditure. Moreover, controlling the total health care expenditures is not the main priority to make keeping UHC more sustainable. Conclusion To achieve UHC in Iran, the Ministry of Health and Medical Education and health insurance schemes should devise and follow the policies to control health care expenditures. Working mechanisms should be implemented to extend free health insurance coverage for those in need. More studies are needed to evaluate the impact of health insurance reforms in terms of health equity, sustainability, coverage, and access.
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Affiliation(s)
- Leila Doshmangir
- Social Determinants of Health Research Center, Health Management & Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Health Policy& Management, Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, School of Management& Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Bazyar
- Department of Public Health, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran.
| | - Arash Rashidian
- Department of Science, Information and Dissemination, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Vladimir Sergeevich Gordeev
- Institute of Population Health Sciences, Queen Mary University of London, London, UK.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Bahmanziari N, Takian A. Health system stewardship in Iran: Far from perfect! Med J Islam Repub Iran 2021; 34:144. [PMID: 33437740 PMCID: PMC7787014 DOI: 10.34171/mjiri.34.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Indexed: 11/07/2022] Open
Abstract
This debate article highlights that to perform efficiently and meaningfully, the structure and organization of a health system need to be adjusted to its philosophy, mission, and expected duties. Development of the required organizational structure, in line with the objectives and strategies of the national health policy are fundamental principles of healthcare stewardship. Despite several reforms and initiatives in the course of the last few decades, the Ministry of Health and Medical Education (MoHME), as the steward of the health system in Iran, has not been performing efficient enough to respond to serious emerging challenges. In order to move in line with sustainable health development agenda and reach universal health coverage (UHC), we advocate fundamental structural and institutional reforms within the MoHME in Iran.
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Affiliation(s)
- Najmeh Bahmanziari
- Department of Healthcare Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Takian
- Department of Healthcare Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Global Health & Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran
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12
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Bazyar M, Yazdi-Feyzabadi V, Rahimi N, Rashidian A. What are the potential advantages and disadvantages of merging health insurance funds? A qualitative policy analysis from Iran. BMC Public Health 2020; 20:1315. [PMID: 32867732 PMCID: PMC7457517 DOI: 10.1186/s12889-020-09417-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In countries with health insurance systems, the number and size of insurance funds along with the amount of risk distribution among them are a major concern. One possible solution to overcome problems resulting from fragmentation is to combine risk pools to create a single pool. This study aimed to investigate the potential advantages and disadvantages of merging health insurance funds in Iran. METHODS In this qualitative study, a purposeful sampling with maximum variation was used to obtain representativeness and rich data. To this end, sixty-seven face-to-face interviews were conducted. Moreover, a documentary review was used as a supplementary source of data collection. Content analysis using the 'framework method' was used to analyze the data. Four trustworthiness criteria, including credibility, transferability, dependability, and confirmability, were used to assure the quality of results. RESULTS The potential consequences were grouped into seven categories, including stewardship, financing, population, benefit package, structure, operational procedures, and interaction with providers. According to the interviewees, controlling total health care expenditures; improving strategic purchasing; removing duplication in population coverage; centralizing the profile of providers in a single database; controlling the volume of provided health care services; making hospitals interact with single insurance with a single set of instructions for contracting, claiming review, and reimbursement; and reducing administrative costs were among the main benefits of merging health insurance funds. The interviewees enumerated the following drawbacks as well: the social security organization's unwillingness to collect insurance premiums from private workers actively as before; increased dissatisfaction among population groups enjoying a generous basic benefits package; risk of financial fraud and corruption due to gathering all premiums in a single bank; and risk of putting more financial pressure on providers in case of delay in reimbursement with a single-payer system. CONCLUSION Merging health insurance schemes in Iran is influenced by a wide range of potential merits and drawbacks. Thus, to facilitate the process and lessen opponents' objection, policy makers should act as brokers by taking into account contextual factors and adopting tailored policies to respectively maximize and minimize the potential benefits and drawbacks of consolidation in Iran.
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Affiliation(s)
- Mohammad Bazyar
- Health Policy, Department of Health Promotion, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Vahid Yazdi-Feyzabadi
- Health Policy, Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Haftbagh Highway, Kerman, Iran.
| | | | - Arash Rashidian
- Information, Evidence, and Research Department, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt
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13
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Sajadi HS, Goodarzi Z, Takian A, Mohamadi E, Olyaeemanesh A, Hosseinzadeh Lotfi F, Sharafi H, Noori Hekmat S, Jowett M, Majdzadeh R. Assessing the efficiency of Iran health system in making progress towards universal health coverage: a comparative panel data analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:20. [PMID: 32612458 PMCID: PMC7324989 DOI: 10.1186/s12962-020-00215-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/15/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Building upon decades of continuous reforms, Iran has been implementing various initiatives to reach universal health coverage (UHC). Improving efficiency is a crucial intermediate policy objective for UHC. Therefore, this article aimed to measure the efficiency and productivity changes of the Iranian health system in making progress towards UHC during 2010-2015 in comparison with 36 selected other upper-middle-income countries. METHODS We used panel data to measure the variations in technical efficiency (TE) and total factor productivity (TFP) through an extended data envelopment analysis (EDEA) and Malmquist productivity index, respectively. General government health expenditure (GGHE) per capita (International dollar) was selected as the input variable. Service coverage of diphtheria, tetanus and pertussis; family planning; antiretroviral therapy; skilled attendants at birth; Tuberculosis treatment success rate; and GGHE as % of total health expenditure (THE) were considered as output variables. The data for each indicator were taken from the Global Health Observatory data repository and World Development Indicator database, for 6 years (2010-2015). RESULTS The TE scores of Iran's health system were 0.75, 0.77, 0.74, 0.74, 0.97, and 0.84 in the period 2010-2015, respectively. TFP improved in 2011 (1.02), 2013 (1.01), and 2014 (1.30, generally). The overall efficiency and TFP increased in 2014. Changes made in CCHE per capita and GGHE/THE attributed to the increase of efficiency. CONCLUSION There is a growing demand for efficiency improvements in the health systems to achieve UHC. While there are no defined set of indicators or precise methods to measure health system efficiency, EDEA helped us to draw the picture of health system efficiency in Iran. Our findings highlighted the essential need for targeted and sustained interventions, i.e., allocation of enough proportion of public funds to the health sector, to improve universal financial coverage against health costs aiming to enhance the future performance of Iran's health system, ultimately. Such tailored interventions may also be useful for settings with similar context to speed up their movement towards improving efficiency, which in turn might lead to more resources to reach UHC.
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Affiliation(s)
- Haniye Sadat Sajadi
- Knowledge Utilization Research Center, University Research and Development Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Goodarzi
- National Institute for Health Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Takian
- Department of Global Health & Public Policy, Department of Management Sciences & Health Economics, School of Public Health, Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Efat Mohamadi
- Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Olyaeemanesh
- National Institute for Health Research, Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hamid Sharafi
- Department of Mathematics, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Somayeh Noori Hekmat
- Management and Leadership in Medical Education Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Matthew Jowett
- Department of Health Systems Governance & Financing, World Health Organization, Geneva, Switzerland
| | - Reza Majdzadeh
- Knowledge Utilization Research Center, Community-Based Participatory-Research Center,and School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Mostafavi F, Piroozi B, Mosquera P, Majdzadeh R, Moradi G. Assessing horizontal equity in health care utilization in Iran: a decomposition analysis. BMC Public Health 2020; 20:914. [PMID: 32532229 PMCID: PMC7291751 DOI: 10.1186/s12889-020-09071-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 06/08/2020] [Indexed: 11/24/2022] Open
Abstract
Background Despite the goal of horizontal equity in Iran, little is known about it. This study aimed i) to assess socioeconomic inequality and horizontal inequity in the healthcare utilization; and ii) to explore the contribution of need and non-need variables to the observed inequalities. Methods This study used national cross sectional dataset from Utilization of Health Services survey in 2015. Concentration Index (C), Concentration Curve (CC) and Horizontal Inequity index (HI) were calculated to measure inequality in inpatient and outpatient health care utilization. Decomposition analysis was used to determine the contribution of need and non-need factors to the observed inequalities. Result Results showed the pro-poor inpatient services in both rural (C = − 0.079) and non-rural areas (C = − 0.096) and the pro-rich outpatient services in both rural (C = 0.038) and non-rural (C = 0.007). After controlling for need factors, HI was positive and significant for outpatient services in rural (HI = 0.039) and non-rural (HI = 0.008), indicating that for given need, the better off especially in rural make greater use of outpatient services. The HI was pro-poor for inpatient services in both rural (HI = − 0.068) and non-rural (HI = -0.090), was significant only in non-rural area. Non-need factors were the most important contributors to explain inequalities in the decomposition analysis. Conclusion Disentangle the different contribution of determinants, as well as greater HI in rural areas for outpatient and in non-rural areas for inpatient services, provide helpful information for decision makers to re-design policy and re-distribute resource allocation in order to reduce the socioeconomic gradient in health care utilization.
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Affiliation(s)
- Farideh Mostafavi
- Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Bakhtiar Piroozi
- Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Paola Mosquera
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Reza Majdzadeh
- School of Public Health and Institute of Public Health Research, Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghobad Moradi
- Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran. .,Department of Epidemiology and Biostatistics, Kurdistan University of Medical Sciences, Pasdaran Ave, Sanandaj, Iran.
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15
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Doshmangir L, Moshiri E, Farzadfar F. Seven Decades of Primary Healthcare during Various Development Plans in Iran: A Historical Review. ARCHIVES OF IRANIAN MEDICINE 2020; 23:338-352. [PMID: 32383619 DOI: 10.34172/aim.2020.24] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/26/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To explore historically primary healthcare (PHC) development in Iran in the light of development plans before and after the Islamic Revolution. The results of this study can be used to outline the future of PHC in the Iranian health system. METHODS We conducted a retrospective analysis of the PHC development in the Iranian health system using data from relevant published and unpublished policy documents. The literature was retrieved and reviewed on the basis of predetermined inclusion criteria with no language or date restriction. The data were integrated and analyzed using content analysis. RESULTS During various upstream development plans, the attitude of the policy makers to PHC has been very different, resulting in fundamental differences in addressing such an important issue and the consequent outcomes. In the aftermath of Iran's revolution, due to more understanding of PHC services importance and the principal slogans of the revolution to pay attention to villagers and vulnerable people, health policymakers paid more attention to PHC, which was not evident in previous periods. CONCLUSION Despite considerable achievements in PHC, the history of PHC in Iran indicates frequent changes in planning and health provision structure. This suggests that the challenges facing the health sector today, the evolving needs and demands of the people, and population changes necessitate reinforcement and reform in the structure of the current PHC network as the main mission of Iran's Ministry of Health.
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Affiliation(s)
- Leila Doshmangir
- Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran.,Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Esmaeil Moshiri
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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16
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Bazyar M, Rashidian A, Alipouri Sakha M, Vaez Mahdavi MR, Doshmangir L. Combining health insurance funds in a fragmented context: what kind of challenges should be considered? BMC Health Serv Res 2020; 20:26. [PMID: 31915003 PMCID: PMC6950996 DOI: 10.1186/s12913-019-4858-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 12/22/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Iran's Parliament passed a Law in 2010 to merge the existing health insurance schemes to boost risk pooling. Merging can be challenging as there are differences among health insurance schemes in various aspects. This qualitative prospective policy analysis aims to reveal key challenges and implementation barriers of the policy as introduced in Iran. METHODS A qualitative study of key informants and documentary review was conducted. Sixty-seven semi-structured face-to-face interviews were conducted, with key informants from relevant stakeholders. Purposive and snowball sampling techniques were used for selecting the interviewees. The related policy documents were also reviewed and analyzed to supplement interviews. Data analysis was conducted through an existing health financing World Bank framework. RESULTS This study demonstrated that for combining health insurance funds, operational challenges in the following areas should be taken into account: financing mechanisms, population coverage, benefits package, provider engagement, organizational structure, health service delivery and operational processes. It is also important to have adequate cogent reasons to "the justification of the consolidation process" in the given context. When moving towards combining health insurance funds, especially in countries with a purchaser-provider split, it is critical for policy makers to make sure that the health insurance system is aligned with the policies and Stewardship of the broader health care system. CONCLUSIONS Implementation of major reforms in a health system with fragmented insurance schemes with different target populations, prepayment structures, benefit packages and history of development is inherently difficult, especially when different stakeholders have vetoing powers over the proposed reforms. Solving the differences and operational challenges in the main areas of health insurance system generated in this study may provide a platform for the designing and implementing merging process of social health insurance schemes in Iran and other countries with similar situations.
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Affiliation(s)
- Mohammad Bazyar
- Department of Health Promotion, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Minoo Alipouri Sakha
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Leila Doshmangir
- Department of Health Policy and Management,Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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17
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Alinia C, Davoodi Lahijan J. Moving Toward Universal Health Coverage: Four Decades Of Experience From The Iranian Health System. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:651-657. [PMID: 31807038 PMCID: PMC6848985 DOI: 10.2147/ceor.s219802] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022] Open
Abstract
Universal health coverage (UHC) during the past decade has become the main goal of the World Health Organization. Access to health services, without suffering financial hardship for the patients, constitutes the key foundation definition of UHC and its three dimensions: population coverage, service coverage, and financial protection. Iranian health policymakers have purposefully or non-purposefully been pursued the UHC goals during the last four decades by the following macro plans: Health corps, establishing and expanding Health-Care Networks, Law of Universal Health and Social Security Insurances, Family Physician, and Health Transformation Plan. In this paper, we evaluated the situation of UHC in the Iranian health system, presented the weaknesses, strengths, and challenges faced with the health system in its implementation, and finally provided some policy recommendations to complete implementation of the policy in the country.
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Affiliation(s)
- Cyrus Alinia
- Department of Health Management and Economics, School of Public Health, Urmia University Of Medical Sciences, Urmia, Iran
| | - Jalal Davoodi Lahijan
- Department of Health Management and Economics, School of Public Health, Urmia University Of Medical Sciences, Urmia, Iran
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18
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Doshmangir L, Moshiri E, Mostafavi H, Sakha MA, Assan A. Policy analysis of the Iranian Health Transformation Plan in primary healthcare. BMC Health Serv Res 2019; 19:670. [PMID: 31533710 PMCID: PMC6751681 DOI: 10.1186/s12913-019-4505-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 08/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health systems reform is inevitable due to the never-ending changing nature of societal health needs and policy dynamism. Today, the Health Transformation Plan (HTP) remains the major tool to facilitate the achievements of universal health coverage (UHC) in Iran. It was initially implemented in hospital-based setting and later expanded to primary health care (PHC). This study aimed to analyze the HTP at the PHC level in Iran. METHODS Qualitative data were collected through document analysis, round-table discussion, and semi-structured interviews with stakeholders at the micro, meso and macro levels of the health system. A tailored version of Walt & Gilson's policy triangle model incorporating the stages heuristic model was used to guide data analysis. RESULTS The HTP emerged through a political process. Although the initiative aimed to facilitate the achievements of UHC by improving the entire health system of Iran, little attention was given to PHC especially during the first phases of policy development - a gap that occurred because politicians were in a great haste to fulfil a campaign promise. CONCLUSIONS Health reforms targeting UHC and the health-related Sustainable Development Goals require the political will to improve PHC through engagements of all stakeholders of the health system, plus improved fiscal capacity of the country and financial commitments to implement evidence-informed initiatives.
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Affiliation(s)
- Leila Doshmangir
- Social Determinants of Health Research Center, Iranian Center of Excellence in Health Management, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Health Services Management, Tabriz Health Services Management Research Centre, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Daneshgah St, Tabriz, 5165665811 Iran
| | - Esmaeil Moshiri
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Hakimeh Mostafavi
- Health Economy, Standard and Health Technology Office, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Minoo Alipouri Sakha
- Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Abraham Assan
- Global Policy and Advocacy Network (GLOOPLAN), Accra, Ghana
- Ghana College of Nurses and Midwives (GCNM), Accra, Ghana
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19
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Designing Interactional Pattern of Health Financing Between Ministry of Health and Social Health Insurances in Iran. HEALTH SCOPE 2019. [DOI: 10.5812/jhealthscope.84928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Rashidian A, Salavati S, Hajimahmoodi H, Kheirandish M. Does rural health system reform aimed at improving access to primary health care affect hospitalization rates? An interrupted time series analysis of national policy reforms in Iran. J Health Serv Res Policy 2019; 24:73-80. [PMID: 30638078 DOI: 10.1177/1355819618815721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the effects of rural health insurance and family physician reforms on hospitalization rates in Iran. METHODS An interrupted time series analysis of national monthly hospitalization rates in Iran (2003-2014), starting from two years before the intervention. Segmented regression analysis was used to assess the effects of the reforms on hospitalization rates. RESULTS The analyses showed that hospitalization rates increased one year after the initiation of the reforms: 1.55 (95% CI: 1.24-1.86) additional hospitalizations per 1000 rural inhabitants per month ('immediate effect'). This increase was followed by a further gradual increase of 0.034 per 1000 inhabitants per month (95% CI: 0.02-0.04). The gradual monthly increase continued for two years after the reforms. The higher hospitalization rates were maintained in the following years. We observed a significant increase in hospitalization rates at a national level in rural areas that continued for over 10 years after the policy implementation. CONCLUSION Primary health care reforms are often proposed for their efficiency outcomes (i.e. reduction in costs and use of hospitals) as well as their impact on improving health outcomes. We demonstrated that in populations with unmet needs, such reforms are likely to substantially increase hospitalization rates. This is an important consideration for successful design and implementation of interventions aimed at achieving universal health coverage in low- and middle-income countries.
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Affiliation(s)
- Arash Rashidian
- 1 Professor, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Science, Iran
| | - Sedigheh Salavati
- 2 PhD Candidate, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Science, Iran
| | - Hanan Hajimahmoodi
- 3 Physician, Director General of Family Physician Program, Iran Health Insurance Organization, Iran
| | - Mehrnaz Kheirandish
- 4 Director General of Assessment and Control of Prescribing and Use of Medicines and Health Products, Food and Drug administration, Iran
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21
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Zandian H, Takian A, Rashidian A, Bayati M, Zahirian Moghadam T, Rezaei S, Olyaeemanesh A. Effects of Iranian Economic Reforms on Equity in Social and Healthcare Financing: A Segmented Regression Analysis. J Prev Med Public Health 2018; 51:83-91. [PMID: 29631352 PMCID: PMC5897235 DOI: 10.3961/jpmph.17.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 01/15/2018] [Indexed: 11/09/2022] Open
Abstract
Objectives One of the main objectives of the Targeted Subsidies Law (TSL) in Iran was to improve equity in healthcare financing. This study aimed at measuring the effects of the TSL, which was implemented in Iran in 2010, on equity in healthcare financing. Methods Segmented regression analysis was applied to assess the effects of TSL implementation on the Gini and Kakwani indices of outcome variables in Iranian households. Data for the years 1977-2014 were retrieved from formal databases. Changes in the levels and trends of the outcome variables before and after TSL implementation were assessed using Stata version 13. Results In the 33 years before the implementation of the TSL, the Gini index decreased from 0.401 to 0.381. The Gini index and its intercept significantly decreased to 0.362 (p<0.001) 5 years after the implementation of the TSL. There was no statistically significant change in the gross domestic product or inflation rate after TSL implementation. The Kakwani index significantly increased from -0.020 to 0.007 (p<0.001) before the implementation of the TSL, while we observed no statistically significant change (p=0.81) in the Kakwani index after TSL implementation. Conclusions The TSL reform, which was introduced as part of an economic development plan in Iran in 2010, led to a significant reduction in households' income inequality. However, the TSL did not significantly affect equity in healthcare financing. Hence, while measuring the long-term impact of TSL is paramount, healthcare decision-makers need to consider the efficacy of the TSL in order to develop plans for achieving the desired equity in healthcare financing.
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Affiliation(s)
- Hamed Zandian
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Amirhossein Takian
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Arash Rashidian
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mohsen Bayati
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Telma Zahirian Moghadam
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Satar Rezaei
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Alireza Olyaeemanesh
- Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
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22
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Provider payment to primary care physicians in China: background, challenges, and a reform framework. Prim Health Care Res Dev 2018; 20:e34. [PMID: 29618391 PMCID: PMC6536753 DOI: 10.1017/s146342361800021x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To provide a framework for provider payment reform for primary care physicians in China. Background: Primary health care is central to health system reform and payment incentives have significant consequences for the equity and efficiency of it. Methods: This paper describes the special payments system for public primary health institutions and the subsequent internal salary remuneration to primary care physicians in China. Based on an analysis of the major challenges, we suggest a reform framework including the pattern of governance, and payments to primary health institutions and employed physicians. Findings: A mixed system of input-based and output-based payments to institutions would probably be appropriate under a long-term and relational contract with the government. It was also advised that internal remuneration is provided by a basic salary plus a bonus based on performance, and an extra-regional allowance. We hope that the results can be used to shift the passive budgeting of in-house staff within the public primary health institutions toward strategic purchasing.
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23
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Etemadi M, Gorji HA, Kangarani HM, Ashtarian K. Power structure among the actors of financial support to the poor to access health services: Social network analysis approach. Soc Sci Med 2017; 195:1-11. [PMID: 29096148 DOI: 10.1016/j.socscimed.2017.10.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/30/2022]
Abstract
The extent of universal health coverage in terms of financial protection is worrisome in Iran. There are challenges in health policies to guarantee financial accessibility to health services, especially for poor people. Various institutions offer support to ensure that the poor have financial access to health services. The aim of this study is to investigate the relationship network among the institutions active in this field. This study is a policy document analysis. It evaluates the country's legal documents in the field of financial support to the poor for healthcare after the Islamic Revolution in Iran. The researchers looked for the documents on the related websites and referred to the related organizations. The social network analysis approach was chosen for the analysis of the documents. Block-modelling and multi-dimensional scaling (MDS) was used to determine the network structures. The UCINET software was employed to analyse the data. Most the main actors of this network are chosen from the government budget. There is no legal communication and cooperation among some of the actors because of their improper position in the network. Seven blocks have been clustered by CONCOR in terms of the actor's degree of similarity. The social distance among the actors of the seven blocks is very short. Power distribution in the field of financial support to the poor has a fragmented structure; however, it is mainly run by a dominant block consisting of The Supreme Council of Welfare and Social Security, Health Insurance Organization, and the Ministry of Health and Medical Education. The financial support for the poor network involves multiple actors. This variety has created a series of confusions in terms of the type, level, and scope of responsibilities among the actors. The weak presence legislative and regulatory institutions and also non-governmental institutions are the main weak points of this network.
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Affiliation(s)
- Manal Etemadi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Abolghasem Gorji
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran; Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Hannaneh Mohammadi Kangarani
- Department of Agriculture and Natural Resources, University of Hormozgan, Bandar Abbas, Iran; Academic Member of Research Center for Environment and Sustainable Development, Tehran, Iran
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Doshmangir L, Rashidian A, Jafari M, Ravaghi H, Takian A. Fail to prepare and you can prepare to fail: the experience of financing path changes in teaching hospitals in Iran. BMC Health Serv Res 2016; 16:138. [PMID: 27102262 PMCID: PMC4841059 DOI: 10.1186/s12913-016-1405-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/18/2016] [Indexed: 11/21/2022] Open
Abstract
Background In 1995, teaching and public hospitals that are affiliated with the ministry of health and medical education (MOHME) in Iran were granted financial self-sufficiency to practice contract-based relations with insurance organizations. The so-called “hospital autonomy” policy involved giving authority to the insurance organizations to purchase health services. The policy aimed at improving hospitals’ performance, hoping to reduce government’s costs. However, the policy was never implemented as intended. This was because most participating hospitals gave up to implement autonomous financing and took other financing pathways. This paper analyses the reasons for the gap between the intended policy and its execution. The lessons learned from this analysis can inform, we envisage, the implementation of similar initiatives in other settings. Methods We conducted semi-structured interviews with 28 national and 13 regional health policy experts. We also gathered a comprehensive and purposeful set of related documents and analyzed their content. The qualitative data were analyzed by thematic inductive-deductive approach. Results We found a number of prerequisites and requirements that were not prepared prior to the implementing hospital autonomy policy and categorized them into policy content (sources of funds for the policy), implementation context (organization of insurance organizations, medical tariffs, hospitals’ organization, feasibility of policy implementation, actors and stakeholders’ support), and implementation approach (implementation method, blanket approach to the implementation and timing of implementation). These characteristics resulted in unsuitable platform for policy implementation and eventually led to policy failure. Conclusions Autonomy of teaching hospitals and their exclusive financing through insurance organizations did not achieve the desired goals of purchaser-provider split in Iran. Unless contextual preparations are in place, hospital autonomy will not succeed and problematic financial relations between service providers and patients in autonomous hospitals may not be ceased as a result.
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Affiliation(s)
- Leila Doshmangir
- Iranian Center of Excellence in Health Management, School of Health Services Management, Tabriz University of Medical Sciences, Tabriz, Iran.,Tabriz Health Management Research Center (NPMC), Tabriz University of Medical sciences, Tabriz, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Jafari
- School of Health Management and information Sciences, Iran University of Medical Sciences, Tehran, Iran.,Health Management and Economics Sciences Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Ravaghi
- Health Management and Economics Sciences Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Takian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Global Health & Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. .,College of Health & Life Sciences, Brunel University London, Uxbridge, UK.
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25
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Bazyar M, Rashidian A, Kane S, Vaez Mahdavi MR, Akbari Sari A, Doshmangir L. Policy Options to Reduce Fragmentation in the Pooling of Health Insurance Funds in Iran. Int J Health Policy Manag 2016; 5:253-8. [PMID: 27239868 DOI: 10.15171/ijhpm.2016.12] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 02/03/2016] [Indexed: 11/09/2022] Open
Abstract
There are fragmentations in Iran's health insurance system. Multiple health insurance funds exist, without adequate provisions for transfer or redistribution of cross subsidy among them. Multiple risk pools, including several private secondary insurance schemes, have resulted in a tiered health insurance system with inequitable benefit packages for different segments of the population. Also fragmentation might have contributed to inefficiency in the health insurance systems, a low financial protection against healthcare expenditures for the insured persons, high coinsurance rates, a notable rate of insurance coverage duplication, low contribution of well-funded institutes with generous benefit package to the public health insurance schemes, underfunding and severe financial shortages for the public funds, and a lack of transparency and reliable data and statistics for policy-making. We have conducted a policy analysis study, including qualitative interviews of key informants and document analysis. As a result we introduce three policy options: keeping the existing structural fragmentations of social health insurance (SHI)schemes but implementing a comprehensive "policy integration" strategy; consolidation of existing health insurance funds and creating a single national health insurance scheme; and reducing fragmentation by merging minor well-resourced funds together and creating two or three large insurance funds under the umbrella of the existing organizations. These policy options with their advantages and disadvantages are explained in the paper.
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Affiliation(s)
- Mohammad Bazyar
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Sumit Kane
- Department of Development Policy and Practice, Royal Tropical Institute, Amsterdam, The Netherlands
| | | | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Doshmangir
- Department of Health Services Management, School of Management and Medical Informatics, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran
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