Classification and focus comparison of health financing frameworks: A scoping review

OBJECTIVE

The purpose of this study is to review the current frameworks for understanding and assessing health financing and draw out the dimensions of conceptual frameworks.

METHODS

This scoping review was conducted using the five stages of Arksey and O'Malley's framework. We reviewed all published peer-reviewed literature indexed in PubMed, SCOPUS, and Embase from 2000 up to 2021 for inclusion.

RESULTS

We identified 21 frameworks developed to assess financing in the health system. We classified frameworks by grouping them into: frameworks focusing on health financing as a constituent of health system and frameworks focusing on health financing only. We classified health financing frameworks further into three main groups according to the general commonalities among them. These three groups are as follows: (1) frameworks providing general recommendations for improving health financing system regardless of sources of financing, (2) frameworks focusing on improving the performance of health insurance schemes, and (3) frameworks focusing on managing public health financing.

CONCLUSION

Despite being diverse, various health financing frameworks offer synergistic views to the health financing system and provide a comprehensive picture of the health financing system. These frameworks can help policy makers decide which framework is more appropriate to start with based on their local contextual features and the changes they are going to bring about in their health financing system.

Physician Induced Demand: The Empirical Evidence of Angiography for Suspected Coronary Artery Disease

Background

We aimed to investigate the existence of unnecessary demand for angiography and the factors affecting it to provide evidence for decision makers.

Methods

This longitudinal panel study was conducted in public hospitals in Tehran, Iran by using 2458 patients' records that were undergoing angiography for suspected coronary artery disease 2013-2015. To modeling the physicians' behavior based on physician-induced demand (PID), the patients were classified as appropriate, uncertain, and inappropriate and then Hierarchical Linear Modeling (HLM) model besides the physician ethic index was developed and finally the existence of PID showed based on three scenarios.

Results

Angiographies were performed inappropriately in 23.8% of 2458 patients as well 46.7% were uncertain, and 29.5% were appropriate. According to the HLM model, the physician-to-population ratio (δ0= -0.161) and the interaction variable coefficient are higher than zero and significant (δ1 = 253). The results of the physician ethic index showed that most physicians were at a moderate rate, meaning that their utility was a combination of both pecuniary and non-pecuniary profits (0 < | ɛpδ |<1). Considering the HLM model and the medical ethics index together has almost shown the condition of PID (the necessary condition δ1> 0 and the sufficient condition (1 ≤ |ɛpδ|)) existed for about 26% of all studied physicians who had pure profit maximizer.

Conclusion

To reduce induced demand and improve medical ethics adherence in cardiologist, policy makers should develop native guidelines, rules, and instructions besides policies related to education, and increasing patients' awareness.

Criteria for the selection of complementary private health insurance: the experience of a large organisation in Iran

Background

Expenses related to employee’s health benefit packages are rising. Hence, organisations are looking for complementary health financing arrangements to provide more financial protection for employees. This study aims to develop criteria to choose the most appropriate complementary health insurance company based on the experience of a large organisation in Iran.

Methods

This study was conducted in 2021 in Iran, in the Foundation of Martyrs and Veterans Affairs to find as many applicable criteria as possible. To develop a comprehensive list of criteria, we used triangulation in data sources, including review of relevant national and international documents, in-depth interviews of key informants, focus group discussion, and examining similar but unpublished checklists used by other organisations in Iran. The list of criteria was prioritised during focus group discussions. We used the best-worst method as a multi-criteria decision making method and a qualitative consensus among the key informants to value the importance of each of the finalised criteria.

Findings

Out of 85 criteria, we selected 28 criteria to choose an insurer for implementing complementary private health insurance. The finalised criteria were fell into six domains: (i) Previous experience of the applicants; (ii) Communication with clients; (iii) Financial status; (iv) Health care providers’ network; (v) Technical infrastructure and workforce; (vi) and Process of reviewing claims and reimbursement.

Conclusion

We propose a quantitative decision-making checklist to choose the best complimentary private health insurance provider. We invite colleagues to utilise, adapt, modify, or develop these criteria to suit their organisational needs. This checklist can be applied in any low- and middle-income country where the industry of complementary health insurance is blooming.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08777-7.

Nursing work intention, stress, and professionalism in response to the COVID-19 outbreak in Iran: A cross-sectional study

BACKGROUND

Professionalism, stress and demographic factors are the three key influences in nurses' intention to provide care.

OBJECTIVES

This study examined the levels of work intention, stress and professionalism of nurses and determine the relationship between nursing work intention and factors in response to COVID-19.

METHODS

This cross-sectional study was conducted on 362 nurses from COVID-19-devoted hospitals in Iran. A self-administered electronic-based questionnaire was developed and used to determine levels of stress, professionalism, and nursing intention. Multiple regression analysis was carried out to analyze the correlation between nursing intention with respect to stress and professionalism.

RESULTS

The overall stress, professionalism, and nursing intention scores were 48.56, 21.46, and 17.83 respectively. There were significant differences in nursing intention scores between gender, marital status, and having training groups (p < 0.05). The regression analysis revealed that nursing intention had a significant relationship with older age (p < 0.001,S.E = 1.11,B = 17.02), higher income level (p < 0.001,S.E = 1.81,B = 6.98), having previous training (p = 0.008,S.E = 1.22,B = 3.27), higher stress level (p < 0.001,S.E = 2.37,B = -21.39), and high professionalism level (p < 0.001,S.E = 1.16,B = 11.99).

CONCLUSION

Having an adequate staff requirement plan, planning appropriate training for nurses, and proactive psychological support are crucial to prevent burnout and continue to provide nursing services.

Evaluating the health promoting schools in Iran: across-sectional study

Purpose

Health-promoting schools have been associated with improvements in the health status of students globally. This study is a secondary analysis study assessing Iranian HPSs.

Design/methodology/approach

This was a cross-sectional study on routinely collected data using an external audit 63-item checklist, which was utilized to evaluate 440 HPSs between 2014 and 2017. The mean score for each of the checklists' components was calculated. Nonparametric tests were conducted to investigate the association between the presence of a school caregiver, students' educational level and the school's score.

Findings

While the number of five- and four-star schools increased significantly, one- to three-star schools declined. Providing clinical and counseling services had negative growth. Despite the steady growth of the staff's health, this category still had the lowest score among; on the contrary, physical activity had the highest score in 2017. The presence of a full-time school caregiver and middle schools were both significantly correlated with achieving higher scores (p < 0.005).

Originality/value

It seems that in addition to developing school facilities to promote physical activities, measures should be taken to promote access to counseling services, considering health issues of students and staff and finally increasing the number of full-time school caregiver

Exploring the changes of physicians' behaviour toward informal payment based on Health Transformation Plan in Iran: A qualitative study

By implementation of the Health Transformation Plan (HTP), a revised tariff system for healthcare services was executed in Iran. This study explores the changes in physicians' behaviour in facing informal payment (IP) based on HTP implementation in Iran. We conducted in-depth semi-structured interviews with 15 purposefully selected physicians and policy makers to explore the changes (positive, negative and no) in physicians' behaviours with and without the implementation of HTP. The interviews were conducted individually and face to face. The conventional content analysis for data analysis by MAXQDA ver.10 was used. Based on the results, regardless of the HTP implemented, market competitiveness could control physicians' demand for IP. However, unreal tariffs, irregular payments, inflation, expensive healthcare and comparing income with other occupations increase physicians' demand for IP as negative behaviour. This study explored three patterns of physicians' behavioural change because of HTP implementation: 1-positive behavioural change with four factors; 2-negative behavioural changes with two factors; and 3-no behavioural change with four factors. Various factors influenced physicians' behaviour towards IP with and without the HTP. To combat IP more efficiently, we recommend strengthening the HTP's positive interventions, compensation of physicians' target income, enhancing supervision, reducing the gap among various medical specialities and taking a systematic approach with law offenders.

Correction to: Combining health insurance funds in a fragmented context: what kind of challenges should be considered?

In the original publication of this article [1], there are two corrections.

Combining health insurance funds in a fragmented context: what kind of challenges should be considered?

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.

Strategies to reduce informal payments in health systems: a systematic review

Background

Informal payment is a major barrier to universal health coverage, particularly in low and middle-income countries.

Aims

The aim of this study was to determine appropriate methods to reduce informal payments in health care via a systematic review.

Methods

For this systematic review, we searched the Cochrane Library, PubMed and SCOPUS covering the period 2000-2014: 10 papers which considered reduction strategies for IP were finally included in the review. Three of the authors independently extracted data and assessed the papers against inclusion and exclusion criteria.

Results

Improving public awareness and measures towards changing the culture were the main policies to combat informal payment. In addition, providing additional financial support to motivate physicians and other health service providers, appropriate monitoring of legislation, and converting informal to formal payment through tailored new policies were other solutions mentioned towards reducing or removing informal payments.

Conclusions

No unique strategy exists for reducing informal payments in any health system. Choosing an appropriate strategy depends on the context and financing structure of the health system in any particular setting.

Policy analysis of the Iranian Health Transformation Plan in primary healthcare

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.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4505-3) contains supplementary material, which is available to authorized users.

Effects of the Health Transformation Plan on caesarean section rate in the Islamic Republic of Iran: an interrupted time series

Background

In recent decades, the rate of caesarian section (C-section) has increased in the Islamic Republic of Iran. A reform in the Iranian health system - the Health Transformation Plan (HTP) - was launched in 2014 in which one of the objectives of HTP is decreasing the rate of C-section.

Aims

This study aimed to assess the effects of the Health Transformation Plan (HTP) on the C-section rate in the Islamic Republic of Iran.

Methods

This study was an interrupted time series analysis that used segmented regression analysis to assess the immediate and long-term effects of the HTP on C-section rate in two groups of hospitals affiliated and not affiliated to the Ministry of Health and Medical Education (MoHME) in Kurdistan province. Study samples were selected using the data on monthly C-section rate collected over a period of four years.

Results

We observed significant decreases in C-section rate immediately after the HTP in both groups of hospitals by 0.0629 and 0.0013, respectively (P < 0.05). In the long run, we observed no significant decrease in the regression slope of C-section rate in both groups.

Conclusions

The implementation of HTP decreased the C-section rate. However, the reduction does not meet expectations.

The impact of health transformation plan on hospitalization rates in Iran: An interrupted time series

OBJECTIVE

The study aims to assess the impact of health transformation plan (HTP) as a major health system reform on hospitalization rate in Iran. Health transformation plan adopted different measures to increase the coverage of basic health insurance, increase the quality of outpatient visit care, improve and expand the family physician program, expand health services to suburban areas, reduce out-of-pocket (OOP) payments for inpatient services, and update tariffs to more realistic ones.

METHODS

We selected Kurdistan province, a province that was not a patient referral hub, for the collection of monthly hospitalization data over a period of 50 months. Interrupted time series (ITS) analysis was carried out, and segmented regression analysis was employed to assess the abrupt (or short-term) and gradual (or long-term) effects of HTP on hospitalization rate.

RESULTS

Although before the intervention, there was no significant increase or decline in hospitalization rate in the Kurdistan province, after the implementation of HTP, a significant increase in the intercept and slope of hospitalization rate was observed (P < 0.001).

CONCLUSION

Health transformation plan has improved the utilization of hospitalization care services in a province that historically had been suffering from underutilized hospital services.

CHALLENGES AND SUCCESSES OF HARM REDUCTION SERVICES IN WOMEN'S DROP-IN CENTRES: PERSPECTIVE OF VULNERABLE WOMEN

BACKGROUND

The objective of this study was to shed light on the challenges and successes of HIV/AIDS services delivery as perceived by Sex workers.

METHODS

Face-to-face semi-structured interviews were conducted with 20 IDUs and Sex workers in drop-in centers in Shiraz. A thematic analysis of these qualitative data was conducted by the authors.

RESULTS

Participants identified major challenges and successes of HIV/AIDS services delivery. Access services, services delivery in terms of challenges and the successes concept were classified.

CONCLUSIONS

Our study demonstrates that while there is greater availability of HIV/AIDS services, this does not equate with greater accessibility because multiple, complex and interrelated barriers to HIV/AIDS service utilization at the service delivery level such as Stigma, discrimination, violence, harassment and social equity issues are critical concerns of FSW.