The experience of implementing the board of trustees’ policy in teaching hospitals in Iran: an example of health system decentralization

Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy of teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in each hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor policy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as enhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were never realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of trustees’ policy did not achieve its perceived objectives. Methods: We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 and 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive and snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed verbatim and analyzed thematically, following a mixed inductive-deductive approach. Results: Three main themes emerged from the analysis. The implementation approach (including the processes, views about the policy and the links between the policy components), using research evidence about the policy (local and global), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity and actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization policies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration of the above factors in policy implementation into account. Conclusion: The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals in Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not prepared appropriately and key stakeholders, particularly the government, did not support the decentralization of Iran’s health system

Untangling the Complex Knot of Health Services Tariffs in Iran

The health services tariff system is a cornerstone of every nation's healthcare system, with direct implications for resource allocation, service quality, and public access to healthcare. With the enactment of the Universal Health Insurance Act in November 1994, efforts were made to establish a scientific, structural, and legal foundation for setting tariffs for diagnostic and therapeutic services. This initiative aimed to enhance efficiency and equity while increasing stakeholder satisfaction within the healthcare system. Since then, government oversight and interaction between service providers and consumers have determined health services tariffs (diagnostic and therapeutic services). However, the tariff-setting mechanisms and the resulting tariffs have consistently faced criticism from healthcare stakeholders. Evidence suggests that, despite 30 years of implementation, the Act has fallen short of achieving its legislative objectives. Both the supply and demand sides of healthcare services remain dissatisfied with the approved tariffs under this framework. Service providers, particularly in recent years, argue that the tariffs are unrealistic and fail to cover service costs. Concurrently, patients and insurers express dissatisfaction with the financial burdens imposed on them

Search Strategies and Information Search Tools Used by Pharmacy PhD Students: A Qualitative Study

Objectives: This study aimed to investigate search tools and strategies of PhD students to access required information. Methods: Semi-structured interviews with pharmacy Ph.D. students in Tabriz University of Medical Sciences were conducted. We used MaxQDA software to analyze the content of the interviews. Results: Scopus and Google Scholar were the most popular search tools used by participants. These databases were also recognized as the most common starting points for searches among participants. Participants’ search strategies were categorized into two themes (search tools and search strategies) and six subthemes which include: search start up tools, search tools used, reasons to use, keyword selection and modification, type of search and field searching. Conclusion: Google Scholar has become a serious alternative for specialized databases such as Web of Science, Pubmed and Scopus. The results of this study would be benefit for policy makers and information suppliers in academic settings

Determining factors in the retention of physicians in rural and underdeveloped areas : a systematic review

Background: Imbalance in distribution of Health Care Workers (HCWs) in a country is a global challenge. Almost all of the rural and underdeveloped areas are struggling with the shortage of HCWs, especially physicians. Therefore, this study aimed to identify factors governing the retention of physicians in rural and underdeveloped areas. Methods: International databases including Scopus, PubMed, Web of Science, Proquest, and Embase were searched using Mesh terms in order to find peer-reviewed journal articles addressing physicians’ retention factors in rural and underdeveloped areas. The records were screened, and any duplicate results were removed. The quality of the studies was assessed according to the Critical Appraisal Skills Program developed for different types of studies. Then, through content analysis, the related factors were identified from finally selected papers, coded, and categorized. Results: The initial search resulted in 2312 relevant articles. On the basis of specific selection criteria, 35 full-text articles were finally reviewed.. The major affecting factors in physicians’ retention in rural and underdeveloped regions were classified into the following six categories: 1) financial; 2) career and professional; 3) working conditions; 4) personal; 5) cultural; and 6) living conditions factors. Conclusion: There is a complex interplay of factors governing physicians’ retention in rural and underdeveloped areas. If health organizations are concerned with physicians’ retention in deprived areas, they should take into account these main factors. Moreover, they should develop policies and strategies to attract and retain physicians in rural and underdeveloped areas

Retaining clinicians in suburban areas:An experience from Iran's primary health care system reform

In June 2014, the first Health Complex was established in the suburban area of Tabriz, a northwest city of Iran. Health Complexes, as one of the decentralized models, have been formed based on universal health coverage principles. However, nearly two years after commencing work in the province, Health Complexes experience a high turnover of health care workers. This study aims to explore why primary health care workers set aside their roles in the health system and leave their jobs in opposition to the planned objectives. In this qualitative research, purposive and snowball sampling techniques were used for participants' selection. Data were collected through semistructured interviews and documentary review. Interviews were conducted with health officials, health care specialists, and other health workers who had left their jobs in Health Complexes in the suburban areas of Tabriz. Inductive and deductive content analysis was used to analyse data. The leading causes for health care workers leaving a job were divided into four main categories including organizational policies and regulations, financial and economic factors, sociocultural, and personal factors. Developing evidence-informed interventions and strategies to improve payment systems, provide job security and opportunities for professional development, and adopt cooperative leadership are essential to decrease the turnover rate of health care workers at Health Complexes

Exploring nationwide policy interventions to control <scp>COVID</scp> ‐19 from the perspective of the rapid learning health system approach

Abstract Introduction The health systems needed to improve their learning capacities during the COVID‐19 pandemic. Iran is one of the countries massively struck by the pandemic. This study aimed to explore whether and how the policy interventions made by Iran's policymakers at the national level to control COVID‐19, could improve the rapid learning characteristics of the health system. Methods A guide to clarify rapid learning health system (RLHS) characteristics was developed. The guide was used by two independent authors to select the policy interventions that could improve RLHS characteristics, then, to analyze the content of the selected policy interventions. In each stage, results were compared and discussed by all three authors. Final results were presented based on different RLHS characteristics and the potential mechanisms of contribution. Results Five hundred policy interventions were developed during the first 7 months of the outbreak. Thirty‐one policy interventions could potentially improve RLHS characteristics (6.2%). Two characteristics, such as the timely production of research evidence and the appropriate decision support were addressed by selected policy interventions. Policies, that could improve learning capacities, focused on decision‐maker groups more than user groups or researcher groups. Conclusions Most of the developed policy interventions during the first months of the epidemic did not address the learning capacities of the health system. To improve health system functions, improving RLHS characteristics of the health system, especially in patient‐centered and data linkage characteristics, is recommended

Strategies to strengthen non-governmental organizations' participation in the Iranian health system

Background: Non-governmental organizations (NGOs) added a new dimension to intersectoral action for health. Involving the NGOs in health system strengthening could lead to a more efficient, equitable, and better-governed healthcare system. This qualitative study explored effective strategies for NGO participation in the Iranian health system to achieve broader health system goals. Method: We conducted 33 semi-structured interviews with health policymakers and planners, NGO actors at the national and provincial levels, and other key informants. The qualitative data were analyzed through a thematic analysis approach. Trustworthiness in the study was observed at all stages of the study. Result: Four main themes- were identified: empowerment for learning leadership and management skills, creating active participation in policy-making, capacity building for participation, clarifying participation process, falling into 17 sub-themes. Along with the government and health sector policymakers, NGOs may have a significant role in improving health system goals and increasing equity, social responsiveness, financial risk protection, and efficiency. Conclusion: The participation of NGOs in the Iranian health system is a complex process. All elements and dimensions of this process need to be considered when developing a platform for the appropriate participation of NGOs in the health system functions. Evidence-informed strategies for strengthening the participation of NGOs in the health system should be used to utilize NGOs potential to the fullest

Primary health care reforms: a scoping review.

BACKGROUND: Demographic transitions, societal changes, and evolving population health needs are placing increasing pressure on healthcare systems, necessitating ongoing reforms. Primary health care (PHC) is a foundational component of Universal Health Coverage (UHC) and sustainable health systems. Many countries have undertaken PHC reforms aimed at improving population health. This review explores the objectives, implementation mechanisms, challenges, and outcomes of these reforms. METHODS: We conducted a systematic review of studies sourced from five databases (PubMed, Scopus, Proquest, Embase, and Science Direct), applying the World Health Organization's Health Systems Framework for deductive content analysis. The PRISMA guidelines were followed to ensure transparency and rigour in summarizing the published literature. RESULTS: A total of 147 types of interventions were identified, with most targeting service delivery and financing. Key reform objectives included expanding access to care, improving financing and payment systems, scaling up family physician programmes, increasing government health expenditure, leveraging private sector capacities, and strengthening the PHC workforce. These interventions resulted in expanded public health coverage, enhanced access to PHC, increased utilization of services among low-income populations, broader social insurance coverage, and improved service quality, contributing to better community health outcomes. CONCLUSION: The success of PHC reforms depends on their alignment with political, social, and cultural contexts, as well as consideration of the social determinants of health. Strong governmental support, managerial stability, decentralization, and regional capacity building are essential for sustainable implementation. Reforms should be gradual, supported by accurate forecasting, adequate and sustainable resources, and evidence-based strategies, drawing on international experiences

Analysis of Iranian health workforce emigration based on a system dynamics approach: a study protocol.

Background: Emigration of health workers has emerged as a significant obstacle in Iran, compelling policymakers to implement a diverse range of interventions and reforms to enhance healthcare services. It is imperative to comprehend the efficacy of emigration control interventions. To explore the intricate dynamics of elite emigration, this study employs a system dynamics modeling approach. The objective is to scrutinize Iranian health workers' emigration, examine the relationships, and evaluate the impact of various factors involved. Objectives: The general purpose of this study is to analyze the policy interventions affecting the emigration of human resources in the field of health in Iran based on the system's dynamic approach. Method: The research consists of four phases including analyzing the emigration status of health workers in developing countries, studying health personnel emigration in Iran, developing a System Dynamics (SD) model, and determining evidence-based policy interventions to address health worker emigration. These phases involve realist review, document analysis, qualitative interviews, data integration, and policy scenario planning. The primary objective is to gain a profound understanding of the underlying causes, mechanisms, and consequences of migration, as well as assess the impact of policies, in order to prioritize effective interventions. Results: It seems that the SD model developed in this study can highlight the interconnectedness of various factors that influence health worker emigration, including demographic changes, economic conditions, and characteristics of healthcare systems. Conclusion: This study uses a systems dynamics approach to analyze health worker emigration from Iran, focusing on policies that promote retention and explore the implications of emigration on the healthcare system. By examining interrelationships and feedback loops within the healthcare system and socioeconomic factors, the study aims to identify effective policy interventions that can mitigate the negative effects of emigration