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
