Applying ethical theories to the Iranian health system governance: a critical empirical assessment

The policies of health systems are inspired by ethical priorities. A critical review of policies can reveal the ethical theories/justice schools behind them. This study aimed to identify the ethical theory(ies) underpinning the Iranian health system governance over the past 50 years. This was a qualitative study conducted in two stages during 2019. First, we identified and constructed the key concepts and distinctive notions of prominent ethical theories/justice schools. Then, we spotted and selected 24 strategic laws and policy documents in the Iranian health system governance during the past 50 years and analyzed their content to surmise their underlying ethical theory. The results showed that the dominant theory affecting the policies of the Iranian health system governance over the past 50 years was egalitarian liberalism and then objective utilitarianism and relativist communitarianism. Retrospective empirical application of ethical theories to health system governance is methodologically doable, and this application reveals the mood or priorities of the politics. Also, highlighting the underpinning ethical theories of health system governance as well as the gap between ambitions versus realization are insightful and may prospectively empower and strengthen egalitarianism

Donors' Participation in Iran's Health System: Challenges and Solutions

Background: Philanthropic activities play an important role in health systems. Donors contribute to financing, generating resources, and providing healthcare services in Iranian health system. However, they face many challenges. This study aimed to identify barriers to donors' participation in the Iranian health system and to provide solutions. Methods: This qualitative study was performed using semi-structured interviews with 38 donors and 26 policymakers and managers in the social affairs department of health ministry and medical universities in 2018. In addition, document analysis was performed and the relevant data were extracted. Thematic analysis was used for data analysis. All ethical considerations were followed in this research. Results: Insufficient structures, poor communications, low trust, ineffective working processes, bureaucracy, insufficient senior managers’ support, weak legal support and poor monitoring were the most important challenges for donors’ participation in the Iranian health system. Effective donor participation in the health system requires the creation of an appropriate system including the right structures, processes, culture, and management. The necessary changes must be planned, led and monitored to promote donors’ participation in healthcare. A conceptual model was developed to strengthen donors’ participation in the health system. Conclusion: Iranian donors face structural, procedural, cultural, and managerial challenges when financing the health system, generating resources, and providing health services. Policymakers and managers should tackle these challenges and adopt strategies to reinforce donors' participation in the health system. Planning, organizing, leading, monitoring, evaluation, transparency, accountability, and a commitment to meet donors’ needs are necessary for successful philanthropy initiatives in the health sector.

Satisfaction Level with the Health Transformation Plan in Iran: A Systematic Review

Background: The Health Transformation Plan (HTP) had been one of the most significant recent reforms in the Iranian health system. Notwithstanding, it has strengths and weaknesses that should be assessed. One of the most important aspects of assessing programs is the people and the personnel's satisfaction. Consequently, this study has reviewed studies that have measured satisfaction with HTP. Methods: In this systematic review, databases of Web of Science, Scopus, PubMed, Google Scholar were searched until May 2019. The Ministry of Health website, and the National Institutes of Health Research website were also searched. All studies that evaluated HTP satisfaction were included. Data were collected and analyzed utilizing a data extraction form and reported by narrative review. Results: 20 studies were included that were conducted in the period 2014 to 2017. The overall results of the studies indicate that nurses and physicians have not been satisfied with HTP, while retaining physicians in disadvantaged regions and patients have been approximately satisfied with HTP. Only three before and after studies have been conducted, and the rest studies are related to after HTP. Two before and after studies concluded that patients and nurses 'satisfaction is decreased and one study concluded that mothers' satisfaction is increased. Nurses and physicians dissatisfaction was due to the causes such as increasing the number of clients, injustice in payments, unbalanced workload and salary and other working conditions. Conclusion: Influential, comprehensive, and national studies, including satisfactory before- and after-studies, are still not available to draw definite conclusions about public and employee satisfaction with HTP. It appears that despite the expensive cost of HTP and relative satisfaction of patients, the government did not meet all the demands of nurses and some physicians.

Identifying Economic Resistance Components in COVID-19 Pandemic: The Case of Iranian Health System

Background: As economic resistance is largely defined as the capacity of an economy to improve or adapt to the effects of unexpected, exterior shocks such as COVID-19 pandemic for health systems, the purpose of this study was to identify the economic resistance components of the Iranian health system during COVID-19 pandemic. Methods: This qualitative study was conducted using the content analysis method from 2020 to 2021. The statistical population of the study consisted of health system experts who are familiar with the subject of resistance economy. Using the snowball sampling method, semi-structured interviews with 30 selected participants were done. The reliability and transparency were determined by Guba and Linkon criteria such as credibility, transferability, confirmability, and consistency, or dependability. Data were analyzed using the Clarke and Braun thematic six-step method. Results: It was found that economic growth, economic stability, justice, and economic resilience, as four main components, affected the economic resistance of the health system in COVID-19 pandemic. Each of these components encompasses a number of sub-components that can help reinforce the health system in two restorative and resilient categories. Conclusions: To the best of our knowledge, a comprehensive study with an exploratory approach was not retrieved to find the main determinants of economic resistance components in COVID-19 pandemic. The present study can greatly contribute to the available knowledge to guide the policymakers for better understanding of the system during unexpected situations and applying the most applied solutions as well. It may help the health systems particularly those who encounter unpleasant macro-trends and unplanned crises, to keep their preparedness and readiness and improve their resilience.

Insecure Employment Contracts during the COVID-19 Pandemic and the Need for Participation in Policy Making

Job security influences the ability of nurses to provide high-quality nursing care. The Iranian health system has always faced nursing shortages, and the COVID-19 pandemic has worsened this situation. Although nurses have been labelled ‘heroes’ across the globe, many of them have been hired using insecure employment contracts. This commentary aims to describe issues surrounding job contracts for Iranian nurses during the COVID-19 pandemic and discusses how the current situation can be improved. Iranian nurses are at the frontline of the fight against COVID-19 and need to receive better support in terms of job security and dignity. They should participate more in policymaking activities to improve their job condition and prevent the development and implementation of the short-term and insecure job contracts that lead to job insecurity.

The Reasons for Informal Payments from the Perspective of Health Care Providers and Recipients: A Qualitative Study in Iran

Background: Informal payments are one of the major obstacles to health system reform in many developing countries, and its elimination is on the agenda of health system policymakers in many countries, including Iran. This study was conducted to identify the causes of informal payments in the Iranian health system.Methods: This was a qualitative and exploratory study. The study population included health care providers and health care recipients. Data were collected using open-ended questions and semi-structured interviews. Convenience and snowball sampling methods were used to select the providers. Content analysis method was used to analyze the data.Results: In the present study, 6 participants were physicians, 4 were hospital managers or CEOs, 4 were treatment or technical managers, 2 were nurses and 12 were patients or their companions. Reasons for informal payments divided in 4 themes include Economic factors, Socio-cultural factors, Service delivery challenges and Legal-political factors.Conclusions: In the Iranian health system, there is a great effort in order to reduce and eliminate the informal payments phenomenon, especially with the implementation of the health system transformation plan. Knowing the causes of this phenomenon can help reduce or eliminate it.

Fuzzy Analytical Hierarchy Process )AHP( of Good Governance Components for Health System Policy-Making in the Islamic Republic of Iran

Background: Good governance in the last two decades attracted the attention of scientific and international circles around the world. It is a type of governance that is committed to supporting and promoting human health. In order to achieve good governance, components have been identified that knowledge of the weight and importance of each component is undoubtedly necessary to achieve the desired results in the policy-making of the Iranian health system. Methods: This research is descriptive-survey in terms of goal setting and methodology. The multi-stage stratification and availability method was used for sampling and the theoretical saturation rule was used to determine the sample size. In order to define and explain the concept of components of good governance and health policy-making, the library method and review of reference sources were used. 100 survey managers and experts in the Ministry of Health and Golestan, Mazandaran and Neishabour Universities of Medical Sciences were interviewed using a survey method and using a checklist tool (researcher-made (pairwise comparisons)). To analyze the data, Chang's improved fuzzy AHP method and Expert choice software were used. Results: Among the components of good governance (for the policy-making process of the Iranian health system), the rule of law included the most important component. After the rule of law, consensus and agreement, transparency, accountability, justice and fairness, effectiveness and efficiency and ethics were in the next ranks. Conclusion: Good governance is a new narrative of concepts such as democracy, human rights and justice to pursue people-centered human development goals. The rankings obtained from the analyses of this research indicate the need to pay more attention to the rule of law in the health policy-making cycle. It is suggested that in designing the health sector of the seventh economic, social and cultural development plan, executive strategies are paid attention to strengthening the components of good governance, respectively.

Physician induced demand for knee replacement surgery in Iran

Background The structure of the Iranian health system has raised this hypothesis that a part of the Knee Replacement Surgery (KRS) services are provided due to Physician-Induced Demand (PID). Methods This paper used an unbalanced individual panel data covering the steady-state 15,729 KRSs performed by 995 surgeons provided by the Armed Forces Insurance Organization at the provincial level over the 60 months (2014–2018). We use a generalized method of moment’s system (GMM-SYS) to obtain consistent and asymptotically efficient estimates, which provide a vital instrument for our dynamic panel data. Results The outcomes show that with unequal increasing orthopedic surgeons to population ratio, both the number and size of KRS services were increased significantly at a 1 % level. Given that the positive elasticity obtained for the service size was significantly larger than the number of services, the findings give strong support for the existence of PID in the Iran system for KRS care. Also, the raw and population-adjusted number of KRS, cost, and the surgery per active physician increased significantly at the monthly province level. Conclusions This is the first time that the existence of PID in the Iranian health system is investigated using approved econometric models. The findings indicate that the health system structure has been provided the conditions for aggressive, costly, and high-risk services such as KRS to be exposed to PID.

A conceptual framework for socializing the Iranian health system

Background: Socializing the health system is a new approach to participatory governance that aims to promote community health and enhance sustainable health equity in the community. This approach is a part of health system reform in the Islamic Republic of Iran. Aims: This study aimed to develop a conceptual framework for socializing the health system in the Islamic Republic of Iran as a theoretical basis for this reform. Methods: Data were gathered through a review of the literature, in-depth interviews, focus group discussions, and panel discussions. Participants were experts in the field of health systems within the health ministry and medical universities. Content analysis was used to analyse the data and identify core values, principles, and approaches for socializing the health system. Results: The core values identified included human dignity, equity, ethics, and trust. The principles were participation, empowerment, human rights, and responsiveness. The approaches identified were good governance, a health-oriented focus, capacity-building, a process-oriented method, and improvement in the social determinants of health. A strong political will was considered essential for socializing the health system. Conclusions: The conceptual framework outlines requirements for socializing the Iranian health system. As this is a new approach in health system governance, however, it needs to be refined and redefined through implementation and evaluation.

Network governance theory as basic pattern for promoting financial support system of the poor in Iranian health system

Background The share of out-of-pocket payments in Iranian families has the greatest burden on the poor and lead to an impoverishment caused by catastrophic health expenditures. In order to improve access of the poor to public resources, it is necessary to create a better governance system and effective policy-making. The purpose of this study is to improve network effectiveness of the Iranian health system and to design a financial protection network for the poor, based on the network governance theory. Methods We are using a quantitative method framework in conjunction with a Social network analysis (SNA) strategy. To draw an optimal network, we conducted interviews with experts by focusing on the arrangement and relationship among different institutions. The research sample was purposefully selected. We used UCINET software for data analysis and NetDraw software to draw networks. Results In this article, an optimal network was proposed with the following characteristics: First, the problem of the density of relationships among several central institutions and the isolation of the other institutions have been solved. Second, in our model, the relationships have been distributed in a balanced manner among all institutions in the network. Third, the number of participants has been reduced and consensus on poor people support policies has been achieved in this optimal network. Forth, executive organizations keep their central positions and upper institutions are not at the central position, so that the power is distributed in favor of more balanced governance. However, in order to increase efficiency and to have coherent decision-making, it is necessary to establish a “core” for this optimal network. The “core” has to include the organizations with the most relationship with others. Conclusion The result revealed that the usefulness of network analysis as a tool for proposing the effectiveness of governance. By strengthening the relationship among the main actors, an organized system of network management can be achieved. The network has to include all actors from different levels, from policy-making to implementation. The network also has to clarify the tasks from identifying the poor to covering costs. From an academic perspective, this study showed the adequacy of network analysis as a tool for policy sciences. Governance in our optimal health financial protection model follows the shared-governance pattern due to its high density, low centralization and low distance. The model of network governance can be the source of changes in the health governance system. It is a necessary structural condition to provide access to universal health coverage.