Introduction
In 2019, 74% of all deaths and 63.8% of disability-adjusted life years (DALY) had occurred due to NCDs [
1]. According to the World Health Organization (WHO), such diseases take the lives of 15 million individuals aged 30-69 each year, with more than 80% of premature death happening in developing and low-income countries [
2]. As a middle-income nation, Iran, recorded 83.5% of mortalities and 78.1% of the total disease burden in 2019 that were related to NCDs [
1,
3,
4]. Accordingly, coronary artery disease, low back pain, road traffic crashes, major depressive disorder, and stroke had the highest burdens in Iran in 2010. This trend was not similar to the pattern of NCDs in developing countries but that in developed nations [
5,
6]. Given the rising prevalence rates of such diseases worldwide and as a priority for sustainable development in 2018-2030 (according to the Non-Communicable Diseases Roadmap (3rd Meeting)), all countries were required to reduce NCDs caused premature death rates by up to 25% until 2025 based on nine voluntary global targets and recommended interventions [
5,
7‐
9].
To successfully realize such targets in Iran, several measures, including the Development of National Documents on the Prevention and Control of Non-Communicable Diseases, the establishment of the National Committee for the Prevention and Control of Non-Communicable Diseases, the formulation of the National Action Plan for NCDs 2015-2020, and the implementation of the WHO Essential Intervention Package (IraPEN) in the field of primary healthcare (PHC) have been considered. Recent research on the implementation of the WHO policies in 151 countries also shows that Iran and Costa Rica have obtained the highest scores (86.1%) with a mean value of 49.3 [
10]. Similarly, in early 2017, the WHO officially declared Iran as a fast-track country in preventing and controlling NCDs. In October 2017, Iran was further applauded in the WHO Non-Communicable Diseases Conference in Uruguay for its success in fighting against NCDs [
11]. Likewise, in September 2018, at the UN Summit in New York in the United States, Iran was acknowledged for its outstanding contribution to preventing and controlling chronic diseases and mental illnesses related to the Sustainable Development Goals [
11].
Nevertheless, studies demonstrate that most countries have faced challenges in implementing the WHO policies and recommendations so far. For example, the results of one study in seven Asian countries in 2018 revealed that the most important obstacles to the implementation of the WHO policies were insufficient budgets, limited organizational capacities, poor sectoral coordination, and lack of formal monitoring and evaluation activities [
12]. Despite many achievements in the prevention and control of NCDs in Iran, such conditions are still the most significant challenges that Iran's healthcare system faces. Accordingly, problems facing the healthcare services' rationing and referral systems, lack of finance, defects in health information management (HIM), and the use of private sector capacity and effective inter-sectoral collaboration are among the dozens of other challenges hindering the process of combating NCDs. To identify and eliminate such challenges interfering with the implementation of the relevant policies, empowering the dimensions of governance, and effective and timely responsiveness by Iran's healthcare system to NCDs, this study was conducted based on a qualitative approach and conventional content analysis method. The study design of most previous NCDs-related studies have been quantitative and review, and most had investigated the analysis of policies to risk factors of NCDs in Iran, but fewer cases had examined challenges facing the programs for the prevention and control of non-communicable diseases [
4,
13‐
19]. We used qualitative research to evaluate and report the complexity and the hidden aspects of the challenges, which this was not feasible with quantitative approaches [
20]. More specifically, in this study, the viewpoints of managers, policy-makers, and experts involved in programs for the prevention and control of NCDs were evaluated, and gave us deep and comprehensive information about the challenges facing the programs for the prevention and control of non-communicable diseases, thereby increasing our understanding of these challenges.
Discussion
This study aimed to explore the challenges interfering with the implementation of the program for the prevention and control of NCDs in Iran from the viewpoints of senior managers. The challenges from the viewpoints of senior managers who are involved in the healthcare system were placed into six main categories: financing, human resources, infrastructure and inputs, legal, executive, administrative, inter-sectoral collaboration, and management and policy-making challenges with their own sub-categories. The present study results revealed that one of the important challenges in achieving the program's goals for the prevention and control of NCDs and obtaining effective results was financing, which included the lack of sustainability of financial resources and insufficient allocations of specialized budgets for NCDs. Of note, financing was not merely possible through government resources, and at a time that was not long from now, the planned programs would be suspended due to the depletion of the necessary credits and budgets, especially in combating NCDs. Obviously, one of the reasons for the lack of financial resources and instability could be the lack of transparency in financing. In this sense, the lack of concentrated financial resources and health expenditures in a specific position, the dispersion of available resources, variation in costs, and uncertainties about the levels of participation by the public and private sectors, households, and charities could further undermine the sustainability of financial resources [
26,
27]. In line with our findings, funding stability problems on the program for the prevention and control of NCDs is a common challenge described in previous studies [
28‐
32]. The insufficient allocations of budgets for NCDs were novel findings in the study that have not been studied in Iran [
3,
4,
6,
11,
33,
34]. Major problems such as low per capita allocated to healthcare services, unfair distribution of credits at the national level, and the priority of treatment budgets over the budgets on prevention and PHC (because the latter lack in rapid financial returns) had always been addressed among the permanent challenges [
35]. However, in order to implement general health policies for a low per capita allocated to healthcare services, the share of health in the gross domestic product had increased to 7.6% as well as 22.6% of the general government budget in 2015, which was higher in comparison to other neighbor countries with the same ranking [
36]. However, the problem was that among the deputies and at the smaller scale, i.e., healthcare programs, the rational distribution of budgets had not been performed with the allocation efficiency, and the credits were not commensurate with the burden of diseases, their prevalence rates, and risk factors.
The findings of numerous studies have further revealed that this issue was not restricted to Iran, and the distribution of budgets for the prevention and control of NCDs had been even disregarded in the international scene. For example, according to the global statistics released between 2000 and 2015, only 1.3% of development aids had been allocated to NCDs despite the fact that such conditions accounted for 50% of the total disease burden in low- and middle-income nations [
12]. The study of the implementation of the WHO interventions in seven Asian countries had also indicated that one of the most important obstacles to the implementation of the associated policies was insufficient budgets. Thus, the only way out of financial constraints and instability was to create innovative resources, including earmarked taxes, taxes on goods harmful to health, financial transparency in order to generate accurate information about revenue and spending, equitable access to this information for all stakeholders, and ultimately preventing these resources from being consumed on expenditures other than those in healthcare programs [
12].
Another category obtained from participants' views was the human resources, which consisted of improper distribution and shortage, insufficient knowledge and skills, and the lack of motivation of human resource. Unfortunately, in Iran, the education system is not consistent with the needs of the healthcare sector, especially for combating NCDs. Despite the presence of various educational platforms and facilities, including universities and research institutes of medical sciences, specialized scientific associations, and various journals and databases, the scientific strength of healthcare workers has been evaluated as weak. More specifically, in rural areas, the priority in recruiting PHC workers is with local individuals and applicants. This strategy results in hiring workforces with low educational levels, insufficient training, and low skills who can not meet the current needs of different populations [
37,
38]. On the other hand, rehiring retired workforce and those with very long service records was a new finding in the study. Naturally, elderly and retired employees do not have the necessary efficiency because of out-of-date knowledge and training, which are not consistent with the actual conditions of society. They would hinder the dynamism and progress of such programs, questioning the benefits of multidisciplinary healthcare teams [
39]. Basic measures such as revising educational curricula with the participation of the deputy of health at the ministry and university levels, the use of multidisciplinary technical teams, giving sufficient authority to healthcare managers to select the required personnel based on meritocracy, and preventing the interferences of other units ,and offering job enrichment programs are thus required [
39,
40]. Previous studies have further shown that inefficiencies in knowlegde to diagnose and treat chronic diseases and the lack of skills to meet the new needs of patients could also prevent the healthcare system from handling such problems [
41]. For example, in Mozambique, despite the adequacy and supply of insulin, the conditions of diabetic patients were not improved due to inadequate training of personnel and their lack of necessary skills [
42]. In addition, the current personnel face problems with these issues in terms of motivation and job satisfaction. The prevention, care, and management of chronic conditions and NCDs put a heavy workload on the shoulders of these individuals. This occurs when a wide variety of programs issued by the MoHME and the medical sciences universities are announced more frequently without clear priority and coordination. Consequently, each program would require a series of particular actions and interventions, specialized activities and documentation, and statistical activities that would increase the workload of the workforce and, as a result, cause motivational problems. Mannava [
43] examined detection of oral precancerous lesions and indicated that lack of incentives, specifically the lack of the delineation of targets, and the absence of official orders mandating detection of lesions caused motivational problems [
43]. These findings are consistent with the results of studies from Bangladesh [
44‐
47] and Vietnam [
48].
Another category obtained from data was infrastructure, which consisted of inconsistency between programs and infrastructure and capacity of medical sciences universities, shortcomings in the HIM system, weaknesses in evaluations, and lack of a comprehensive evaluation system.
Of note, the implementation of all programs in any field requires a series of platforms and infrastructure that are needed as inputs to provide services. The findings of Rawal and those of our study indicate that there was no suitable infrastructure for implementing the program for the prevention and control of NCDs [
47]. Several key challenges were identified, including inadequate logistics, supplies and medications, inefficient referral mechanisms, and unavailability of systematic recording and reporting systems. These findings are in line with the results of studies from Bangladesh [
44‐
47],Vietnam [
48], and Mumbai [
49]. In the field of HIM, the designed system did not comply with the priorities of the PHC one, and the requirements for the use of the system were not available. There was also no integrated information system in practice, and the existing system could not provide the necessary information for decision-making. On the other hand, there was no assurance of the accuracy of statistics and outputs, and the personnel did not have the essential skills and capabilities to utilize them and even work with existing systems. Structural platforms and equipment for information and communication technology without increasing the ability of personnel to use them may impose high costs on the healthcare system and do not yield favorable outputs. Studies in developing countries have also indicated unavailability of information and data, insufficient investments in HIM systems, the inappropriateness of indicators related to chronic diseases, ambiguous data conversion and management methods, lack of information distribution and their use for comprehensive planning for such diseases as the main challenges of the healthcare systems [
50,
51]. Studies have also found that upgrading standards through retraining, job assistance, and electronic health systems for rapid and easy retrieval of information could effectively advance the program for the prevention and control of NCDs [
51]. Other studies have further shown that statistical systems have not evolved in line with information technologies, and they were still being traditionally employed to record, analyze, and report data [
40].
Another category was administrative, executive, and legal problems, which included non-allocation of organizational positions and administrative charts for personnel involved in the program, inadequacy of salaries and benefits with the volume of program activities, and lack of transparency in job descriptions at different units and deputies in relation to the program.
Non-allocation of organizational positions and administrative charts for personnel involved in the program was a new finding in the study. Despite the achievements in the field of PHC, organizational structures and contexts have failed to fully fit the program for the prevention and control of such diseases. Factors such as the vagueness of financial resources for dealing with NCDs, insufficient credits, the lack of authority to pay the personnel from existing funds, and lack of transparency in obtaining recruitment licenses and organizational charts could thus play important roles in the non-allocation of organizational positions and administrative charts [
52]. As mentioned in the human resource category, all these factors would reduce healthcare workers' motivation and job satisfaction. In some cases, their desire to work in the healthcare sector decrease, and they may ask to move to other units. Thus, it is necessary to review the organizational charts in accordance with the needs of the community and the action plan for the prevention and control of NCDs, and even give authority to local and regional managers to organize, review, and move the personnel in the charts with regard to supervision mechanisms from higher levels. One of the other challenges was the incompatibility of salaries and benefits with the tasks performed, which was especially of utmost importance among the permanent and contractual workforce. Lack of organizational positions and transparency in job classification and descriptions could further lead to paying improper salaries and benefits to some healthcare workers, which are significantly lower from their permanent counterparts. As a result, it discourages the personnel from improving their performance and providing high-quality, safe services. Our results in this concern are in concordance with the findings of Rawal [
44].
According to the inter-sectoral collaboration category, the challenges consist of weaknesses in the understanding of program policies and objectives by units, organizations, and other bodies, weaknesses in the skills related to seeking the support of experts and managers in terms of attracting intersectoral collaboration and the lack of the transparency with respect to the role of NGOs, charities, and volunteer groups. Inter-sectoral collaboration on the program for the prevention and control of NCDs is the main subject described by Russell [
29], Samb [
27], Tuangratananon [
12], Vali [
13], and Mannava [
43]. In this respect, the evaluation study by the Supreme Council of Health and Food Security found that a significant part of the inter-sectoral approvals had not been operationalized [
33,
53]. A review of the approvals of the specialized working groups in the Supreme Council of Health and Food Security in Iran's provinces had also demonstrated that such approvals in the field of NCDs were negligible, and the weaknesses in inter-sectoral collaboration had been further mentioned [
54,
55]. The lack of motivation in managers and experts due to weak and incomplete infrastructure and the lack of clear visions and comprehensive plans regarding the duties and roles of other bodies and institutions affiliated with healthcare had also induced the ambiguous expectations of the healthcare sector from other agencies. The other side of the issue for the lack of success was associated with the lack of appreciation for the cooperation of other organizations and agencies by the MoHME and the healthcare sector. In this way, the activities of partner organizations in advancing the goals of most programs were ignored, and success and progress were merely attributed to the MoHME and the medical sciences universities alone. In one study, the subtle point of the collaboration between the MoHME and other agencies had been further underscored. In this way, the MoHME could have a share in the social components affecting health, but the question was whether the given ministry was aware of its share and role and had a written plan for them or not. Moreover, the think win-win from the MoHME and other agencies and institutions could be a key element in advancing healthcare goals [
56]. It was also necessary to determine the share of inter-sectoral collaboration in all programs issued by the MoHME, empower managers and experts of the healthcare system at all senior and executive levels to the lowest ones, monitor and evaluate joint programs, and provide accurate executive instructions and procedures. In the field of inter-sectoral collaboration, the capacities of NGOs, particularly charities and public participation, should be considered, but as indicated by participants, there were fundamental weaknesses in this regard. According to the findings of Gholamzadeh [
57] charities could also have the potential capacity to provide such services in all three areas of prevention, treatment, and rehabilitation because these institutions have the deepest and closest relationships with the members of society, above all the deprived ones. The government could thus easily implement the capacity of charities to produce, disseminate, and increase public awareness regarding NCDs, conduct health-related research and use the results of such studies, finance healthcare services, and change social attitudes toward NCDs [
51,
57].
Another challenge was concerned with the management and policy-making, including insufficient support of national and regional policy-makers and lack of understanding of the associated policies, individual-dependent programs, and weaknesses in evidence-based decision-making and policy-making system. Accordingly, improper expectations of some representatives and officials, political tendencies, lack of prioritization of PHC and advancements in the field of treatment, the declaration of many programs and plans without any coordination and prioritization, and as a result, the busy times of university presidents and deputies have reduced attention and supervision to the program for the prevention and control of NCDs [
35,
40].
In the research by Amerzadeh political support and commitment were identified as factors affecting the prevention and control of NCDs [
11]. Also, another issue presented as a challenge to implementing the program for the prevention and control of NCDs was the dependence of plans on individuals. Due to the lack of clear visions and comprehensive plans regarding the duties and roles of other bodies and institutions associated with the program for the prevention and control of NCDs, with the relocations of managers, especially those at the senior levels, other executive and expert levels could also be affected, and political support for programs might be even shrouded in series of ambiguities. Another problem was the weaknesses in evidence-based decisions. Factors such as the lack of comprehensive systems to the documentation of studies and evidence, absence of the understanding of the importance of policy-making, insufficient cognition about the programs and the current situation, unclear research priorities in the healthcare system, unawareness of policy-makers and planners regarding studies and evidence provided for this purpose in creating the given problem were also discussed [
58].
Conclusion
Unfortunately, the traditional system of PHC, which is mainly concentrated in rural areas, is incapable of providing complex, integrated, multi-sectoral, and continuous measures and interventions required for chronic conditions and NCDs. Such diseases demand a multifaceted response from the healthcare systems that must be accompanied by a structure of constant and sustainable healthcare, evidence-based interventions, effective public policies to address key risk factors, health professionals with diverse skills, appropriate technologies, reliable HIM systems, and available and secure health facilities in a stable and continuous manner. These interventions would be only possible with active healthcare systems that provide education and disease prevention services alongside integrated care and inter-sectoral collaboration beyond the healthcare sector.
Our results suggest that lack of financial resources were the most significant challenge interfering with the successful implementation of the program for the prevention and control of NCDs, but strengthening the healthcare system in the field of prevention of such diseases demanded more innovative measures and methods, such as coordinated efforts in various clinical, political, social areas with designated leadership, the use of feedback loops, the involvement of the public and physicians as partners for change, commitment to the requirements and goals of the program, and focus on the value of interdisciplinary and inter-organizational relationships with no need for financing.
Limitation and strengths
This study's findings should be trusted despite some limitations. One of the main limitations was the widespread prevalence of COVID-19, which prevented some top managers from participating in the in-person interviews due to their busy schedules and adherence to health protocols. Therefore, the interviews were conducted via phone calls. Despite these limitations, our study is the first one to explore challenges facing implementing the program for the prevention and control of NCDs in Iran from the viewpoints of senior managers with a qualitative approach. It provides valuable information for health professionals, policy-makers, and government officials to empower the dimensions of governance, cope with some risk factors, and be responsive in an effective and timely manner to NCDs.
Recommendations for future studies
It is suggested that future research explore challenges facing implementing the program for the prevention and control of NCDs in Iran from the middle level or operative managers' viewpoints. It is also suggested that quantitative studies be conducted to better understand other challenges and plan and take actions to improve them.