Background
-
a) Patients can receive higher quality health care from specialized supra-regional or international health centers in the context of health tourism. (b) Patients can visit medical centers when they are abroad for other reasons c) Neighboring regions or provinces may have more advanced facilities. (d) due to lack of access to specialized care such as lack of specialist doctors and lack of advanced medical equipment [12].
Methods
Study design
Data collection
Variable
|
Definition and explanation
|
Data Source
| |
---|---|---|---|
Dependent variable | Intra-provincial patient mobility rate | The number of patients who left their cities to receive curative services in hospitals in other cities in the province [21] Intra-provincial patient mobility index is calculated as follows:
\(\frac{\mathrm{total}\;\mathrm{number}\;\mathrm{of}\;\mathrm{patients}\;\mathrm{moving}\;\mathrm{within}\;\mathrm{the}\;\mathrm{province}}{\mathrm{total}\;\mathrm{number}\;\mathrm{of}\;\mathrm{hospitalized}\;\mathrm{patients}\;\mathrm{in}\;\mathrm{the}\;\mathrm{province}}\) | Survey using HIS data of governmental hospitals in 349 cities in Iran |
Independent variables | Distribution of hospital beds | The number of hospital beds in each city Hospital beds in this study included all inpatient beds used for acute patients in governmental hospitals but did not include long-term care beds | A survey using the NEDA platforma was filled in all medical universities across the country |
Distribution of specialist physicians | The number of specialist physicians in each city A specialist physician is a medical school graduate who has completed advanced training in a specific field of medicine [22] | ||
Coefficient of variation of health resources (CV) | The coefficient of variation of health resources indicates the degree of dispersion of resources around the mean. A higher coefficient of variation percentage indicates a greater maldistribution of resources in the country [23]. The index is calculated as follows:
\(\frac{\mathrm{Standard}\;\mathrm{deviation}}{\mathrm{The}\;\mathrm{average}\;\mathrm{annual}\;\mathrm{number}\;\mathrm{of}\;\mathrm{resources}}\)
| ||
Population density | The number of inhabitants per square kilometer which is calculated by dividing the population by the area of the province [24] | Country Statistics Organization and statistical reports | |
Total health expenditure (THE) | Total health expenditures include all health sector expenditures, including costs of treatment, health, prevention, allied health, pharmaceutics, equipment, administration, infrastructure investment, health education, and research. THE is calculated as follows:
\(\frac{\mathrm{The}\;\mathrm{absolute}\;\mathrm{value}\;\mathrm{of}\;\mathrm{the}\;\mathrm{total}\;\mathrm{health}\;\mathrm{expenditure}}{\mathrm{Population}\;\mathrm{of}\;\mathrm{each}\;\mathrm{province}}\)
| Total health expenditures and the share of out-of-pocket payments in Iranian provinces [25] | |
Human development index (HDI) | Human development index is a composite indicator that shows the impact of economic strategies on human living standards. HDI is calculated by three main factors of income, education, and health [26] | Provincial Human Development Index, a Guide for Efficiency Level Analysis: The Case of Iran [26] | |
Under-five mortality rate (U5MR) | Child mortality indices are principal indicators of population health and well-being. Under-five mortality is defined as the probability of a child born in a given year dying before reaching their fifth birthday and is expressed per 1000 live births [27] | Measuring Iran’s success in achieving Millennium Development Goals 4: a systematic analysis of under-5 mortality at national and subnational levels from 1990 to 2015 [28] |
Data analysis
-
PM: patient mobility
-
HB: number of hospital beds
-
Sp: number of specialist physicians
-
HDI: human development index
-
THE: total health expenditure
-
PD: population density
-
U5MR: under-five mortality rate
-
PM: patient mobility
-
HBCV: coefficient of variation of hospital beds
-
NCV: coefficient of variation of nurses
-
SPCV: coefficient of variation of specialist physicians
Results
Descriptive findings
Geographical area
|
Province
|
Population
|
Number of inpatients (August 2017)
|
Number of intra-provincial immigrant patients
|
Share of the capital city of the province
|
Percentage of intra-provincial migration
|
Percentage of migration to the capital city of the province
|
Patient mobility rate
|
---|---|---|---|---|---|---|---|---|
North
| Mazandaran | 3,171,946 | 23,261 | 3,257 | 1,861 | 14% | 8% | 23% |
Gilan | 2,533,407 | 17,312 | 3,462 | 1,904 | 20% | 11% | 20% | |
Golestan | 1,896,278 | 12,168 | 2,190 | 243 | 18% | 2% | 19% | |
East Azarbaijan | 3,920,544 | 29,404 | 4,705 | 0 | 16% | 0% | 15% | |
Ardabil | 1,309,768 | 8,295 | 498 | 498 | 6% | 6% | 6% | |
North Khorasan | 927,448 | 6,338 | 824 | 444 | 13% | 7% | 13% | |
West
| Kohgiloyeh and Boyerahmad | 681,147 | 4,257 | 85 | 85 | 2% | 2% | 4% |
West Azerbaijan | 3,267,165 | 22,870 | 915 | 229 | 4% | 1% | 4% | |
Kermanshah | 2,036,042 | 15,440 | 1,235 | 618 | 8% | 4% | 8% | |
Kurdistan | 1,574,757 | 9,842 | 1,083 | 787 | 11% | 8% | 11% | |
Hamedan | 1,836,489 | 12,855 | 2,185 | 2,185 | 17% | 17% | 17% | |
Ilam | 569,147 | 3,557 | 391 | 391 | 11% | 11% | 11% | |
Khuzestan | 4,843,427 | 38,344 | 4,985 | 4,218 | 13% | 11% | 12% | |
Lorestan | 1,791,285 | 11,793 | 2,359 | 1,887 | 20% | 16% | 20% | |
Zanjan | 1,071,071 | 8,479 | 509 | 170 | 6% | 2% | 6% | |
South
| Fars | 4,823,378 | 37,783 | 3,023 | 1,133 | 8% | 3% | 8% |
Hormozgan | 1,710,608 | 11,832 | 710 | 355 | 6% | 3% | 6% | |
Bushehr | 1,104,742 | 6,905 | 1,519 | 1,312 | 22% | 19% | 22% | |
Center
| Tehran | 12,707,586 | 102,720 | 18,490 | 18,490 | 18% | 18% | 11% |
Qom | 1,226,978 | 8,282 | 0 | 0 | 0% | 0% | 0% | |
Alborz | 2,758,741 | 17,242 | 1,035 | 1,035 | 6% | 6% | 6% | |
Qazvin | 1,260,478 | 8,508 | 766 | 681 | 9% | 8% | 9% | |
Semnan | 658,129 | 4,333 | 130 | 87 | 3% | 2% | 2% | |
Markazi | 1,560,281 | 11,052 | 332 | 221 | 3% | 2% | 3% | |
Esfahan | 5,072,296 | 39,310 | 4,717 | 4,324 | 12% | 11% | 11% | |
Yazd | 1,067,793 | 8,453 | 507 | 254 | 6% | 3% | 6% | |
Chaharmahal and Bakhtiari | 929,556 | 6,197 | 868 | 682 | 14% | 11% | 14% | |
East
| Kerman | 3,150,695 | 22,580 | 2,484 | 2,258 | 11% | 10% | 24% |
Sistan and Baluchestan | 2,634,564 | 17,783 | 1,245 | 889 | 7% | 5% | 7% | |
Khorasan Razavi | 7,043,548 | 53,414 | 4,273 | 3,739 | 8% | 7% | 8% | |
Southern Khorasan | 780,406 | 5,073 | 913 | 812 | 18% | 16% | 18% | |
Total | 79,919,699 | 585,681 | 69,692 | 51,789 | 0.12 | 0.09 |
Geographical area
|
Province
|
Independent variables
|
Coefficient of variation of health resources (CV)
|
Dependent variable
| ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Density
|
U5MR 2014
|
HDI
|
THE per capita
|
Resources Number
|
Patient mobility rate
| |||||||
Hospital bed
|
Nurses
|
Specialists
|
Hospital bed
|
Nurses
|
Specialists
| |||||||
North
| Mazandaran | 87 | 9.33 | 0.63 | 7.54 | 4792 | 5681 | 1704 | 29 | 23 | 28 | 23% |
Gilan | 60 | 16 | 0.7 | 8.06 | 3322 | 2951 | 1143 | 40 | 33 | 42 | 20% | |
Golestan | 63 | 17.67 | 0.65 | 7.03 | 2375 | 2710 | 677 | 57 | 52 | 56 | 19% | |
East Azarbaijan | 33 | 19 | 0.66 | 7.61 | 5856 | 5204 | 1934 | 32 | 32 | 36 | 15% | |
Ardabil | 17 | 19.67 | 0.7 | 7.41 | 1994 | 1839 | 426 | 48 | 38 | 41 | 6% | |
North Khorasan | 14 | 32.33 | 0.62 | 5.36 | 1008 | 1277 | 233 | 58 | 48 | 55 | 13% | |
West
| Kohgiloyeh and Boyerahmad | 2 | 20.67 | 0.74 | 11.79 | 862 | 1051 | 222 | 63 | 66 | 61 | 4% |
West Azerbaijan | 134 | 27.33 | 0.72 | 10.05 | 4120 | 3448 | 920 | 29 | 27 | 36 | 4% | |
Kermanshah | 7 | 23.67 | 0.74 | 10.8 | 2876 | 2393 | 557 | 40 | 44 | 41 | 8% | |
Kurdistan | 77 | 32.33 | 0.72 | 10.44 | 2102 | 2410 | 492 | 41 | 59 | 49 | 11% | |
Hamedan | 14 | 20.67 | 0.74 | 11.85 | 2660 | 2196 | 495 | 41 | 43 | 35 | 17% | |
Ilam | 44 | 13.67 | 0.65 | 10.61 | 811 | 733 | 164 | 47 | 43 | 55 | 11% | |
Khuzestan | 11 | 19.67 | 0.68 | 11.19 | 7150 | 4905 | 148 | 54 | 56 | 7 | 12% | |
Lorestan | 76 | 16.67 | 0.73 | 9.92 | 2165 | 1933 | 465 | 48 | 45 | 52 | 20% | |
Zanjan | 39 | 23 | 0.74 | 10.66 | 1545 | 1390 | 394 | 60 | 52 | 67 | 6% | |
South
| Fars | 94 | 27 | 0.66 | 13.09 | 7685 | 8554 | 2405 | 43 | 38 | 11 | 8% |
Hormozgan | 57 | 25.33 | 0.71 | 12.42 | 2084 | 1636 | 418 | 60 | 67 | 63 | 6% | |
Bushehr | 47 | 19 | 0.75 | 11.88 | 1337 | 1209 | 423 | 52 | 60 | 64 | 22% | |
Center
| Tehran | 780 | 17 | 0.75 | 15.92 | 25,501 | 20,799 | 11,226 | 54 | 53 | 15 | 11% |
Qom | 62 | 13 | 0.7 | 8.42 | 1675 | 1684 | 477 | 0 | 0 | 0 | 0% | |
Alborz | 54 | 19.33 | 0.63 | 8.46 | 2125 | 1829 | 163 | 52 | 53 | 66 | 6% | |
Qazvin | 5 | 16.67 | 0.66 | 8.41 | 1779 | 1799 | 480 | 67 | 61 | 60 | 9% | |
Semnan | 73 | 20 | 0.65 | 9.08 | 1534 | 1248 | 356 | 54 | 48 | 16 | 2% | |
Markazi | 48 | 18 | 0.74 | 8.67 | 2054 | 1576 | 778 | 71 | 44 | 50 | 3% | |
Esfahan | 28 | 19.67 | 0.74 | 9.28 | 7341 | 7489 | 29 | 46 | 37 | 25 | 11% | |
Yazd | 81 | 21.33 | 0.75 | 9.08 | 2538 | 1952 | 541 | 41 | 49 | 40 | 6% | |
Chaharmahal and Bakhtiari | 24 | 17.67 | 0.69 | 9.6 | 1442 | 1385 | 266 | 58 | 58 | 81 | 14% | |
East
| Kerman | 109 | 21.67 | 0.72 | 9.72 | 4373 | 4499 | 1034 | 56 | 57 | 54 | 24% |
Sistan and Baluchestan | 48 | 28.67 | 0.67 | 9.62 | 2369 | 1955 | 419 | 66 | 70 | 13 | 7% | |
Khorasan Razavi | 529 | 26 | 0.74 | 9.75 | 9077 | 7859 | 282 | 61 | 74 | 35 | 8% | |
Southern Khorasan | 81 | 47.67 | 0.66 | 9.9 | 1008 | 871 | 227 | 66 | 50 | 67 | 18% | |
IR. Iran
|
117,580
|
106,465
|
36,345
|
22
|
23
|
30
|
Analytical findings
Independent Variables
|
Irr
a
|
SE
|
P
-Value
|
---|---|---|---|
Hospital beds | 1.09 | 0.22 | 0.681 |
Specialist physicians | 0.99 | 0.53 | 0.981 |
Human development index | 0.16 | 0.83 | 0.722 |
Total health expenditure | 1.03 | 0.13 | 0.774 |
Population density | 0.99 | 0.002 | 0.293 |
U5MR | 0.99 | 0.02 | 0.787 |
Variables
|
Margins
|
P
-Value
|
---|---|---|
Bed CV | -0.067 | 0.636 |
Nurse CV | -0.018 | 0.884 |
Specialists CV | 0.13 | 0.009 |
Clusters
|
Provinces
|
Ratio of (specialist /population)
is high
|
Ratio of (specialist /population)
is moderate
|
Ratio of (specialist /population)
is low
|
---|---|---|---|---|
The first cluster (CV of specialist physicians: low) | Tehran, Semnan, Fars, Isfahan, Qom, Sistan and Baluchestan | Tehran, Semnan, Fars, Isfahan, | Qom | Sistan and Baluchestan |
The second cluster
(CV of specialist physicians: medium) | Mazandaran, Gilan, Ardabil, West Azerbaijan, Yazd, East Azerbaijan, Kermanshah, Kurdistan, Hamadan, Markazi, Khorasan Razavi | Mazandaran, Gilan, Yazd, East Azerbaijan, | Ardabil, Kurdistan, Markazi, Khorasan Razavi | Hamedan, Kermanshah, West Azerbaijan |
The third cluster
(CV of specialist physician: high) | Golestan, Ilam, Khuzestan, Lorestan, Hormozgan, Bushehr, Kohgiluyeh and Boyer Ahmad, Alborz, Qazvin, Zanjan, Chaharmahal and Bakhtiari, Kerman, South Khorasan, North Khorasan | Qazvin | Golestan, Khuzestan, Hormozgan, Bushehr, Kohgiluyeh and Boyer Ahmad, Alborz, Zanjan, Chaharmahal and Bakhtiari, Kerman | Lorestan, Ilam, North Khorasan, South Khorasan |