Introduction
Methods
Study setting
Study design
Document review
Key informant interviews
Participants
Conceptual framework of the study
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Accessibility: Document accessibility may be a facilitator or barrier to the usefulness and implementation of policy [30].
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Policy background: Policy background encompasses the consideration of scientific results, so the Rütten criterion ‘scientific results demand the action’ has been incorporated into this section. Sources may be of different types: authority (e.g. persons, books, articles), quantitative or qualitative analysis, and deduction (premises established from an authority, observation, intuition, or all three) [30].
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Monitoring and evaluation: Independent evaluation strengthens the analyses’ credibility. Data collection before and after implementation also increases the credibility of the evaluation [30].
Analysis
Ethics
Result
Document analysis
No | Year | Policy document | Explanation of the document |
---|---|---|---|
1 | 1979 | Article 29 of the Constitution | Emphasis on universal health insurance coverage |
2 | 1980 | The Law on Regulation of Health Care expenditures | The obligation of the MOHME to carry out the necessary studies within two months for the correct and fair regulation of medical and health expenses and to implement the relevant regulations in a timely manner |
3 | 1984 | Primary healthcare (PHC) system | The establishment of a PHC system through the National Health Network was one of the major transitions in the Iranian health system to achieve equity of financing and utilization |
4 | 1994 | The Public Medical Service Insurance Coverage Act (PMSICA) | This law was the second most important reform that provides formal health insurance coverage to several target populations (e.g. civil servants, people with disabilities, village dwellers, and nomadic tribes) |
5 | 1995 | Executive Regulations of Article 7 of the Public Insurance Law | Organizations were allowed to enter into contracts with medical centers to ensure the health of their employees |
6 | 2000 | Article 192 of the Third Development Plan Law | Moving toward UHC by the establishment of a surveillance system and preparedness for rationing services and referral system implementation to provide all health services free by the government |
7 | 2002 | The law of organization of health and treatment | The obligation of Iran’s government to close the annual budget from the beginning of 2003 in such a way that the grounds for the implementation of the UHC are formed and empowering people through self-employed insurance |
8 | 2004 | Regulation for social insurance of villagers and nomads | Establishing an insurance fund and covering more than 300 thousand villagers |
9 | 2005 | Fourth Development Plan Law (Article 90) | For the first time, clear targeting was done on the issue of equitable (or fair) financing for health care. "Fairness in household financial contribution index (FFCI)" should be increased to 90%, people's share of health expenses should not increase from thirty percent 30%, and the number of impoverished households due to unaffordable health expenses should be reduced to 1% |
10 | 2006 | Communicating the general policies of "health" by the Supreme Leader of Iran (paragraphs 9 and 10) | Quantitative and qualitative development of health insurance and providing sustainable financial resources in the health sector |
11 | 2007 | Executive Regulations, Article 91 of the Fourth Development Plan | This article oversees the implementation of the family physician program in the country's health service delivery system |
12 | 2008 | Executive Regulations, Article 90 of the Fourth Development Plan | All government hospitals are obliged to provide all the supplies, equipment and medicine needed by the patients, and the patient is only responsible for the hospitalization deductible |
13 | 2010 | The Law of Targeting Subsidies | The implementation of this law has led to an increase in the costs of the health sector |
14 | 2011 | Article 38 of the Fifth Development Plan | The issue of reducing people's share of the health expenditures has been emphasized in a more complete way and with the same targeting of the fourth plan |
15 | 2012 | Family physician program | The urban family physician program was implemented in some parts of the country with extensive advertising and the full support of the Minister of Health |
16 | 2013 | Statute of Iran Health Insurance Organization | The first step was to implement Article 38 of the 5th National Development Plan and consolidate the country's insurance funds |
17 | 2014 | A collection of health transformation plan programs | This program aims to reduce out-of-pocket payments and increase the quality of hospital services at the level of Ministry of Health hospitals. Allocating appropriate credit from the government to this program is one of its key points |
18 | 2017 | Article 78 of the Sixth Development Plan | Reducing the percentage of households exposed to CHE through the extension and promotion of social health insurance to 1% and reducing OOP to 25% |
Criteria | Definition |
---|---|
Accessibility | |
1. The policy is accessible (hard copy and online) | Evaluated during the data collection stage—online availability was enough to satisfy this requirement |
Policy Background | |
1. The scientific grounds of the policy are established | The policy includes a discussion of health financing. The share of out-of-pocket payments (OOP, both formal and informal) in Total Health Expenditure (THE) and Measuring incidence and intensity of catastrophic payments are made explicit |
2. The goals are drawn from a conclusive review of the literature | The policy shows evidence that the literature was reviewed, and this literature review was used in the decision-making process |
3. The source of the health policy is explicit (Authority, data analysis, deduction) | The policy references a reputable source such as the World Health Report 2000 and draws on scientific studies such as the national health account, OOP index, and other health indices. Also, important documents, including the constitution and general healthcare policies, have predicted such a policy |
4. policy encompasses some set of feasible alternatives | The policy describes potential alternative solutions to those that are intended to be implemented. For example, CHE reduction by increasing enrolment in government health insurance; compulsory membership, increasing financial stability through stable government subsidies, and increasing the government share of spending on health are stated in policy documents |
Goals | |
1. The goals are explicitly stated | The policy clearly states the overarching aims the policy program seeks to achieve; reduction of the OOP proportion of THE to 30%, and the reduction of households’ exposure to CHE to 1% |
2. The goals are concrete enough to be evaluated later | Quantitative targets or benchmarks are built into the goal, as well as a time frame within which it is to be achieved |
3. The goal is clear in its intent and in the mechanism with which to achieve the desired goal | Each goal is not accompanied by specific strategies or action items that can help achieve this goal once implemented |
4. The action centers on improving the health of the population | Each goal in the policy is relevant, either directly or indirectly, to improving health outcomes. For example, the policy links the goal of WHO to ensure that the cost of care does not put people at risk of financial catastrophe |
5. The policy is supported by evidence of external consistency in logically drawing a health outcome from the goals and policy outcome | The policy doesn't describe the influence of policies from other countries or Inter-Governmental Organizations' documentation on decision-making |
6. The policy is supported by internal validity in logically drawing a health outcome from the goals and policy outcome | The policy doesn't link the scientific evidence to the goals and strategies being proposed |
Resources | |
1. The cost of condition to the community has been mentioned | In the implementation regulations of Article 90 of the 4th Development Plan, it has been specifically mentioned that the information related to the health expenditure index should be prepared by the Iranian Statistics Center and the Ministry of Health and Medical Education (MoHME) and included in the annual budgets |
2. Estimated financial resources for the implementation of the policy are given | Despite the emphasis of the program and the approval of the law, none of the documents related to the policy, a specific source for financing the implementation of the policy has not been identified. Annual budgets are not provided in this field either |
3. Allocated financial resources for the implementation of the policy are clear | The policy doesn't estimate the amount of money available for implementing the policy, and the sources of this money (the government, NGOs and IGO donors, etc.) |
4. There are rewards/sanctions for spending the allocated resources on appropriate programs | The policy doesn't describe either financial rewards for implementing the policy or financial sanctions for not implementing the policy |
5. Human resources are addressed | A description of the equitable distribution of human resources needed for implementation isn't provided. Also, there isn't an assessment of the resources based on WHO recommendations |
6. Organizational capacity is addressed | The policy describes the infrastructure in place for implementation; for example, the MoHME responsible for carrying out policy implementation is described |
Monitoring and Evaluation | |
1. The policy indicates monitoring and evaluation mechanisms | The policy doesn't clearly describe the method by which monitoring and evaluation of the policy is to proceed |
2. The policy nominates a committee or independent body to perform the evaluation | The policy mentions a Statistical Center of Iran responsible for monitoring and evaluation, by providing statistics and information necessary to analyze health cost indicators and transfer them to annual budgets. In this context, it is mentioned in the executive regulations of Article 90 of the fourth plan |
3. The outcome measures are identified for each of the explicit and implicit objectives | For each goal, there is a description of the indicators that are used to measure the progress toward this goal |
4. The data, for evaluation, are collected before, during and after the introduction of the new policy | The policy doesn't report the baseline quantitative (or qualitative) data for each goal |
5. Follow-up takes place after a sufficient period to allow the effects of the policy change to become evident | The policy doesn't describe the time periods within which evaluations of the policy implementation are to be conducted |
6. Other factors that could have produced the change (other than policy) are identified | The policy doesn't consider social, economic, cultural, and other factors that could increase CHE rates that may fall outside the specific strategies that are implemented |
7. Criteria for evaluation are adequate and clear | The policy doesn't describe the method for collecting and evaluating data to obtain specific outcome measures |
Public Opportunities | |
1. Multiple stakeholders are involved | The policy names multiple individuals, groups, or organizations that have a role in decision-making or policy implementation, such as insurance organizations, MoHME, NGOs, and services providers,… |
2. Primary concerns of stakeholders are recognized and acknowledged to obtain longer term support | The policy doesn't identify the primary concern of each stakeholder and doesn't take it into account in decision-making |
Political Opportunities | |
1. The political climate has either worsened or improved | The policy doesn't describe the political factors that may have influenced decision-making and how they have changed over time |
2. Cooperation between public and private organizations has either worsened or improved | The policy doesn't describe the nature and extent of the cooperation between the public and private sectors of health care |
3. The lobby for the action has either worsened or improve | Lobbying groups, their mandates, and the effect they have on decision-making aren't described |
Obligations | |
1. The obligations of the various implementers are specified—who must do what? | Each goal or strategy has a specific actor (individual or organization), but the responsibility for implementing the strategy is not specified |
2. Scientific results are compelling for action | The policy doesn't express a clear obligation to act based on scientific results laid out in the document. Failure to implement the policy clearly indicates a lack of professional obligation to the policy. Due to the complexity of the issue and its intersectoral nature, organizations are not independent in the implementation of this policy and its strategies, and these interactions have sometimes created role interference |
Context, content, actors, and process in the development of the CHE reduction policy
Context
Theme | Sub-theme | Category | Subcategory |
---|---|---|---|
Context | Political | political atmosphere in Iran | Factionalism in health policy making |
The government's opposition to the fourth development plan | |||
Political decisions-making | Lack of political will to implement programs | ||
Lack of public demand | |||
Lack of priority for health in the governance perspectives | |||
Lack of support from political authorities | |||
The superiority of the political component over the technical component of the decision | |||
Situational | Economic factors | Inefficient economic system | |
Economic impulses caused by sanctions | |||
Economic problems caused by the spread of covid-19 | |||
Economic instability | |||
The decrease in gross domestic product per capita (GDP) | |||
The effect of targeted subsidies | |||
The high cost and large copayment for some medical services | |||
The high administrative costs of the departments | |||
Improper payment system | |||
The high inflation in the health sector | |||
Resource shortage problem | Domestic general government health expenditure (GGHE-D) as percentage of general government expenditure [46] (%) | ||
Planning without resource allocation | |||
Insufficient financial resources of the health sector | |||
Resource management | High priority for allocating resources to treatment | ||
Poor resource management | |||
Weakness of compliance with the referral system | |||
Structural | Service delivery structure | Inefficiency of the health insurance system | |
Fragmentations in Iran’s health insurance system | |||
The inefficiency of the public sector in providing quality services | |||
Low financial protection against healthcare expenditures for the insured persons | |||
High coinsurance rates | |||
A notable rate of insurance coverage duplication | |||
Government entrepreneurship in the health sector | |||
Decision making structure | Concentration of policy-making, monitoring and implementation in one institution | ||
Improper organization of health care system components | |||
Incompetence of implementing organizations | |||
Weakness of the health system structure | |||
lack of reliable data and statistics | |||
Lack of transparency of responsibilities | |||
Cultural | Cultural factors | The culture of specialization care in Iran | |
The culture of consumerism in health care in Iran | |||
The public demand for utilizing advanced technologies | |||
The paternalism and medicalization | |||
Changing people's lifestyles | |||
The lack of media in promoting CHE reduction policies | |||
Social factors | Consumer moral hazard | ||
Lack of real health literacy | |||
Lack of public demand | |||
Ignoring policy by the media | |||
Social determinants of health | |||
Supplier induced demand |
“Health has never been the priority of the government and the government has never fully paid the health share of the budget. This has caused a delay in financing from insurance companies and an increase in the people's share of health payments.”
Content
“The plans were very idealistic and far from reality, and the country's economic power and capacity were not taken into account.”
“There is no executive policy and mechanisms for reducing out-of-pocket payments that can be used as supporting documents for legal regulations.”
Theme | Sub theme | Category | Subcategory |
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Content | Consistency of goals | Targeting | Targeting has been ideal |
Failure to clearly state goals | |||
Weakness in supporting documents | |||
Technical requirements of the application | Failure to implement legal mechanisms | ||
Lack of budget support for politics | |||
Inconsistency in the rules | |||
Internal logic | Prioritize | Lack of priority of the health sector in the government's view | |
Sectoral perspective on program design | |||
The program is paper-based | |||
The populist point of view of senior managers to issues | |||
Competition between programs and commitments to attract resources | |||
The nature of politics | This policy is imported as an international policy | ||
The populist nature of this policy | |||
Incorrect program defaults | |||
Lack of serious attention to people’s needs | |||
Imposing the need for the government by experts |
Actors
“Both top-down and bottom-up approaches have not been employed in formulating and implementing policies. The use of a top-down approach alone can be seen as ineffective in addressing the complex and nuanced issues involved in reducing CHE, as stakeholders may have different perspectives and priorities. Similarly, a bottom-up approach that only involves those directly affected may not fully consider the broader implications of the policy. A more inclusive and participatory approach that incorporates both top-down and bottom-up perspectives, and establishes a dialogue among all stakeholders, could be more effective in addressing this.”
“The mastery of the physician profession on decisions is definitely very important.”
“There is a huge conflict of interest in the Ministry of Health. The Minister of Health and the Deputy Ministers and most of their experts are physicians and their hands are in the health market. This prevents the implementation of approved laws.”“The Ministry of Health's role is stewardship and it should define the guidelines, but when it acts as a service provider, it is certain that it works in such a way that its hospitals are managed well and their debts are paid, so it implements as a presentation the health service provider, not the health stewardship.”
Theme | Sub theme | Category | Subcategory |
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Actors | Conflict of interest | Clinical perspective in Iran health system | The presence of the majority of physicians in all policy making and decision-making authorities |
Physician authority | |||
Professional bias of physicians in legislation and implementation | |||
Model of policy making | Lack of a unique decision maker stewardship for health system | ||
General policy patterns in the country | |||
Priority of specialized and curative care in policy making | |||
Ignoring the scientific bases of policy making | |||
Power arrangement | Health service provider behavior | Healthcare provider profitability | |
Improper distribution of power | |||
System design based on the interests of service providers | |||
Strong provider lobby | |||
Health market behavior | The difference in payment in the public and private sector of the market | ||
The role of the market in increasing induced demand | |||
Expansion of informal payments | |||
Privatization in the health system | |||
The inability of the government to regulate the health market | |||
Non-participation of the provider in the health market risk |
Process
“One of the most important planning problems in Iran is that we do not specify who should be responsible for what. In the policy of reducing catastrophic health expenditures, despite the passage of years since the approval of the policy and the failure to achieve the goals of the policy, it is not clear who should answer and who should be asked for an answer.”
“Roles are not well defined and the relationship between roles and organizations is not clear. The role of the Ministry of Health is stewardship, but it plays the role of a health service provider. Also, there is poor coordination and communication between organizations and departments.”
Theme | Sub theme | Category | Subcategory |
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Process | Stakeholder participation | Importance of stakeholders | Non-participation of stakeholders in policy design |
Non-acceptance of responsibility between stakeholders | |||
Non-alignment of stakeholders in the program | |||
Intersectoral collaboration | Improperly implement program mechanisms | ||
Weak intersectoral coordination | |||
Disagreement of various stakeholders with the program | |||
Improper organization of health system components | |||
Monitoring and evaluation | Monitoring and evaluation | Weakness of regulatory institutions | |
Uncertainty of policy monitoring authority | |||
Selective enforcement of rules | |||
Weak oversight of the entire health system | |||
Weakness in parliamentary oversight | |||
Stewardship and leadership | Internal governance | Lack of determination in implementing programs | |
Managers are not familiar with the subject | |||
Managers' short-term attitude to solving problems | |||
Weakness in the stewardship of the MoHME | |||
lack of commitment | |||
Management instability (change management) | |||
Interdisciplinary governance | Weakness in leadership and governance of the health system | ||
Lack of transparency of duties | |||
Lack of interaction between policy-makers and executives | |||
Gap exists between policy formulation and implementation |