Background
In line with the WHO objectives for Primary Health Care (PHC) [
1,
2] and the Comprehensive Health.
Action Plan 2013–2020 [
3], health policies have been established to create a balance between different levels of prevention and to provide community-based services [
4].In some countries, some basic changes in health system policies have made family and community-based services grow to the level that they now account for half of all the health services provided to the public, and the amount of health services provided by hospitals is now equal to the amount of services given by the community [
5].
The activities of Counseling and Nursing Care Service Centers (CNCSCs) in Iran can be considered a logical step in promoting nurses’ professional role in the community [
6].These private centers are allowed to offer different nursing services to individuals, families and the community; however, the majority of their services are currently offered at homes. Community-based nursing care has a longer history in countries such as the United States and Canada, where these centers are supported by the local health systems and have a major share in the delivery of health services [
7‐
9]. In developing countries the role of nurses in community-based healthcare provision is ambiguous [
10‐
12] and nursing care is mostly restricted to hospitals [
13‐
15].
Community-based health services offer several advantages, such as saving in costs [
16,
17]. A major challenge for health system managers is to improve the quality of healthcare at the same time as reducing its costs [
18]. The costs of providing health care are always increasing [
19] and the need to increase the budget allocated to the health sector and design efficient input-output evaluation mechanisms for improving the efficiency of health financing [
20] are more evident than ever. Performing cost-benefits and cost-effectiveness analyses and adjusting reimbursement policies can accelerate the process of expanding community-based health service provision [
21,
22].
Particularly in developing countries, health systems are faced with the serious challenge of resource management [
23] and healthcare delivery [
24,
25]. At present, the privatization of health care services might be a step too far in assisting the health system to face its challenges [
26]; nonetheless, this step is being taken in developing countries without a clear and coherent strategy [
27].
Modern approaches to health care have identified three main goals for an ideal health care system, which include quality improvement, accountability and fair financial contribution to health care services [
28,
29]. From the clients’ perspective, the most important attributes of good health care services are their easy accessibility, cost-effectiveness, affordability and high quality [
30]. In addition, health care organizations and community-based health care centers need to have an acceptable level of income in order to be able to continue providing their services.
Financial profit is naturally a priority of private nursing services, even with the governmental support offered to these centers in developed countries, financing the services was a main concern [
7,
31]. Few studies have examined the economic aspect of community-based nursing care [
22]. Identifying the challenges in the financial management of nursing services can help policymakers and CNCSC managers design appropriate strategies for expanding community-based nursing services.
Having a payment schedule and providing cost-effective services are important for service providers, clients and other stakeholders in any financial affair. In addition to the price of the commodities or services, how and when the costs are calculated and paid and what documentations are needed for these financial transactions is also key. In other words, the mean of financial transaction means how to calculate the cost of services, how and when should to pay and which documentation is required.
In spite of nearly two decades of activity, the services provided by CNCSCs are not well-organized and are faced with great financial problems. The present study was conducted to explore the financial transaction between CNCSCs and their clients and the challenges in their management and the contributing factors.
Methods
The present qualitative study was conducted using the content analysis method. The main participants included CNCSC managers, but the data obtained made the researchers recruit physicians and clients too. Sampling continued until data saturation was achieved with 28participants and complementary interviews were conducted with two other family members(Table
1).The inclusion criterion was to have at least one year of work experience(in the past or the present) for having sufficient experience in a CNCSC and the exclusion criterion was unwillingness to participate in the study.
Table 1
Participants’ demographic characteristics
NCSC managers 11 | Man19 | 37–67 | 1–35 | PHD 4 |
Nurse 8 | Woman 11 | | | Bachelor’s degree: 18 |
nursing assistant 3 | | | | Master’s degree student: 4 |
inspector of NCCC 1 | | | | Diploma 4 |
family member 3 | | | | |
Physician 4 | | | | |
Data collection began with in-depth individual interviews, and the researcher tried to gather complementary data through the observation of the financial transactions made in the centers and their related documents, if possible. The main interview questions were‘ Please discuss your experiences of communicating with clients and providing care to them’ and ‘Please discuss your experiences of establishing a financial relationship with your clients, the estimated costs of the services, the tariffs and their payment by the clients’(Additional File
1: interview guides).
Before each interview, the researchers introduced themselves to the interviewees and briefed them on the study objectives and methods and ensured them of the confidentiality of their data and that they would not be used against them. The participants then signed informed written consent forms for participation in the study. The recorded interviews were transcribed verbatim. Data were analyzed using the conventional content analysis, in which pre-existing theories had no place and where data analysis was based on the meanings that the data conveyed. In this approach to data analysis, the researcher repeatedly peruses the collected data in order to obtain a general understanding of the subject [
32]. The data obtained in the study were analyzed through the following steps: Preparing the data, defining the unit of analysis, developing codes and categories and a sample text, encoding the entire body of text, ensuring consistency in encoding, drawing conclusions from the encoded data, and reporting the findings [
33].
The trustworthiness of the data was ensured through different strategies, such as the allocation of adequate time to the research, holding in-depth interviews, explaining the objectives of the study to the participants in detail and performing a member check and a peer review [
34].
Discussion
The findings revealed the flaunted atmosphere due to direct financial transaction and instability in determining tariffs for nursing services as factors increasing annoyance, confusion, out-of-pocket payment and client dissatisfaction. To reduce the negative effect of these factors on the affordability of the services, CNCSC managers usually use cost-benefit strategies for offering cost-effective services and increasing client satisfaction.
Public insurance plans do not cover the costs of CNCSC services. The inadequate insurance coverage for nursing services negatively affects the financial transaction between nursing care service providers and clients in CNCSCs, increases OOPs and ultimately reduces the use of community-based nursing services. Clients have to pay the entire costs of using these services themselves and may have to pay other costs, simultaneously and therefore experience great financial difficulties. The results of other studies also suggest that the multiplicity of payments for health care services complicates financial transactions and has negative effects on financial management [
35]. The poor insurance coverage offered for nursing services means that even when the services are offered at a fair price, some families find them expensive and unaffordable, especially given that they may be able to receive similar services at a lower cost in public hospitals and clinics.
The increased (CI) coverage by (PI) companies can be considered an opportunity for private health care providers such as CNCSCs. Nonetheless, the relationship between CNCSCs and these companies is gradually growing and some of the barriers, such as not having a clear and customized policy for community-based nursing services, may be resolved. It should be noted that CI helps those of the community who are insured voluntarily (rather than obligatory through their employee) who often are relatively in better financial situation and can pay CIs a premium [
36,
37]. Therefore unlike in advanced countries [
38,
39], low-income peoples benefit from CNCSC services to a lower degree. Like many other studies [
40,
41], the present study found that the inadequate insurance coverage for nursing services imposes a great financial burden on families and makes them reluctant to seek such services. The heavy costs of healthcare can limit the clients’ access to high-quality and cost-effective healthcare services [
19]. Lack of health insurance in developing countries may mean enormous OOPs [
42,
43], while countries with better healthcare systems rely less on OOPs [
44‐
46]. Nursing centers in these countries have a flourishing market and their policies are such that reimbursement for these services is adequate both by public and private insurance companies [
31].
There are three main healthcare delivery models, including public assistance, health insurance and national health services. The health authorities in Iran adopted the Public Assistance model [
47] and fund it in a pluralistic way through the social security organization [
25] and by way of an annual government health budget [
44], taxes, social security insurance payments and out-of-pocket payments [
26,
46]. In this model, health decision-making, planning, resource management and service delivery fall under the responsibility of the government [
47]. Consequently, government policies and plans can dramatically affect the presence and activities of healthcare delivery centers, including CNCSCs. The negative impact of policies counteracts and weakens the health management process [
48].
Like in other developing countries, Iran’s health care system is faced with complexities in marketing and management [
25,
49], such as the overuse of health care services [
26] and insufficient funding (41). Such challenges have imposed serious limitations on the efficiency, quality and equity of the healthcare services [
26]. The role of health insurance is sub-optimal from the perspective of health insurance organizations, health care providers and clients [
25]. In spite of the significant increase in public insurance coverage in the recent decade [
26] and the health transformation program in place [
50], Iran’s health system has not been successful in reducing OOPs in community-based health centers significantly [
51].
According to the present study, the absence of clear tariffs and an agreement on CNCSC services confuses the clients about the real costs of the services. Other studies have similarly shown that clients may pay different fees for a similar service and some insurance plans do not cover the costs of these services and direct payments increase drastically [
45]. Due to the underestimations about the importance of community-based nursing care, most patients and families are reluctant to pay for nursing services. The heavy costs of these services may mean that the patients suffice to lower-quality care from informal service providers. The clients’ willingness to pay is an important component of the cost-benefit analysis of health services [
22,
52]. Nursing has a long history in developed countries and community-based nursing care is very extensively offered; people may also have ample knowledge about the practice of nursing in these countries and might truly appreciate its benefits and thus put their trust in nurses [
53]. In developing countries, however, the novelty of community-based nursing services means that more serious attempts are needed to gain a wider public interest. Increasing the variety of nursing services offered can help the public better perceive the nurses’ role and their capabilities and thus change the attitude toward nursing services and nurses [
54].
The present study showed that public health centers and hospitals in Iran do not collaborate with CNCSCs and have almost no interaction with these centers. Unlike these findings, other studies have shown a good relationship between community-based nursing care centers and the good accessibility of their services [
31]. As a result, people are rarely informed about or referred to these centers in Iran. The poor integrity of health system programs and the weak interactions between the private and public health sector [
55].The lack of economic expertise in health care management, the poor monitoring of the services and OOPs are other challenges faced with the privatization of health care [
25].Improving financial management skills in healthcare managers is therefore as vital as it is in nursing managers [
38,
56].
The conditions of care delivery and the financial transactions between Iranian CNCSCs and their clients are remarkably similar to home-based nursing practices in Turkey. Most Turkish people cannot use home-based nursing services due to the inadequate insurance coverage offered for these services [
57]. In countries such as the United States and Canada, however, most nursing centers are supported by comprehensive healthcare plans such as Medicare or receive financial support from the government, and most people, even low-income groups, can widely benefit from these services [
7,
53,
58].
The three main stakeholders in a health-related financial transaction are the clients, the service providers (CNCSCs) and the insurance organization. Some important points should be taken into account when establishing such financial transaction: 1. The price of the services should be clear and fair; 2. All the stakeholders should achieve a fair profit by engaging in this transaction, 3. Processing monetary payments should be carried out with clarity and simplicity, and 4. Every health care program must have a systematic design and application. The cost-benefit analysis of health care services should consider the costs and the direct and indirect benefits of these services [
59]. Failing to conduct a financial analysis of programs increases the final costs of health care services [
40].
In spite of the greater willingness toward indirect payment and the separation of payment from service delivery [
40], the present study showed that the financial transaction between CNCSCs and their client move toward direct payments. The low insurance coverage’s, the direct payments with complex and low reimbursements and the heavy out-of-pocket payments for CNCSC services have created serious challenges in the affordability and expansion of these private community-based nursing care centers (Additional File
2: FigureS1). Fixing a minimum/maximum time allowed for payment sand finding the best methods of payment are necessary for private health care delivery management [
60].
CNCSC managers use certain strategies to offer cost-effective services and increase their clients’ satisfaction. They enter agreements with semi-private organizations with great financial resources that request various nursing services and try to convince the clients about the benefits of receiving CNCSC services and paying their costs and help them provide appropriate documentation for CI reimbursement by PIs. Nonetheless, some of their actions, such as forcing the clients to make direct payments, are cause for client dissatisfaction.
Iran’s Ministry of Health has well understood the challenges and seeks to up-to-date the tariffs of some of CNCSC services and improves the professional interaction between hospitals and these centers. To date, these efforts have not yielded practical results in terms of increasing the insurance coverage for these services and the problems persist, such as direct payments, high OOPs, poor affordability of the services and increased client dissatisfaction and confusion.
The stability and development of private community-based nursing services rely on cooperation between CNCSCs, clients, the health system and insurance organizations. In addition to the health system, private community-based service centers such as CNCSCs should also seek to develop policies and plans that take account of the benefits of the main stakeholders and thus improve the quality of health services and decrease their costs to a more reasonable level. At the same time, CNCSCs must convince health systems and insurance companies that the expansion of their activity reduces the health system burdens and the costs of public and private insurances.
Limitations
Given the private nature of CNCSC services, they are less obliged to collect and keep their financial documents than formal public health organizations. They can even hide their real incomes and expenses. The researcher was not able to access the CNCSCs’ financial documents, especially their income forms.
Given the limited number of studies on community-based nursing service centers, future studies are recommended to further explore the other aspects of these centers.