Iranian Journal of Epidemiology
Year:2018 | Volume:13 | Issue:5 (SPECIAL ISSUE: (FOUNDATIONS, APPROACHES AND PERFORMANCE OF IRAN'S HEALTH SYSTEM) |Papers Count:17

Background and Objectives: Among health sector resources, hospital beds are the primary unit of calculation for the capacity of the health service and vital capacity in patient care. Lack of appropriate distribution in different parts of the country leads to transfer of patients and irreparable problems. The aim of this study was to provide accurate information on the number and distribution of hospital beds in the country in 2016 and to estimate the number of beds required by 2026.Methods: This descriptive-analytic study was conducted in 2016. The population of the study comprised 439 counties covered by 46 medical universities of the country. In this study, the data of 2016 were used and information about the number and ownership of beds and the size of hospitals were obtained from the treatment deputies of medical universities.Results: The number of active beds in the country was 117580 in 2016, and it is estimated that in order to meet the needs of the community, this number should reach 194471 beds by 2026. There were 1.47 beds for 1, 000 people in 2016, which will increase to 2.9 in 2026 by implementing the NEDA project. The coefficient of variation in 2016 was 36%, which will reach 19% by 2026 according to estimates in the Iran's roadmap project.Conclusion: The distribution of beds was differed in different regions of the country and there are not enough hospital beds in some areas. If the Iran roadmap is implemented, 2026 beds will be distributed more evenly across the country.

Background and Objectives: Different governance approaches have various definitions and systems about health. The purpose of this study was to compare the appropriateness of the health system performance with the ideology of the selected countries.Methods: In this comparative study, liberal countries (America, Canada, France), social countries (Russia, China, Cuba) and mixed countries (Sweden, Norway, England) were selected purposefully. Data were obtained from World Bank and WHO’s published documents and discourse literature studies. Causal layered analysis framework was used for data analysis.Results: Comparison of health indicators showed that mixed countries were in a better position than the other two groups. The health system’s stewardship of the liberal, mixed, and social countries were decentralized, semicentralized, and centralized, respectively. Discourses of the liberal states were based on the capitalist economy, with lack of reliance on natural resources. Socialist countries, a socialist economy system emphasizes the use of natural resources. In these countries governmental involvement is maximum. Mixed countries have a constitutional monarchy government and benefit from both of these approaches to create welfare based on the ideology of liberalism and the welfare state approach.Conclusion: Mixed countries with appropriate economic- social conditions, semi-centralized structure of service delivery, suitable financing system, and regional and local management of services (highlighting the role of municipalities), have better health status than other countries. The ideology of the countries forms the social, economic, and political structures as well health. Iran should consider various layers of metaphor, discourse, casual structures, and litany for redesigning the health system.

Background and Objectives: One of the issues affecting the health sector is the presence of regional inequalities.The purpose of this study was to evaluate the trend of inequality in the distribution of human resources and health facilities in the health sector of Iran.Methods: In this study, inequality in the distribution of human resources and health facilities in the health sector was assessed using the Gini coefficient in 2006, 2011, and 2015. The variables included human resources (6 indicators) and health facilities (10 indicators). Data were collected from the Statistical Center of Iran and the Statistics and Information Technology office of the Ministry of Health. For a Gini coefficient less than 0.35, 0.35-0.5, 0.5-0.6, more than 0.6 indicated relatively balanced inequality, relatively unequal inequality, high inequality, and very high inequality, respectively.Results: The maximum Gini coefficient belonged to radiographic centers (0.61) and the minimum was Behvarz (0.23). In human resources indicators, inequality decreased over the study years from 0.57 to 0.27. However, inequality showed a slight increase in Behvarzes from 0.24 to 0.26. Among the facilities indicators, the Gini coefficient of urban health centers, health care facilities, beds, and radiology centers decreased from 0.45 to 0.31, whereas other indicators had an increasing trend from 0.24 to 0.59. In the private sector, there was a high inequality (0.5 to 0.61).Conclusion: Eliminating inequalities in the distribution of health sector resources can help to improve justice in health outcomes. Therefore, policymakers should be pay more attention to eliminating inequalities.

Background and Objectives: Iran is a large country that is often an importer of major medical equipment. There is no comprehensive databank of the status of the equipment in the country. The present study provides a clear description of the dispersal status of major medical equipment in the country in 2016 and the estimated number of required devices in 2026.Methods: This study was conducted in 2016 in Iran. The study included 8 MRI, CT scan, gamma camera, linear accelerator, PET scan, cardiac angiography, peripheral angiography, and CT angiography devices. The data of the number of equipment in each city were collected through a census of devices.Results: At the beginning of the year 2016, 3.5 MRI devices, 6.93 CT scans, 2.18 gamma cameras, 1.23 linear accelerators, 0.04 PET scans, 2.3 cardiac angiography devices, 0.27 peripheral angiography devices, and 0.25 CT angiography devices per million population were active in Iran. CT scan and MRI devices were the most available equipment. It is estimated that the same pattern should be maintained in 2026, but the distribution of devices as well as the total number of devices in the country should improve.Conclusion: In 2016, for most of the devices, the proportion of the device to the population in the whole country was close to the global average, but there was a large accumulation of devices in large cities. This problem has been identified and interventions have been planned to move towards reducing inequalities In Iran's Health Roadmap.

Background and Objectives: Urban family physician program (UFPP), a program for improving equity in access to, financing, and quality of health services, is piloting in two provinces of Fars and Mazandaran, Iran since 2012. This study aimed to examine the association between the implementation of program and financial protection measures.Methods: This cross-sectional, ecological study was performed on aggregated data of financial protection measures and some independent variables in the above provinces from 2008 to 2015. At first, the Lasso regression model was used for selecting independent variables affecting financial protection indexes. After adjusting the selected independent variables, in separate models, the association between the UFPP and financial protection measures, as outcome variables, was examined using a backward linear regression model.Results: The percentage of households facing catastrophic health expenditure (CHE) in the years of UFPP implementation was 1.82% higher than the years before implementation (P<0.05). This increase was 1.37% in rural areas. the percentage of medical impoverishment in the two provinces increased by 0.83% during the implementation years than the years before (P<0.05). Finally, no significant relationship was observed between UFPP implementation and the Kakwani index and out of pocket payment (as % of total health expenditure) in the two provinces (P>0.05).Conclusion: Despite the achievements attained by UFPP in improving physical access to health services, it seems that this program has had no success in improving financial protection measures and equitable health care financing. However, further research is warranted in this regard.

Background and Objectives: One of the decentralized models that has been formed based on universal health coverage is the model of health complexes in Tabriz. This study was conducted to evaluate the model.Methods: This case study was conducted in 2017. Beside observation, 28 individuals, including informed experts in the field of establishment of health complexes in Tabriz University of Medical Sciences, were purposefully selected and semi-structured interviews were also conducted. To analyze the interviews and the results of observations, the framework analysis was used based on the components of the Primary Care Evaluation Tool (PCET) model.Results: The strengths of the health complex model are decentralized planning, strengthening the private sector participation, have more appropriate methods for assessing the performance of the health team, creating a sense of delivering effective services in providers, using electronic information registration system, using the prospective payment method, strengthening the referral system, enhancing service continuity, and facilitating financial and geographical access, especially in marginalized areas. However, there are some problems such as lack of some facilities and equipment, lack of some workforces and high workload, financial instability, and lack of insurance organizations cooperation with the plan.Conclusion: The health complex model has improved organizational, financial, and geographic access to health services. It seems that if the resources are more stable and by cooperation of basic insurances, the results of this project will be better.

Background and Objectives: The imbalance between the existing human resources and future needs of the health system disturb the service delivery process. The present study aimed at determining human resources needs in the health sector for a 10-year planning program. For this purpose, the researchers examined the geographical distribution of different groups of health system staff in 2016 and 2026.Methods: This descriptive-analytic study was carried out in 2016. The population of this study included 46 universities of medical sciences. Data of the number and distribution of health care staff working in public, private, charity, and semi-public sectors of medical departments of medical universities were collected. The Qlik View software was used for data integration and designing information dashboards.Results: At the beginning of 2016, the ratio of nurses, nursing groups, midwives, pharmacists, dentistry and general physician per 100, 000 individuals was 133, 199, 32, 17, 22, and 53 respectively, which are estimated to reach 223, 272, 37, 26, 27, and 79 in 2025, respectively. The coefficient of dispersion variation of the above was 39%, 32%, 43%, 33%, 43%, and 44% in 2016, respectively, which are estimated to reduce by 2026 if the Iran medical roadmap is implemented.Conclusion: The high dispersion index of the medical personnel relative to the population in the cities covered by medical universities indicates unbalanced distribution. If the estimates of the Iran's 2026 medical roadmap are implemented, more appropriate distribution of the medical staff is expected.

Background and Objectives: The aim of this study was to provide a clear description of the pre-hospital emergency setting and risk management in accidents and disasters in accordance with current Iran’s standards in different regions of the country. This study was part of the national project "Iran Roadmap (Neda 2026) ".Methods: The data of the major medical equipment was gathered from 48 medical universities covering all of the country's 32 provinces. Goal standards were obtained from the “Ministry of Health” and the “Department of Statistics for Medical Accident and Emergency Management Centers” in all universities. Coefficient of dispersion was calculated to evaluate any dispersion in major medical equipment.Results: The results of this study showed that in 2017, the highest and lowest coefficient in “pre-hospital facilities”was related to the ambulance engine (301%) and the operational base personnel (93%), respectively. Nio national standards were implemented in “Risk Management in accidents and disasters needs” in most provinces of Iran. In 2026 estimates, all of the factors improved and dispersion decreased.Conclusion: Despite the poor distribution of prehospital indicators in 2017, forecasting showed desirable conditions in distribution of facilities in the pre-hospital emergency and risk management of accidents and disasters.

Background and Objectives: Universal health coverage will have a problem in achieving it’s goals if it doesn’t consider the quality. This study aimed to Background and Objectives: Universal health coverage cannot achieve it’s goals if it doesn’t consider the quality. This study wants to assess the quality of health services in Iran, identify existing challenges and provide solutions.Methods: This study was a mixed qualitative and review study. In the first stage, the national main indicators of the quality of services were reviewed. Then, the orientation of the available upstream documents on the quality of services was explained. The most important challenges, trends, and recommendations of health quality improvement were extracted via interviews.Results: Proper observation of the Iran health care quality requires appropriate framework and indicators.Upstream documents strongly emphasized on the government's responsibility to play a key role as stewardship and that the health system should provide the necessary structural, procedural, and consequential requirements besides determining appropriate model. Quality management programs had obstacles in some aspects like the performance of managers and human resources, structural/communicational requirements, education, payment system, culture, use of quality management indicators and models, financial, information, and equipment resources, laws and regulations, and supervision.Conclusion: Improving the quality of health services in Iran requires strategies in organizing, resource generation, payment, laws and regulations, and behavior of policy makers and planners. Quality tools should be used without haste and should pay attention changes in the nature of diseases, expectations of stakeholders, and increased global attention to this issue in designing related plans.

Background and Objectives: Promoting health indicators is a key issue in most societies. In this regard, health deputies, through stewardship, monitoring, and coordination, take meassures to promote these indicators. The aim of the present study was to design a model for ranking the performance of the deputies.Methods: This applied qualitative study was conducted in 2012. The research team included 12 health experts who were selected according to management records and long experience in the health deputy. In this study, a review of the literature and documents was done and then, with the focus group discussions and expert opinions, key indicators were defined.Results: a model consisting of 9 process criteria (13 general indicators and 15 specific indicators) was identified for ranking of health deputies. The general processes included leadership and management, programs and strategies, resources and partnerships, manpower, and comprehensive information and statistics system And specific processes included primary health care (PHC), family physician (FP), social determinants of health (SDH) and pilot national plans. The range of indicators scores was between 1-8, which were compared with the zero indicator.Conclusion: The findings showed that the process components and indicators were more effective in determining the status of the health deputies’ performance, and the proposed model is based on the matter. So, it is recommended that the Ministry of Health ranks health deputies every two years to improve process components and criteria of the model based on practical results.

Background and Objectives: The distribution of specialists is important in two ways: geographical and specialty. In this study, we provided a description of the distribution of specialists in Iran in 2016 and its estimates in 2026.Methods: This descriptive-analytical study was conducted in 2016 to estimate the number of specialists in 2026.Data were gathered through a census of specialists working in each of 439 cities in the country, including those in public and private sectors. Coefficient of variation and the number of specialists in 100000 populations were applied as distribution measures.Results: In the year 2016, there were 46 specialists per 100, 000 populations, and it is estimated that considering the full-time equivalent index of 1.2, 63 specialists per 100, 000 populations will be required in the year 2026. The highest and lowest ratio of specialists per population in the year 2016 was reported in Tehran (89 per 100, 000 populations) and Jiroft (10 per 100, 000 populations), respectively. The gynecologist group and geriatric specialists group were the largest (4747 specialists) and smallest group (4 specialists), respectively.Conclusion: There was a considerable disparity between different regions of the country in terms of access to specialists. Furthermore, the ratio of specialist per population in different specialty groups varied from one province to another. Upon implementation of the Iran Roadmap, according to 2026 estimates, this dispersion will be reduced to some extent; however, part of the dispersion related to the regionalisation pilicy.

Background and Objectives: Due to lack of proper health system coverage in cities, the urban family physician program began as pilot in two provinces in Iran. Decision on developing the program to other provinces requires a comprehensive assessment. The study aimed to evaluate the program in Iran.Methods: This cross-sectional study was conducted in 2015 and 2016 in two provinces (Fars and Mazandaran).The data of 141 family physicians working in health centers and 710 patients were collected using a questionnaire. A multi-stage sampling method was used for the samples. Data analysis was performed using descriptive and inferential statistical methods.Results: 81% of the workload of family physicians in a week was patient visits. Co-payment in second and third levels was a real obstacle for some patients. The majority of the patients could receive their required healthcare facilities in up to 40 minutes. Software programs were infrequently used. Patients were visited by their physicians 5.5 times in a week. The mean duration of each patient visit was less than 10 minutes in 80% of the cases. Referral rate was reported by 14% (Fars=21.8%, Mazandaran=4%).30 out of 45 medical devices were available to family physicians on average.Conclusion: Although the program has been successful in areas such as access to health services and comprehensiveness of care, there are some challenges in coordination and continuity of care. Therefore, it is suggested that the root causes of these challenges be resolved prior to extending this program to other provinces.

The human approach to health and identification of the factors affecting it over time has changed. Understanding these approaches is helpful in promoting policymaking and good governance can be helpful in the health sector. Biomedical, psychological, health promotion, health determinants, health in all policies and one health are the most important health approaches that have emerged in different years in order. Each of these approaches has many challenges and strengths. Documents and studies show that although these health approaches have been inconsistently addressed in Iran, no specific doctrine has been define to guide the health policies. Therefore, in practice, what seems to be that a biomedical approach to health is the dominant approach in Iran's health system.

Health and human rights are two inseparable and interrelated elements, whose provision and assurance enhance welfare in any society. Definition of welfare, human rights, and health as indicators of welfare development is controversial which is done in accordance with different approaches and discourses. Although the WHO definition is currently the only definition of health agreed upon by the member states of the Organization, it has been subject to criticism by the international society. In general, the most important criticisms include ambiguity, ideality, limitlessness, lack of comprehensiveness, lack of weighting to aspects of health, being nonoperational, reductionism, and lack of a precise definition of the normal condition and disease. These criticisms would expose health systems to some challenges such as increased expectations of people, rapidly growing health expenditure, inconsistent expansion of technology-based systems, increased vulnerability to corruption, and equity and efficiency issues. Identifying and examining these criticisms can lead to a more informed decision to redefine health according to the favorable and context-sensitive discourse of the health doctrine in each country. This short review briefly describes the context and the most important criticisms of the WHO definition of health. Eventually, some policy suggestions are presented for redefining health according to Islamic-Iranian discourse.

One of the main functions of the health systems in each country is health services delivery which includes a wide spectrum of four levels. The first level includes the reduction of disease prevalence, the second level includes early detection, screening and timely treatment. In the third level, we have rehabilitation and relief services, and finally the fourth level is reducing and controlling unnecessary medical interventions. Health services delivery should encompass all of the health needs of each population in the form of these levels. The focus on just one level leads to a reduction in the importance of other levels, and disrupts comprehensive services delivery. It is obvious that, paying attention to the prevention levels can have a significant impact on reducing the later costs and consequences. At present, the provision of services at different levels of Iran's health system is not balanced, and the promotion of these services requires more attention from health policymakers. The health system of Iran is more focused on treatment and medical services and there are many challenges such as poor stewardship and disadvantages of integrated systems in the rehabilitation, relief and palliative services.