elham ehsanichimeh

Context: 

Evaluation of health policies and identification of their challenges are vital for improving and implementing reforms in the healthcare system. The present study was conducted to identify interventions aimed at improving primary healthcare (PHC) services in Iran.

Evidence Acquisition: 

This research utilizes a scoping review to examine reform interventions in PHC services across 10 selected countries: Qatar, Oman, Turkey, Georgia, Armenia, United Arab Emirates, Saudi Arabia, Bahrain, Kazakhstan, and Kuwait. The study covers areas such as the PHC delivery system, human resource management, financial mechanisms, and the framework of community participation and intersectoral collaboration from 2010 to 2022.

The main reform strategies for PHC systems in the reviewed countries included the establishment of family medical centers with nurse support as a comprehensive strategy for service provision in public health centers; providing comprehensive and quality healthcare service packages including maternal and child health, infectious disease immunization, chronic disease monitoring, and dental care services; health education; access to essential medications; improvement of electronic health services; implementation of health promotion and continuous prevention programs; capacity enhancement; and a greater focus on health screening programs and grading of healthcare centers.

The major findings from the reviewed countries indicate that healthcare policymakers focus on providing preventive care services, reducing maternal and child mortality, and increasing life expectancy. Programs such as referral systems, service grading, and the adoption of electronic health services are part of their reform agenda.

Economic sanctions have had adverse effects on the health of Iranians, leading to financial difficulties and negative impacts on the availability and preparedness of health facilities. Considering the limitations of the existing researches about the impact of sanctions in the health system, this study aimed to identify evidence gaps in sanction’s impacts in Iran's health system.

The research consisted of two phases: the first was a qualitative study involving 10 semi-structured interviews with key informants to identify the research needs related to the impacts of sanctions on Iran's health system. Data were analyzed using Atlas-ti software and content analysis. The second phase was a scoping review aimed to gathering existing evidence about the impacts of sanctions on health systems, utilizing targeted keywords across three English databases. The process included searching, screening,و extracting and analyzing data narratively. Finally, a comparison of research needs and existing evidence revealed gaps, leading to the formulation of questions for future research

We identified 66 research questions which organized into 5 main categories and 18 subcategories. Our review of 49 articles highlighted the impact of sanctions on Iran’s health system, including its goals, functions, contextual determinants, health education, research, and coping strategies. Notably, we synthesized the most critical research questions into 32 key areas.

Further investigations are warranted to assess the impact of sanctions on the responsiveness of the health system, governance, infrastructure, health human resources, and information systems as well as developing a comprehensive framework for the health system’s effective response to sanctions.

Providing pre-hospital emergency services is accessible in Iran but costly for the country’s health system. This study calculated the willingness to pay (WTP) for pre-hospital emergency services in Iran. Discrete choice experiment (DCE) was used to measure the population’s WTP for ambulance services focusing on time, price, and quality of services. Four hundred and sixty people in Rasht city, Iran, participated in this online survey. Participants preferred lower transfer fees (β = -0.7, P˂ 0.05), lower time of reaching to the scene (β = -0.061, P˂ 0.05), lower time to arrive to the hospitals (β = -0.038, P ˂ 0.05), Private ambulance (β = -0.151, P ˂ 0.05), and emergency medical services (EMS) technicians (β = 0.209, P ˂ 0.05). Patients’ WTP in selecting EMS services can help policymakers to provide the best services.

Assessment of disease risk with the ultimatevaim of implementing preventive strategies in the workplace is a necessity. This study was conducted to assess the risk of COVID-19 in hospital occupational groups in Saghez city, Iran.

This cross-sectional study was conducted in 2021 among three hospital occupational groups (total sample size = 300) in Saghez city, Iran, including physicians and nurses, as well as laboratory, administrative, financial, radiology and general service personnel, using the COVID-19 rapid risk analysis technique. Data were collected using a valid questionnaire based on the Likert scale and analysed (to determine acceptable, tolerable and intolerable risks) using the descriptive and inferential methods, the software used being SPSS-26.

As regards the probability variable, the highest probability of occurrence of COVID-19 was related to the general service and administrative-financial occupational groups with an average of 1.6 and 1.5, respectively. The level of attitude was generally good and excellent. The analysis of the severity of the outcome variable was at a critical level in the physicians group (42.5) and at a catastrophic level in the other groups. In total, all occupations were rated at an unacceptable risk level (H), the general service and administrative-financial occupational groups being at a higher risk than other groups. There were statistically significant differences between the types of occupation on the one hand and the variables studied, as well as the individual characteristics and COVID-19 morbidity on the other hand.

Considering the high risk of occurrence of COVID-19 among the hospital professionals it is essential to develop and implement plans aiming at preventing and reducing the disease risk in them.

In pursuing improving healthcare quality and enhancing efficiency, public hospitals in Iran have undergone numerous reforms over the past two decades. This study aimed to assess the efficiency of all public hospitals in Iran from 2012 to 2016. This study was conducted as a quantitative and descriptive-analytical research project. The authors employed an innovative approach called Extended Data Envelopment Analysis (Extended-DEA), a modification of conventional DEA, to assess the technical efficiency and productivity of 568 public hospitals. They obtained nationally representative data from official annual health reports. The data were analyzed using GAMS software version 24.3. The study found that the average efficiency score for all hospitals was 0.733. Among all the hospitals, 10.1% were deemed efficient, while 2.68% had low-efficiency scores below 0.2. The Malmquist Productivity Index (MPI) showed improvement in 49.3% of hospitals and remained unchanged at 2.3%. In comparison, 48.2% of hospitals experienced a regression in productivity from 2015 to 2016. On average, the MPI was 1.07 throughout the analysis. The findings of this study suggest that there is a need for increased efforts to improve the efficient utilization of resources in public hospitals. It highlights the importance of developing appropriate policy solutions and tools to address these efficiency challenges. In particular, one proposed strategy is the merger of small-sized district hospitals to establish larger and more efficient hospitals in different geographical regions across the country.

Drowning is one of the most prevalent accidents in aquatic environments. Although drowning has been noticed by healthcare policymakers in the world today, the issue of drowning has been neglected in the safety management of students. This research was conducted with the aim of investigating the predictors of adopting preventive behaviors from drowning trauma among students in the west of Tehran city with the approach of safety management.

This study was descriptive-analytical (cross-sectional). The statistical population of this research included all parents of students who were studying in the first grade of the selected public schools in West of Tehran city in the academic year of 2021-2022 (N=3000). The random convenience sampling was used and 340 parents participated in this study. The data collection tool was a researcher-made questionnaire with a new approach to safety management (preventing accidents by doing preventive behaviors) based on a protection motivation model (preventive behavior model), of which reliability and validity were checked. Data analysis was done using SPSS 26 software and Pearson correlation test and linear regression.

The constructs of the protection motivation model explained 67% of the variance of the behavioral intention of protection motivation and 69.7% students had no history of taking swimming classes. The highest correlation was between behavior and perceived costs (r=-0.579 and P<0.01) and 237 students (69.7%) had never exhibited preventive behaviors of learning swimming techniques or gaining swimming abilities from professional swimming coaches.

A significant relationship between the most constructs of the protection motivation model by performing drowning prevention behaviors, as well as the strongest correlation between preventive behaviors and perceived cost structure, emphasizes the design of free educational programs to increase students’ knowledge and motivation in the field of drowning prevention behaviors.

The concentration of physicians in urban areas and the lack of specialist physicians in deprived ‎areas is a global challenge. It is necessary to adopt specific, scientific and evidence-based policies ‎to increase the health sector’s resources and reduce inequality in the distribution and allocation of ‎these resources in different regions of the‏ ‏country. The Ministry of Health and Medical ‎Education, as the most important custodian of planning and policy-making for distribution of ‎specialized manpower in Iran, has designed policies.

This study aimed to analyze the incentive ‎policies for the retaining physicians in deprived areas of the country. This study has a qualitative ‎‎– retrospective design to analyze the most effective policies using the Walt and Gilson policy ‎model. Various methods were used to analyze the policies, including reviewing texts and ‎documents.

Findings of the study were classified based on the policy context, policy content, ‎policy-making process and role makers in the four law (policies or plan) of service of physicians ‎and paramedics, family physician plan, health transformation plan, and instructions on how to ‎distribute the Specialized medical graduates. Five legal, political-economic, socio-cultural, ‎international and structural factors were identified as policy making factors‏. ‏‎ In addition, ‎attention to upstream documents and the use of evidence in policy-making were identified as ‎strong points, and stakeholder ignorance and a top-down approach to planning were identified as ‎common weak points of policies.

Considering the priority of needs, provision of resources and ‎requirements, constructive interaction of planners, and continuous evaluation of programs are ‎required to formulate and implement policies and interventions.

SASHA, which stands for “evidence-informed health policy-making (EIHP)” in Persian, is a national project to draw a roadmap for strengthening EIHP in Iran. As a part of SASHA, this research aimed to develop evidencebased and context-aware policy options for increasing the capacity of decision-makers to apply EIHP in Iran.

This was a qualitative study, which was informed by a literature review of pull efforts’ capacity building programs. Based on the review, we developed policy options and validated them through an expert panel that involved twelve experts. Data were analyzed using a content analysis method.

We extracted data from 11 articles. The objectives of capacity building programs were: single-skill development, personal/professional development, and organizational development. According to these objectives, the contents and training methods of the programs vary. Capacity building programs have shown positive impacts on individual knowledge/attitudes to use EIHP. However, the impacts of programs at the organizational or the health system level remain under-researched. We followed several threads from the literature review through to the expert panel that included training the management team, instead of training managers, training for problem-solving skills, and designing tailored programs. Barriers of capacity building for EIHP regard the context of the health system (weak accountability and the widespread conflict of interest) and healthcare organizational structures (decision support systems, knowledge management infrastructures, and lack of management team). Experts suggested interventions on the barriers, particularly on resolving the conflict of interests before launching new programs. A proposed framework to increase the capacity of health policy-makers incorporates strategies at three levels: capacity building program, organizational structure, and health system context.

Conclusion :

To prepare the context of Iranian healthcare organizations for capacity building programs, the conflict of interests needs to be resolved, decision-makers should be made more accountable, and healthcare organizations need to provide more knowledge management infrastructures and decision support systems.

The prevalence of emerging and re-emerging diseases has made the need for basic preparations for all health care organizations more crucial. Strengthening preparedness and formulating crisis strategies will have a great impact on reducing casualties. Given the importance of preparing hospitals to deal with such an outbreak and reduce the resulting mortality, the present study was conducted to assess their readiness against Covid-19.

The present study is a quantitative and descriptive cross-sectional research conducted from October to March 2019. Data collection used the standard checklists prepared by the European Center for the Prevention and Control of Coronavirus and the Centers for Disease Control and Prevention, consisting of eight domains and 21 components. The minimum score that each hospital could get in this checklist was 143 and the maximum was 429. The sampling method in the present study was a census, and nine reference hospitals for Corona were included in the study. All hospitals’ directors, managers, quality officers and crisis secretaries and others related to hospital readiness during Covid-19 were recruited by the census.

On average, the hospitals scored 391 out of 429, indicating a fairly "high readiness" in dealing with Covid-19. The highest score obtained by the hospitals was 425 and the lowest score was 349. In terms of preparation areas, the hospitals’ readiness was higher than 80% in all areas. The highest readiness of hospitals was in the fifth  domain, i.e. Hand hygiene, personal protective equipment and hospital waste management. The 7th domain namely, patient placement and relocation, and patient visitor access was of the lowest preparation.

The hospitals were of fairly appropriate readiness to deal with Covid-19. This level of preparedness, despite being desirable, might not reflect the real capacity of hospitals to deal with this disease. Regular evaluation of the Covid referral hospitals could help make these hospitals more prepared. Also, the experiences of hospitals that were more prepared should be used to improve the condition of other hospitals.

 Annually, over 131000 new cases of cancer have been identified in Iran, with an increasing trend that is predicted to grow by 40% by 2025. The most important contributing factors to this increase are the improvement of the health service delivery system, increased life expectancy, and the aging of the population. The aim of this study was to develop Iran's "National Cancer Control Program" (IrNCCP).

 The present study is a cross-sectional study that was conducted in 2013 using the method of reviewing studies and documents and focused group discussions and a panel of experts. In this study, the available evidence related to cancer status and its care in Iran and other countries, as well as national and international upstream documents, were reviewed and analyzed. Then, by analyzing the current situation in Iran and other countries and conducting stakeholder analysis with the strategic planning approach, the IrNCCP was developed with a 12-year horizon consisting of goals, strategies, programs, and performance indicators.

 This program has 4 main components, including Prevention, Early Detection, Diagnosis and Treatment, and Supportive and Palliative care, as well as 7 supporting components including Governance and policy-making, Cancer Research, Developing facilities, equipment, and service delivery network, Providing and managing human resources, Providing and managing financial resources, Cancer information system management and registry, and Participation of NGOs, charities, and the private sector.

 Iran's National Cancer Control Program has been developed comprehensively with cross-sectoral cooperation and stakeholder participation. However, like any long-term health intervention, strengthening its governance structure both in terms of implementation and achievement of expected goals and evaluation and modification during the implementation of the program is essential.

Divorce is one of the most important social harms. This study investigated the divorce trends, causes, and implemented interventions.

 A qualitative approach with a content analysis method was conducted. The study data were collected by reviewing relevant documents such as scientific articles and official reports, interviewing experts, and holding focus group Discussion. Sampling was performed with purposive sampling and the snowball technique to identify experts and professionals in this area.

 In recent years, the ratio of the divorce to marriage has been increasing, and in 2016, it reached its highest level (25.3 divorce per 100 marriages). Weak literacy and marital skills, changing patterns of matching, increased individualism and self-interest seeking, unemployment, addiction, and cyber ads (online advertising) were considered the most important reasons for divorce, according to the experts’ views. Currently, a program for controlling and decreasing the divorce rate is implemented. However, the most critical challenges of the program are weak inter-sectoral collaboration and community participation, dispersing and islanding social services, and also the effect of political, economic, social, technological, environmental, and international macro factors on mentioned national program.

 Social harms inside the family are complicated. So, it requires the cooperation of scattered and islanding services in the form of comprehensive social care units for the target population throughout the country. Also, capacity building and national programs institution literacy should be strengthened.

Marine trauma threatens the lives of many people in Iran and other countries every year. It affects a majority of the young population who are in a critical period of life to be effective for the development of their society. Increasing awareness can have a positive effect on reducing these injuries. This study aimed to assess the awareness of sports science students about the factors that cause marine trauma.

The statistical population of this descriptive survey was all sports science students in the Islamic Azad University of Science and Research in 2021 (N = 325). The sample size based on Morgan's table and Cochran's formula calculation was 176 people who were selected by stratified sampling method. The data collection tool was a two-part researcher-made questionnaire including demographic information and questions. Data analysis was performed using SPSS21 software and t-test, Wilcoxon, Kruskal-Wallis, and one-way analysis of variance.

The knowledge of the majority of students (62.5%) about marine trauma was below average. The lowest score (1.86) belonged to "awareness of trauma caused by strong winds and storms" and the highest score (4.76) was related to "awareness of injuries caused by the bite of marine animals (sharks, etc."). There was no statistical l y significant relationship between gender and awareness of marine trauma. There was a significant relationship between age, education, and experience in swimming with the level of awareness of marine trauma in some components.

The majority of sports science students had poor awareness about the causes ofmarine trauma, which shows the need to pay attention to increasing the level of awareness of these students.

Despite the high prevalence of drowning in the world, global estimates may underestimate the real public health problem of drowning. The aim of this study was to determine the predictive extent of protection motivation model constructs in drowning prevention behaviors from the perspective of parents of elementary school students.

In this descriptive-analytical study, 340 parents of primary school students in the west of Tehran province were studied. Sampling was done by cluster sampling method. First, among the government schools in the west of Tehran province, 4 schools were randomly selected (2 girl’s school and 2 boys' schools with a population of approximately 300 students in the elementary school) (N = 1200). Based on Krejcie and Morgan table, the sample size was estimated 291 people.Considering the 20% drop, the sample number was 349. The data collection tool was a researcher-made questionnaire, the reliability and validity of which were assessed. Data were analyzed using SPSS19 software and Pearson correlation test and linear regression.

The mean and standard deviation of the age of the parents was 32.55± 7.50. The present research findings show that this model explains 67% of the variance of drowning marine trauma prevention behaviors. In this model, perceived severity (ß =0.157 and P = 0.011), fear (ß =0.150 and P = 0.011), perceived cost (ß-=0.153 and P = 0.019) and behavior (ß =0.213 and P = 0.004) significantly predicted drowning prevention behavior.

Due to the greater correlation between protection motivation model constructs with the observance of drowning marine trauma prevention recommendations, the design and implementation of educational programs by school health educators are effective for increasing the motivation of primary school students.

The incidence rate of cancer in Iran is lower than the global average, but this rate is increasing both in the world and in Iran in the next two decades

"Iran National Cancer Control" was developed in 2013 with a strategic planning approach and consists of 4 main processes and 7 support processes.

Some of the significant interventions taken in the main processes are: implementation of training programs, vaccinations and multi-sectoral collaboration to reduce the burden of risk factors, in the prevention component; implementation of breast, cervical and colon cancer screening programs and development of relevant protocols, cheap HPV testing with insurance coverage, and production of FIT kits, in the early detection component; development of 12 National Practice Guidelines for anticancer drugs and standardizing chemotherapy and radiotherapy services, in diagnosis and treatment component; development of supportive and palliative care management protocols and standardizing these services. In the supporting processes, the main measures taken in the form of 7 components of this program are: developing National Cancer Control Program and forming its secretariat, designing and implementing a geospatial infrastructure program, creating, developing and equipping early detection, and cancer treatment centers and referral laboratories, holding training courses, promoting insurance coverage for cancer services, and implementing an integrated cancer information management system.

This program has been able to achieve its short-term objectives in the defined periods, but in order to fully implement the program and achieve the expected outcomes, it is necessary to strengthen its governance structure and the commitment of health system policy makers to this program.

Proper management of Coronavirus Disease 2019 pandemic requires that hospitals be prepared to face the disease. The aim of this study was to review the existing tools to access the preparedness of hospitals in confrontation with COVID-19 and make their Persian translation available to health policymakers and researchers.

This was a narrative review study. The existing tools were retrieved by online searching with suitable keywords in Google, Google Scholar and PubMed, in addition to hand searching in the websites of the relevant international organizations. Searches were limited to English documents, but no time limitation was considered. After removing duplications, 335 references were entered in Endnote-5. After screening for titles and abstracts, the full texts of the remaining referencing were screened and the required information was extracted. Finally, the structure and content of the found tools were compared and analysed.

In general, three checklists compatible with the purpose of this study were found and their translations were attached to this article.
One was the Checklist developed by the CDC of Europe containing 8 domains, 21 sub-domains and 135 items. The second was developed by the CDC of the US including 3 domains, 8 sub-domains and 80 items and the last one was developed by the WHO containing 11 domains and 104 items.

With regard to the content, there was a high similarity between the checklists. The minor differences on the checklists should be considered in localizing the tools. The next step should be choosing one checklist or making a checklist with combination of the available checklists and then making validation and localization of that checklist to be able to use it in different contexts.

The Covid-19 epidemic is a great threat to human health. Countries have taken several measures to control the disease, as well as dealing with infodemics. In a situation where the infodemics makes it difficult to distinguish correct and scientific information from incorrect ones, the preparation of evidence-based content has been an effective measure, recommended by World Health Organization.In this regard, the school of Public Health at Tehran University of Medical Sciences, in collaboration with the Iran National Institute of Health Research formed a specialized committee for public education to provide evidence-based answers to public questions. The achievements of this collective efforts were providing useful and practical educational content based on the most credible evidence. In this editorial, we will look at the actions taken and the achievements of this experience.

The retention of health human resources in the deprived areas is a global challenge, especially in countries with high geographic dispersion. This study endeavored to identify incentive policies for the retention of physicians and nurses in deprived areas of Iran.

The study was conducted in two stages of review and qualitative. In the review stage, health system policies and interventions for the retention of physicians and nurses in deprived areas of Iran were identified. The list compiled to announce the opinion and complete the policies and interventions of the health system for the retention of physicians and nurses in the deprived areas was provided to 18 experts in the field of health human resources. In the second stage, these policies were prioritized by 44 experts using an electronic questionnaire. Data obtained from the responses were described using frequency, percentage, and mean. The compiled list was approved using the opinions of 18 experts in the field of health human resources. Second, these policies were prioritized through an electronic questionnaire by 44 experts. The data were described through frequency, percentage, and mean.

Following the Islamic Revolution, the Iranian health system designed and implemented eight policies, including 40 interventions, for the retention of physicians and nurses in deprived areas. Prioritization findings indicated that the Law of Service of Physicians and Paramedics, Family Physician Program, Instructions on how to distribute medical graduates, and the health transformation plan have greater and longer-term impact on retention of physicians; and the Law of Service for Physicians and Paramedics, the Law on Promoting Clinical Staff Productivity, and the health transformation plan had longer-term effects on retention of nurses.

Although policies have been effective in attracting and retaining physicians and nurses in deprived areas, they face challenges and failures. Therefore, it seems necessary for policymakers to review the overall incentive policies, and take serious action to address program challenges by creating cross-sectional coordination, sustainable funding and cost management, and awareness of physicians, nurses and patients' preferences as well as aligning policies with their services and demands.

 Coronavirus disease (COVID 19) has spread around the world since the beginning of 2020.  The definitive diagnosis of COVID19 is RT-PCR laboratory test. However because of low sensitivity, the use of the chest CT scan has become important for the rapid diagnosis and clinical decision-making. This study aims to define the diagnostic value of CT scans in the process of diagnosing COVID 19 in medical Centers.

 This study is a rapid health technology assessment (HTA) and had two major phases. In Phase 1, Rapid review was done for defining sensitivity and specificity rate of CT. During this phase, studies related to the diagnostic and technical data on the use of CT in the diagnosis of COVID19 was reviewed and sensitivity and specificity of CT in these studies were extracted. In phase 2, sequential testing was run to evaluate the diagnostic value of chest CT to diagnose COVID 19 according to 2 scenarios before and after adding RT-PCR test result.

CT scan has a high sensitivity to diagnosing cases of COVID 19. Due to its low specificity, relying on CT scan to diagnose COVID 19 alone in medical centers, can lead to a significant proportion of false positive cases. This Study showed if the probability of COVID 19 before the CT scan were about 50%, with a positive CT scan, this probability will be between 60 and 70% depending on the CT specificity.

With the available evidence, the use of CT scan lonely is not sufficient for diagnosis. The RT-PCR test is also necessary to improve the diagnosis and continue the process of treatment and isolation of patients.

Assessing the quality and evaluation of university professors is important to provide feedback on basic decision making, educational analysis and comprehensive and strategic planning for education officials. The purpose of this study was to identify factors affecting the evaluation of teachers at a military university. This study was conducted using systematic and Delphi methods in the military university of Tehran in 2016. The study included all published papers related to teaching quality. A search was performed of the following databases: SID, IranMedex, IranDoc, Magiran, PubMed, Ovid, Medline, Science Direct, Scopus, Web of Science databases and Google Scholar. Different combinations of keywords were used, and the search was limited to articles published from 2000 to 2016. The Delphi method was used for finalized and categorized factors a military university were. Out of the 838 articles, 56 papers were considered relevant and 50 effective factors in the evaluation of teachers were extracted according to the frequency of their repetition in the articles. The conceptual model of assessment of educational faculty includes 4 dimensions: "teaching quality", "individual characteristics", "educational rules" and "professional features". This was obtained using the Delphi method. The teaching quality included 20 factors, individual characteristics included 8 factors, educational rules included 5 factors and professional characteristics included 16 factors. Professors should pay attention to the factors that influence educational evaluation at a military university that may not directly affect their academic performance. Professors should also aim to acquire effective educational evaluation scores. Academic centers should familiarize faculty members with the perspectives, methods and innovations available in the field of teaching quality.

Self-medication is the use of drugs which have not been prescribed by health professionals. It is considered an important issue especially in developing countries because of side effects of irrational use of drugs and economic burden of disease. This study aim to analyze the prevalence of self-medication in Iran by provinces and socio economic and demographic factors that affect it. Data of Iranian household income and expenditures survey (HEIS) in 2016 (source Iranian Statistical Center) was used in this study. Multilevel mixed effect regression was used to find relation between explanatory variables and self-medication ratio. STATA SE v 14 was used to perform the analysis. the results of this study showed that income (coefficient = - 0.00286) and socioeconomic status had negative significant relationship with self-medication ratio, while self-medication ratio was higher in some provinces like Ardebil, Sistan va Baluchistan and Ilam and it was lower in some provinces like Khuzestan and Kurdistan. The prevalence of self-medication among Iranian people was relatively high and this ratio varies in provinces. In addition to promote population awareness about undesirable effects of the irrational drug consumption, developing strategies for drug consumption by improving prescribing pattern, OTC drugs and also increasing inspection of pharmacies is needed.

We thank Joulaei et al (1) for their insightful comments on our paper on Universal Health Coverage in Iran (2). They criticized some parts of Iran's Health Transformation Plan (HTP), and we do not disagree with some of their comments on HTP. However, we think that an evidence-based approach is needed for an in-depth analysis of HTP, which is beyond our correspondence and Joulaei et al.’s comments. Therefore, we only focus on the criticisms made to our correspondence which was related to the starting point of HTP as to whether public hospitals were an appropriate starting point or whether the primary health care (PHC) should have been the starting point for HTP. While we believe that strengthening PHC is a strategic approach and vital to achieve Universal Health Coverage (UHC), at the same time, starting HTP from hospital services was a tactically correct decision, as public policymakers were looking for a showcase of using targeted subsidies funds to do something sensible for people in social welfare. The inpatient services were an urgent challenge which caused extreme public dissatisfaction. Much earlier, the first measure taken in the health transformation plan of Turkey was prohibition of holding the corpse hostage in hospitals due to unpaid hospital costs. While this was not a significant intervention for strengthening the health system, it softened the ugly face of the system and had tangible results for people. The second reason was the ease of implementing interventions in hospital services; 70% of outpatient services are provided by the private sector in Iran, which is not well-manageable by the government. In contrast, the public sector is the largest provider of inpatient services, providing inpatient care to almost 80% of the population. As a result, intervention in public hospitals, compared to outpatient services, has been more feasible. The third reason was the chance of achieving the desired results in a shorter time. The impacts of promotive and preventive measures appear in the long-term, while curative affair measures have short-term impacts.In sum, we entirely agree that reform is useful when it addresses the most fundamental challenges of the health system. However, the progressive realization of UHC is a crucial principle, meaning that the reform should be a long-term plan which must gradually be evolved (3). Starting HTP from the public hospital should not be considered as a disadvantage since, in reality, it has attracted enough attention and support; however, HTP should have not ended up in the hospital, and it had to address other aspects that were essential for a fundamental transformation such as PHC.

Over the last 4 decades, many initiatives have been implemented to accomplish equitable accessible health care for all Iranian citizens. The latest reform to address universal health coverage (UHC) is Health Transformation Plan (HTP), which resulted in significant improvements in health outcomes. Nevertheless, several challenges in the fields of sustainability of resources, service delivery, and health governance continued to exist. These challenges should be addressed in next steps to achieve the defined goals. To tackle these challenges, a number of practical solutions can be proposed, including making health financing more resilient, defining and implementing cost control policies and cost-effective package of services, changing the current method of providers’ payment, and ensuring good governance in the health system.

Resource generation, stewardship, financing, and provision of health care services are 4 major functions of the health system. In this study, human resource management, as a vital aspect of resource generation, was studied and some interventions have been suggested for Iran.

This was a mixed method study.  Data were collected through the review of the relevant articles and government documents, interviews with human resources managers and experts in the health sector, and focus group discussions with selected authorities. The interview questions were based on a model proposed by the WHO.

The collected data were categorized into 3 broad sets: description of the current status, factors contributing to the current status, and suggested interventions for improvement. Lack of a comprehensive human resources management policy and inattention to the human resources management in the developmental plans are some of the most common problems in Iran’s health sector. Also, unequal distribution, unemployment, migration of graduates, and inadequate and ineffective participation of faculty members in universities are some other problems referred to as lack of a unified stewardship and dearth of a comprehensive human resources planning. Suggested interventions have focused on stewardship function of the health care system.

A policy brief on the human resources for health needs should be developed and added as a separate article to the upstream documents of the country (eg, Iran’s 20-year outlook plan). Implementing and monitoring operational plans for policy execution at Ministry of health has a major role in executing the adopted strategies.

Many factors affect physicians’ dispersion across various locations in Iran. Identifying these factors can be effective in planning for a fair distribution of physicians throughout geographical areas.
This study aims to identify the key factors affecting newly graduated general practitioners’ (GPs’) choice of service delivery in Iran in regard to location.
This was a mixed-method, applied study using a descriptive survey. A questionnaire was designed based on key variables extracted from relevant literature and analyzed from interviews with experts in the field. We used expert opinions to assess the questionnaire’s validity, and Cronbach’s coefficient alpha was calculated (0.925) to confirm its reliability. The questionnaire was randomly distributed among 400 participants (GPs) applying for their mandatory service in Iran during four periods in 2015 (100 participants were surveyed in each period). The data was analyzed using the 8th edition of SPSS and AMOS, and both exploratory and confirmatory factor analysis methods were applied.
Forty key factors were identified loading on five main factors during EFA, which explained 77.90% of the total variance. We used the following designations for the five factors: 1) socioeconomic developmental status, 2) geographical conditions, 3) personal reasons, 4) district health services, and 5) demographics. In CFA, the third factor has the highest weight with 0.97, and the first factor has the lowest weight with 0.89. But the slight differences among factor load show the importance of all factors. The highest weighted factor relates to a number of health center variables, such as the type of roads in the district, social development and liberation, physician efficiency in the region, and distance from the provincial capital.
To resolve the unequal geographic distribution of physicians, it is necessary to consider the key factors affecting the attractiveness of a district for GPs and the existing demand for health services. Attempting to resolve the developmental inequalities among different districts, as well as implementing motivational policies to encourage physicians to work in less developed districts, is recommended.

Academic collaboration is sharing the expertise, resources and abilities by researchers. This study examined academic collaboration among the authors of articles published in Iranian English language journals of ministry of health, indexed in the Web of Science and its correlation with article citations, 2005-2011. This study was a descriptive-analytical and cross-sectional study. The data were collected using a researcher-designed checklist. The study population was 6388 articles from 21 Iranian English language journals of ministry of health, indexed in the Web of Science. Data were collected by referring to each journal and counting the number of authors and citations allocated to any article. The obtained data were analyzed by SPSS and Excel software. A total of 6388 articles published in 21 journals were analyzed according to the intended criteria. %17.8 of journals was monthly, %19.6 was tow-monthly and% 62.7 was quarterly. On average, 4.37 authors collaborated in writing each article. The mean of collaborative coefficient was 0.67. There was positively significant correlation between the number of authors and the number of citations to each article. The academic collaboration among the authors of examined articles enjoyed a favorable status, which is indicative of spirit of teamwork among the Iranian researchers. However, the rate of citations to articles in the examined journals was not in a good condition; hence, the factors affecting citation to articles, especially academic collaboration between researchers should be taken into consideration.