reza majdzadeh

The introduction of a suitable subjective model is the first step in drawing up an evaluation plan. This research was conducted to design an evaluation model for the National Maternal Mortality Surveillance System (MMSS) in Iran.

This mix method study was carried out in four phases. Firstly, the current status of the Iranian MMSS was analyzed, and secondly, various sources of information were examined to identify the guidelines on the evaluation of public health surveillance systems. The guidelines were compared to identify the evaluation steps and the actions required at each step. In addition, the components of the initial model were identified using an expert panel and through considering the results of previous phases. Two rounds of the Delphi method were employed to determine acceptance or rejection of the extracted components.

The obtained model includes four axes: (a) the description of the surveillance system (b) the general evaluation planning (c) implementation of the evaluation and (d) post-evaluation follow-ups. Some components of this model are: the purpose and operation of the system, triggers, purpose and objectives of the evaluation, data collection methods and tools, the method of presenting the findings and giving feedback.

This model presents different indicators concerning the importance of the system, questions and indicators for the evaluation of system features, standards for assessment the quality of the evaluation activities, and other important components. Using this information to design the evaluations can lead to comparable evaluation results.

 Monitoring and evaluation are crucial in ensuring the effective implementation of health priorities. This descriptive study examined the progress towards implementing Iran’s General Health Policies (IGHP) to illustrate how countries can effectively monitor and evaluate their national plans. Additionally, the study sought to identify factors that impede the full implementation of these policies.

 Available data sources, formal reports, and studies were examined to gather data on selected indicators. Then, documentary analysis and 21 semi-structured interviews were conducted to identify measures taken to materialize IGHP and factors that hindered the full implementation of IGHP. Data were analyzed using the content analysis method.

 The results showed that several indicators improved during these years, while there was no data for some indicators. There are some barriers to implementing the IGHP, including lack of full understanding of the policies, absence of necessary mechanisms and infrastructures, lack of coherency and alignment of national health plans and policies, absence of monitoring and evaluation framework, and lack of transparency and accountability in the health system. As countries continue to develop their health plans and policies, lack of clarity regarding the progress of these plans remains a concern.

 Countries need to strengthen their health planning systems and expedite the implementation of accountability mechanisms within the health system. Enhancing capacity building is essential to establish a comprehensive monitoring and evaluation framework. By fortifying these systems, countries will be better equipped to measure and track progress toward achieving their health objectives.

The economic sanctions imposed on Iran in recent decades have impacted the country's healthcare system and the health of its people. However, there has not been a thorough examination of the full scope and changes in these effects over time. Therefore, we designed a mixed-methods study, comprising a parallel quantitative analysis and qualitative study. The quantitative part assesses the effects of sanctions on public health and the healthcare system using 28 indicators, i.e., macroeconomic, healthcare resources, and health outcomes indicators at both national and sub-national levels from 2000 to 2020. The analyses will include descriptive analysis, change point regression analysis, and mediation analysis, performed using R software. The concurrent qualitative study aims to explore the pathways of the sanction effects by considering the perceptions of both patients and health policymakers. The perceptions and experiences of patients regarding living with and dealing with the long- and short-term health implications of sanctions, and the experiences of health policymakers regarding the effects of sanctions on the healthcare system will be analyzed. This study will provide comprehensive and evidence-informed recommendations for global health policymakers to support countries under economic sanctions to protect and promote the human right to health and well-being.

As a vulnerable group in HIV control programs, immigrants face various obstacles to HIV testing. Despite the effectiveness of peer interventions on health promotion in HIV testing, relatively little is known about how these interventions work. This realist review aims to understand why, how, and under what conditions peer interventions can improve immigrants’ HIV testing uptake.

We followed the steps suggested by Pawson and colleagues for conducting the realist review. To test a initial program theory, we first systematically searched databases of PubMed, Web of Science, Scopus, Embase, and Cochrane, as well as the websites of UNAIDS, World Bank, Global Fund, WHO, and IOM. After data extraction and quality appraisal, data synthesis was conducted to explain the intervention pathways corresponding to context-mechanism-outcome configurations.

Seventeen studies were included in the review. Peer interventions for improving immigrants’ HIV testing uptake worked through four pathways: Following the improvement of communications (as a proximal mechanism): 1) increasing awareness, 2) reduced stigma, 3) improved support, and 4) increased access to services could lead to improved HIV testing uptake among immigrants. The identified mechanisms were influenced by three groups of individual/ interpersonal, service delivery, and structural factors.

Peer interventions with multiple strategies to be designed and implemented considering the barriers to HIV testing and also moving beyond one-size-fits-all approaches can successfully improve the immigrants’ HIV testing uptake. The refined program theory in this study can help the healthcare providers and policy-makers promote the immigrants’ HIV testing uptake and reduce the risk of disease transmission.

Background  This review was conducted to identify the impact of economic sanctions on household food and nutrition security and policies to cope with them in countries exposed to sanctions.Methods  The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 2020 were used to identify, select, appraise, and synthesize studies. Electronic databases in addition to Persian ones have been systematically searched for all related documents published until March 2022. Exclusion criteria were: lack of data related to food insecurity in countries subject to sanction and very low quality of the article. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal checklists. The results were presented as qualitative and quantitative syntheses.Results  Of 1428 identified studies, 36 publications remained in the review, which belong to Iran (n = 8), Cuba (n = 8), Russia (n = 7), Iraq (n = 7), and Haiti (n = 6), respectively. Declining gross domestic product (GDP), devaluation of the national currency, and the quality of food, increase in inflation, unemployment, and consumer prices, infant and under 5 years mortality, energy, and protein deficiency, and the poverty rate were reported as sanction consequences. The most important strategies to improve food security were the humanitarian assistance provided by the international community (Haiti), equity and priority for vulnerable groups mainly by expanding the healthcare system (Cuba), adopting a food ration system in the oil-for-food program, and fixing the price of food baskets (Iraq), import substitution and self-sufficiency (Russia), support domestic production, direct and indirect support and compensation packages for vulnerable households (the approach of resistance economy in Iran).Conclusion  Due to the heterogeneity of studies, meta-analysis was not possible. Since inadequate physical and economic food access caused by sanctions affects especially disadvantaged and vulnerable groups, planning to improve food security and providing support packages for these groups seems necessary.

The evidence-informed deliberative processes (EDPs) guide provides a practical framework for fair priority setting of the health benefits package (HBP) that countries can reasonably use. The steps presented in the EDPs are applicable for prioritising health services in designing HBP and are consistent with practical experience in countries. However, institutionalisation must be considered an element of fairness in the priority-setting process if the aim is to reach broader goals of a health system, such as universal health coverage (UHC). Otherwise, the EDPs for priority setting might not be integrated into the formal health system or impactful, resulting in a waste of time and resources, which is unfair. Institutionalisation means formalising the desired change as an embedded and integrated system so that the change lasts over time. For the institutionalisation of EPDs, four stages are suggested, which are (1) establishing a supportive legal framework, (2) designating governance and institutional structure, (3) stipulating the EDPs processes and (4) individual and institutional capacity building.

In May 2014, the Iranian government announced it would cover all uninsured Iranians. Despite free-of-charge insurance, the studies found that the coverage still needed to be completed (93%). This study aimed to understand why certain population groups remain without insurance despite the accessibility of free-of-charge coverage. This issue is not unique to Iran; it is prevalent in many other countries where, despite free coverage, not all individuals avail themselves of it, thereby exposing themselves to risks.

In a matched case-control study, 89 non-insured patients were compared with 178 hospital-based controls with health insurance (2:1). The samples were recruited at one of the leading public hospitals in the country (Imam Khomeini Hospital Complex in Tehran) in 2019. Two insured controls were selected and matched for age (± five years) and sex for each person without insurance. A conditional logistic regression was performed to assess the magnitude of effects and the goodness of fit test used to examine the model.

Unemployment (Odds Ratio (OR)=8.33, 95% Confidence interval (CI): 1.05-50.0), being single (OR=3.69, CI: 1.18-11.55), low economic status (OR=1.85, CI: 1.02-3.33) and attitude towards performance of health insurance (OR=0.86, CI: 0.75-0.99) were affected not having health insurance.

Approaches that cover the entire population may struggle to ensure no one is left without needed services. There is a need for greater focus on vulnerable groups to achieve universal health coverage conscientiously. Moreover, improved services and education can positively shape public perceptions of insurance efficacy, affecting their enrollment choices.Health sector reform

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.

Community participation has been accepted as a promising approach to promoting health and health equality. Based on Iran's constitution and the general health policies, community participation in health is addressed as a right, and during recent decades, some measures have been put in place. However, it is critical to improve public participation in Iran's health system and institutionalize community participation in health policymaking. This study aimed to identify barriers and facilities affecting public participation in Iran's health policymaking.  

Semi-structured qualitative interviews with health policymakers, health managers and planners, and other stakeholders were conducted to collect data. The conventional content analysis approach was used to analyze the data.  

Two themes—including community level and government level—and 10 categories were identified through the qualitative analysis.  Cultural and motivational factors, lack of awareness of the right to participate, and lack of sufficient knowledge and skills are among the identified barriers in the process of establishing effective interaction. From the health governance perspective, a lack of political will is identified as one of the obstacles.   

A culture of community involvement and political will are pivotal in the sustainability of community participation in health policymaking. The provision of a suitable context for participatory processes and capacity building on the community and government levels can be useful in institutionalizing community participation in the health system.

Despite all the advancements and publicity made in regard to classical medicine, every day more and more people are interested in complementary medicine. This study was designed and conducted to determine the relative frequency of the use of Persian traditional medicine services by the people of Tehran.

This cross-sectional study was conducted using the telephone survey method in Tehran. A total of 1824 samples were included in the study based on Cochran's formula. At first, by searching databases, including Google Scholar, PubMed, Embase, and internal sources, including the Iran Medex database, numerous medical texts and articles were reviewed in the field of using traditional medicine services. Then, interview guide questions were designed and asked over the phone. Finally, the data were extracted and subjected to quantitative analysis. Frequency and percentage of relative frequency were used to describe the study data.

In the study, 62% (n = 1131) of the participants were women, and 60.5% (n = 1103) of the participants have turned to modern medicine for treatment and have also used traditional medical treatments. Also, 43.5% (n = 864) of the participants have used herbal medicines and their products; 43% (n = 616) of the participants have used Persian traditional medicine treatments as selftreatment based on their personal information; and only 46.5% (n = 666) have evaluated the therapeutic effect of Persian traditional medicine methods as “good.”

The results of the study indicate the need for more emphasis on Persian traditional medicine alongside modern medicine, more organization and supervision of traditional medicine service providers in the country, and the creation of coherent and integrated management in this field.

Childhood obesity and overweight have become major public health problems worldwide. To combat this problem, effective, sustainable, and consistent strategies are needed. In this study, the long-term effect of a school-based intervention for weight reduction was evaluated in primary school students in Tehran, Iran.

This was a cluster randomized controlled trial (RCT) conducted in 12 primary schools in a low- to middle-class district in Tehran, Iran. The participants were 334 overweight or obese primary school students (girls =164) based on World Health Organization standards, equally distributed in the intervention (n=167) and comparison (n=167) groups. It was a multi-component intervention and included nutrition education and increased physical activity (PA), a lifestyle modification program for parents, and changing the food items sold in canteens of the schools. Body mass index Z-score [BMI-Z] was determined as the primary outcome and measured at baseline, three months after baseline, at post-test (after 18 weeks), and follow-up (13-month). In total, 205 students (59.5%) completed the follow-up. Analyses were carried out based on the intention-to-treat principle using linear mixed models.

After 13 months, the BMI Z-score decreased in both intervention and comparison groups. However, the change was more significantly observed in the intervention group (adjusted change: 0.098, 95% CI: (0.03-0.16) compared with comparison group (P=0.003(. The intervention had a more significant effect on BMI Z-score among girls (adjusted change: 0.36, 95% CI: (0.27-0.45) compared with the comparison group (P<0.001)( than among boys (adjusted change: -0.14, 95% CI: (-0.23- -0.05) compared with the comparison group (P=0.002).

The intervention was an effective way to reduce BMI in the girls and the effect lasted for a relatively long time.

In 2010, Iran became the first major oil-exporting country to reduce substantially implicit energy subsidies by increasing domestic energy and agricultural prices by up to 20 times. The current research aims to evaluate the profound impact of the countywide implementation of this targeted subsidy reform (TSR) on the consumption patterns of households in Iran, specifically in relation to the consumption of healthy food commodities.

This study employed a robust approach to examine the impact of the TSR on household food consumption, as a natural experiment, using pooled cross-section data from the Household Income and Expenditure Survey (HIES) spanning the years 1992 to 2019. The analysis was based on a comprehensive interpretation of survey data, which served as the primary source for analysis. The estimation procedure utilized an interrupted time series (ITS) model to capture the parameters associated with food consumption.

The findings revealed a substantial increase in household expenditures on food immediately following the policy intervention, with an impressive rise of 823 thousand Rials (equivalent to approximately $6.36 based on the floating exchange rate in 2019). Furthermore, the results strongly indicate a significant annual upward trend in total monthly food expenditures per adult person, surpassing the pre-intervention trend by 441 thousand Rials (approximately $3.40) (P=0.044, CI=[12.86, 1016.81]). Moreover, the implementation of the policy led to an annual per capita increase in fruit consumption by 1.02 grams per day (P=0.225, CI=[- 0.68; 2.72]).

This study shows that the initial positive effects of the TSR have gradually been eroded by inflation in subsequent years. This experience can serve as a lesson for all countries that TSR should be accompanied by other measures, such as poverty alleviation interventions, in order to achieve desired long-term results.

Complementary and Alternative Medicine (CAM) is a vast area of medicine that includes both diagnosis and therapies using conventional medicine; and in this type of medicine, the principle is to maintain human health first, and then to cure diseases. Despite a huge range of advances in modern medicine, there has been surprisingly an increasing interest in CAM within recent years. Thus, it is somehow recognized as a serious, worldwide public health concern (1). One in three people uses the CAM treatments in his/her lifetime, especially for the common ailments such as backache, headache, anxiety, and depression. Many medical schools in the world have included CAM in their curriculums. For example, at the National Center for Complementary and Alternative Medicine in the United States (2), CAM covers for some educational materials in homeopathy and naturopathy courses. It is also significantly integrated in the alternative medicine systems in ancient countries such as Iran, India, and China. CAM is patient-centered and claims to facilitate patients’ self-healing process. According to the theories of this medicine, human body has innate mechanisms for maintaining health and, of course, curing illnesses. The major goal of CAM is to activate such mechanisms and mobilize the emotional and spiritual forces of each individual to fight the diseases (3). We know that CAM is basically based on empirical studies. Many researchers have reported that the social components of the tendency for complementary medicine fall into two main categories including repulsive and attractive factors. The repulsive factors are “iatrogenic effects of conventional medicine” and “superior position of the physician,” and the attractive factors consist of “systemic approach,” “socio-cultural attitude,” and “economic advantage of CAM” (4). This letter attempts to show that the reasons can be more than those factors. We believe that the reasons for the growing public tendency for CAM also consist of “Holistic factor, which means CAM relies on the body’s healing power instead of treating symptoms using medication. Thus, with this holistic belief that is spiritually, psychologically and socially more attractive to the believers, therefore, accordingly this belief increases patients’ satisfaction. Another major component of CAM is based on lifestyle modification, therefore, most of CAM methods have five common principles for a better lifestyle including proper management of stresses; spiritual approaches; exercises; removing/reducing any type of addiction (especially smoking and alcohol); and dietary recommendations. Most people believe in spirituality, so as a consequence of lacking this factor in classical medicine, CAM looks more attractive to people. CAM claims that by strengthening the immune system via self-medication methods, patient’s body is able to achieve a desirable result; thus, such an approach causes interest of patients. On the other hand, economic issues also play another major role in making CAM more interesting to the public, especially in lower socio-economic level. For example, a study indicated that about 80% of people from the Southern Hemisphere were more interested in CAM than modern medicine due to the financial issues and the lower cost of CAM treatments. Dissatisfaction with current modern drugs and the bad attitude of health care providers play another important role in higher public interest in CAM. In developing countries, over a third of the population does not have access to the basic medical facilities, so better and easier accessibility to CAM makes it more feasible and attractive in such societies.

The process of diagnosis and treatment in Persian medicine (PM) are based on the concept of Mizaj (temperament). Among the indices of Mizaj determination, anthropometric indices are less influenceable regarding age change and other environmental factors. The purpose of this study was to investigate the relationship between anthropometric indices and Mizaj.

Four PM experts determined the Mizaj of 121 participants. Those who had ≥70% agreement in their Mizaj determination by the experts were selected and their anthropometric indices were measured. The best cutoff point of each index and its relationship with the defined Mizaj were extracted using Receiver Operative Characteristic Curve and Binary Logistic Regression.

52 out of 121 participants entered the main study. The warm-Mizaj people had larger dimensions in height, shoulder, chest, palm and sole width, and head height. Cold-Mizaj people had smaller dimensions in weight, height, shoulder, chest and head. High levels of BMI, chest depth and head dimensions had the highest correlation with the wet Mizaj and lower dimensions of these indices had the highest correlation with the dry Mizaj. 

Among the anthropometric indices, chest, palm, sole dimensions, head height and weight had the highest correlation with warmness/coldness and BMI, head width and chest dimensions had the highest correlation with wetness/dryness. The BMI which is more closely related to the soft tissue, only correlates with the wetness/dryness, while, bone dimensions are associated with warmness/coldness. Further studies are needed to metricize the anthropometric indices for Mizaj determination.

In adolescence, there is a heightened inclination to cultivate stronger social networks within schools, resulting in the exchange of information. This study investigates the influential factors that shape the exchange of information among students within their classrooms.

The study involved 350 male and female middle and high school students in Hamadan. Two types of networks were constructed within each class: the communication network, representing ordinary students’ interactions, and the specific network, which focused on the exchange of sensitive information about puberty. The network centrality index was calculated, and factors influencing information transfer were evaluated through a questionnaire.

The degree of centrality in the social network of boys exceeded that of girls, with values of 55.4% versus 47.6% in the communication network, and 33.4% versus 20.1% in the specific network, respectively. The degree of centrality of students had significant positive association with the length of time that they spent with their friends. Moreover, we found the degree of centrality of students in both networks, particularly in special network, was stronger in high schools.

During adolescence, boys tend to possess a broader communication network within their classrooms, enabling them to effectively exchange information about puberty. Factors such as effective communication skills, knowledge about puberty, and spending time with their classmates play crucial roles in facilitating the exchange of information among adolescents in schools.

To improve healthcare services’ quality, countries should measure their health systems’ efficiency and performance by robust methods.

We aimed to develop a national study to measure the efficiency of the health system in Iran.

The literature review identified several methods for measuring efficiency; the most common one was data envelopment analysis (DEA). We adopted DEA, but its findings were simplistic and inaccurate, so we began to modify the method by determining the weight of each indicator. We identified the efficiency measurement indicators, in line with international standards and uniformed units, and then readjusted our input/output indicators according to the study context through four expert panels. We collected data and classified the input/output indicators, followed by determining each indicator’s weight and standard limits. Then we rationalized our previous results by applying the revised model. The initial new results of the refined model were valid, accurate, and consistent with previous studies, as approved by experts. We defined proper modeling to achieve the stated objectives. After investigating various DEA models, we finally designed a new model that was consistent with the existing data and conditions, entitled EDEA (extended DEA), to analyze other subprojects.

The conventional DEA methods may not be accurate enough to measure health systems’ efficiency. By modifying modeling process, we propose a modified DEA with a very low error rate. We suggest that others interested in measuring health system efficiency adopt our modified approach to increase accuracy and create more meaningful policy-oriented results.

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.

A successful response to the risk of human immunodefficiency virus (HIV) infection among immigrants requires improved access to HIV prevention, diagnosis, and treatment services. However, most immigrants face significant challenges in accessing HIV/AIDS services. The aim of this study was to explore the aspects influencing access to HIV/AIDS services among Afghan immigrants in Iran. This was a qualitative study using conventional content analysis that was conducted from June 2018 to April 2020 in Tehran, Iran. Purposeful sampling method was performed. We conducted 25 semi-structured interviews with three groups of stakeholders including Afghan immigrants infected with or at risk of HIV (n=8), service providers (n=8), and policymakers/managers/experts (n=9). Inductive qualitative content analysis was applied according to the Granheim and Lundman method. Data were analyzed using Open Code software version 4.03. Aspects influencing access to HIV/AIDS health services were categorized into 3 themes (that were extracted from 9 categories): 1. Cultural aspects (cultural similarities and differences, values and beliefs); 2. Psychosocial aspects (social support, stigma and discrimination); and 3. Service delivery related aspects (awareness, health services coverage and integrity, health services financing, accessibility, and continuity of care). The findings suggest that efforts to improve Afghan immigrants’ access to HIV/AIDS health services in Iran need to consider the cultural aspects, increasing HIV awareness, providing support, reducing stigma and discrimination, and improving health services coverage, integrity, financing, and continuity of accessible services.

Reliance heavily on out-of-pocket (OOP) payments, including informal payments (IPs), has undesired effects on financial risk protection and access to care. While a significant share of total health expenditure is spent on outpatient services, there is scant evidence of the patient's amount paid informally in outpatient services. Such evidence is available for inpatient services, showing the high prevalence of informal payments, ranging from 14 to 48% in the whole hospital. This study aimed to investigate the extent of OOP and IPs for outpatient services in Iran.  

A secondary data analysis of the 2015 IR Iran's Utilization of Healthcare Services (IrUHS) survey was conducted. A sample of 11,782 individuals with basic health insurance who were visited at least once by a physician in two private and public health care centers was included in this analysis. The percentage of OOP was determined and compared with the defined copayment (30%). The frequency of IPs was determined regarding the number of individuals who paid more than the defined copayments. The Mann-Whitney test also investigated the relationships between OOP percentage and IPs frequency with demographic variables.  

The share that insured patients in Iran pay for a general practitioner (GP) visit was 38% in public versus 61% in the private sector, while for a specialist practitioner visit, the figures were 80% and 96%, respectively, which is higher than defined copayment (30%). This share was significantly higher in females, urban areas, highly educated people, private service providers, and specialist visits. The frequency of IPs, who paid more than the defined copayments, was 73% for a GP in public versus 86% in the private sector, while for a specialist practitioner visit, these were 90% and 93%, respectively.   

Informal patient payments for outpatient services are prevalent in Iran. Hence, more interventions are required to eliminate or control the IPs in outpatient services, particularly in the private sector. In this regard, making a well-regulated market, reinforcing the referral system, and developing an equity-oriented essential health services package would be fundamental.

 To evaluate the structure of students' social networks (So. N) generally and in a specific network (Sp. N), in which students discuss delicate puberty concerns with their classmates, the present research examined the communication networks of students in Hamadan, Iran, a mid-sized city in Iran.   

 In this cross-sectional study, the data were collected from a total of 350 students in 14 classes from 14 schools using a stratified sampling method. In each class, the communication networks of students were examined by asking direct questions about links among them. The students’ centrality indices were computed using UCINET 6 software. Since the size of the classes was different, the centrality index was reported as a percentage, which was the number of reported links over the maximum number of possible ones.  

 The centrality index in So. Ns and Sp. Ns in boys was more than those in girls (55.4% vs 47.6% in So. N, and 33.4% vs 20.1% in Sp. N). The students’ centrality indices in So. Ns and Sp. Ns were also positively correlated (r=0.58; p<0.001). In addition, the Sp. N was around 45% lower than So. N in both sexes.  

 The communication styles among students in Sp. N appeared to be very different from those in So. N and the styles were related to demographic traits. As a result, it was determined that a thorough investigation of communication networks was essential for customizing health promotion initiatives for students.

The aim of Universal Health Coverage (UHC) is to ensure receiving essential health services without financial hardship. Good governance in the health system guarantees success in UHC. Meaningful public participation in the health policy-making cycle is one of the vital and challenging aspects of good health governance. Considering the role and importance of legislation in formation and sustainability of participatory decision-making and good governance approach in the health sector, this study endeavors to survey the alignment of the 1st-6th development plans with the Islamic Republic of Iran (IRI) Constitution regarding public participation approach in the health sector since 1989.

This study is designed and implemented as a qualitative Study. Data was extracted from legal documents including the development plan laws from 1989-2016, and IRI Constitution Law approved in 1989 and its subsequent amendments. Content analysis was carried out in a summative method.

During the years under review, governments have always received the necessary legal mandate in their program to attract public financial participation in the construction sector or to pay part of health care costs, which is in accordance with the 29th Article of the Constitution based on health rights for the Iranian population. According to various constitutional principles such as; Paragraph eight of the third principle, paragraph three of the forty-third principle and the one-hundredth principle, the engagement of the population in identifying issues and making appropriate decisions in the administration of the country, including the health sector, is recognize, but there is no legislation in the government development plans to implement these laws.

Despite the emphasis on upstream legislation and the existence of two structures, the High Council for Health and Food Security, the High Council for Health Insurance at the national level and the Islamic town and village councils at the local level, governments have focused on participatory budgeting in health rather than participatory policymaking, during the years under review in this study. Given the importance of social participation in health sector decisions in eliminating or reducing inequalities in use of health services, suggestions for the government and Ministry of Health and Medical Education are represented

Universities of medical sciences (UMSs) in Iran have geographic catchment areas (normally a province) in which they are responsible for public health services as well as provision of care by public providers. The present study strived to analyze and rank the performance of the medical sciences universities in improving the public health and primary healthcare.

Data on 41 indicators on the output (16 indicators), outcome (16 indicators), and impact (9 indicators) levels were extracted from various data sources. Principal component analysis (PCA) was used to calculate the weight for each of the indicators. The score range for each level of performance is between 0 and 1. A score of 1 indicates the highest and a score of 0 indicates the lowest level of performance. Finally, the UMSs were ranked by their scores.

The national mean performance scores of the UMSs on the output, outcome, impact, and the composite indicator levels were 0.756, 0.641, 0.561, and 0.563, respectively. The results show that the changes in performance scores at different levels of the results chain are remarkable.

The national mean performance of the UMSs of Iran is not satisfactory. However, there is considerable dispersion in their performance. Designing effective interventions in proportion to the conditions of universities on different levels of the results chain, developing a robust information system, conducting continuous monitoring and evaluation of public health are recommended for balanced improvements in public health and primary healthcare indicators in the country.