مجله تحقیقات نظام سلامت حکیم
سال بیست و یکم شماره 2 (پیاپی 81، تابستان 1397)

  A significant portion of household’s expenses is allocated to health services. This study aimed to investigate the share of health expenditure in total households’ expenditure during 2009 - 2016 and capture the changing patterns of health expenditure associated to the implantation of the Health Transformation Plan. The study relied on data from the Household, Expenditure and Income survey, which the sample size is about 38000 households per year. The average annual out-of-pocket (OOP) expenses paid by households as well as the ratio of necessary expenditure in total consumption expenditure were calculated in order to study the trend of health expenditure. Out of pocket payment among all households has a slow decreasing trend. The ratio of health expenditure to total consumption expenditure in the 10th and 1st declines of urban and rural population was 26% and 1.3%, respectively; the national level was 7% in this period. The difference in OOP between the 1st and 10th decline in urban and rural households was 29942534 Rials and 15441113 Rials, respectively in 2016. The results indicate that there is a considerable difference between OOP paid by the poorest and the richest households. However, the share of health expenditure in total households’ expenditure was almost stable during these years. Despite, the increased coverage of universal health insurance in recent years, the difference between health expenditures among income groups is almost considerable. Nevertheless, health expenditure represents a lower share of total households’ expenditure compared with other expenditures among all expenditure deciles.

  Health Transformation Plan (HTP) is the most important effort done in Iran to achieve Universal Health Coverage. This study aimed to conduct a policy analysis of HTP in therapeutic services in Iran. To qualitative analysis of HTP, Walt and Gilson’s Policy triangle and Kingdon’s multiple streams were employed. Data was collected through key informant interviews with stakeholders as well as a review of relevant documents and was analyzed using framework analysis. MAXQDA software was used. Legal, political, socioeconomic, international factors, and health system problems were the main factors triggering HTP. Challenges of therapeutic services implementing the second phase of the subsidy program and change of the government opened the political window of opportunity. The main strengths in HTP policy making process were using evidence, aligning with upstream documents, analyzing the situation, attracting the views of senior political leaders, planning simultaneously in different areas of the health service delivery, and prioritizing the urgent problems. Using a “top-down” approach in planning, ignoring some stakeholders, and the lack of coordination between the two areas of health service delivery were identified as weaknesses. The main objective of the HTP interventions was increasing the financial risk protection. Developing a master plan based on health priorities, the efficient way of resource use and constructive collaboration with relevant stakeholders is needed to make sustainable and purposeful change in next steps of HTP. The implementation of this plan undoubtedly will require sustained financing and on-time resource allocation

This study is a qualitative study that was conducted at Tehran University of Medical Sciences with the aim of identifying obstacles and facilitators of providing services at participatory sites covered by Tehran University of Medical Sciences. Experts were interviewed, the implementation was carried out, and the indexing process was performed on all interviews. All coding subjects and topics as well as the charts table were completed. Then, based on the conceptual structure form, indexing and data analysis were done. The process was positive toward the experience. The most important facilitators were the private sector, job creation, transparent guidelines, specific credits for payments, and experiences from other countries. Some of the main obstacles were inadequate physical space, shortage of manpower, lack of physician placement, weariness of equipment, delayed payments to founders, insufficient salaries for staff, strict supervision of staff oversight and attention to quantity rather than service quality, insurance and taxes. The policy of small government, the privatization of services to the private sector, and supervision by the state system has led to a positive attitude of managers towards participatory bases. In addition, the ineffectiveness of government personnel from other countries has led to the creation of participatory bases successfully. The financial and administrative constraints in purchasing, constructing, and repairing state civil-engineering units and reducing employment capacity are also due to the transfer of participatory bases. Furthermore, bases were dissatisfied with low job security and low salaries.

  According to the role of appropriate health care services in the process of economic development in each country, the availability of balanced health facilities in different geographical areas of the country is very important. Hence, in this study, the relationship between health expenditure and economic growth in Iran’s provinces in the time period of 2004 - 2015 is investigated based on the panel models and using fixed and random effect estimators. The underlying provinces are divided into three groups such as developed, less developed, and undeveloped, based on the Index of Ministry of Industry, Mining, and Trade. The results indicate that health expenditure has the positive and significant effect on economic growth in all provinces, however, this effect in developed provinces are more than two other groups. Therefore, a part of the existence gap between three groups of the provinces could be explained by the gap in health expenditure.

  Public-private partnerships (PPPs) have been constructively considered in recent years to reform health sectors in many countries. This study was conducted to review the experiences of selected countries in the use of PPP in the provision of hospital services. This study was a comparative-applied type study conducted in 2015. To collect data, valid databases and other related resources in the field of the private-sector partnership in hospital services were employed. Purposive sampling was used to choose countries such as Australia, Lesotho, Portugal, Spain, Canada, Brazil, UK, and Turkey, which had successful experiences in the field of application of the PPP in hospital services for inclusion in the study. Likewise, the only experience of Iranians in this field was reviewed. The results obtained from each country were compared in a comparative table. The findings of this study showed that items such as financing, construction, operation, maintenance, management, provision of clinical and non-clinical services, and payment structure in different PPP models can be variable from country to country. In the studied countries, successful experiences in the use of PPP, in the provision of hospital services were observed. By utilizing the experiences of successful countries and localization of participatory patterns, a good development in the health sector can be created and provide a background for the development and promotion of this model

  Rural insurance has been designed and implemented in our country to develop social justice. In the health system, identifying its challenges to improve and implement reforms is essential. The present study aimed to assess the quality of rural insurance challenges in Khorasan Razavi Province. This study was conducted with a qualitative approach and a content analysis method in 2015 in Mashhad. Eighteen managers, policy makers, family physicians, and insurers who were selected by targeted sampling until data saturation were reached. After conducting the interviews, data were analyzed through conventional content analysis approach using the MAXQDA software version 10. Data analysis consists of two main themes including: Management challenges of the rural insurance system (Inefficient financial management of credits, non-comprehensive rules, inadequate implementation of guidelines, and deficiencies in the health information management system), and cultural challenges (lack of referral system observance and inappropriate cultural context). Each category contained several subcategories. Inefficient financial management of credits, lack of comprehensive guidelines, lack of information management and inappropriate cultural context of providers are essential challenges of rural insurance challenges in Mashhad. Since the rural insurance system plays a key role in the success of family physician policy and the development of social justice, it is necessary to use the results of this study to solve the problems and challenges of rural insurance

  The cost of the hospital and the determination of the patient’s bed-day are in accordance with the needs of health and medical managers. The purpose of this study was to calculate the cost of bed-day of the intensive care unit (ICU) of Dr. Sapir Charity Hospital in Activity-Based Costing Method and compare it with the tariffs approved by the Ministry of Health and Medical Education. The type of research is applied and data collection tool is library and field. The statistical society is the cost of the financial statements of the hospital and the cases of patients admitted to the intensive care unit. Determination of the cost of the day of the ICU in 2014 was calculated using the Activity-Based Costing Method, and Microsoft Excel 2007 software. The calculations show that the cost of ICU services is 13416075195 Rials, in which direct wages cost and overhead costs are 33% and 67%, respectively. Also, the patient’s bed-day cost, by the Activity-Based Costing Method, 5250910 Rials. The main reason for the difference in calculating the cost of the study in relation to the various studies is the number of hospitalized patients, the occupational day, and the amount of costs incurred in the hospital. It was found that the cost of the flat day is higher than the approved tariff.

  Reducing the global burden of non-communicable diseases is a priority and a necessity for sustainable development. This study seeks to determine the factors affecting the maintenance of customers in the prevention and control units for noninvasive diseases. In this descriptive-analytic study in 2014, 418 patients from non-communicable disease prevention and control units of Southern Tehran health center were selected through systematic random sampling. The data were analyzed by descriptive and regression analysis and the satisfaction level of the services was examined through telephone calls. About two thirds of the participants were female. Nearly half of customers were illiterate with an elementary education and only 6% were above a diploma. A total of 94% of customers were satisfied with the services. There was a direct positive correlation between the number of visits during the period of observation and the number of contacts during the period of observation (r = 0.53, P < 0.001). The duration of follow-up was significantly correlated with the maintenance of customers (P = 0.004, OR = 1.002). Duration of follow-up of the patient, number of follow-ups from the health center, and number of visits during follow-up in those who had active documents was significantly higher than that of whom had inactive documents (P < 0.001). Despite the fact that the number of visits and number of calls during a follow-up is related to the number of referrals and their active records, which lead to greater customer loyalty, the mere satisfaction with services does not necessarily result in customer retention.

With the Eastern Mediterranean Regional Office of World Health Organization co-ordination, a regional meeting was held with the subject of “development road to universal health coverage”, with the presence of senior representatives of member countries (health minister, undersecretary of health minister, and the successor of health minister), on September 2nd to 5th in Salaleh, Oman.
In this meeting, the place of Iran had been considered special and in all of the topics, Iran had been an example stated by the lecturers.
The most important efforts were as followed: (1) The experience of four decades of providing primary health care and the input of health network, (2) financial risk protection, (3) developing the integrated health coverage interventions, and (4) correcting Health Insurance Scheme program. However, it seems that with a careful and accurate manner, deficiencies and limitation in the UHC should be identified and addressed. Some of the most important are as follows: Sustainability of financial resources for health system, improve the allocative and technical efficiency, considering the effective coverage of interventions, proper governance of health services provision, establishment and enhancement of routine health system information, and considering the health workforce distributions.