نشریه راهبردهای مدیریت در نظام سلامت
سال ششم شماره 4 (پیاپی 22، زمستان 1400)

Governance in the health system is not just a vision, or a model for delivering services, but a key element in planning, implementing and evaluating activities to improve health. The main purpose of this study was to design a pattern for assessing Iran's Health System Governance.

The present study was descriptive in terms of purpose, qualitative in terms of application, and qualitative in terms of data type, which was conducted based on thematic analysis and deductive-inductive approach. 14 health system experts were selected through non-random-purposive sampling. To calculate reliability, test-retest reliability and coder reliability were used, which were 70 and 87 %, respectively. Also, Waltz and Basel method was used to assess the content validity of the extracted indices which was 85 %.

After 6 stages of thematic analysis, 137 basic themes, 15 organizing themes and 5 comprehensive themes (health system accountability, health system participation, health system policy formulation, health system service provision, health system efficiency and quality) were obtained, and finally, a model for assessing the governance of the health system in the Islamic Republic of Iran was designed. Organizational accountability included 7 themes, ethical accountability, 9, and legal accountability included 6 .Financial accountability included 8 basic themes, and efficiency and quality, 10 basic themes. Implementation included 8 themes, comprehensiveness, 4, reporting, 12, and transparency, 6. Structural policy included 23 themes, social inclusion and justice policy, 6, and fiscal policy included 11 basic themes. Medical services included 4 themes, financial services, 7, human services and human rights, 9, and information and technology services included 7 basic themes. In this pattern, participation and policy formulation were considered input, and accountability, efficiency and quality and service delivery were considered output.

Lack of a clear definition for an appropriate interdepartmental cooperation, Lack of meritocracy, having a guild oriented attitude, conflict of interests, not using a policymaking approach based on a collective evidence and wisdom are among the shortcomings of the current health system governance. In addition, healthcare costs imposed on people are too high.

The Comprehensive Child Development Center was established in 2012 in the center of Isfahan province to rapidly identify and intervene in the developmental problems of children. The aim of this study was to evaluate the implementation of this program.

This was a descriptive-analytical study conducted based on the framework for evaluating public health programs established by the Center for Disease Control and Prevention of United States of America with regard to evaluation of infrastructure, process and outcome. The infrastructure’s checklist included an area of land, equipment, workforce and equipment completed with presence of researcher at the center. Process and outcome evaluation was performed for 127 registered children during 2019. A satisfaction questionnaire was completed in person or remotely by parents of 144 children referred to the center in 2019 and 2020. Data were analyzed using descriptive statistics and independent t-test, and one-way ANOVA was carried out through SPSS 16 software.

The overall compliance of infrastructure with standards was 75.42%, with the highest compliance related to the equipment and the lowest related to the specialized workforce. The degree of compliance of the process compared with the standard one varied in different dimensions. 6.30 % of the children were cured and 76.38 % quit treatment. The most common reasons for treatment discontinuation were lack of appointment (29.53 %) and long distance (18.12 %). The overall satisfaction score was 83.90 ± 14.08. The satisfaction of the parents who completed the questionnaire in person was higher than those who completed the questionnaire remotely.

The results of this study revealed that the rate of complete cure is low and the rate of treatment discontinuation is high, whose main reasons were the lack of appointment to admit children with developmental disorders and long distance. It is suggested that, in order to solve the problem, the Ministry of Health establish more centers and provide the required workforce.

Healthcare policymakers and planners use the economic burden of the disease to determine the total cost of an outcome, illness, or accident imposed on the country. The aim of this study was to calculate the direct and indirect medical costs in Covid-19 patients with critical conditions hospitalized in the intensive care unit in Golestan province.

This descriptive-analytical study was a partial economic evaluation performed cross-sectionally, and included all hospitalized patients with critical conditions in the first 6 months of 2020 in a public hospital in the Covid-19 center (158 patients).The required data were collected from patients' records by the hospital information system. Data analysis and calculation of direct medical and indirect costs of the disease in this research study was carried out based on the incidence approach and bottom-up method from the perspective of the society.

The average direct medical cost per hospitalized patient in a critical condition was 214,926,500 rials. Hospitalization and pharmaceutical services accounted for the largest share of the costs. The average indirect cost for each patient in a critical condition was estimated at 959,577,714 rials.

The results of the study showed a huge economic burden of Covid-19 on society and the health system. The high prevalence of this disease has imposed huge economic damages on society and the country's health system.

Having an inclusive approach and explaining involvement practices and the roles played by the actors in healthcare ecosystems is a critical factor in healthcare industry. The aim of this study was to design the process pattern of value co-creation in the healthcare ecosystem.

This study was practical in terms of the goal, and descriptive-survey with a two-staged qualitative method in terms of data collection. At first, 23 articles and scientific reports regarding theoretical foundations of value co-creation in healthcare were reviewed using the systematic review, and the basic pattern was designed. Then, in order to confirm and complete the identified factors in the first stage, 10 academic and professional experts familiar with value co-creation and health care ecosystem in the country were interviewed ,selected by combining targeted judgmental and chain sampling. The data gathered from these interviews were analyzed using thematic analysis.

In this study, 3 categories and 54 subcategories concerning health ecosystem were extracted. According to the results, the final pattern was designed in 3 stages of process readiness, value network and process achievements in 3 micro, meso and macro levels. Accordingly, the roles and tasks of the actors in the health service ecosystem were explained.

Clarity of the role of the actors and making necessary preparations to implement them, paves the way for structural innovations of value co-creation process. In addition, establishing technical and legislative grounds to facilitate participation, leads to more participation. The suggested pattern can be used as a guide for value co-creation in the health service ecosystem.

Determining the income elasticities of the household health expenditures, especially for income deciles, leads to adoption of appropriate policies to control and manage health expenditures among income deciles. Therefore, the main purpose of this study was to estimate the income elasticities of urban household health expenditures by income quintiles, and also calculate inequality in distribution of urban household health expenditures in Iran.

This was a descriptive-analytical and applied study performed cross-sectionally with the Hackman two-stage method in Stata 16 software in 2021. The sample included 16,943 urban households in Statistics Center of Iran, and the data was extracted from the raw data of different sections of the cost and income questionnaire regarding urban households. Health expenditure inequality was measured by Gini coefficient, Robin Hood and Herfindal-Hershman indices.

The results showed that the income elasticity of health expenditures was 0.31 for the entire sample and 0.28, 0.66 and 0.36 for the first, second and fifth quintiles, respectively. The Gini, Robin Hood and Herfindal Hirschman indices were 0.240, 0.272 and 0.231, respectively. The increase in parents' educational level and household income, and having a child under seven and a private home had a positive effect and maternal employment had a negative effect on the increase of household health expenditures.

Health is an important asset for urban households and the income quintiles; therefore, the adoption of redistributive policies is recommended to support households, especially the ones in the 2 lowest quintiles. The results of inequality indicators demonstrate the existence of inequality in the distribution of health expenditures; so, it is recommended to upgrade health insurance programs for low-income deciles, expand the coverage of essential medical services and receive premiums based on their ability to pay.

Health belief model is a preventive model for health problems such as heart diseases. The aim of this study was defining the effect of educational intervention according to the health belief model on the beliefs of patients with a primary diagnosis of acute coronary syndrome regarding preventive behaviors of readmission.

This was a quasi-experimental study. Convenience sampling was done on patients with the primary diagnosis of acute coronary syndrome, discharging from Seyed-al-Shohada Hospital of Urmia, who were randomly selected and put into 2 groups of intervention and control (35 subjects). A researcher- made questionnaire titled “preventive behaviors of cardiac disease and readmission” was used just before, 1, and 3 months after the intervention. For statistical analysis, multiple comparisons of Bonferroni, t-test, chi-square and SPSS 17 software were used.

Before the intervention, the mean scores of all the studied areas were not significantly different in the 2 groups of intervention and control (p > 0.05), indicating that the scores of the 2 groups were similar before the study.But, after calculating the difference between the mean scores of preventive behaviors regarding readmission, in the areas of knowledge, perceived severity, perceived barriers, self-efficacy and preventive behaviors regarding readmission 1 month after the intervention, and in the areas of knowledge, perceived barriers, and guidelines for preventive behaviors and actions regarding readmission 3 months after the intervention, there was a statistically significant difference (p < 0.05). The intervention, 1 and 3 months after the implementation, had no effect on the perceived sensitivity and benefits of heart patients (p > 0.05).

Considering the positive effect of implementing the health belief model on health beliefs and preventive behaviors regarding Readmission, it is possible to improve health behaviors by holding regular training sessions and following up on patients’ status, and prevent from patients’ Readmission and hospitalization costs, which also increases the quality of their life.

Supporting domestic production, by assuming its effect on the increase of accessibility, has been acknowledged as one of the main pharmaceutical policies from two dimensions of better provision of the drugs in the market and the increase of affordability by reducing prices. Therefore, it is expected from the domestic industries to produce pharmaceutical products that, in addition to increasing access and a sustainable supply of drugs, have competitive prices compared to the rival imported products, and reduce the medical costs imposed on patients and the health system. In this study the price of domestically produced drugs were compared with the price of the similar generic ones in India.

In this study, first, India was selected for comparison due to reasons such as low price, good quality, and the possibility of commerce despite sanctions. Then, from the Iranian pharmaceutical statistics, drugs which were only produced in Iran and were highly consumed with respect to the number of sales were included in the study. Prices of Iranian and Indian medicines were extracted from related valid websites. Finally, the price of 110 drugs were compared to determine the success rate of the domestic production industry in offering a reasonable price in the absence of foreign competitors.

 According to the findings from 57 % of the drugs under study, the median consumer price of these drugs in India was lower than the Iranian consumer price. If this comparison was made with the minimum price of the Indian medicine, this percentage would reach 88.

According to the findings mentioned above, it can be concluded that reducing the drugs prices and costs does not occur in all cases of domestic production, and this alone cannot be a good justification for a complete support of the domestic production of drugs; however, it should be noted that reducing costs is not the only reason to support domestic production of these products, and policy makers may act with regard to other factors in line with supportive policies; thus,  the reasons regarding each case should be clearly defined for the health system.

One important goal of policymakers regarding economy in developed countries is to improve quality, standard and level of well-being in society. The purpose of this study was to provide a model that leads to improving the quality of public welfare in the country's governance system.

This was a combined (qualitative-quantitative) research conducted in 2020. To collect data in the qualitative section, exploratory interviews based on theme analysis, and in the quantitative part, a questionnaire, were used. Analysis of the qualitative section was done through MaxQDA 18 software, and in the quantitative section, it was done by SPSS 22 and SmartPLS 2 software. The statistical population in the qualitative method included experts in the field of policymaking and social welfare. Purposive and snowball sampling were used, which resulted in 18 interviews. The statistical population in the quantitative method included 150 managers from the Ministry of Cooperatives, Labor, and Social Welfare selected based on Cochran's formula 108.

In the qualitative part, after recording the data from the interviews, 99 initial indicators were identified. After coding based on theme analysis method, 69 indicators, 8 dimensions (social capital; public policies and policymaking; domestic and international environment; public participation and management; transparency in affairs; social security; social health; quality of governance and public welfare), and 5 components (causal, intervention, and contextual causes, strategies and consequences) were approved, and led to the creation of a public welfare governance model based on theme analysis. The results of the quantitative part indicated that the dimensions of public policies and policymaking and social capital affect domestic and international environment, public participation and management, as well as the dimension of transparency in affairs. They also affect social security and health, which in turn, affect the quality of public welfare governance.

One of the requirements for establishing and improving the governance of public welfare in Iran is addressing the 8 components and 69 indicators extracted in this model.