Inputs of Iranian health system reform plan from health sector managers and policy-makers' points of view

Network analysis of Iranian's health insurance ecosystem before and after the introduction of Universal Health Insurance law

INTRODUCTION

The policy-making process in health reform is challenging due to the complexity of organizations, overlapping roles, and diversity of responsibilities. The present study aims to investigate and analyze the network of actors in the Iran health insurance ecosystem regarding the laws before and after the adoption of the Universal Health Insurance (UHI).

METHODS

The present study was done by sequential exploratory mixed method research, consisting of two distinct phases. During the qualitative phase, the actors and issues pertaining to the laws of the Iranian health insurance ecosystem from 1971 to 2021 were identified through a systematic search of the laws and regulations section of the Research Center of the Islamic Legislative Assembly website. Qualitative data was analyzed in three steps using directed content analysis. During the quantitative phase, in order to draw the communication network of the actors in Iran's health insurance ecosystem, the data related to the nodes and links of the networks was collected. The communication networks were drawn using Gephi software and the micro- and macro-indicators of network were calculated and analyzed.

RESULTS

There were 245 laws and 510 articles identified in the field of health insurance in Iran from 1971 to 2021. Most of the legal comments were on financial matters and credit allocation, and the payment of premiums. The number of actors before and after the enactment of the UHI Law was 33 and 137, respectively. The Ministry of Health and Medical Education and the Iran Health Insurance Organization were found the two main actors in the network before and after the approval of this law.

CONCLUSIONS

Adopting a UHI Law and delegating various legal missions and tasks, often with support to the health insurance organization, have facilitated the achievement of the law objectives. However, it has created a poor governance system and a network of actors with low coherence. Based on the results of the study, it is suggested to reduce actor roles and separate them for better governance and to prevent corruption in health insurance ecosystem. Introducing knowledge and technology brokers can be effective in strengthening governance and filling the structural gaps between actors.

A critical analysis of Iran health system reform plan

INTRODUCTION

Iran's Health System Reform Plan (HSRP) were initiated in public and hospitals affiliated to Medical Sciences Universities in June 2015. The purpose of the present paper is to provide a critical analyse of the HSRP and its outcomes.

METHODS

The study was carried out as a review critical analyse in 2019. The pertinent articles were searched for in Science Direct, PubMed, Ovid, and Google Scholar using keywords "health sector," "reform plan," "health system reform," "health services," "health care system," and "Iran." Published articles in scientific national and international journals in Persian and English language, of which the full-texts were available, were entered into the study. Finally, from a total of 75 articles obtained, 45 studies were carefully reviewed.

RESULTS

Several factors, which impact in the success of Iran's HSRP such as social-economic and political outlooks, lack of official information and a comprehensive management system, in addition to failure to extend continuous performance control, economic sanctions against Iran. Other factors are limitations on financial transactions between Iran and the rest of the world due to the sanctions, relying merely on a few instructions, and negligence of the required infrastructures. In terms of advantages of the plan, relative decrease in patient's share in medical expenses, improvement of emergency wards, and relative decrease in the rate of C-section operations are notable.

CONCLUSION

Better implementation of Iran's HSRP entails the provision of resources and facilities such as stable and adequate resources, proper management of available resources, payment mechanisms reform, attracting, and facilitating private sector's participation.

Effect of two major health reforms on health care cost and utilization in Fars Province of Iran: family physician program and health transformation plan

Background

Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran’s health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services.

Methods

This longitudinal study was conducted on people insured by social security organization in Fars province during 2009–2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms.

Results

FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners’ and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods.

Conclusions

FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people’s access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan.

The effect of the Iranian health transformation plan on hospitalization rate: insights from an interrupted time series analysis

BACKGROUND

Healthcare policy- and decision-makers make efforts to build and maintain high-performing and effective health systems, implementing effectiveness programs and health reforms. In May 2014, the Iranian Ministry of Health and Medical Education has launched a series of ambitious reforms, known as the Health Transformation Plan (HTP). This study aimed to determine the effect of the HTP on hospitalization rate in Iranian public hospitals affiliated to the Ministry of Health and Medical Education.

METHODS

This study was designed as a quasi-experimental, counterfactual study utilizing the interrupted time series analysis (ITSA), comparing the trend of hospitalization rate before and after the HTP implementation in 16 hospitals in the Lorestan province. Data was collected from March 2012 to February 2019.

RESULTS

In the first month of the HTP implementation, an increase of 2.627 [95% CI: 1.62-3.63] was noted (P < 0.001). Hospitalization rate increased by 0.68 [95% CI: 0.32-0.85] after the HTP implementation compared to the first month after the launch of the HTP (P < 0.001). After the HTP implementation, monthly hospitalization rate per 1000 persons significantly increased by 0.049 [95% CI: 0.023-0.076] (P < 0.001).

CONCLUSIONS

The HTP implementation has resulted in an increased hospitalization rate. Health planners should continue to further improve this service. ITSA can play a role in evaluating the impact of a given health policy.

What do Iranian general practitioners expect from family physician contracts?

Background

Family medicine has become a main prerequisite of providing primary healthcare and a main reforming strategy to ensure the delivery of efficient and high-quality health services.

Aim

This study aimed to investigate general practitioners’ (GP) preferences regarding family physician contract.

Design and setting

Cross-sectional study was conducted among GPs who registered in Ministry of Health and Medical Education (MoHME) family physician plan and were working in the health network of moderately developed regions in Iran. The sample size was calculated to be 150 GPs who were randomly selected from MoHME database.

Method

Developed questionnaire was distributed to GPs. Results were analysed by ordinal regression model.

Results

Study results confirmed that ‘type of employer’ had the most significant effect on GPs’ preferences (β=0.86). Then attributes including ‘allocating quota for being accepted in medical specialty’ (β=0.78), ‘increased length of contract’ (β=0.00.42) and ‘capitation payment+15% bonus’ had respectively the great effects on participants’ decision. Findings also revealed that a scenario of contracting with medical council was 2.4 times more likely to be chosen by GPs compared with a scenario of contracting with a medical university. Furthermore, a scenario that allocated a quota for admission to medical specialty courses was 2.18 times more probable to be preferred by them (p<0.001).

Conclusion

Successful implementation of family medicine requires development of suitable solutions for attracting and attaining GPs in the programme. It seems that using a variety of incentives and applying them in physicians’ work contract would be helpful in this regard.