The Dilemma of Underutilized Health Insurance: A Matched Case-Control Study Investigating Reasons in Iran's Free Universal Health Insurance

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Relevance of the COVID-19 rapid response system to public health policymaking in Islamic Republic of Iran

BACKGROUND

The COVID-19 pandemic has increased awareness of the need for high-quality and timely evidence to support policy- and decision-making in emergency situations.

AIMS

To describe the experiences of the National Institute of Health Research (NIHR), Islamic Republic of Iran, in adopting evidence-informed policymaking during the COVID-19 pandemic.

METHODS

During the COVID-19 pandemic, NIHR institutionalized a rapid response system that was backed up by evidence-informed policy- and decision-making. Activities included establishment of a preparedness and response management committee, gathering and providing timely pandemic information to policymakers, establishing a timeline of actions and activities, and a feedback system for policy responses and queries.

RESULTS

The COVID-19 rapid response committee addressed the questions of 40 policymakers by synthesizing and analysing evidence and making it available to relevant stakeholders. It developed and disseminated knowledge products to provide relevant information. We identified the need for more timely data and more reliable research evidence for pandemic management.

CONCLUSION

National institutions responding to health emergencies need to take responsibility for establishing and managing a robust rapid response systems that can provide valid and timely evidence to policymakers. Over time, their capacity should be monitored, evaluated and strengthened to adapt and respond appropriately to pandemics, outbreaks and epidemics.

Developing Iranian sub-national primary health care measurement framework: a mixed-method study

BACKGROUND

Desired health outcomes are more achievable through strong Primary Health Care (PHC). Using comprehensive and scientific tools, decision-makers are guided to formulate better PHC reforms and policies. This study introduces a sub-national framework based on the World Health Organization (WHO) proposed frameworks for the PHC performance measurement.

METHOD

By a mixed-method and qualitative approach, the Iranian sub-national PHC Measurement Framework (PHCMF) was developed through a review of the WHO's PHC measurement conceptual framework (for selecting Key Performance Indicators (KPIs)), literature review (academic database), PHC-related national documents, consultations with an advisory committee of national experts (6-meetings), and the Delphi technique for finalizing the framework.

RESULTS

The Iranian sub-national PHCMF was finalized with 100 KPIs in three components including Health systems determinants, Service Delivery, and Health system objectives. Based on the result chain domain, most KPIs were related to the output (24 KPIs) and the least were related to the input and the process (9 KPIs).

CONCLUSION

Regarding the comprehensiveness of the developed measurement framework due to its focus on all PHC operational levers and key aspects of PHC systems' performance, it can be used as a practical tool for assessing and improving the Iranian sub-national PHC system.

The impact of health reform on poverty estimates in Iran: Implications for monitoring the first goal of Sustainable Development Goals

INTRODUCTION

Iran launched a series of health reforms called Health Transformation Plan (HTP) in order to improve financial protection and access to health care in 2014. This study aimed to investigate the extent of impoverishment due to out of pocket (OOP) payments during 2011-2016 and to assess the implications of health expenditures to overall national poverty rate before and after the HTP implementation, with a focus on monitoring the first Sustainable Development Goals (SDGs).

METHODS

The study relied on data from a nationally representative household income and expenditure survey. Two measures of poverty were estimated in this study: the prevalence (poverty headcount) and the intensity of poverty before and after OOP health payments (poverty gap). Proportion of the population fell into poverty due to OOP spending for health care from total poor population calculated for 2 years before and after the HTP implementation using three poverty lines suggested by the World Bank for global poverty comparison ($1.90, $3.2 and $5.5 per day in 2011 purchasing power parity (PPP) $).

RESULTS

Our results indicate that the incidence of impoverishing health expenditures has remained relatively low during 2011-2016. At the 2011 PPP $5.5 daily poverty line, the average incidence rate at the national level was 1.36% during the period. The percentage of population impoverished due to OOP health expenditures increased after HTP implementation, irrespective of the poverty line used. However, the proportion of individuals that pushed further into poverty decreased after HTP implementation. It was estimated that around 12.5% of total poor population fell below poverty line due to paying OOP payments in 2016.

CONCLUSION

Although health care costs are not major causes of impoverishment in Iran, the relative impact of OOP spending for health is not negligible. To attain SDG 1, pro-poor interventions that aim to reduce the burden of OOP payments should be advocated and implemented with an inter-sectoral approach.

A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses

BACKGROUND

Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment.

METHODS

We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021.

RESULTS

A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process.

CONCLUSION

Our findings highlight the need for having holistic approaches to assess community's health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal-assessment of the community health needs assessment impacts.

Developing Iranian sub-national Primary Health Care Measurement Framework: a study protocol

BACKGROUND

Developing an effective system for measurement and improvement of primary health care (PHC) based on the conditions and characteristics of the countries' health systems is one of the World Health Organization (WHO) recommendations.

AIMS

This study will aim to develop a framework to assess the Iranian sub-national PHC system performance using the WHO measurement framework for PHC.

METHODS/DESIGNS

This is a mix-method study with a triangulation design. The Iranian sub-national PHC Measurement Framework (PHCMF) will be developed through a review of the WHO's PHC measurement conceptual framework (for selecting key performance indicators (KPIs)), literature review (academic database), PHC-related national documents, consultations with national experts, and the Delphi technique for finalizing the framework. The required data for calculating selected KPIs is expected to encompass qualitative and quantitative data. Discussion: Iranian PHC system performance is not measured based on the holistic and scientific framework and international standards. The information obtained from this project will guide managers and policymakers to be aware of the current situation and the success rate of the PHC system in achieving the desired goals, as well as identify strengths and weaknesses of the PHC system and provide the solution to better policy formulation.

Safety and Effectiveness of Molnupiravir in Covid-19 Treatment: A Rapid Review

In the first stage of viral replication, Covid-19 may cause a remarkable inflammatory response in patients. Molnupiravir is an oral antiviral medicine which functions through inhibiting the viral replication of RNA viruses including Corona virus (SARS-CoV-2). The present study intends to help the policymakers decide on using of this medication in Iran. This study is conducted on Jan. 22, 2022 (from Jan. 2014 -the year of molnupiravir production for treatment of RNA virus diseases), using a rapid review of evidence as well as reviewing reliable databases including the Cochrane library, PubMed and Google scholar. The inclusion criteria were the randomized controlled trials that investigated the safety and efficacy of Molnupiravir at different doses in patients with Covid-19, comparing with placebo or other routine care methods (Population: Covid-19 patients, Intervention: molnupiravir, Control: placebo or other routine care methods, Outcome: Safety, Efficacy and Economic status, Study design: the randomized controlled trials or HTA reports). Prescription for oral administration in 800 mg dose twice daily for 5 days to inpatients and outpatients with mild, moderate or severe symptoms in the early stages of the disease (viral phase) had the most desirable level of efficacy. This medicine has no serious side effects; since the mutations caused by this medication have not been clarified yet, it is not recommended during pregnancy and/or for women planning to become pregnant. According to the manufacturing company, in the United States, each drug package is priced at $712 for a 5-day treatment period. Molnupiravir can be used in outpatients and inpatients (Over 18 years old) with moderate or severe symptoms in the early stages of the disease. But it is not recommended during pregnancy and/or for women planning to become pregnant.

COVID-19 cases, hospitalizations and deaths after vaccination: a cohort event monitoring study, Islamic Republic of Iran

Objective

To investigate the incidence of coronavirus disease 2019 (COVID-19) cases, hospitalizations and deaths in Iranians vaccinated with either AZD1222 Vaxzevria, CovIran® vaccine, SARS-CoV-2 Vaccine (Vero Cell), Inactivated (lnCoV) or Sputnik V.

Methods

We enrolled individuals 18 years or older receiving their first COVID-19 vaccine dose between April 2021 and January 2022 in seven Iranian cities. Participants completed weekly follow-up surveys for 17 weeks (25 weeks for AZD1222) to report their COVID-19 status and hospitalization. We used Cox regression models to assess risk factors for contracting COVID-19, hospitalization and death.

Findings

Of 89 783 participants enrolled, incidence rates per 1 000 000 person-days were: 528.2 (95% confidence interval, CI: 514.0-542.7) for contracting COVID-19; 55.8 (95% CI: 51.4-60.5) for hospitalization; and 4.1 (95% CI: 3.0-5.5) for death. Compared with SARS-CoV-2 Vaccine (Vero Cell), hazard ratios (HR) for contracting COVID-19 were: 0.70 (95% CI: 0.61-0.80) with AZD1222; 0.73 (95% CI: 0.62-0.86) with Sputnik V; and 0.73 (95% CI: 0.63-0.86) with CovIran®. For hospitalization and death, all vaccines provided similar protection 14 days after the second dose. History of COVID-19 protected against contracting COVID-19 again (HR: 0.76; 95% CI: 0.69-0.84). Diabetes and respiratory, cardiac and renal disease were associated with higher risks of contracting COVID-19 after vaccination.

Conclusion

The rates of contracting COVID-19 after vaccination were relatively high. SARS-CoV-2 Vaccine (Vero Cell) provided lower protection against COVID-19 than other vaccines. People with comorbidities had higher risks of contracting COVID-19 and hospitalization and should be prioritized for preventive interventions.

Prevalence, awareness, treatment and control of diabetes among Iranian population: results of four national cross-sectional STEPwise approach to surveillance surveys

Background

Diabetes as a leading cause of death imposes a heavy burden on health systems worldwide. This study investigated the trends in prevalence, awareness, treatment and control of diabetes among Iranian population aged 25 to 65 years over 12 years (2004-2016).

Methods

Secondary data analysis was performed using data from a national population-based survey, STEPwise approach to surveillance (STEPS) for non-communicable diseases (NCDs) in four rounds (2004, 2007, 2011, 2016). The sample sizes were 89,404, 29,991, 12,103 and 30,541 individuals, respectively across the country in both rural and urban areas. Data were analyzed using descriptive statistics and a logistic regression model with odds ratio at a significance level of less than 5% with no adjustment for age and sex. Logistic regression was used to identify socio-demographic factors associated with the levels of awareness, treatment and control of diabetes mellitus.

Results

The prevalence of diabetes in four rounds was 8.4, 9, 11.1 and 13.2%, respectively. Among people with diabetes, 53.5, 65.6, 70.5 and 82.2% were aware of their condition and 35.9, 42, 46 and 39.6% were treated for this condition, respectively. In four rounds of study, 14.5, 20.8, 20.4 and 18.5% of all diabetic patients had adequate glycemic control, respectively. In the multivariable logistic regression analysis, there was a significant relationship between female gender, age over 40, living in the urban area, being in the third wealth quintile and having health insurance with diabetes prevalence. Female participants were more likely to be aware of the disease. Older participants were more likely to receive treatment and had adequate glycemic control.

Conclusion

The prevalence of diabetes in Iran has been increasing and despite the great awareness of the disease, receiving treatment and effective control of the disease are suboptimal. While several national policies to improve diabetes screening and care have been passed in recent years, it seems large gaps remain in disease detection and treatment. It is suggested that more attention be paid to the treatment and control of diabetes by NCDs national policies to prevent the growing burden associated with the disease.

Global school-based student health survey: country profiles and survey results in the eastern Mediterranean region countries

Background

The increasing prevalence of non-communicable diseases (NCDs) has some major implications on many countries to achieve universal health coverage. This study aimed to investigate the implementation of Global School-based Student Health Survey (GSHS), which is used to assess the risk factors of NCDs among children and adolescents in the eastern Mediterranean region (EMR).

Methods

This study was a meta-analysis and systematic literature review of 2001–2018 published studies, which were found by searching PubMed, Google Scholar, WHO, and CDC databases. In this study, the target group was students aged between 13 and 17 years old. GSHS implementation as well as risk factors of NCDs were compared across different countries. The random-effect model for meta-analysis was considered at 95% confidence interval.

Result

In the EMR, 19 countries have implemented GSHS at least once following the survey manual (37 surveys). Overall, 201,795 students were included in our analysis. The overall estimation prevalence rateof the overweight was 24.5% (20.6–28.8), obesity was 7.3% (5.4–9.5), insufficient physical activity was 82.4% (80.7–84.1), tobacco usage was 14.3% (10.53–18.67), and smoking was 9.6% (8.1–11.3), respectively. Among those aged 13 to 17 years old, these rates were estimated as 19.8 (13.2–27.3), 9.7 (6.2–14.0), 86.1 (84.1–87.9), 17.8 (11.8–24.7), and 11.5 (9.4–13.8), respectively.

Conclusion

GSHS has been widely implemented across EMR countries. Using nationally representative data, the results show that more efforts are needed to target the NCDs risk factors among adolescents in the region.

Prevalence of tobacco use in adults; 2016 nationally representative household survey in Iran

Background:

Tobacco use is an established preventable risk factor for many noncommunicable diseases and is considered as an important indicator for monitoring progress towards Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs). This study aimed to determine the situation of tobacco use among Iranian adults using 2016 household survey.

Methods:

This is a secondary analysis of the data from 2016 nationally representative STEPwise approach to Surveillance (STEPs) survey with a sample size of 31,050. The data on tobacco consumption was gathered using questions incorporated in the survey questionnaire.

Results:

The prevalence of current tobacco use in Iran was 25.2 % (24.4-25.9) in men versus 4% (3.7-4.3) in women. The prevalence was higher in rural areas and among second wealth group. The prevalence of current daily cigarette smoking was 20.1% (19.4-20.7) in men versus 0.9% (0.8-1.1) in women). Average number of cigarettes per day among current cigarette smokers was 14.5% (14.1-14.9), mean age at start smoking among daily cigarette smokers was 21.6% (21.1-22), and 95.2% (94.4-96) of daily current daily cigarette smokers attempted for cessation during past 12 months. Prevalences of exposure to secondhand cigarette smoke among nonsmokers at homes and workplaces were 23.21% (22.65-23.76) and 18.04% (17.2-18.87), respectively.

Conclusions:

There was a large difference between the prevalence of tobacco use between men and women (25.2% vs. 4%). Higher prevalences of tobacco use in rural areas and among lower wealth quintiles require more equity-based approaches in tobacco combatting actions.

Funding for health policy and systems research in the Eastern Mediterranean region: amount, source and key determinants

OBJECTIVES

To provide an overview of the current state of funding for health policy and systems research (HPSR) on a national level across the Eastern Mediterranean region (EMR), and to examine the key factors influencing funding for HPSR in the region.

METHODS

A multistep approach was employed, involving a documentation review, secondary data analysis and key informant interviews with 30 stakeholders from five countries in the EMR. Findings are presented narratively (and where applicable as percentages).

RESULTS

National funding for research and development (R&D) in general, and for health research in particular, has been low in comparative terms and lagging behind at the global scale, while funding for HPSR has been lacking on a national level. None of the 22 EMR countries studied had explicit national funding or a budget line for HPSR. Analysis of funding sources of 1821 published HPSR articles in the EMR (2010-2019) showed that the most notable source was external/international grants (45.6%), followed by university/academia (35.1%), and government (9.5%). Although HPSR publications have been increasing over time, this still falls short of the scale needed for strengthening health systems and informing current transformations in the region. Findings from the interviews identified several factors influencing investment in or funding for HPSR in the EMR.

CONCLUSIONS

Many of the EMR's policy priorities are related to health systems, however our research finds that overall investment in health research and HPSR is still low, with limited recognition of the importance of HPSR in the EMR.

An analysis of financial protection before and after the Iranian Health Transformation Plan

Background

Protecting people against the financial consequences of health-care payments is a key objective of health systems.

Aims

We carried out a descriptive analysis of changes in health spending associated with the implementation of the latest health sector reform in the Islamic Republic of Iran, the Health Transformation Plan (HTP).

Methods

The study relied on 2 rounds of data from the Household Expenditure and Income Survey (2014 and 2015). Key indicators of financial protection in health expenditure were estimated. The Kakwani index was used for out-of-pocket (OOP) health expenditure to measure the degree of progressivity in the distribution of such payments.

Results

Total OOP per capita health expenditure showed a 2.5% relative decrease in real terms in 2015 compared to 2014. Estimation of the Kakwani index suggested OOP spending became slightly more progressive over the time period of HTP reform. The share of the population facing catastrophic health expenditure also decreased significantly from 2.9% to 2.1% at the national level. However, the incidence of impoverishment due to OOP payments increased slightly between preand post-HTP, from 0.2% to 0.5%.

Conclusion

Our findings suggest that the new policies have a positive association in improving financial protection against health costs among Iranians, albeit slightly less so for the poor. Future efforts to increase public spending for financial protection would be challenging and should rely on efficiency gains such as a move from fee-for-service to performance- based payment systems and more organized OOP collection mechanisms involving prepayment and risk pooling.

How health transformation plan was designed and implemented in the Islamic Republic of Iran?

Following his inauguration in late 2013, President Rouhani aimed to boost quality and equity in the health care delivery system. To fulfill this aim, a set of interventions, called Health Transformation Plan (HTP), were implemented. So far, it has been a heated debate whether HTP breathes a spirit of a new reform. HTP has targeted long-standing historical deficits of the Iranian health system as well as urgent problems, both of which have been, to some extent, resolved. To decrease Out-Of-Pocket (OOP) health expenditures, HTP has presented new financing mechanisms to expand a safety net to Iranian citizens fundamentally. HTP also encompassed interventions to overcome problems in the provision of health care by recruitment of health workforces, establishing new health facilities, and expanding primary health care to urban and peri-urban areas. Furthermore, performance indicators including access, quality, and patient satisfaction have been affected. Given these changes, HTP is entitled to be a health system reform. However, a new agenda within HTP is required so that the Iranian health system can obtain better value for money that is to be spending on it.

Evaluating maternal and child health indicators for the Sustainable Development Goals in 2018: what is Iran's position?

OBJECTIVES

Since many Millennium Development Goals (MDGs) were not achieved, countries including Iran—despite achieving some of the MDGs—need regular planning to achieve the Sustainable Development Goals (SDGs) by 2030. This article examines maternal and child health indicators in the early years of the SDGs in Iran relative to several other countries.

METHODS

This study was carried out through a secondary analysis of maternal and child health indicators in Iran. The results were compared with data from other countries divided into three groups: countries with upper-middle income levels, countries in the Eastern Mediterranean region, and the countries covered by the Outlook Document 1,404 (a regional classification). Then, the relationship between these indicators and the Human Development Index was investigated.

RESULTS

Iran has attained better results than other countries with respect to maternal mortality, family planning, skilled birth attendance, under-5 deaths, incidence of hepatitis B, diphtheria-tetanus-pertussis vaccination coverage, and antenatal care. In contrast, Iran performed worse than other countries with respect to under-5 wasting, under-5 stunting, and care-seeking behavior for children.

CONCLUSIONS

Overall, among the 11 indicators surveyed, Iran has attained better-than-average results and seems to be improving. We recommend that Iran continue interventions in the field of maternal and child health.

The impact of health reform in Iran on catastrophic health expenditures: Equity and policy implications

PURPOSE

In 2014, the Islamic Republic of Iran launched the Health Transformation Plan (HTP), with the goal of achieving universal health coverage (UHC) through improved financial protection and access to high-quality health services among Iranian households. We aimed to investigate the impact of the HTP on the level and pattern of out-of-pocket (OOP) payments for health care.

METHODS

Using data from two rounds (2013 and 2016) of the Iranian Statistics Centre's Household Expenditure and Income Survey (HEIS), collected before and after implementation of the HTP, we estimate changes in the level and drivers of OOP payments, and the prevalence, intensity, and distribution of catastrophic health expenditures (CHEs) among Iranian households.

FINDINGS

Our results indicate that per capita OOP payments on health remained stable during the observed period, with the largest proportion of OOP payments spent on medicines. Using thresholds of 10% and 25% of total consumption, there was a slight increase in the prevalence of CHE. The prevalence of CHE increased from 3.76% to 3.82% at threshold of 25% of total consumption. Using 40% capacity to pay threshold, prevalence diminished modestly from 2.5% to 2.37% and the intensity decreased from 13.16% to 12.32%. At all thresholds, CHE were more concentrated among wealthier households.

CONCLUSION

These results suggest that while financial protection of the poor in Iran has improved due to the HTP, more work is needed to achieve UHC in Iran. For the next phase of health reforms, more emphasis should be placed on shifting away from OOP co-payments for health financing to progressive prepayment mechanisms to facilitate better sharing of financial risks across population groups.

Developing a framework for the monitoring and evaluation of the Health Transformation Plan in the Islamic Republic of Iran: lessons learned

Background

Monitoring and evaluation of health system reforms are essential to ensure the achievement of their objectives. The latest heath sector reform in the Islamic Republic of Iran, namely, the Health Transformation Plan (HTP), was launched in 2014 and the country is embarking on the HTP to achieve universal health coverage (UHC).

Aims

The study aimed to develop the most appropriate monitoring and evaluation framework for the HTP in accordance with national and global goals and priorities, and to identify data gaps in its monitoring and evaluation.

Method

A case study and evidence-based approach was applied to develop the monitoring and evaluation framework. The model that was proposed jointly by the World Bank and the World Health Organization for monitoring and evaluation of UHC was used as the basis for the potential list of the indicators and key policy documents were reviewed, accordingly. The framework formulation process was carried out through a series of meetings with experts and senior managers working at the Ministry of Health and Medical Education, whose perspectives on the frameworks functionality and usage were regarded as valuable. The final draft was presented to policy-makers for input and approval.

Results

A data mapping revealed that at least nine national surveys were required to obtain the indicators for effective monitoring. At the time of framework designing, many indicators were not available or had not been updated for several years due to lack of available and appropriate data sources.

Conclusions

Results indicated that the country's health information system had many information gaps that should be filled to enable the tracking of UHC goals and measuring the success of the plan. Applying the proposed framework would increase the comparability of the country's health indicators at the global level and specify a path to successfully achieve the objectives of the reform.

Universal health coverage in Iran: What kind of knowledge is needed to achieve the goals?

Achieving universal health coverage (UHC), which means ensuring access to high quality and equitable services by all without financial hardship, requires local evidence. To find interventions appropriate to local needs, local knowledge and evidence are required in addition to global evidence. Thus, every country should have its own plan for research production and utilization and strengthening researchers' capacities to achieve UHC. To accomplish the goals of UHC, the research system should be able to determine the research priorities and agenda, collect resources, improve the capacity for evidence generation, and maximally utilize the country's capacity for finding local solutions by establishing research networks. In this study, inputs for UHC research priority setting in Iran and its challenges have been discussed.

Setting research priorities to achieve long-term health targets in Iran

Background

In 2015, it was estimated that the burden of disease in Iran comprised of 19 million disability-adjusted life years (DALYs), 74% of which were due to non-communicable diseases (NCDs). The observed leading causes of death were cardiovascular diseases (41.9%), neoplasms (14.9%), and road traffic injuries (7.4%). Even so, the health research investment in Iran continues to remain limited. This study aims to identify national health research priorities in Iran for the next five years to assist the efficient use of resources towards achieving the long-term health targets.

Methods

Adapting the Child Health and Nutrition Research Initiative (CHNRI) method, this study engaged 48 prominent Iranian academic leaders in the areas related to Iran’s long-term health targets, a group of research funders and policy makers, and 68 stakeholders from the wider society. 128 proposed research questions were scored independently using a set of five criteria: feasibility, impact on health, impact on economy, capacity building, and equity.

Findings

The top-10 priorities were focused on the research questions relating to: health insurance system reforms to improve equity; integration of NCDs prevention strategy into primary health care; cost-effective population-level interventions for NCDs and road traffic injury prevention; tailoring medical qualifications; epidemiological assessment of NCDs by geographic areas; equality in the distribution of health resources and services; current and future common health problems in Iran’s elderly and strategies to reduce their economic burden; the status of antibiotic resistance in Iran and strategies to promote rational use of antibiotics; the health impacts of water crisis; and research to replace the physician-centered health system with a team-based one.

Conclusions

These findings highlight consensus amongst various prominent Iranian researchers and stakeholders over the research priorities that require investment to generate information and knowledge relevant to the national health targets and policies. The exercise should assist in addressing the knowledge gaps to support both the National General Health Policies by 2025 and the health targets of the United Nations’ Sustainable Development Goals by 2030.

Feasibility assessment of using geoinformatics technology in disaster disease surveillance in a developing country, iran

BACKGROUND AND PURPOSE

Geoinformatics technology retains an unprecedented trait of performing with a supersonic speed and precision in public health management whereas the existing disease surveillance systems in developing countries lack using this technology. This article aims to assess the feasibility of using geoinformatics technology in disaster disease surveillance in a developing country, Iran.

METHODS

A self-administered questionnaire was developed based on technology acceptance model (TAM), and a semi-quantitative survey was conducted in order to collect data. Fifty TUMS & HS personnel, currently involve in disease surveillance and information technology, were included. Initially, a pilot study was conducted to test the validity and reliability of the questionnaire. Cronbach alpha, confirmatory factor analysis (CFA), and standard error of measurement (SEM) were calculated to validate the causal model.

RESULTS

The results from structural equation analysis suggested that TAM provided a constructive picture of using geoinformatics technology in disaster disease surveillance at TUMS &HS. The study found attitude (ATT) had a significant influence on participants intention to use (ITU) a new technology, and perceived ease of use (PEOU) was a strong determinant of perceived of usefulness (PU). Subsequently, PU and PEOU explained ATT substantially; even though the analysis showed insignificant statistical association among these constructs. The high R2 (Coefficient of determination) of the constructs described respondents positive instinct towards accepting a new technology.

CONCLUSION

The study reveals that personnel intent to adopt geoinformatics technology in disaster disease surveillance; and at the same time, they possess a positive attitude towards the technology. This study also found PEOU has a strong influence on PU, so information sessions and training on geoinformatics technology need to focus primarily on the applications and impacts of technology on disaster disease surveillance.

Prevalence of anemia and correlated factors in the reproductive age women in rural areas of tabas

OBJECTIVE

To find out the prevalence and relationship of anemia in reproductive age women in rural area of Tabas, center of Iran. Iron deficiency anemia is the most common nutritional problem, affecting about 41.8% of pregnant and 30.2% of non-pregnant women worldwide.

MATERIALS AND METHODS

A cross-sectional study was conducted on the random sample of 382 reproductive age women in rural areas of Tabas in March 2010. Independent sample t-test, one way analysis of variance (ANOVA) and logistic regression were applied for the data analysis.

RESULTS

The obtained data revealed a total response rate of 13.8% for prevalence of anemia, while 14.5% and 5.9% belonged to non-pregnant and pregnant participants, respectively. Low socioeconomic status (odds ratio 3.35) and high parity index (odds ratio 2.31) were associated with higher prevalence of anemia.

CONCLUSION

Although this study was conducted in a rural area of Tabas, where their average incomes were lower than average income of major cities in Iran, the prevalence of anemia was lower than the rate reported in previous studies carried out in other locations of Iran, even in high risk (pregnant women) groups.

Excess mortality during heat waves, Tehran Iran: an ecological time-series study

BACKGROUND

In the past three decades, Tehran has experienced warmer summer so we need to determine heat-related mortality to establish appropriate public health activities during hot summers. The aim of the present study was to detect heat waves during the last decades and then determine excess mortality in immediate and lagged times.

METHODS

An ecological study based on time-series model was conducted in Tehran for recent decade using generalized linear lagged model (GLLM) with Poisson regression. Maximum daily temperature was heat exposure for death outcome on the same day (lag 0), 3 (lag01) and also 7 (lag02) day moving average. Relative risk with 95% confidence was reported to quantify for increasing of daily mortalities for 1°C risen exposure. Air pollutants considered as confounders in final model.

RESULTS

Total excess mortality during 17 heat waves was 1069 (8.9 deaths/Heat wave days). All non-external cause of death increased significantly during heat waves (3-9%) and after adjusting for ozone and PM10, raised. Cause-specific deaths (especially circulatory disease) and death among elderly increased during heat waves (especially in the hottest wave). The largest positive lagged effect of hot temperature although seen during hottest waves for all mortalities. Three waves had the most harvest effect for all categories of mortalities.

CONCLUSION

Study showed excess mortalities resulted from hot temperatures and exacerbated with air pollutants in Tehran in the context of climate change. Forward displacement mortality and lagged mortalities as well as were seen, but our results were not conclusive about the displacement pattern of mortalities.

Important Risk Factors of Mortality Among Children Aged 1-59 Months in Rural Areas of Shahroud, Iran: A Community-based Nested Case-Control Study

Background:

The aim of the study was to evaluate potential risk factors of children mortality between 1-59 months of age.

Methods:

This nested case-control study was conducted among children born from June 1999 to March 2009 in rural areas of Shahroud, located in the central region of Iran using health care visit reports and follow-up data available in household health records.

Results:

Mortality was significantly associated with breastfeeding duration (OR: 0.87, 95% CI: 0.81-0.93), total health care visits (OR: 0.90, 95% CI: 0.83-0.98) and low birth weight (LBW) (OR: 7.38, 95% CI: 1.37-39.67).

Conclusion:

In our study, a longer breastfeeding period and more frequent health care visits were two important protective factors, while LBW was an important risk factor for 1-59 month child mortality. It seems, that complex and multiple factors may be involved in mortality of under 5-year-old children, so combined efforts would be necessary to improve child health indicators.

Evaluation and cost analysis of national health policy of thalassaemia screening in west-azerbaijan province of iran

BACKGROUND

Thalassaemia is one of the most common Mendelian disorders in Mediterranean area. Iran has about 26,000 Thalassaemic patients, so it is one of the most affected countries. The aim of this study was to evaluate the screening program and cost analysis of Thalassaemia prevention program in West-Azerbaijan province of Iran.

METHODS

This study evaluated the efficacy of Health system's Thalassaemia prevention program with a sensitivity analysis for its costs. The second five years of the program was evaluated. The economic burden of Thalassaemia is determined by the birth prevalence of the affected infants and the cost that is accrued to treat the infected individuals and was compared with the total cost of screening the couples for thalassemia trait.

RESULTS

The average incidence rate of major Thalassaemia was 19.8 per 100,000 live births and mean coverage rate of program was 74%. The rate of canceling the marriage among carrier couples was 53%. Cost analysis showed that the cost of screening and prenatal diagnosis program was much lower than the cost of treatment in potential thalassaemic patients.

CONCLUSIONS

The prevention program of Thalassaemia including a premarital and pre-natal screening in west Azerbaijan province is demonstrated to be cost-effective. Taking some actions in order to increase the coverage of pre-marital screening, providing pre-natal diagnosis in private and public sector, complete insurance coverage for the high-risk couples to perform the investigations more easily, were recommended.

2012-2025 Roadmap of I.R.Iran's Disaster Health Management

Objective: In line with Iran’s Comprehensive Health Sector Road Map, the National Institute of Health Research at the Tehran University of Medical Sciences developed the 2012-2025 road map of Disaster Health Management (DHM), including goals and objectives, strategies, activities and related prerequisites. This article presents the process and results of this road mapping project. Methods: The project started with an expanded literature review followed by stakeholder analysis to assess level of interest and impact of related organizations to DHM; STEEP.V methodology to define determinants with a potential impact on Iran’s HDM for duration of 2012 to 2025; strength, weakness, opportunity and threat (SWOT) analysis and formulation of goals and objectives, strategies, activities, and prerequisites. Brainstorming, group discussion and interviews with key informants were used for data collection; nominal group technique was used whenever prioritization was necessary, and Delphi panel methodology was applied for consensus development. Results: STEEP.V analysis revealed the most important Social, Technological, Environmental, Economic, Political and Value-based determinants. Iran’s DHM mission and vision were defined respectively as “Mitigation from, preparedness for, response to and recovery from consequences of natural and man-made hazards at the community level as well as to the health facilities and resources of I.R.Iran” and “In 2025, Iran’s DHM will be the most developed system in the region resulting in the least vulnerability, the highest readiness in health facilities and resources, and the highest and most effective contribution of the Iranian community to disaster resilience”, respectively. Sixteen strategies and related activities, along with the necessary prerequisites, were developed. Conclusions: This was the first attempt at comprehensive strategic planning in the field of DHM in Iran. The current framework provides Iran’s health system with a list of strategies and activities to be considered in operational planning and actions. However, a dynamic process of evaluation and revision is required to ensure that Iran’s health system goals are met by 2025. Address for correspondence: Ali Ardalan, No. 78, Italia Ave, Department of Disaster and Emergency Health, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran. Email: aardalan@gmail.com or aardalan@tums.ac.ir Citation: Ardalan A, Rajaei MH, Masoumi G, Azin A, Zonoobi V, Sarvar M, Vaskoei Eshkevari K, Ahmadnezhad E, Jafari G. 2012-2025 Roadmap of I.R.Iran’s Disaster Health Management. PLoS Currents Disasters. 2012 Jul 16

Screening for asymptomatic kidney disease in high-risk population of Urmia, Iran

INTRODUCTION. Screening programs for chronic kidney disease (CKD) are deemed to be cost effective only when they are limited to high-risk groups. We screened a sample of high-risk population of Urima, Iran. MATERIALS AND METHODS. As a pilot study for a national project, we enrolled 905 participants who had at least one risk factor for CKD (including hypertension, diabetes mellitus, or a family history of CKD). The study population was selected from among patients with Dm or hypertension and family members of those with CKD in Urima urban area and 2 randomly selected neighbor rural areas. Urine dipstick tests were done and blood sample was obtained to detect proteinuria and measure serum creatinine concentration, respectively. RESULTS. A total of 607 participants (67.1%) were enrolled from rural areas and 298 (32.9%) from the urban area. The mean serum creatinine level was 1.27 ± 0.60 mg/dL. A high serum creatinine level was demonstrated in 343 participants (37.9%), and 212 (23.4%) were demonstrated to have proteinuria. There was a significant correlation between serum creatinine level and urinary protein excretion (P = .001). There were no significant differences between rural and urban subgroups in terms of proteinuria (P = .42) and serum creatinine level (P = .08). CONCLUSIONS. The prevalence of a high creatinine level (37.9%) is so high in the high-risk population of Urmia. Our most important goal of implementing this preliminary study was to assess probable limitations and problems of performing an extensive national screening program for CKD in the future.