Key factors affecting health promoting behaviors among adolescents: a scoping review.

BACKGROUND: Health-promoting behaviors have been noticed recently as one of the most critical factors in raising life expectancy, which can be formed during adolescence. Thus, the current scoping review aimed to identify the key factors affecting health-promoting behaviors among adolescents. METHODS: In this scoping review, we searched multiple English online databases, including PubMed, Web of Science, Science Direct, ProQuest, and Scopus, for articles published between 1977 and 2020. All eligible studies describing health-promoting behaviors in adolescents were included. We followed the JBI guideline for conducting a scoping review and increasing the study's rigor. Extracted data were synthesized through inductive approaches. RESULTS: A total of 3199 articles were identified during the first phase. After the screening process, 20 articles were found eligible for final inclusion. Educational factors (individualized education and school health promotion programs), Economic factors (income, economic incentives and national health insurance), Social factors (support system, responsibility and peers), Spiritual, Psychological and Personal factors (gender, family structure, patterns of living, and medical problems) were found effective in health-promoting behaviors among adolescents. CONCLUSIONS: Health-promoting behaviors among adolescents require careful consideration. The current review identified some fundamental factors affecting health-promoting behaviors in adolescents. Based on the findings, it is recommended that policymakers and healthcare providers develop several interventions based on identified factors to increase adolescent's health-promoting behaviors among adolescents.

Road safety lead agency challenges of three decades of intervention for road safety in Iran: implications for policy-makers.

BACKGROUND: Road traffic crashes and associated injuries and mortalities are one of the big public health challenges, especially in low/middle-income countries. Road safety lead agency (RSLA) is a vital factor in the sustainable prevention and promotes road safety. In the recent decades, various policy interventions have been conducted for road safety in Iran. This study aimed at exploring the challenges of RSLA from the perspectives of stakeholders at various levels. METHODS: A qualitative study was conducted. In-depth interviews and document reviews were used for data collection. To conduct interviews, different stakeholders at various levels such as policy-makers, senior national authorities, researchers and faculty members were selected. Data collection was conducted between November 2019 and June 2020. Thematic content analysis approach was used for data analysis. RESULTS: The experts' perspectives were analysed and then categorised under five main themes including the role and position of the lead agency, the role and duties of the actors and players, translating policy into practice, intrasectoral and intersectoral cooperation and coordination and evidence production and application and a total of 22 subthemes were identified. The current structure of the RSLA is one of the main challenges emphasised by the research participants. CONCLUSION: To achieve significant improvements in road safety at the national level, a strong management system and leadership body is a critical issue. Organisational reform to establish an effective unique lead agency is proposed to cope with RSLA challenges.

Factors Affecting Health Policies for Older People in Iran.

Globally, the number and proportion of people aged 60 years and older is growing fast. As people age, health needs become more complex, and the health system's responsiveness to older people's needs requires evidence-informed policies. Hence, this study explores the factors affecting the health policy development process for older people in Iran. We conducted 32 interviewers with people aged 60 years and older and 21 interviews with key informants involved in policy making related to older people. Qualitative data were analyzed using thematic analysis. Actors and stakeholders, policy structure, selected health policy processes, the health care service delivery system, government financial support, and community and culture building are the most influential factors in health policy making for older people. Government policies and health priority interventions are needed to address these influential factors for older people to ensure healthy aging over the life course.

Incidence of symptomatic COVID-19 in close contacts of patients after discharge from hospital.

BACKGROUND: There is a little evidence about the infectiousness of recovered COVID-19 patients. Considering that the circumstance of the isolation of the COVID-19 patients after-discharge is not always optimal, it is not very unlikely that viral transmission still occurs after hospital discharge. This study aims to investigate the incidence of symptomatic COVID-19 in close contacts of recovered patients after discharge from hospital. METHODS: Four hundred fifty discharged COVID-19 patients discharged from the largest public treatment center in Tehran, capital city of Iran, were followed up. Demographic and clinical data of participants were collected from medical records. Follow-up data were acquired via telephone call interviews with patients or their main caregivers at home. RESULTS: The study's response rate was 93.77% (422 participated in the study). 60.90% patients were male and 39.10% were female (sex ratio = 1.55 male). The most prevalent comorbidities in these patients were hypertension (29.68%) and diabetes (24.80%). The mean of home isolation after discharge was 25.85. Forty-one (9.71%) patients had at least one new case in their close contacts, up to 3 weeks after they were discharged. There was a significant association between having at least a comorbidity with the odds of getting infected in close contacts [OR (CI) 2.22 (1.05-4.68)]. Density of inhabitant per room in a house' and the quality of isolation had significant associations with observing new cases in the patients' close contacts [high to moderate; OR (CI) 2.44 (1.06-5.61], [bad to good; OR (CI) 2.31 (1.17-4.59)], respectively. CONCLUSION: After hospital discharge, COVID-19 transmission can still occur, when a large number of people lives together in a single house. Another explanation can be that the less precaution measures are taken by recovered patients' cohabitants. Such conditions are also likely to happen when the recovered patient has other chronic diseases and requires additional care.

Strategies for utilisation management of hospital services: a systematic review of interventions.

BACKGROUND: To achieve efficiency and high quality in health systems, the appropriate use of hospital services is essential. We identified the initiatives intended to manage adult hospital services and reduce unnecessary hospital use among the general adult population. METHODS: We systematically reviewed studies published in English using five databases (PubMed, ProQuest, Scopus, Web of Science, and MEDLINE via Ovid). We only included studies that evaluated interventions aiming to reduce the use of hospital services or emergency department, frequency of hospital admissions, length of hospital stay, or the use of diagnostic tests in a general adult population. Studies reporting no relevant outcomes or focusing on a specific patient population or children were excluded. RESULTS: In total, 64 articles were included in the systematic review. Nine utilisation management methods were identified: care plan, case management, care coordination, utilisation review, clinical information system, physician profiling, consultation, education, and discharge planning. Primary case management was shown to effectively reduce emergency department use. Care coordination reduced 30-day post-discharge hospital readmission or emergency department visit rates. The pre-admission review program decreased elective admissions. The physician profiling, concurrent review, and discharge planning effectively reduced the length of hospital stay. Twenty three studies that evaluated costs, reported cost savings in the hospitals. CONCLUSIONS: Utilisation management interventions can decrease hospital use by improving the use of community-based health services and improving the quality of care by providing appropriate care at the right time and at the right level of care.

Individual and institutional capacity-building for evidence-informed health policy-making in Iran: a mix of local and global evidence.

BACKGROUND: Providing valid evidence to policy-makers is a key factor in the development of evidence-informed policy-making (EIPM). This study aims to review interventions used to promote researchers' and knowledge-producing organizations' knowledge and skills in the production and translation of evidence to policy-making and explore the interventions at the individual and institutional level in the Iranian health system to strengthen EIPM. METHODS: The study was conducted in two main phases: a systematic review and a qualitative study. First, to conduct the systematic review, the PubMed and Scopus databases were searched. Quality appraisal was done using the Joanna Briggs Institute checklists. Second, semi-structured interviews and document review were used to collect local data. Purposive sampling was used and continued until data saturation. A qualitative content analysis approach was used for data analysis. RESULTS: From a total of 11,514 retrieved articles, 18 papers were eligible for the analysis. Based on the global evidence, face-to-face training workshops for researchers was the most widely used intervention for strengthening researchers' capacity regarding EIPM. Target audiences in almost all of the training programmes were researchers. Setting up joint training sessions that helped empower researchers in understanding the needs of health policy-makers had a considerable effect on strengthening EIPM. Based on the local collected evidence, the main interventions for individual and institutional capacity-building were educational and training programmes or courses related to the health system, policy-making and policy analysis, and research cycle management. To implement the individual and institutional interventions, health system planners and authorities and the community were found to have a key role as facilitating factors. CONCLUSION: The use of evidence-based interventions for strengthening research centres, such as training health researchers on knowledge translation and tackling institutional barriers that can prevent well-trained researchers from translating their knowledge, as well as the use of mechanisms and networks for effective interactions among policy-makers at the macro and meso (organizational) level and the research centre, will be constructive for individual and institutional capacity-building. The health system needs to strengthen its strategic capacity to facilitate an educational and training culture in order to motivate researchers in producing appropriate evidence for policy-makers.

Policy options for strengthening evidence-informed health policy-making in Iran: overall SASHA project findings.

BACKGROUND: The institutionalization of evidence-informed health policy-making (EIHP) is complex and complicated. It is complex because it has many players and is complicated because its institutionalization will require many changes that will be challenging to make. Like many other issues, strengthening EIHP needs a road map, which should consider challenges and address them through effective, harmonized and contextualized strategies. This study aims to develop a road map for enhancing EIHP in Iran based on steps of planning. METHODS: This study consisted of three phases: (1) identifying barriers to EIHP, (2) recognizing interventions and (3) measuring the use of evidence in Iran's health policy-making. A set of activities was established for conducting these, including foresight, systematic review and policy dialogue, to identify the current and potential barriers for the first phase. For the second phase, an evidence synthesis was performed through a scoping review, by searching the websites of benchmark institutions which had good examples of EIHP practices in order to extract and identify interventions, and through eight policy dialogues and two broad opinion polls to contextualize the list of interventions. Simultaneously, two qualitative-quantitative studies were conducted to design and use a tool for assessing EIHP in the third phase. RESULTS: We identified 97 barriers to EIHP and categorized them into three groups, including 35 barriers on the "generation of evidence" (push side), 41 on the "use of evidence" (pull side) and 21 on the "interaction between these two" (exchange side). The list of 41 interventions identified through evidence synthesis and eight policy dialogues was reduced to 32 interventions after two expert opinion polling rounds. These interventions were classified into four main strategies for strengthening (1) the education and training system (6 interventions), (2) the incentives programmes (7 interventions), (3) the structure of policy support organizations (4 interventions) and (4) the enabling processes to support EIHP (15 interventions). CONCLUSION: The policy options developed in the study provide a comprehensive framework to chart a path for strengthening the country's EIHP considering both global practices and the context of Iran. It is recommended that operational plans be prepared for road map interventions, and the necessary resources provided for their implementation. The implementation of the road map will require attention to the principles of good governance, with a focus on transparency and accountability. Video abstract.

Iran health insurance system in transition: equity concerns and steps to achieve universal health coverage.

BACKGROUND: Equity, efficiency, sustainability, acceptability to clients and providers, and quality are the cornerstones of universal health coverage (UHC). No country has a single way to achieve efficient UHC. In this study, we documented the Iranian health insurance reforms, focusing on how and why certain policies were introduced and implemented, and which challenges remain to keep a sustainable UHC. METHODS: This retrospective policy analysis used three sources of data: a comprehensive and chronological scoping review of literature, interviews with Iran health insurance policy actors and stakeholders, and a review of published and unpublished official documents and local media. All data were analysed using thematic content analysis. RESULTS: Health insurance reforms, especially health transformation plan (HTP) in 2014, helped to progress towards UHC and health equity by expanding population coverage, a benefits package, and enhancing financial protection. However, several challenges can jeopardize sustaining this progress. There is a lack of suitable mechanisms to collect contributions from those without a regular income. The compulsory health insurance coverage law is not implemented in full. A substantial gap between private and public medical tariffs leads to high out-of-pocket health expenditure. Moreover, controlling the total health care expenditures is not the main priority to make keeping UHC more sustainable. CONCLUSION: To achieve UHC in Iran, the Ministry of Health and Medical Education and health insurance schemes should devise and follow the policies to control health care expenditures. Working mechanisms should be implemented to extend free health insurance coverage for those in need. More studies are needed to evaluate the impact of health insurance reforms in terms of health equity, sustainability, coverage, and access.

Assessment of medical equipment maintenance management: proposed checklist using Iranian experience.

BACKGROUND: Effective maintenance management of medical equipment is one of the major issues for quality of care, for providing cost-effective health services and for saving scarce resources. This study aimed to develop a comprehensive checklist for assessing the medical equipment maintenance management (MEMM) in the Iranian hospitals. METHODS: This is a multi-methods study. First, data related to factors which affect the assessment of MEMM were collected through a systematic review in PubMed, ProQuest, Scopus, Embase, and web of science without any time limitation until October 2015, updated in June 2017. Then, we investigated these factors affecting using document review and interviews with experts in the Iranian hospitals. In the end, the results of the first and second stages were combined using content analysis and the final checklist was developed in a two-round Delphi. RESULTS: Using a combination of factors extracted from the systematic and qualitative studies, the primary checklist was developed in the form of assessment checklists in seven dimensions. The final checklist includes 7 dimensions and 19 sub-categories: "resources = 3," "quality control = 3," "information bank = 4," "education = 1," "service = 3," "inspection and preventive maintenance = 2" and "design and implementation = 3." CONCLUSIONS: Developing an assessment checklist for MEMM provide a comprehensive framework for the proper implementation of accurate assessment of medical equipment maintenance. This checklist can be used to improve the profitability of health facilities and the reliability of medical equipment. In addition, it is implicated in the decision-making in support of selection, purchase, repair and maintenance of medical equipment, especially for capital equipment managers and medical engineers in hospitals and also for the assessment of this process.

Engagement of non-governmental organisations in moving towards universal health coverage: a scoping review.

BACKGROUND: Developing essential health services through non-governmental organisations (NGOs) is an important strategy for progressing towards Universal Health Coverage (UHC), especially in low- and middle-income countries. It is crucial to understand NGOs' role in reaching UHC and the best way to engage them. OBJECTIVE: This study reviewed the role of NGOs and their engagement strategies in progress toward UHC. METHOD: We systematically reviewed studies from five databases (PubMed, Web of Science (ISI), ProQuest, EMBASE and Scopus) that investigated NGOs interventions in public health-related activities. The quality of the selected studies was assessed using the mixed methods appraisal tool. PRISMA reporting guidelines were followed. FINDINGS: Seventy-eight studies met the eligibility criteria. NGOs main activities related to service and population coverage and used different strategies to progress towards UHC. To ensure services coverage, NGOs provided adequate and competent human resources, necessary health equipment and facilities, and provided public health and health care services strategies. To achieve population coverage, they provided services to vulnerable groups through community participation. Most studies were conducted in middle-income countries. Overall, the quality of the reported evidence was good. The main funding sources of NGOs were self-financing and grants from the government, international organisations, and donors. CONCLUSION: NGOs can play a significant role in the country's progress towards UHC along with the government and other key health players. The government should use strategies and interventions in supporting NGOs, accelerating their movement toward UHC.

Preventing and controlling water pipe smoking: a systematic review of management interventions.

BACKGROUND: Water pipe smoking (WPS) is re-gaining widespread use and popularity among various groups of people, especially adolescents. Despite different adverse health effects of WPS, many of the WPS interventions have failed to control this type of tobacco smoking. This study was conducted to identify experienced management interventions in preventing and controlling WPS worldwide. METHODS: A systematic literature review was conducted. Electronic databases were searched for recordes which were published from beginning 1990 to August 2018. Studies aiming at evaluating, at least, one intervention in preventing and controlling WPS were included in this review, followed by performing the quality assessment and data extraction of eligible studies by two independent investigators. Finally, interventions that were identified from the content analysis process were discussed and classified into relevant categories. RESULTS: After deleting duplications, 2228 out of 4343 retrieved records remained and 38 studies were selected as the main corpus of the present study. Then, the identified 27 interventions were grouped into four main categories including preventive (5, 18.51%) and control (8, 29.62%) interventions, as well as the enactment and implementation of legislations and policies for controlling WPS at national (7, 25.92%) and international (7, 25.92%) levels. CONCLUSION: The current enforced legislations for preventing and controlling WPS are not supported by rigorous evidence. Informed school-based interventions, especially among adolescents can lead to promising results in preventing and controlling WPS and decreasing the effects of this important social and health crisis in the global arena.

Developing a prioritisation framework for patients in need of coronary artery angiography.

BACKGROUND: Effective waiting list management and comprehensive prioritisation can provide timely delivery of appropriate services to ensure that the patient needs are met and increase equity in the provision of health services. We developed a prioritisation framework for patients in need of coronary artery angiography (CAA). METHODS: We used a multi-methods approach to elicit effective factors that affect CAA patient prioritisation. Qualitative data wase collected using semi-structured interviews with 15 experts. The final set of factors was selected using experts' consensus through modifed Delphi technique. The framework was finalised during expert panel meetings. RESULTS: 212 effective factors were identified based on the literature review, interviews, and expert panel discussion of them, 37 factors were selected for modifed Delphi study. Following two rounds of Delphi discussions, seven final factors were selected and weighed by ten experts using pair-wise comparisons. The following weights were given: the severity of pain and symptoms (0.22), stress testing (0.18), background diseases (0.15), number of myocardial infarctions (0.15), waiting time (0.10), reduction of economic and social performance (0.12), and special conditions (0.08). CONCLUSION: Clinical effective factors were important for CAA prioritisation framework. Using this framework can potentially lead to improved accountability and justice in the health system.

Public-private partnerships in primary health care: a scoping review.

BACKGROUND: The Astana Declaration on Primary Health Care reiterated that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals. It called for governments to give high priority to PHC in partnership with their public and private sector organisations and other stakeholders. Each country has a unique path towards UHC, and different models for public-private partnerships (PPPs) are possible. The goal of this paper is to examine evidence on the use of PPPs in the provision of PHC services, reported challenges and recommendations. METHODS: We systematically reviewed peer-reviewed studies in six databases (ScienceDirect, Ovid Medline, PubMed, Web of Science, Embase, and Scopus) and supplemented it by the search of grey literature. PRISMA reporting guidelines were followed. RESULTS: Sixty-one studies were included in the final review. Results showed that most PPPs projects were conducted to increase access and to facilitate the provision of prevention and treatment services (i.e., tuberculosis, education and health promotion, malaria, and HIV/AIDS services) for certain target groups. Most projects reported challenges of providing PHC via PPPs in the starting and implementation phases. The reported challenges and recommendations on how to overcome them related to education, management, human resources, financial resources, information, and technology systems aspects. CONCLUSION: Despite various challenges, PPPs in PHC can facilitate access to health care services, especially in remote areas. Governments should consider long-term plans and sustainable policies to start PPPs in PHC and should not ignore local needs and context.

A scoping review of public hospitals autonomy in Iran: from budgetary hospitals to corporate hospitals.

BACKGROUND: Organizational reforms of hospitals in Iran are mainly aimed at improving efficiency, reducing government spending on health care, and improving the quality of services. These reforms began with hospital autonomization and have continued with other initiatives such as formation of board of trustees, independent and corporatized hospitals. OBJECTIVE: The purpose of this scoping review was to summarize and compare the results of studies conducted on organizational reform of hospitals in Iran to paint a more clear picture of the status quo by identifying knowledge gaps, inform policymakers, and guide future studies and policies. METHOD: This review's methodology was inspired by Arksey and O'Malley's methodological framework to examine the extent, range, and nature of research activity about organizational hospital reforms in Iran. A literature search was performed using PubMed, Scopus, Web of Science, and Google Scholar for English papers as well as SID, IranDoc, Magiran, and the Social Security Research Institute Database for Persian papers from 1991 to April 2020. RESULTS: Twenty studies were included in the review. Studies were grouped by the types of organizational reform, study's objective, setting, methodology, data collection and analysis techniques, and key findings. Thematic construction was used based on the types of organizational reform to present a narrative account of existing literature. CONCLUSIONS: The autonomy granted to the hospitals was unbalanced and paradoxical in terms of key effective dimensions. Poor governance and regulatory arrangements, low commitment to corporate governance, Inappropriate board composition, weak internal controls, unsustainable financing and inefficient payment mechanisms, poor interaction with stakeholders and ignoring contextual factors have been cited as the main reasons for the failure of organizational reforms in Iran. The limited use of evidence and research was obvious at different stages of policymaking, especially in the policy formulation phase and evaluation of its results.

Rethinking health services operations to embrace patient experience of healthcare journey.

Patient experience is assumed pivotal for improving health services operations. The patient experience of healthcare services in Iran has been mostly assessed through the satisfaction and quality of single services or activities at individual providers, clinical departments, or health facilities. However, given the rise of chronic and multi-morbid conditions, health services for these conditions consist of several activities and interactions through a journey that patients take in the health system. To fill in this gap, we propose focusing on the assessment of patient experience on the patient journey through the health system. We advocate that there is much potential for improving the patient experience by rethinking the operations management of health services to embrace the patient experience of the healthcare journey. Rethinking health operations management may include an exhaustive list of interventions. Concisely, at the strategic level, policy-makers while understanding the need for shifting towards the patient experience, make sure that operational level management is experience oriented. This would be pursued through a strategic approach to patient experience, reconsidering qualifications for operational management, and benchmarking to identify and share best practices. Lessons learnt from previous quality improvement programmes are also considered as a capacity to establish the experience orientation.

Iran in transition.

Being the second-largest country in the Middle East, Iran has a long history of civilisation during which several dynasties have been overthrown and established and health-related structures have been reorganised. Iran has had the replacement of traditional practices with modern medical treatments, emergence of multiple pioneer scientists and physicians with great contributions to the advancement of science, environmental and ecological changes in addition to large-scale natural disasters, epidemics of multiple communicable diseases, and the shift towards non-communicable diseases in recent decades. Given the lessons learnt from political instabilities in the past centuries and the approaches undertaken to overcome health challenges at the time, Iran has emerged as it is today. Iran is now a country with a population exceeding 80 million, mainly inhabiting urban regions, and has an increasing burden of non-communicable diseases, including cardiovascular diseases, hypertension, diabetes, malignancies, mental disorders, substance abuse, and road injuries.

Setting health care services tariffs in Iran: half a century quest for a window of opportunity.

BACKGROUND: The process of medical tariffs setting in Iran remains to be a contentious issue and is heavily criticized by many stakeholders. This paper explores the experience of setting health care services tariffs in the Iranian health care system over the last five decades. METHODS: We analyzed data collected through literature review and reviews of the official documents developed at the various levels of the Iranian health system using inductive and deductive content analysis. Twenty-two face-to-face semi-structured interviews supplemented the analysis. Data were analysed and interpreted using 'policy triangle' and 'garbage can' models. RESULTS: Our comprehensive review of changes in the medical tariff setting provides valuable lessons for major stakeholders. Most changes were implemented in a sporadic, inadequate, and a non-evidence-based manner. Disparities in tariffs between public and private sectors continue to exist. Lack of clarity in tariffs setting mechanisms and its process makes negotiations between various stakeholders difficult and can potentially become a source of a corrupt income. Such clarity can be achieved by using fair and technically sound tariffs. Technical aspects of tariff setting should be separated from the political negotiations over the overall payment to the medical professionals. Transparency regarding a conflict of interest and establishing punitive measures against those violating the rules could help improving trust in the doctor-patient relationship. CONCLUSION: Use of evidence-informed models and methods in medical tariff setting could help to strike the right balance in the process of health care services provision to address health system objectives. A sensitive application of policy models can offer significant insights into the nature of medical tariff setting and highlight existing constraints and opportunities. This study generates lessons learned in tariffs setting, particularly for low- and middle-income countries.

Determinants of catastrophic health expenditures in Iran: a systematic review and meta-analysis.

BACKGROUND: Catastrophic health expenditures (CHE) are of concern to policy makers and can prevent individuals accessing effective health care services. The exposure of households to CHE is one of the indices used to evaluate and address the level of financial risk protection in health systems, which is a key priority in the global health policy agenda and an indicator of progress toward the UN Sustainable Development Goal for Universal Health Coverage. This study aims to assess the CHE at population and disease levels and its influencing factors in Iran. METHODS: This study is a systematic review and meta-analysis. The following keywords and their Persian equivalents were used for the review: Catastrophic Health Expenditures; Health Equity; Health System Equity; Financial Contribution; Health Expenditures; Financial Protection; Financial Catastrophe; and Health Financing Equity. These keywords were searched with no time limit until October 2019 in PubMed, Web of Science, Scopus, ProQuest, ScienceDirect, Embase, and the national databases of Iran. Studies that met a set of inclusion criteria formed part of the meta-analysis and results were analyzed using a random-effects model. RESULTS: The review identified 53 relevant studies, of which 40 are conducted at the population level and 13 are disease specific. At the population level, the rate of CHE is 4.7% (95% CI 4.1% to 5.3%, n = 52). Across diseases, the percentage of CHE is 25.3% (95% CI 11.7% to 46.5%, n = 13), among cancer patients, while people undergoing dialysis face the highest percentage of CHE (54.5%). The most important factors influencing the rate of CHE in these studies are health insurance status, having a household member aged 60-65 years or older, gender of the head of household, and the use of inpatient and outpatient services. CONCLUSION: The results suggest that catastrophic health spending in Iran has increased from 2001 to 2015 and has reached its highest levels in the last 5 years. It is therefore imperative to review and develop fair health financing policies to protect people against financial hardship. This review and meta-analysis provides evidence to help inform effective health financing strategies and policies to prioritise high-burden disease groups and address the determinants of CHE.

Informal payments for inpatient health care in post-health transformation plan period: evidence from Iran.

BACKGROUND: In 2014, a revision of the national medical tariffs for inpatient health care services took place in Iran, and a new hotline was set up to report informal payments. It was expected that such measures would eliminate or decrease informal payments prevalence. This study estimates the prevalence of informal payments for inpatient health care services in the post-reform period, explores factors associated with informal payments and examines patients' and healthcare providers' views regarding the causes of informal payments and possible practical solutions for their reduction. METHODS: We surveyed by phone patients who used inpatient health care services in seven Iranian hospitals in 2016. Descriptive and regression analyses were used to estimate the prevalence and determine factors associated with informal payments. We conducted a qualitative analysis through thematic analyses based on focus group discussions and in-depth interviews. RESULTS: Of 2696 respondents, 14% reported paying informally for inpatient services. Informal payments were reported more frequently among private hospital users, given more frequently to physicians in public teaching hospitals and 'other staff' in private hospitals, in the form of cash and voluntary. Being an adult, hospital or treatment type, being insured, and household head's education influenced the probability of paying informally. The amount paid informally was associated with being insured, the educational status of the household's head, household size, service, and hospital types. Based on qualitative findings, the leading causes of informal payments reported by patients and healthcare providers can be categorized into four groups - financing challenges; governance challenges; service delivery challenges; and actors and stakeholders. Modifying, adjusting and applying policy interventions; supervision, monitoring and evaluation; and actors and stakeholders were identified as possible solutions for tackling informal payment in the inpatient health care services. CONCLUSION: The prevalence of informal patient payments for inpatient services in the post-reform period seems to have reduced; however, they remain to be common. Regular monitoring, reviewing of payment policies to the physicians, informing patients, changing the behaviour of healthcare providers and patients, and developing ethical guidelines to prevent informal payments were suggested for reduction and elimination of informal payments in the Iranian healthcare sector.