The experiences and perceptions of people with chronic and rare diseases during political-economic sanctions in Iran: a qualitative study.

BACKGROUND: Economic sanctions aim to exert pressure on political and economic foundations. Hypothesizing that sanctions might affect various aspects of population health, this study, as a component of a broader investigation to ascertain the trend effects of sanctions on selected health outcomes in Iran, seeks to explore the experiences of Iranian citizens associated with the imposed sanctions. METHODS: This is a qualitative study. We conducted 31 semi-structured interviews with randomly selected patients diagnosed with at least one chronic and rare disease from diverse backgrounds across four provinces in Iran. We analyzed data using an inductive content analysis approach, facilitated by the MAXQDA10 software. RESULTS: We identified three primary themes: direct effects, side effects, and coping strategies. The immediate effects were perceived to be manifested through the restriction of healthcare service availability and affordability for citizens. The side effects included the economic hardships experienced in individuals' lives and the perceived devastation caused by these difficulties. Some coping mechanisms adopted by patients or their families/relatives included prioritizing comorbidities, prioritizing health needs within families with multiple ill members, and readjusting health/illness requirements in light of daily living needs. CONCLUSION: In addition to the inherent burden of their illness, patients faced substantial healthcare costs as a result of sanctions, restricted access to medications, and availability of low-quality medications. We advocate considering these challenges within the healthcare system resilience framework as a crucial first step for policymakers, aiming to determine actionable measures and mitigate the adverse effects of sanctions on citizens, particularly the most vulnerable groups.

Sustainable political commitment is necessary for institutionalizing community participation in health policy-making: Insights from Iran.

BACKGROUND: Community participation is currently utilized as a national strategy to promote public health and mitigate health inequalities across the world. While community participation is acknowledged as a civic right in the Constitution of Iran and other related upstream documents, the government has typically failed in translating, integrating and implementing community participation in health system policy. The present study was conducted to determine the level of public voice consideration within the health policy in Iran and address fundamental interventions required to promote the public voice in the context of Islamic Republic of Iran (IRI). This study has originality because there is no study that addresses the requirements of institutionalizing community participation especially in low-middle-income countries, so Iran's experience can be useful for other countries. METHODS: Methodologically, this study utilized a multi-method and multi-strand sequential research design, including qualitative, comparative and documentary studies. In the first phase, the current level of community participation in the health policy cycle of Iran was identified using the International Association for Public Participation (IAP2) spectrum. In the second phase, a comparative study was designed to identify relevant interventions to promote the community participation level in the selected countries under study. In the third phase, a qualitative study was conducted to address the barriers, facilitators and strategies for improving the level of public participation. Accordingly, appropriate interventions and policy options were recommended. Interventions were reviewed in a policy dialogue with policy-makers and community representatives, and their effectiveness, applicability and practical feasibility were evaluated. RESULTS: Based on the IAP2 spectrum, the level of community participation in the health policy-making process is non-participation, while empowerment is set at the highest level in the upstream documents. Moreover, capacity-building, demand, mobilization of the local population, provision of resources and setting a specific structure were found to be among the key interventions to improve the level of community participation in Iran's health sector. More importantly, "political will for action" was identified as the driving force for implementing the necessary health interventions. CONCLUSIONS: To sum up, a paradigm shift in the governing social, economic and political philosophy; establishing a real-world and moral dialogue and communication between the government and the society; identifying and managing the conflicts of interest in the leading stockholders of the healthcare system; and, more importantly, maintaining a stable political will for action are integral to promote and institutionalize participatory governance in the health sector of Iran. All of the above will lead us to scheme, implement and institutionalize suitable interventions for participatory governance in health and medicine.

Health burden and attributable economic damage of conflict and terrorism in the Eastern Mediterranean Region.

This study aimed to vividly describe the direct and severe health impacts of conflict in the Eastern Mediterranean Region (EMR) using data from the Global Burden of Disease (GBD). It also sought to quantify the staggering portion of economic damage attributable to the health burden of conflict and terrorism. From 1990 to 2019, the region endured the devastating effects of conflict and terrorism. These circumstances led to 64%, 50%, and 35% of all causes of Disability-Adjusted Life Years (DALYs) in Libya, Syria, and Palestine, respectively, in 2011, 2016, and 2008. These figures represent not just statistics but the profound human cost of these conflicts. The health-related economic burden (HEB) due to conflict was estimated at $4.6 billion in Iraq, $3.7 billion in Afghanistan, and $1.7 billion in Libya in current international dollars. However, due to missing data, the HEB could not be calculated for Yemen and Syria despite significant conflict-related DALYs. In 2019, the HEB to Current Health Expenditure (CHE) ratio, which indicates the proportion of the health-related economic burden compared to health expenditure, was 30% in Afghanistan and 25% in Iraq. This high ratio underscores the significant strain that conflict places on the health systems.

Revising the essential package of health services through stakeholder alignment, Somalia.

Problem: The fragmented health sector in Somalia, burdened by financial challenges and an inadequate regulatory system, struggles to provide equitable essential health services to the entire population. Approach: To revise an essential package of health services that stakeholders could support and that aligned with stakeholders' financial and technical resources, the federal health ministry invited all key stakeholders in 2020 to participate in the revision process of the essential package. The ministry distributed a concept note to invited stakeholders, describing the scope and purpose of the revision process of the essential package. The note also contained a timeline and the expected contribution of each stakeholder. Stakeholders nominated representatives based on their technical expertise and knowledge of the health sector in Somalia. Local setting: The health sector in Somalia involves multiple stakeholders, including the health ministry and many development partners. The private sector plays a substantial role in health-care provision. Public spending is an estimated 17% of the total health expenditure. Relevant changes: After an 18-month revision process, the health ministry and development partners agreed to prioritize high-impact, cost-effective services and use a progressive realization of the package to improve access and coverage. The implementation strategy considers the health system and operational capacity of service providers, particularly in security-compromised areas. Lessons learnt: The approach showed that inclusivity, collaboration and transparency were of importance for a successful revision of the package. These achievements in consensus-building and priority alignment advance the government's pursuit of equitable and comprehensive health care for all.

Construction and validation of CAPSES scale as a composite indicator of SES for health research: an application to modeling social determinants of cardiovascular diseases.

BACKGROUND: The main objective of this study was to construct and validate a composite socioeconomic status indicator containing material capital, human capital, and social capital (CAPSES scale) and also appropriate it for CVDs in a large population-based study. METHODS: This cross-sectional study, the Urban HEART-2 project, was conducted in Tehran, Iran, in 2011. A total of 34,116 households covering 118,542 individuals were assessed in this study. A 14-parts questionnaire was completed for all selected households. All the gathered data were based on the participants' self-reports. Literacy, wealth index, expenditure, skill level, and Townsend index were used as SES indexes. CVDs, including Hypertension, Myocardial infarction, and stroke, were considered the main outcomes. A structural equation model (SEM) was used to construct a CAPSES scale and a composition index of SES. Criterion validity and Construct validity were used to assess this scale. RESULTS: A total of 91,830 subjects consisting of 33,884 (49%) men were included in this analysis. The mean age of the participants was 41.5 ± 11.37 years. Among the assessed participants, 5904(6.4%) reported hypertension, 1507(1.6%) myocardial infarction, and 407(0.4%) strokes. The overall weighted prevalence of self-reported cardiovascular events (hypertension, stroke, and MI) was 8.03% (95%CI: 7.8-8.2). Inverse associations were seen between the CAPSES scale and its domains with CVDs, adjusted for sex, age, BMI, smoking, and diabetes by a multiple logistic regression model. CONCLUSION: The CAPSES scale was significantly associated with stroke and hypertension. Our findings showed that the CAPSES index could be useful for public health research.

Mapping of national population-based surveys for better reporting of health-related indicators in the Eastern Mediterranean Region.

BACKGROUND: Population-based surveys are the main data source to generate health-related indicators required to monitor progress toward national, regional and global goals effectively. Although the Eastern Mediterranean Region of World Health Organization (WHO) member states conduct many population-based surveys, they are not led regularly and fail to provide relevant indicators appropriately. Therefore, this study aims two-fold: to map out population-based surveys to be conducted data for the health-related indicators in the Region and propose a timetable for conducting national population-based surveys in the Region. METHODS: The study was conducted in six phases: 1) Selecting survey-based indicators; 2) Extracting and comparing relevant survey modules; 3) Identifying sources of data for the indicators; 4) Assessing countries' status in reporting on core health indicators; 5) Review and confirmation of the results by the experts. RESULTS: Population-based surveys are the sources of data for 44 (65%) out of 68 regional core health indicators and two (18%) out of 11 health-related Sustainable Development Goals (SDG) 3 indicators. The Health Examination Survey (HES) could cover 65% of the survey-based indicators. A total of 91% of survey-based indicators are obtained by a combination of HES, Demographic and Health Survey (DHS), Multiple Indicator Cluster Survey (MICS) and Global School-based Student Health Survey (GSHS). CONCLUSION: In order to effectively report health-related indicators, HES, DHS/MICS and GSHS are considered essential in national survey timetables. Each country needs to devise and implement a plan for population-based surveys by considering factors such as national health priorities, financial and human capacities, and previous experiences.

The human cost of economic sanctions and strategies for building health system resilience: A scoping review of studies in Iran.

OBJECTIVES: This review aimed to analyse the impacts of international economic sanctions on the overall health status of Iranians and the health system performance of Iran, in addition to identifying effective strategies for making the health system resilient to sanctions. STUDY DESIGN: A scoping review. METHODS: Three databases and grey literature were reviewed, and additional papers were identified in the lists of references. Two authors reviewed papers to check duplications and screen through inclusion/exclusion criteria. Furthermore, a narrative approach was employed to synthesise the findings. RESULTS: Given overall health impacts, economic sanctions are believed to have adverse effects on Iranian's health and cause significant financial hardships in accessing healthcare services. These hardships mostly affect those in marginalised and vulnerable groups. Economic sanctions degrade Iran's health system by negatively impacting health services' availability. The detrimental effects of sanctions on economic and social circumstances were also documented. Economic sanctions could also adversely affect health research and education. Most strategies identified for health system resilience to sanctions are related to the health system governance. CONCLUSIONS: Even if essential medicines and supplies are exempted from the sanction regime, the impact of economic sanctions on public health is unavoidable. The quantification of the effect economic sanctions on different health-related areas needs by further research. The measures identified for dealing with sanction can be considered in other countries but more work is needed to explore how health of people can be resilient against negative consequences of sanctions.

Barriers and Facilitators to Participatory Governance in Iran Health Policymaking: A Qualitative Study.

Background: Community participation has been accepted as a promising approach to promoting health and health equality. Based on Iran's constitution and the general health policies, community participation in health is addressed as a right, and during recent decades, some measures have been put in place. However, it is critical to improve public participation in Iran's health system and institutionalize community participation in health policymaking. This study aimed to identify barriers and facilities affecting public participation in Iran's health policymaking. Methods: Semi-structured qualitative interviews with health policymakers, health managers and planners, and other stakeholders were conducted to collect data. The conventional content analysis approach was used to analyze the data. Results: Two themes-including community level and government level-and 10 categories were identified through the qualitative analysis. Cultural and motivational factors, lack of awareness of the right to participate, and lack of sufficient knowledge and skills are among the identified barriers in the process of establishing effective interaction. From the health governance perspective, a lack of political will is identified as one of the obstacles. Conclusion: A culture of community involvement and political will are pivotal in the sustainability of community participation in health policymaking. The provision of a suitable context for participatory processes and capacity building on the community and government levels can be useful in institutionalizing community participation in the health system.

Investigating the Rate of the Use of Persian Traditional Medicine Services in Tehran.

Background: Despite all the advancements and publicity made in regard to classical medicine, every day more and more people are interested in complementary medicine. This study was designed and conducted to determine the relative frequency of the use of Persian traditional medicine services by the people of Tehran. Methods: This cross-sectional study was conducted using the telephone survey method in Tehran. A total of 1824 samples were included in the study based on Cochran's formula. At first, by searching databases, including Google Scholar, PubMed, Embase, and internal sources, including the Iran Medex database, numerous medical texts and articles were reviewed in the field of using traditional medicine services. Then, interview guide questions were designed and asked over the phone. Finally, the data were extracted and subjected to quantitative analysis. Frequency and percentage of relative frequency were used to describe the study data. Results: In the study, 62% (n = 1131) of the participants were women, and 60.5% (n = 1103) of the participants have turned to modern medicine for treatment and have also used traditional medical treatments. Also, 43.5% (n = 864) of the participants have used herbal medicines and their products; 43% (n = 616) of the participants have used Persian traditional medicine treatments as self-treatment based on their personal information; and only 46.5% (n = 666) have evaluated the therapeutic effect of Persian traditional medicine methods as "good." Conclusion: The results of the study indicate the need for more emphasis on Persian traditional medicine alongside modern medicine, more organization and supervision of traditional medicine service providers in the country, and the creation of coherent and integrated management in this field.

Development and validation of an online tool for assessment of health care providers' management of suspected malaria in an area, where transmission has been interrupted.

BACKGROUND: The alertness and practice of health care providers (HCPs) in the correct management of suspected malaria (CMSM) (vigilance) is a central component of malaria surveillance following elimination, and it must be established before malaria elimination certification can be granted. This study was designed to develop and validate a rapid tool, Simulated Malaria Online Tool (SMOT), to evaluate HCPs' practice in relation to the CMSM. METHODS: The study was conducted in East Azerbaijan Province, Islamic Republic of Iran, where no malaria transmission has been reported since 2005. An online tool presenting a suspected malaria case for detection of HCPs' failures in recognition, diagnosis, treatment and reporting was developed based on literature review and expert opinion. A total of 360 HCPs were allocated to two groups. In one group their performance was tested by simulated patient (SP) methodology as gold standard, and one month later by the online tool to allow assessment of its sensitivity. In the other group, they were tested only by the online tool to allow assessment of any possible bias incurred by the exposure to SPs before the tool. RESULTS: The sensitivity of the tool was (98.7%; CI 93.6-99.3). The overall agreement and kappa statistics were 96.6% and 85.6%, respectively. In the group tested by both methods, the failure proportion by SP was 86.1% (CI 80.1-90.8) and by tool 87.2% (CI 81.4-91.7). In the other group, the tool found 85.6% (CI 79.5-90.3) failures. There were no significant differences in detecting failures within or between the groups. CONCLUSION: The SMOT tool not only showed high validity for detecting HCPs' failures in relation to CMSM, but it had high rates of agreement with the real-world situation, where malaria transmission has been interrupted. The tool can be used by program managers to evaluate HCPs' performance and identify sub-groups, whose malaria vigilance should be strengthened. It could also contribute to the evidence base for certification of malaria elimination, and to strengthening prevention of re-establishment of malaria transmission.

Health system to response to economic sanctions: global evidence and lesson learned from Iran.

BACKGROUND: Sanctions have direct and indirect impacts on people's lives. Therefore, the health systems of countries targeted by sanctions must respond effectively. This study proposes a set of mitigating measures and response strategies to improve the health systems of countries under sanctions. METHODS: This three-stage study was conducted in Iran within the 2020-2021 period, in which a rapid review of evidence was carried out to identify the measures implemented or proposed to make the health system resilient in confronting sanctions. A qualitative approach was then adopted to determine how the health system could be improved to response to sanctions from the perspectives of 10 key experts. Semi-structured interviews and document analysis were conducted for data collection. Finally, a two-round Delphi technique was employed to help eleven experts reach a consensus on a set of mitigating measures, which were then prioritized. RESULTS: In this research, 62 proposed or implemented mitigating measures were extracted from 13 eligible studies to improve the health system performance in confronting sanctions. Moreover, 18 measures were identified in interviews for a better health system response to sanctions. They were then classified as five categories: sustained financing, good governance, integrated and updated health information systems, qualified workforce, and efficient and equitable service delivery. In the first Delphi round, 28 mitigating measures were discovered. Nine measures were identified as more effective and feasible in both short and long runs. They were introduced as below: conducting proactive inventory control, developing the nationally essential list of medicines, providing additional clarification that oil revenues can be freely used for medicines procurement, defining tailored health service packages for vulnerable populations, establishing and enhancing an efficient surveillance system, reducing prices of imported medicines, developing dual policies of equity and priority for vulnerable groups, institutionalizing fair and effective resource allocations, and providing clinical guidelines. CONCLUSIONS: According to the findings, the most critical areas for the resilience of a health system in confronting sanctions include strengthening particular components of governance, improving efficiency, and caring for vulnerable populations. The experts collectively emphasized investment in domestic capacities, public participation, and health diplomacy. Despite the proposed measures, it is unclear how effective these are and, especially whether they can significantly affect the harsh impacts of sanctions on health. Moreover, intensive and long-term sanctions have significant irreversible outcomes that cannot be reversed easily or quickly.

Intersectoral collaboration in the management of non-communicable disease's risk factors in Iran: stakeholders and social network analysis.

INTRODUCTION: As the major cause of premature death worldwide, noncommunicable diseases (NCDs) are complex and multidimensional, prevention and control of which need global, national, local, and multisectoral collaboration. Governmental stakeholder analysis and social network analysis (SNA) are among the recognized techniques to understand and improve collaboration. Through stakeholder analysis, social network analysis, and identifying the leverage points, we investigated the intersectoral collaboration (ISC) in preventing and controlling NCDs-related risk factors in Iran. METHODS: This is a mixed-methods study based on semi-structured interviews and reviewing of the legal documents and acts to identify and assess the interest, position, and power of collective decision-making centers on NCDs, followed by the social network analysis of related councils and the risk factors of NCDs. We used Gephi software version 0.9.2 to facilitate SNA. We determined the supreme councils' interest, position, power, and influence on NCDs and related risk factors. The Intervention Level Framework (ILF) and expert opinion were utilized to identify interventions to enhance inter-sectoral collaboration. RESULTS: We identified 113 national collective decision-making centers. Five councils had the highest evaluation score for the four criteria (Interest, Position, Power, and Influence), including the Supreme Council for Health and Food Security (SCHFS), Supreme Council for Standards (SCS), Supreme Council for Environmental Protection (SCIP), Supreme Council for Health Insurance (SCHI) and Supreme Council of the Centers of Excellence for Medical Sciences. We calculated degree, in degree, out-degree, weighted out-degree, closeness centrality, betweenness centrality, and Eigenvector centrality for all councils. Supreme Council for Standards and SCHFS have the highest betweenness centrality, showing Node's higher importance in information flow. Interventions to facilitate inter-sectoral collaboration were identified and reported based on Intervention Level Framework's five levels (ILF). CONCLUSION: A variety of stakeholders influences the risk factors of non-communicable diseases. Through an investigation of stakeholders and their social networks, we determined the primary actors for each risk factor. Through the different (levels and types) of interventions identified in this study, the MoHME can leverage the ability of identified stakeholders to improve risk factors management. The proposed interventions for identified stakeholders could facilitate intersectoral collaboration, which is critical for more effective prevention and control of modifiable risk factors for NCDs in Iran. Supreme councils and their members could serve as key hubs for implementing targeted inter-sectoral approaches to address NCDs' risk factors.

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.

How Iranian Students Communicate About Puberty Information: Results of a Network Analysis.

Background: To evaluate the structure of students' social networks (So. N) generally and in a specific network (Sp. N), in which students discuss delicate puberty concerns with their classmates, the present research examined the communication networks of students in Hamadan, Iran, a mid-sized city in Iran. Methods: In this cross-sectional study, the data were collected from a total of 350 students in 14 classes from 14 schools using a stratified sampling method. In each class, the communication networks of students were examined by asking direct questions about links among them. The students' centrality indices were computed using UCINET 6 software. Since the size of the classes was different, the centrality index was reported as a percentage, which was the number of reported links over the maximum number of possible ones. Results: The centrality index in So. Ns and Sp. Ns in boys was more than those in girls (55.4% vs 47.6% in So. N, and 33.4% vs 20.1% in Sp. N). The students' centrality indices in So. Ns and Sp. Ns were also positively correlated (r=0.58; p<0.001). In addition, the Sp. N was around 45% lower than So. N in both sexes. Conclusion: The communication styles among students in Sp. N appeared to be very different from those in So. N and the styles were related to demographic traits. As a result, it was determined that a thorough investigation of communication networks was essential for customizing health promotion initiatives for students.

Informal Payments for Outpatient Health Care: Country-Wide Evidence from Iran.

Background: Reliance heavily on out-of-pocket (OOP) payments, including informal payments (IPs), has undesired effects on financial risk protection and access to care. While a significant share of total health expenditure is spent on outpatient services, there is scant evidence of the patient's amount paid informally in outpatient services. Such evidence is available for inpatient services, showing the high prevalence of informal payments, ranging from 14 to 48% in the whole hospital. This study aimed to investigate the extent of OOP and IPs for outpatient services in Iran. Methods: A secondary data analysis of the 2015 IR Iran's Utilization of Healthcare Services (IrUHS) survey was conducted. A sample of 11,782 individuals with basic health insurance who were visited at least once by a physician in two private and public health care centers was included in this analysis. The percentage of OOP was determined and compared with the defined copayment (30%). The frequency of IPs was determined regarding the number of individuals who paid more than the defined copayments. The Mann-Whitney test also investigated the relationships between OOP percentage and IPs frequency with demographic variables. Results: The share that insured patients in Iran pay for a general practitioner (GP) visit was 38% in public versus 61% in the private sector, while for a specialist practitioner visit, the figures were 80% and 96%, respectively, which is higher than defined copayment (30%). This share was significantly higher in females, urban areas, highly educated people, private service providers, and specialist visits. The frequency of IPs, who paid more than the defined copayments, was 73% for a GP in public versus 86% in the private sector, while for a specialist practitioner visit, these were 90% and 93%, respectively. Conclusion: Informal patient payments for outpatient services are prevalent in Iran. Hence, more interventions are required to eliminate or control the IPs in outpatient services, particularly in the private sector. In this regard, making a well-regulated market, reinforcing the referral system, and developing an equity-oriented essential health services package would be fundamental.

Health workers readiness and practice in malaria case detection and appropriate treatment: a meta-analysis and meta-regression.

BACKGROUND: Health workers (HWs) appropriate malaria case management includes early detection and prompt treatment with appropriate anti-malarial drugs. Subsequently, HWs readiness and practice are considered authentic evidence to measure the health system performance regarding malaria control programme milestones and to issue malaria elimination certification. There is no comprehensive evidence based on meta-analysis, to measure the performance of HWs in case management of malaria. This study aimed to evaluate HWs performance in early malaria case detection (testing) and the appropriate treatment. METHODS: The published literature in English was systematically searched from Medline, Scopus, Embase, and Malaria Journal up to 30th December 2020. The inclusion criteria were any studies that assessed HWs practice in early case detection by malaria testing and appropriate treatment. Eligibility assessment of records was performed independently in a blinded, standardized way by two reviewers. Pooled prevalence estimates were stratified by HWs cadre type. Meta-regression analysis was performed to explore the impact of the appropriateness of the method and risk of bias as potential sources of the heterogeneity in the presence of effective factors. RESULTS: The study pooled data of 9245 HWs obtained from 15 included studies. No study has been found in eliminating settings. The pooled estimate for appropriate malaria treatment and malaria testing were 60%; 95% CI: 53-67% and 57%; 95% CI: 49-65%, respectively. In the final multivariable meta-regression, HWs cadre and numbers, appropriateness of study methods, malaria morbidity and mortality, total admissions of malaria suspected cases, gross domestic product, availability of anti-malarial drugs, and year of the publication were explained 85 and 83% of the total variance between studies and potential sources of the heterogeneity for malaria testing and treating, respectively. CONCLUSION: HWs adherence to appropriate malaria case management guidelines were generally low while no study has been found in eliminating countries. Studies with the inappropriateness methods and risk of bias could be overestimating the actual proportion of malaria appropriate testing and treating. Strategies that focus on improving readiness and early identification of acute febrile diseases especially in the countries that progress to malaria elimination should be highly promoted.

Malaria intermittent preventive treatment in Nigeria: a qualitative study to explore barriers.

BACKGROUND: While the use of sulphadoxine pyrimethamine (SP) is effective in preventing malaria infection during pregnancy, there are challenges limiting its uptake in Nigeria. This study aimed at exploring the barriers to IPTp usage among pregnant women in Kano state - Nigeria. METHODS: This is a qualitative study. The purposive sampling strategy was used for identification and selection of 14 key informants for interviews. In addition, six focus group discussions (FGDs) were conducted with pregnant women (3 FGDs) and married men (3 FGDs). The conventional content analysis method was used to interpret meaning from the content of the data. MAXQDA 10 software was used for data management and analysis. RESULTS: Poor policy implementation, poor antenatal care attendance, inadequate access to intermittent preventive treatment at the community levels, lack of sustainable funding, and poor community engagement emerged as major barriers to IPTp use in Nigeria. CONCLUSION: While the political will to allocate sufficient financial resources could help improve service delivery and IPTp usage among pregnant women, community participation is critical to sustain the gains.

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.

"Applying Intersectionality in designing and implementing health interventions: a scoping review".

BACKGROUND: Given the potential of intersectionality to identify the causes of inequalities, there is a growing tendency toward applying it in the field of health. Nevertheless, the extent of the application of intersectionality in designing and implementing health interventions is unclear. Therefore, this study aimed to determine the extent to which previous studies have applied intersectionality and its principles in designing and implementing health interventions. METHODS: The title and abstract of the articles which were published in different databases e.g. PubMed, Web of Science, Proquest, Embase, Scopus, Cochrane, and PsychInfo were screened. Those articles that met the screening criteria were reviewed in full text. The data about the application of principles of intersectionality, according to the stages heuristic model (problem identification, design & implementation, and evaluation), were extracted through a 38-item researcher-made checklist. RESULTS: Initially, 2677 articles were found through reviewing the target databases. After removing the duplicated ones and screening the titles and abstracts of 1601 studies, 107 articles were selected to be reviewed in detail and 4 articles could meet the criteria. The most frequently considered intersectionality principles were "intersecting categories" and "power", particularly at the stages of 'problem identification' as well as 'design & implementation'. The results showed that "multilevel analysis" principle received less attention; most of the studies conducted the interventions at the micro level and did not aim at bringing about change at structural levels. There was a lack of clarity regarding the attention to some of the main items of principles such as "reflexivity" as well as "social justice and equity". These principles might have been implemented in the selected articles; however, the authors have not explicitly discussed them in their studies. CONCLUSIONS: Given the small number of included studies, there is still insufficient evidence within empirical studies to show the implication of intersectionality in designing and conducting health interventions. To operationalize the intersectionality, there is a need to address the principles at various stages of health policies and interventions. To this end, designing and availability of user-friendly tools may help researchers and health policymakers appropriately apply the intersectionality.