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.

The role of midwives in implementing reproductive health services in Islamic Republic of Iran.

Background: It is essential to study the availability of reproductive health services and the capacities of providers, to provide evidence for improving service quality. Aims: To identify the role of midwives in the provision of reproductive health services and recommend improvements. Methods: A national review of government health resources in the Islamic Republic of Iran was conducted to explore available reproductive health services. Through semi-structured interviews with 30 midwives, information was collected about the compatibility of services with the capacity and scope of the activities of midwives. A panel of 12 experts was assembled to develop a proposed service package. The content analysis method was applied to data analysis and interpretation. Results: The service package developed covered 82 services that midwives can offer at the 8 healthcare facility groups. Although midwives were trained to manage a range of primary and gynaecological care services, certain essential aspects of reproductive health services were not being delivered on the frontline. These include sexually transmitted diseases and human papilloma virus management, diagnosis and treatment of common gynaecological problems, sexual education and counselling, and childbirth services. Midwives were not adequately engaged to provide reproductive health care at the secondary level. Conclusion: There are drawbacks to the current reproductive health service delivery in the Islamic Republic of Iran. The service package designed and proposed in this study aims to strengthen reproductive health care services and planning and better integration of midwife-led programmes.

Methods and criteria for the assessment of orphan drugs: a scoping review.

OBJECTIVES: This study aimed to identify different criteria for priority setting of rare diseases to help policy makers in making evidence-informed decisions. METHODS: A scoping review was conducted to comprehensively examine the existing various methods and criteria for prioritizing orphan drugs and rare diseases. We performed searching in Scopus, PubMed, Embase, and websites of health technology assessment (HTA) agencies, 2000-21, and data were extracted. RESULTS: From the 1,580 identified publications, eleven articles were included. Multicriteria decision analysis was the most frequent method (seven out of eleven studies) used for priority setting. The extracted criteria for priority setting of orphan products were analyzed based on six main categories as follows: health outcomes and clinical implications (six subsets which showed clinical implications), economic aspects (four subsets that indicated the economic effects of orphan drugs and rare diseases), disease and population characteristics (six subsets that included the characteristics of the rare diseases), therapeutic alternatives and uniqueness of orphan technologies (two subsets which discussed the alternatives and uniqueness of orphan technologies), evidence (three subsets which regarded the quality and availability of evidence), and other criteria (three subsets dealing with social and organizational criteria). Cost-effectiveness, budget impact, and disease severity were the most frequent criteria in the studies. CONCLUSIONS: Because of the high price of orphan drugs and limitations of using HTA for reimbursement of them, it is critical to explore them by precise technical methods like multiple criteria decision making in priority setting.

Knowledge gaps and national research priorities for COVID-19 in Iran.

BACKGROUND: In the present COVID-19 crisis, one of the greatest challenges for research funding at both the international and national level is selecting the best research topic to achieve efficiency and equity in health research and to address the knowledge gap urgently raised due to the event. Despite international recommendations, countries should consider their context-specific situation and define local research priorities. We aimed to exercise a priority-setting activity to identify the knowledge gaps and suggest research priorities in response to the COVID-19 epidemic in Iran. METHODS: First, we tried to identify the contextual knowledge gaps based on an online survey, performing key informant interviews (i.e. health professionals, policy-makers and managers) and media analysis. We also performed a literature review and considered international research priorities for COVID-19. Subsequently, we prepared a list of research questions and challenges to respond to the COVID-19 crisis in Iran using a systems approach. Then we mapped approved COVID-19 research projects in the country to research questions. Finally, we compared the identified research questions (not challenges) with the prioritized research from international organizations and then prioritized them for Iran. RESULTS: We found risk factors and epidemiological dissemination patterns of the virus and its consequences in an epidemiology domain, implementation of clinical and hygiene in a clinical management domain, genetic studies for targeting prevention and treatment in a candidate treatment and vaccine research and development (R&D) knowledge domain, examination of the manifestations of ethics in society instead of ethics in research in an ethics domain, "care, access and health system" and "public health and participation in response to public health and clinical research" as two sub-domains of a social sciences domain, and finally, no new questions in either the virology, transmission, diagnosis or animal and environmental domain. CONCLUSIONS: In the event of global health crises like COVID-19, prioritization of research questions can be done globally, but some of the research priorities are context-specific and may vary by regional needs. To better manage research resources, researchers must respond to the challenges faced in each country based on its political, economic, social and cultural characteristics, and to make evidence-informed decisions, global knowledge gaps must be customized in each country.

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.

Developing Framework and Strategies for Capacity Building to Apply Evidence-Informed Health Policy-Making in Iran: Mixed Methods Study of SAHSHA Project.

BACKGROUND: SASHA, which stands for "evidence-informed health policy-making (EIHP)" in Persian, is a national project to draw a roadmap for strengthening EIHP in Iran. As a part of SASHA, this research aimed to develop evidence-based and context-aware policy options for increasing the capacity of decision-makers to apply EIHP in Iran. METHODS: This was a qualitative study, which was informed by a literature review of pull efforts' capacity building programs. Based on the review, we developed policy options and validated them through an expert panel that involved twelve experts. Data were analyzed using a content analysis method. RESULTS: We extracted data from 11 articles. The objectives of capacity building programs were: single-skill development, personal/professional development, and organizational development. According to these objectives, the contents and training methods of the programs vary. Capacity building programs have shown positive impacts on individual knowledge/attitudes to use EIHP. However, the impacts of programs at the organizational or the health system level remain under-researched. We followed several threads from the literature review through to the expert panel that included training the management team, instead of training managers, training for problem-solving skills, and designing tailored programs. Barriers of capacity building for EIHP regard the context of the health system (weak accountability and the widespread conflict of interest) and healthcare organizational structures (decision support systems, knowledge management infrastructures, and lack of management team). Experts suggested interventions on the barriers, particularly on resolving the conflict of interests before launching new programs. A proposed framework to increase the capacity of health policy-makers incorporates strategies at three levels: capacity building program, organizational structure, and health system context. CONCLUSION: To prepare the context of Iranian healthcare organizations for capacity building programs, the conflict of interests needs to be resolved, decision-makers should be made more accountable, and healthcare organizations need to provide more knowledge management infrastructures and decision support systems.

IRAN National Cancer Control Program (IrNCCP): Goals, Strategies, and Programs.

Background: Annually, over 131000 new cases of cancer have been identified in Iran, with an increasing trend that is predicted to grow by 40% by 2025. The most important contributing factors to this increase are the improvement of the health service delivery system, increased life expectancy, and the aging of the population. The aim of this study was to develop Iran's "National Cancer Control Program" (IrNCCP). Methods: The present study is a cross-sectional study that was conducted in 2013 using the method of reviewing studies and documents and focused group discussions and a panel of experts. In this study, the available evidence related to cancer status and its care in Iran and other countries, as well as national and international upstream documents, were reviewed and analyzed. Then, by analyzing the current situation in Iran and other countries and conducting stakeholder analysis with the strategic planning approach, the IrNCCP was developed with a 12-year horizon consisting of goals, strategies, programs, and performance indicators. Results: This program has 4 main components, including Prevention, Early Detection, Diagnosis and Treatment, and Supportive and Palliative care, as well as 7 supporting components including Governance and policy-making, Cancer Research, Developing facilities, equipment, and service delivery network, Providing and managing human resources, Providing and managing financial resources, Cancer information system management and registry, and Participation of NGOs, charities, and the private sector. Conclusion: Iran's National Cancer Control Program has been developed comprehensively with cross-sectoral cooperation and stakeholder participation. However, like any long-term health intervention, strengthening its governance structure both in terms of implementation and achievement of expected goals and evaluation and modification during the implementation of the program is essential.

Policy options to increase motivation for improving evidence-informed health policy-making in Iran.

BACKGROUND: Current incentive programmes are not sufficient to motivate researchers and policy-makers to use research evidence in policy-making. We conducted a mixed-methods design to identify context-based policy options for strengthening motivations among health researchers and policy-makers to support evidence-informed health policy-making (EIHP) in Iran. METHODS: This study was conducted in 2019 in two phases. In the first phase, we conducted a scoping review to extract interventions implemented or proposed to strengthen motivations to support EIHP. Additionally, we employed a comparative case study design for reviewing the performance evaluation (PE) processes in Iran and other selected countries to determine the current individual and organizational incentives to encourage EIHP. In the second phase, we developed two policy briefs and then convened two policy dialogues, with 12 and 8 key informants, respectively, where the briefs were discussed. Data were analysed using manifest content analysis in order to propose contextualized policy options. RESULTS: The policy options identified to motivate health researchers and policy-makers to support EIHP in Iran were: revising the criteria of academic PE; designing appropriate incentive programmes for nonacademic researchers; developing an indicator for the evaluation of research impact on policy-making or health outcomes; revising the current policies of scientific journals; revising existing funding mechanisms; presenting the knowledge translation plan when submitting a research proposal, as a mandatory condition; encouraging and supporting mechanisms for increasing interactions between policy-makers and researchers; and revising some administrative processes (e.g. managers and staff PEs; selection, appointment, and changing managers and reward mechanisms). CONCLUSIONS: The current individual or organizational incentives are mainly focused on publications, rather than encouraging researchers and policy-makers to support EIHP. Relying more on incentives that consider the other impacts of research (e.g. impacts on health system and policy, or health outcomes) is recommended. These incentives may encourage individuals and organizations to be more involved in conducting research evidence, resulting in promoting EIHP. TRIAL REGISTRATION: NA.

Current and former smokers among adolescents aged 12-17 years in Iran: a systematic review and meta-analysis.

BACKGROUND: Smoking, especially among adolescents, is considered a serious public health concern worldwide being associated with increased mortality. The present study was designed as the first systematic review and meta-analysis of the prevalence of current and former smoking behavior among adolescents in Iran. METHODS: Seven international scholarly databases, namely Scopus, Embase, Pubmed/Medline, ISI/Web of Science (WOS), the Cochrane Library, Psyc Info and Cinahl, were extensively searched from January 2000 to September 18, 2019. Google Scholar was also mined. Iranian databases were searched as well (namely, MagIran, Scientific Information Database (SID), and Barakatkns). The DerSimonian-Laird's approach, via the Freeman-Tukey double arcsine method, was used to synthesize the prevalence estimates. RESULTS: The prevalence of current smokers among Iranian adolescents was estimated to be 9% (95% CI: 7 to 10). Stratifying based on gender, the prevalence was 12% among boys (95% CI: 10 to 14) and 6% among girls (95% CI: 5 to 8). The prevalence of former smokers among Iranian adolescents using the random-effect model was computed to be 24% (95% CI: 21 to 27). CONCLUSION: The findings of this study showed that the prevalence of current and former smoking behavior among Iranian adolescents is a relevant public health concern. The country's young population should be given more attention by health policy- and decision-makers and implementation of ad hoc prevention and control policies should be on their agenda.

Status of Human resources management in Iran's health sector and the path to development: A qualitative study.

Background: Resource generation, stewardship, financing, and provision of health care services are 4 major functions of the health system. In this study, human resource management, as a vital aspect of resource generation, was studied and some interventions have been suggested for Iran. Methods: This was a mixed method study. Data were collected through the review of the relevant articles and government documents, interviews with human resources managers and experts in the health sector, and focus group discussions with selected authorities. The interview questions were based on a model proposed by the WHO. Results: The collected data were categorized into 3 broad sets: description of the current status, factors contributing to the current status, and suggested interventions for improvement. Lack of a comprehensive human resources management policy and inattention to the human resources management in the developmental plans are some of the most common problems in Iran's health sector. Also, unequal distribution, unemployment, migration of graduates, and inadequate and ineffective participation of faculty members in universities are some other problems referred to as lack of a unified stewardship and dearth of a comprehensive human resources planning. Suggested interventions have focused on stewardship function of the health care system. Conclusion: A policy brief on the human resources for health needs should be developed and added as a separate article to the upstream documents of the country (eg, Iran's 20-year outlook plan). Implementing and monitoring operational plans for policy execution at Ministry of health has a major role in executing the adopted strategies.

Universal health coverage in Iran: Where we stand and how we can move forward.

Over the last 4 decades, many initiatives have been implemented to accomplish equitable accessible health care for all Iranian citizens. The latest reform to address universal health coverage (UHC) is Health Transformation Plan (HTP), which resulted in significant improvements in health outcomes. Nevertheless, several challenges in the fields of sustainability of resources, service delivery, and health governance continued to exist. These challenges should be addressed in next steps to achieve the defined goals. To tackle these challenges, a number of practical solutions can be proposed, including making health financing more resilient, defining and implementing cost control policies and cost-effective package of services, changing the current method of providers' payment, and ensuring good governance in the health system.

Higher Income for Male Physicians: Findings About Salary Differences Between Male and Female Iranian Physicians

Background: In recent decades, the role of women in the organizations of developed and less developed countries has increased, but little is known about gender gap in salaries of Iranian physicians. Aims: To analyze the gender gap in the salary of physicians working in public health sector of Iran and its predicting factors in 2016. Study Design: Cross sectional study. Methods: Thirty thousand eight hundred and twenty four records about characteristics of study population were extracted from national human resources for health database. Nearest neighborhood matching technique was used to find adjusted differences of salary between male and female physicians. In addition, by using Oaxaca decomposition method, the reasons for the differences were found. Results: The results showed that there was a difference of 117 dollars in monthly salaries of male and female physicians in favor of men. Differences in male and female salaries could be predicted by place of work and residency, type of specialty, type of employment and marital status. Conclusion: Gender gap in physicians' salaries exists in public health sector of Iran. The payment methods of salaries for men and women should be revised in order to remove the inequalities.

Physicians' retention rate and its effective factors in the Islamic Republic of Iran.

BACKGROUND: Migration of physicians from less developed countries to affluent ones has become as one of the major concerns of human resource policy-makers. This leads to problems such as inequity in the distribution of physicians, lack of physicians in less developed areas, as well as an excess of the health workforce in developed environs. Thus, policy-makers aim to increase retention of physicians in their places of origin. AIMS: This study aimed to find those effective factors for the retention of physicians in the Islamic Republic of Iran. METHODS: 30 569 records of public sector physicians in 2016 were gathered from the Ministry of Health and Medical Education database, and the retention rate of each province was calculated. Geographic information system (GIS) was used to show retention in each province, and linear and logistic regression analysis were used to determine the effective factors for physicians' retention in the country. RESULTS: There was a significant relationship between per capita gross domestic product of each province and its retention rate of physicians (OR = 1.56), retention rate of family physicians (OR = 7.38), and retention rate of specialists (OR = 1.59). In addition, relationships were significant for the human development index (all physicians [OR = 1.22], family physicians [OR = 2.36], and specialists [OR = 1.23]). Married physicians, higher paid physicians, and those who worked in headquarters and clinics showed greater willingness to stay in their area of origin. CONCLUSIONS: Physicians' retention rate is dependent on both macro and microlevel factors.

Iran towards universal health coverage: The role of human resources for health.

Given the key role of adequate, skilled, well-trained, and motivated human resources for health (HRH) in achieving universal health coverage (UHC), this manuscript aimed to investigate the current situation of Iran HRH after the implementation of the recent Health Transformation Plan (HTP) in accordance with UHC analytical framework using 4 domains of availability, accessibility, acceptability, and quality. Conflicts of interest and multiple interventions from different sectors have controversial and sometimes negative effects on the health workforce. Thus, to achieve the objectives of UHC from the perspective of human resources, Iran needs unified governance and comprehensive planning. Also, the effects of health system interventions on health workforce should be assessed before implementation.

Public Health Activist Skills Pyramid: A Model for Implementing Health in All Policies.

Affecting public health for society requires various competencies. In fact, the prerequisite for the implementation of health in all policies should be effectiveness of public health activists (PHAs) in these competencies. This study aims to determine the competencies of the activists in public health. The present qualitative study reviewed the literature and adopted qualitative methods like content analysis, stakeholder interviews, and conducted focus group discussions with related experts. In each stage, the required competencies were extracted through drawing the main action processes of a PHA. Thereafter, the authors reached an ultimately best-suited working model by classifying and approving extracted competencies. The competencies comprise a pyramid set of three main categories of basic, specialized/professional, and individual updating competencies. Personal management, communication, teamwork, project management, ability to apply principles and concepts of public health, anatomy, physiology, and pathology in the organizations of the society should be included in the basic category. Specialized skills should include ability to plan, public participation, intersectoral collaboration, social marketing, working with the media/media friendly attitude, advocacy, research management and knowledge translation, evaluation of health programs, network establishment and management, deployment and institutionalization, operational research, empowerment and consultation, and protocol and service pack design. Last but not least, individual updating is defined as being informed of the latest scientific articles and reports about health and its situation in different countries as well as determinants that affect health. Implementation of this pyramid requires design and establishment of specific centers for transferring effective public health competencies. This pyramid has also functional use for the revision of educational curriculums in all health study fields. Moreover, it is helpful in designing virtual health education courses and the update of employees in entire parts of society pertaining to the health sector.