What the policy and stewardship landscape of a national health research system looks like in a developing country like Iran: a qualitative study.

BACKGROUND: The health research system (HRS) is an important national priority that requires a systematic and functional approach. Evaluating the HRS of Iran as a developing country and identifying its challenges reveals the stewardship-related role in how the whole system is operating well. This study aims to assess the HRS in terms of stewardship functions and highlight the enhancement points. METHODS: This study was carried out between March 2020 and April 2021 using a systematic review and meta-synthesis of evidence to examine the Iranian HRS stewardship challenges and interview 32 stakeholders, using a critical case sampling and snowballing approach which included both semi-structured and in-depth interviews. The interviewees were selected based on criteria covering policy-makers, managers, research bodies and nongovernmental organizations (NGOs) in health research-related fields like higher education, research, technology, innovation and science. All data were analysed using content analysis to determine eight main groups of findings under three levels: macro, meso, and micro. RESULTS: Analysis of the findings identified eight main themes. The most critical challenges were the lack of an integrated leadership model and a shared vision among different HRS stakeholders. Their scope and activities were often contradictory, and their role was not clarified in a predetermined big picture. The other challenges were legislation, priority-setting, monitoring and evaluation, networking, and using evidence as a decision support base. CONCLUSIONS: Stewardship functions are not appropriately performed and are considered the root causes of many other HRS challenges in Iran. Formulating a clear shared vision and a work scope for HRS actors is critical, along with integrating all efforts towards a unified strategy that assists in addressing many challenges of HRS, including developing strategic plans and future-oriented and systematic research, and evaluating performance. Policy-makers and senior managers need to embrace and use evidence, and effective networking and communication mechanisms among stakeholders need to be enhanced. An effective HRS can be achieved by redesigning the processes, regulations and rules to promote transparency and accountability within a well-organized and systematic framework.

Social, Economic, Technological, and Environmental Factors Affecting Cardiovascular Diseases: A Systematic Review and Thematic Analysis.

Background: Today, cardiovascular disease (CVD) is the leading cause of mortality in both sexes. There are several risk factors for heart diseases; some controllable, others not. However, socioeconomic, technological, and environmental factors can impact CVD as well as exclusive risk factors. Accurate identification and assessment of these factors are often difficult. In the present systematic review, we aimed to explore factors affecting CVD. Methods: Multiple databases (MEDLINE, Scopus, ISI Web of Science, and Cochrane) and gray literature were searched. The included studies described at least one determinant of CVD. The framework method was applied to analyze the qualitative data. Results: A total of 64 studies from 26 countries were included. The contextual determinants of CVD were categorized into 45 determinants, 15 factors, and 4 main social, economic, technological, and environmental categories. The 15 potentially reversible factors were identified as sociodemographic, violence, smoking, occupation, positive childhood experience, social inequalities, psychological distress, eating habits, neighborhood, family income, rapid technology, environmental pollution, living environments, noise, and disaster. Conclusions: Devolution and more efficient health policies are required to achieve further sustained reduction in CVD mortality, increase life expectancy, and reduce its associated risk factors. Policymakers should fully address the value of social, economic, technological, and environmental factors. In fact, a prevention agenda should be developed and updated collaboratively in terms of the determinant factors.

Future Financing Scenarios for Iran's Healthcare System.

BACKGROUND: The financing function within a health system is considered inherently complex, so it is of utmost importance to design a suitable future for this system given uncertainties and complexities of the environment. With regard to the current and future complicated conditions, health system financing is also likely to succeed if it can anticipate the impacts of effective factors in the future and further plan appropriate interventions ahead of time. Thus, the purpose of this study was to develop scenarios for the health system financing in Iran. METHODS: This mixed-design research of exploratory future studies type was conducted using the scenario method. In this respect, the key variables were evaluated using a questionnaire from two aspects of importance and uncertainty as well as formation of a future studies group (focus group). Finally, sensitivity analysis was carried out through cross-impact balance (CIB) analysis using the Scenario Wizard (Version 4.31) software. RESULTS: A total of 25 factors were selected based on the type and the position of the variables (driving force, bi-dimensional, risk, secondary leverage or modifiable-to-secondary leverage) over the diameter of the MICMAC chart. Considering the degree of significance and uncertainty, eight variables including all four driving force variables (oil sales and economic blockade, leadership and advocacy, bureaucracy and corruption, and possibility of using information technology in providing services), as well as the variables of resource sustainability, natural disasters, regional security, and specialization culture were chosen. Then, five variables were finalized as the key changes that would create the scenario based on sensitivity analysis and final expert opinions. According to the defined conditions, 270 scenarios were developed, of which fourteen scenarios were identified as poorly adaptable and five cases as highly adaptable. CONCLUSION: The best scenario identified in this study based on the degree of adaptation included the use of massive technology and oil sales, mediocre economic conditions with high probability of occurrence, strong leadership and advocacy, high regional security, as well as bureaucracy and low corruption with medium probability of occurrence.

Insurance and Improving Its Strategic Purchase in Iran.

As in most countries, patients, health care providers, and insurance organizations are key components of the health care system in Iran. High rates of growth and development in today's financial markets, have made the insurance industry with its unique calculations and models, a prominent player in this specialized economic sector.

Influential factors of out of pocket payments for health care in Iran: A foresight approach using the cross impact analysis.

OBJECTIVE: To identify and explain the interactions and network of the relationship between influential factors of out-ofpocket payments for health services. METHODS: This futures study was conducted in 2015 in Iran, and comprised experts of various sectors. At first, key factors and driven forces of out-of-pocket payments were detected; then, the factors were collected in the form of a square-matrix questionnaire; and completed based on impact of each factor on the occurrence probability of others, with collective agreement, so the role of any factor in forecasting out-of-pocket status in future was identified by cross-impact analysis. MicMac software was used for data analysis. RESULTS: As many as 35 factors were identified which affected out-of pocket payments. The factors were categorised in four main roles, i.e. influencing, two-sided, dependent and independent. Some economic factors which had a higher impact on other system factors were influencing factors; they were the most critical components because the system changes were dependent on them. In contrast, some factors related to organising the health system were depending factors and were affected by the least changes in other factors. There are 10 factors in this group. These factors were mainly related to the utilisation of health services by a special look to the part of delivery (public or private). CONCLUSIONS: Policymakers should consider interactions and influencing network of out-of-pocket payment factors and should understand how a change in one factor can have a series of changes.

Effective factors and drivers of Iran's health care financing system.

Background: Different factors affect Iran's health care financing system, and regardless of this impact, the future of this system will face fundamental challenges. In this environment, a health system is successful if it is able to anticipate the effects of these factors in the future of health care financing and preplan appropriate interventions towards health care financing system. The present study aims to identify these factors and trends. Methods: This study compiled a round view of the experts on the subject, with a future studies approach through a qualitative method. To collect data, a deep and semi-structured interview was performed. The results of the interviews were analyzed using content analysis method, and the primary and secondary themes were extracted using the Micmac software. Results: A total of 71 variables were identified in the form of 12 groups with titles of stewardship, service provision, resource gathering, purchasing and resource allocation, sociocultural, technological, environmental, economic, political, and managerial, and laws and values. Four variables, including distant-service provision, administrative bureaucracy, administrative focus and corruption, low-support decision-making, economic blockade, and sales of oil were among the influential factors and drivers. Conclusion: The findings showed Iran's financing system is relatively stable but fragile and 3 areas of technology, politics, and economics have the most impact on structuring Iran's financing system.

Estimating the cost of vaccination in southeastern Iran.

Background: Specification of vaccination cost of children would help policymakers in determining the nation-wide budget needed for the maintenance of the vaccination program. The budget came these days under scrutiny due to the imposed sanctions tightening the public funds. This study aims at estimating the cost of vaccination in southeastern Iran for obtaining more accurate budget projections. Methods: Fifty-two healthcare centers from 10 cities in south-east Iran participated in using a quota sampling method for their selection. A bottom-up method determined the human resource use, the consumption, and the overhead costs to estimate the cost of vaccination. Data collection used a standard tool that was adjusted to local conditions. Sensitivity analyses were performed. Results: The overall vaccination cost for the region was estimated at around 5,984,000 USD for the year 2015. Salaries took the largest part of the cost estimate (64%), while vaccine cost and its equipment were much lower (22%). The average cost per vaccine dose administrated was 40.94 USD. Sensitivity analysis of the population and inflation rate indicates that the vaccination cost may fluctuate between 37% and 53% over 6 years (2021) from the data of 2015. Conclusion: Maintaining vaccination has a substantial cost. The results of the study will support the budget planning and decision making and will define more precisely the resource allocation needed for maintaining the vaccination at a high level across the country. It may also help to facilitate the assessment of cost-benefit and cost-effectiveness analysis when new vaccines should be introduced.

Forecasting health expenditures in Iran using the ARIMA model (2016-2020).

Background: Accurate economic forecast has important effects on governmental policy and economic planning, and it can help policymakers to make decisions for future and create new infrastructures for the development of new forecasting methods. This study calculated total health expenditure, public health expenditure and out of pocket (OOP) payment for 2016-2020. Methods: Autoregressive Integrated Moving Average Process (ARIMA) is one of the most important forecasting models. In this study, five-year values were forecasted using EViews8 software according to health expenditures in Iran from 1971 to 2015. Results: Applying annual data for total health expenditure, resulted in the ARIMA (1,1,1) model being the most appropriate to predict these costs. The results of this study indicate that total health expenditures will reach from about 1228338 billion IRR in 2016 to 2698346 billion IRR in 2020 and the amount of out of pocket (OOP) will become more than 41% of total health expenditure in 2020. Conclusion: Total health expenditures in 2020 will become more than two halves in 2016. These expenditures indicated there is a need for continued governmental support of this sector during the upcoming years.

Challenges of implementation: Strategic purchasing in Iran Health Insurance Organization.

BACKGROUND: Strategic purchasing has been introduced as a key strategy for solving the problems faced by insurance companies. In Iran, the government has mandated the Iran Health Insurance Organization (IHIO) to implement this strategy. However, there are serious challenges to achieving that. The present study aims to identify these challenges. METHODS: In this qualitative study, a semi-structured interview was conducted on 27 health managers and experts at the national level. The dimensions of the A. Preker model were used to analyze the data. RESULTS: Challenges of strategic purchasing in the IHIO were categorized into five concepts-political economy, policy design, organizational structure, organizational environment, and management capacity; within these concepts, 22 challenges were identified. CONCLUSIONS: Improving strategic purchasing in Iran requires adopting a coherent approach and taking into account all the affecting factors. By revising some policies, and modifying and defining the rules needed to solve the infrastructural problems, the success of strategic purchasing can be obtained.

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

BACKGROUND: In 2015, it was estimated that the burden of disease in Iran comprised of 19 million disability-adjusted life years (DALYs), 74% of which were due to non-communicable diseases (NCDs). The observed leading causes of death were cardiovascular diseases (41.9%), neoplasms (14.9%), and road traffic injuries (7.4%). Even so, the health research investment in Iran continues to remain limited. This study aims to identify national health research priorities in Iran for the next five years to assist the efficient use of resources towards achieving the long-term health targets. METHODS: Adapting the Child Health and Nutrition Research Initiative (CHNRI) method, this study engaged 48 prominent Iranian academic leaders in the areas related to Iran's long-term health targets, a group of research funders and policy makers, and 68 stakeholders from the wider society. 128 proposed research questions were scored independently using a set of five criteria: feasibility, impact on health, impact on economy, capacity building, and equity. FINDINGS: The top-10 priorities were focused on the research questions relating to: health insurance system reforms to improve equity; integration of NCDs prevention strategy into primary health care; cost-effective population-level interventions for NCDs and road traffic injury prevention; tailoring medical qualifications; epidemiological assessment of NCDs by geographic areas; equality in the distribution of health resources and services; current and future common health problems in Iran's elderly and strategies to reduce their economic burden; the status of antibiotic resistance in Iran and strategies to promote rational use of antibiotics; the health impacts of water crisis; and research to replace the physician-centered health system with a team-based one. CONCLUSIONS: These findings highlight consensus amongst various prominent Iranian researchers and stakeholders over the research priorities that require investment to generate information and knowledge relevant to the national health targets and policies. The exercise should assist in addressing the knowledge gaps to support both the National General Health Policies by 2025 and the health targets of the United Nations' Sustainable Development Goals by 2030.

Exploring perceptions of policymakers about main strategies to enhance fertility rate: A qualitative study in Iran.

BACKGROUND: Total fertility rate in Iran has declined unprecedentedly over the past thirty years. However, debating on proper strategies to increase fertility is still a matter of discussion among experts. OBJECTIVE: To explain the main strategies to increase fertility from the viewpoints of the policy makers. METHODS: This is a qualitative study using content analysis. Purposeful sampling approach was used to gather data. The data were collected via semi-structured interviews. Eight experts participated in the study and the main criteria were executive experience related to public health, scientific publication in these areas and availability as well as their own interest. Content analysis was used to extract the codes. RESULTS: The main theme extracted was improving the infrastructures. Almost all participants agreed on interventions around removing marriage obstacles, improving working conditions for women, improving the quality of the educational system, training and consultation, research, and improving services to increase fertility rate. CONCLUSIONS: The government should formulate long-term instead of short-term policies, and note that improving the economic conditions along with the promotion of social welfare, and enabling women in balancing work and family, are highly influential in childbearing decision-making, as they ensure a better future for the next generation. In addition, people should touch on the potential risk of future fertility reduction, so it is suggested to inform the public through free discussions.

Health technology assessment on super oxidized water for treatment of chronic wounds.

BACKGROUND: Super oxidized water (SOW), as a novel antiseptic solution, is used with claims of effectiveness and cost effectiveness in healing chronic wounds such as diabetic foot, infectious postoperative ulcers and burn ulcers. We conducted a health technology assessment to evaluate the clinical evidence from clinical and randomized trials for this disinfection. This study aims to evaluate the safety, effectiveness and cost-effectiveness of this technology in Iran, for using as a wound disinfectant. METHODS: Systematic literature searches were conducted from October 2013 to March 2014 for the following medical databases: OVID MEDLINE, CINAHL, the Cochrane Library and the PICO terms were included and then analyzed by Cochrane assessment criteria. RESULTS: Out of 705 articles, twelve potentially relevant trials were identified. Others that didn't come with the PICO criteria were excluded. 5 randomized controlled trials, 5 clinical trials, a rapid HTA and a case series that had studied the effectiveness of super oxidized water on patients with different chronic wounds, were included. Most of these trials were assessing similar sets of outcomes as the Safety and Effect on Healing days to re-epithelization, healing rate, effect on Infection bacterial counts and infection rates. CONCLUSION: Super oxidized water is a safe, effective and cost effective irrigation and cleansing agent due to the performed analysis in comparison with current treatment as povidone iodine for treating wound infections.

Health technology assessment: Off-site sterilization.

BACKGROUND: Every year millions of dollars are expended to equip and maintain the hospital sterilization centers, and our country is not an exception of this matter. According to this, it is important to use more effective technologies and methods in health system in order to reach more effectiveness and saving in costs. This study was conducted with the aim of evaluating the technology of regional sterilization centers. METHODS: This study was done in four steps. At the first step, safety and effectiveness of technology was studied via systematic study of evidence. The next step was done to evaluate the economical aspect of off-site sterilization technology using gathered data from systematic review of the texts which were related to the technology and costs of off-site and in-site hospital sterilization. Third step was conducted to collect experiences of using technology in some selected hospitals around the world. And in the last step different aspects of acceptance and use of this technology in Iran were evaluated. RESULTS: Review of the selected articles indicated that efficacy and effectiveness of this technology is Confirmed. The results also showed that using this method is not economical in Iran. CONCLUSION: According to the revealed evidences and also cost analysis, due to shortage of necessary substructures and economical aspect, installing the off-site sterilization health technology in hospitals is not possible currently. But this method can be used to provide sterilization services for clinics and outpatients centers.

Proactive risk assessment of blood transfusion process, in pediatric emergency, using the Health Care Failure Mode and Effects Analysis (HFMEA).

INTRODUCTION: Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology. METHODOLOGY: This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts' panel views via the interview and focus group discussion sessions. RESULTS: The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ ("Theory of Inventive Problem Solving.") CONCLUSION: The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency.

The projection of burden of disease in Islamic Republic of Iran to 2025.

OBJECTIVE: Iran as a developing country is in the transition phase, which might have a big impact on the Burden of Disease and Injury (BOD). This study aims to estimate Burden of Disease and Injury (BOD) in Iran up to 2025 due to four broad cause groups using Disability-Adjusted Life Year (DALY). METHODS: The impacts of demographic and epidemiological changes on BOD (DemBOD and EpiBOD) were assessed separately. We estimated DemBOD in nine scenarios, using different projections for life expectancy and total fertility rate. EpiBOD was modeled in two scenarios as a proportion of DemBOD, based on the extracted parameters from an international study. FINDINGS: The BOD is projected to increase from 14.3 million in 2003 to 19.4 million in 2025 (95% uncertainty interval: 16.8, 21.9), which shows an overall increase of 35.3%. Non-communicable diseases (12.7 million DALY, 66.0%), injuries (4.6 million DALY, 24.0%), and communicable diseases, except HIV/AIDS (1.8 million DALY, 9%) will be the leading causes of losing healthy life. Under the most likely scenario, the maximum increase in disease burden due to DemBOD is projected to be observed in HIV/AIDS and Non-communicable diseases (63.9 and 62.4%, respectively) and due to EpiBOD in HIV/AIDS (319.5%). CONCLUSION: It seems that in the following decades, BOD will have a sharp increase in Iran, mainly due to DemBOD. It seems that communicable diseases (except HIV/AIDS) will have less contribution, and especially non-communicable diseases will play a more significant role.

A qualitative study of the difficulties in reaching sustainable universal health insurance coverage in Iran.

OBJECTIVE To understand the Iranian health financing system and provide lessons for policy makers about achieving universal coverage. METHODS Twenty-five interviewees from seven major health insurance companies were selected for a qualitative study in 2007. Using a semi-structured interview, three main tasks of the health financing system (revenue collection, risk pooling and purchasing) were investigated. A framework method was applied for the data analysis. RESULTS The results of the study show the following seven major obstacles to universal coverage: unknown insured rate; regressive financing and non-transparent financial flow; fragmented and non-compulsory system; non-scientifically designed benefit package; non-health-oriented and expensive payment system; uncontrolled demands; and administrative deficiency. A long-term systematic plan is required to address the above problems.