Reforms and innovations in primary health care in different countries: scoping review.

INTRODUCTION: The World Health Organization (WHO) recommends focusing on primary health care (PHC) as the first strategy of countries to achieve the improvement of the health level of communities and has emphasized it again in 2021. Therefore, we intend to take a different look at the PHC system with reform, innovation, and initiative by using the experiences of leading countries and identify practical and evidence-based solutions to achieve greater health. METHODS: This is a scoping review study that has identified innovations and reforms related to PHC since the beginning of 2000 to the end of 2022. In this study, Scopus, Web Of Science, and PubMed databases have been searched using appropriate keywords. This study is done in six steps using Arkesy and O'Malley framework. In this study, the framework of six building blocks of WHO was used to summarize and report the findings. RESULTS: By searching in different databases, we identified 39426 studies related to reforms in primary care, and after the screening process, 106 studies were analyzed. Our findings were classified and reported into 9 categories (aims, stewardship/leadership, financing & payment, service delivery, health workforce, information, outcomes, policies/considerations, and limitations). CONCLUSION: The necessity and importance of strengthening PHC is obvious to everyone due to its great consequences, which requires a lot of will, effort, and coordination at the macro-level of the country, various organizations, and health teams, as well as the participation of people and society.

Costs of inpatient care and out-of-pocket payments for COVID-19 patients: A systematic review.

OBJECTIVE: To identify the costs of hospital care for patients with COVID-19 and the amount of out-of-pocket payments. METHODS: We conducted a systematic review using Scopus and WEB OF SCIENCE and PubMed databases in April 5, 2022 and then updated in January 15, 2023. English articles with no publication year restrictions were included with study designs of cost-of-illness (COI) studies, cost analyses, and observational reports (cross-sectional studies and prospective and retrospective cohorts) that calculated the patient-level cost of care for COVID-19. Costs are reported in USD with purchasing power parity (PPP) conversion in 2020. The PROSPERO registration number is CRD42022334337. RESULTS: The results showed that the highest total cost of hospitalization in intensive care per patient was 100789 USD, which was reported in Germany, and the lowest cost was 5436.77 USD, which was reported in Romania. In the present study, in the special care department, the highest percentage of total expenses is related to treatment expenses (42.23 percent), while in the inpatient department, the highest percentage of total expenses is related to the costs of hospital beds/day of routine services (39.07 percent). The highest percentage of out-of-pocket payments was 30.65 percent, reported in China, and the lowest percentage of out-of-pocket payments was 1.12 percent, reported in Iran. The highest indirect cost per hospitalization was 16049 USD, reported in USA, and the lowest was 449.07 USD, reported in India. CONCLUSION: The results show that the COVID-19 disease imposed a high cost of hospitalization, mainly the cost of hospital beds/day of routine services. Studies have used different methods for calculating the costs, and this has negatively impacted the comparability costs across studies. Therefore, it would be beneficial for researchers to use a similar cost calculation model to increase the compatibility of different studies. Systematic review registration: PROSPERO CRD42022334337.

The challenges facing programs for the prevention and control of non-communicable diseases in Iran: a qualitative study of senior managers' viewpoints.

BACKGROUND: Despite significant achievements in the prevention and control of NCDs in Iran, these conditions are still the biggest challenges to Iran's healthcare system and are estimated to account for 78.1 percent of all deaths. Therefore, this study aimed to reflect on the potential challenges standing in the way to implement the relevant policies, empower the dimensions of governance, and react in an effective and timely manner by Iran's healthcare system to NCDs. METHODS: This study was conducted with a qualitative approach using the conventional content analysis method. A total of 46 senior managers involved in the prevention and control of NCDs at the medical sciences universities across Iran were recruited through the purposive sampling method and were interviewed via semi-structured interviews. Graneheim and Lundman's approach was utilized to analyze the data. RESULTS: According to the analysis of the senior managers' viewpoints, current challenges to implement the program for the prevention and control of NCDs in Iran could be placed into six main categories, including financing, human resources, infrastructure and inputs, legal, executive, administrative, as well as inter-sectoral collaboration, and management and policy-making challenges with their own sub-categories. CONCLUSION: The results revealed that financing was the biggest challenge to successfully implementing the program for the prevention and control of NCDs in Iran. However, strengthening Iran's healthcare system in the field of the prevention of NCDs demanded more innovative measures and strategies, such as the empowerment of human resources, the effective use of intra- and inter-sectoral collaboration, and non-governmental organizations and charities, along with the exploitation of evidence-based studies during policy-making and decision-making processes, with no need for financial resources.

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.

A systematic review of racial/ethnic and socioeconomic disparities in COVID-19.

BACKGROUND: Preliminary evidence from the COVID-19 pandemic shows the presence of health disparities, especially in terms of morbidity and mortality. This study aimed to systematically review the evidence on the association of racial/ethnic and socioeconomic status (SES) with health outcomes and access to healthcare services during the COVID-19 pandemic. METHODS: We retrieved published evidence from late December 2019 through March 1, 2021. The target population was the population of the countries during the COVID-19 pandemic. The exposures were defined as belonging to racial/ethnic minority groups and/or low SES. The primary outcomes of interest include (1) death from COVID-19, (2) COVID-19 incidence/infection, (3) COVID-19 hospitalization, (4) ICU admission, (5) need for mechanical ventilation, (6) confirmed diagnosis, and (7) access to testing. We systematically synthesized the findings from different studies and provided a narrative explanation of the results. RESULTS: After removing the duplicate results and screening for relevant titles and abstracts, 77 studies were selected for full-text review. Finally, 52 studies were included in the review. The majority of the studies were from the United States (37 studies). Despite the significant incongruity among the studies, most of them showed that racial/ethnic minority groups had higher risks of COVID-19 infection and hospitalization, confirmed diagnosis, and death. Additionally, most of the studies cited factors such as low level of education, poverty, poor housing conditions, low household income, speaking in a language other than the national language in a country, and living in overcrowded households as risk factors of COVID-19 incidence/infection, death, and confirmed diagnosis. However, findings in terms of the association of lack of health insurance coverage and unemployment with the outcome measures as well as the association of requiring mechanical ventilation, ICU admission, and access to testing for COVID-19 with race/ethnicity were limited and inconsistent. CONCLUSION: It is evident that racial/ethnic minority groups and those from low SES are more vulnerable to COVID-19; therefore, public health policymakers, practitioners, and clinicians should be aware of these inequalities and strive to narrow the gap by focusing on vulnerable populations. This systematic review also revealed a major incongruity in the definition of the racial/ethnic minority groups and SES among the studies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020190105.

Disparities in the quality of and access to services in children with autism spectrum disorders: a structural equation modeling.

BACKGROUND: Socioeconomic disparities in health and healthcare are global issues that affect both adults as well as children. Children with exceptional healthcare needs, especially those with developmental impairments, including Autism Spectrum Disorders (ASD), encounter major disparities in access to and quality of health services. However, disparities in the population of children are rarely studied. The main aim of this paper is to study the socioeconomic disparities in children with ASD by examining the association between their Social Determinants of Health (SDH) status and access to and the quality of services. METHODS: This is a cross-sectional study on 202 children with ASD conducted in 2019 in two provinces including Ardabil and East-Azerbaijan, in the North-West of Iran. A structured, valid questionnaire was used to collect data on demographic, SDH status, quality of services, and access to services in a population of children with ASD aged 2-16-year-old. Around 77% participants were male and the mean age of children was 2 years and 6 months. Structural Equation Modeling (SEM) were used to assess the relationship. RESULTS: Based on the results of this study, the overall mean scores of the quality of services, access to services, and SDH status were 61.23 (30.01), 65.91 (21.89), and 29.50 (22.32) out of 100, respectively. All the associations between the quality and access dimensions and quality (B: 0.464-0.704) and access (B: 0.265-0.726) scales were statistically significant (P < 0.001). By adjusting to covariates, the access was also significantly related to service quality (P = 0.004). Finally, the associations between SDH score with service quality (P = 0.039) and access (P < 0.001) were positively significant. CONCLUSIONS: There are socioeconomic disparities in the quality of and access to services among children with ASD, who use ASD services, in the North-West of Iran. We recommend health/medical centers, where children are diagnosed with ASD, conducting SDH screening and providing families of low-SDH status with specific information about the quality of and access to services for children with ASD. Additionally, medical universities must have a plan to routinely monitor the quality of and access to services provided for the children with low SDH.

Improvement of the quality payment program by improving data reporting process: an action research.

BACKGROUND: Successful implementation of pay-for-quality (P4Q) programs mostly depends upon a valid, timely, and reliable data about quality measures generated by providers, and interpreted by payers. The aim of this study was to establish a data reporting method for P4Q program through an action research. METHODS: Qualitative method was used to align theory with action through a three-cycle action research. The study was conducted in September 15, 2015 to March 15, 2017, in East-Azerbaijan, Iran. The purposeful sampling was used to select participants. The participants included healthcare providers, staff in district health centers (DHC), experts, and managers in the provincial primary health center (PPHC). Data was collected by interviews, focus group discussions, and expert panels. Content analysis was used to synthesize the data. In each step, decisions about data reporting methods were made through a consensus of expert panel members. RESULTS: The most important dimensions of data reporting method were data entry and accuracy, data reporting, data analysis and interpretations, the flexibility of method, and training. By establishment of an online data reporting system for the P4Q program, a major improvement was observed in the documentation of performance data, the satisfaction of health care providers and staff (e.g. either in DHCs or PPHC), improvement of the P4Q program and acceptance of the P4Q program by providers. Following the present study, the online system was expanded in Iran's public health system for data collection and estimating the amount of incentive payments in P4Q program. Moreover, more improvements were achieved by linking the system to EMRs and also, providing automated feedback to providers about their own performance. CONCLUSIONS: A web-based computerized system with the capability of linking medical record and also its ability to provide feedback to healthcare providers was identified as an appropriate method of data reporting in the P4Q program from the viewpoints of participants in this study.

A framework to assess management performance in district health systems: a qualitative and quantitative case study in Iran.

The aim was to design a district health management performance framework for Iran's healthcare system. The mixed-method study was conducted between September 2015 and May 2016 in Tabriz, Iran. In this study, the indicators of district health management performance were obtained by analyzing the 45 semi-structured surveys of experts in the public health system. Content validity of performance indicators which were generated in qualitative part were reviewed and confirmed based on content validity index (CVI). Also content validity ratio (CVR) was calculated using data acquired from a survey of 21 experts in quantitative part. The result of this study indicated that, initially, 81 indicators were considered in framework of district health management performance and, at the end, 53 indicators were validated and confirmed. These indicators were classified in 11 categories which include: human resources and organizational creativity, management and leadership, rules and ethics, planning and evaluation, district managing, health resources management and economics, community participation, quality improvement, research in health system, health information management, epidemiology and situation analysis. The designed framework model can be used to assess the district health management and facilitates performance improvement at the district level.

Evaluation of the district health management fellowship training programme: a case study in Iran.

OBJECTIVE: To evaluate the district health management fellowship training programme in the north-west of Iran. DATA SOURCES/STUDY SETTING: The programme was introduced to build the managerial capacity of district health managers in Iran. Eighty-nine heads of units in the province's health centre, district health managers and the health deputies of the district health centres in the north-west provinces of Iran had registered for the district health management fellowship training programme in Tabriz in 2015-2016. STUDY DESIGN: This was an educational evaluation study to evaluate training courses to measure participants' reactions and learning and, to a lesser extent, application of training to their job and the organisational impact. DATA COLLECTION/EXTRACTION METHODS: Valid and reliable questionnaires were used to assess learning techniques and views towards the fellowship, and self-assessment of health managers' knowledge and skills. Also, pretest and post-test examinations were conducted in each course and a portfolio was provided to the trainees to be completed in their work settings. PRINCIPAL FINDINGS: About 63% of the participants were medical doctors and 42.3% of them had over 20 years of experience. Learning by practice (scored 18.37 out of 20) and access to publications (17.27) were the most useful methods of training in health planning and management from the participants' perspective. Moreover, meeting peers from other districts and the academic credibility of teachers were the most important features of the current programme. Based on the managers' self-assessment, they were most skilful in quality improvement, managing, planning and evaluation of the district. The results of the post-test analysis on data collected from district health managers showed the highest scores in managing the district (77 out of 100) and planning and evaluation (69) of the courses. CONCLUSION: The results of this study indicated that training courses, methods and improvement in managers' knowledge about the health system and the skills necessary to manage their organisation were acceptable.

A framework to assess management performance in district health systems: a qualitative and quantitative case study in Iran / Um modelo para avaliar a gestão dos distritos sanitários no Irã: um estudo de caso qualitativo e quantitativo / Un marco para evaluar el desempeño de la gestión en el área de sistemas de salud: un estudio de caso cualitativo y cuantitativo en Irán

The aim was to design a district health management performance framework for Iran's healthcare system. The mixed-method study was conducted between September 2015 and May 2016 in Tabriz, Iran. In this study, the indicators of district health management performance were obtained by analyzing the 45 semi-structured surveys of experts in the public health system. Content validity of performance indicators which were generated in qualitative part were reviewed and confirmed based on content validity index (CVI). Also content validity ratio (CVR) was calculated using data acquired from a survey of 21 experts in quantitative part. The result of this study indicated that, initially, 81 indicators were considered in framework of district health management performance and, at the end, 53 indicators were validated and confirmed. These indicators were classified in 11 categories which include: human resources and organizational creativity, management and leadership, rules and ethics, planning and evaluation, district managing, health resources management and economics, community participation, quality improvement, research in health system, health information management, epidemiology and situation analysis. The designed framework model can be used to assess the district health management and facilitates performance improvement at the district level.

O estudo teve como objetivo desenvolver um modelo para avaliar a gestão dos distritos sanitários no sistema de saúde iraniano. Um estudo de métodos mistos foi realizado entre setembro de 2015 e maio de 2016 em Tabriz, Irã. Os indicadores de desempenho da gestão dos distritos sanitários foram obtidos a partir da análise de 45 entrevistas semiestruturadas com especialistas no sistema público de saúde. A validade do conteúdo dos indicadores de desempenho gerados pelo componente qualitativo foi revisada e confirmada com base no índice de validade de conteúdo (IVC). A razão de validade de conteúdo (RVC) foi calculada com os dados adquiridos em entrevistas com 21 especialistas durante a etapa quantitativa. Os resultados do estudo indicam que, inicialmente, 81 indicadores foram considerados no modelo de desempenho de gestão dos distritos sanitários, e que, no final, 53 indicadores foram validados e confirmados. Estes indicadores foram classificados em 11 categorias: recursos humanos e criatividade organizacional, gestão e liderança, regras e ética, planejamento e avaliação, gestão distrital, gestão de recursos de saúde e economia, participação comunitária, melhoria de qualidade, pesquisa no sistema de saúde, gestão da informação em saúde, epidemiologia e análise situacional. O modelo projetado pode ser usado para avaliar a gestão dos distritos sanitários, além de facilitar a melhoria do desempenho em nível distrital.

El objetivo del presente estudio fue diseñar un marco para evaluar el desempeño de la gestión en el ámbito de la salud dentro del sistema de salud iraní. Se realizó un método mixto de estudio entre septiembre 2015 y mayo 2016 en Tabriz, Irán. En este estudio, los indicadores del desempeño en la gestión dentro del ámbito de la salud se obtuvieron analizando 45 encuestas semiestructuradas de expertos en el sistema público de salud. Los indicadores de rendimiento, respecto a la validez del contenido que se generaron en la parte cualitativa, fueron revisados y confirmados basándose en el índice de validez de contenido (IVC). Asimismo, el content validity ratio (CVR) se calculó usando datos obtenidos de una encuesta a 21 expertos en la parte cuantitativa del estudio. El resultado del mismo indicó que, inicialmente, se consideraron 81 indicadores en el marco del desempeño de la gestión en el ámbito de la salud y, al final, se validaron 53 indicadores y confirmados. Estos indicadores se clasificaron en 11 categorías que incluían: rescusos humanos y creatividad organizativa, gestión y liderazgo, reglas y ética, planificación y evaluación, gestión de área, gestión de recursos de salud y económicos, participación en la comunidad, mejora de la calidad, investigación en sistemas de salud, gestión de información sobre la salud, epidemiología y análisis de situación. El modelo de marco diseñado puede ser usado para evaluar la gestión en el ámbito de la salud y facilitar la mejora del desempeño en el ámbito municipal.

Households encountering with catastrophic health expenditures in Ferdows, Iran.

BACKGROUND: Out-of-pocket payments are the main sources of healthcare financing in most developing countries. Healthcare services can impose a massive cost burden on households, especially in developing countries. The purpose of this study was to calculate households encountered with catastrophic healthcare expenditures in Ferdows, Iran. MATERIALS AND METHODS: The sample included 100 households representing 20% of all households in Ferdows, Iran. The data were collected using self-administered questionnaire. The ability to pay of households was calculated, and then if costs of household health were at least 40% of their ability to pay, it was considered as catastrophic expenditures. RESULTS: Rate of households encountered to catastrophic health expenditures was estimated to be 24%, of which dentistry services had the highest part in catastrophic health expenditures. CONCLUSION: Low ability to pay of households should be supported against these expenditures. More equitable health system would solve the problem, although more financial aid should be provided for households encountered to catastrophic costs.

Comparing performance of Tabriz obstetrics and gynaecology hospitals managed as autonomous and budgetary units using Pabon Lasso method.

BACKGROUND: Considering governmental scrutiny and financial constraints in medicine, the need for improved performance, which can provide acceptable care for medical consumers, leads to the conduct of new managerial methods to improve effectiveness. AIMS: This study aimed to compare performance indicators of obstetrics and gynaecology teaching hospitals in Tabriz. METHOD: A longitudinal, retrospective study was conducted to compare performance indexes of Tabriz obstetrics and gynaecology teaching hospitals during 2010-2012. Al-Zahra is Tabriz's central teaching hospital in obstetrics and gynaecology that is authorised under a board of trustees as an autonomous hospital and Taleghani hospital is managed under centralised administration. Study variables included: Average Length of Stay (ALOS), Bed Occupancy Rate (BOR), and Bed Turnover Ratio (BTR). The data was extracted via the Hospital Information Systems (HIS) within the hospitals' admission and discharge units. Pabon Lasso model was used to assess hospital performance. Data was analysed and graphs were plotted using the SPSS-17 software package. RESULTS: According to study findings, overall ALOS in Al-Zahra hospital is 3.15 (2.15) days (1.88 (0.97) days for prenatal wards and 6.13 (0.97) days for neonatal wards) and ALOS in Taleghani Hospital is 3.37 (3.09) days (1.74 (0.14) days for perinatal wards and 5.96 (3.55) days for neonatal wards). In this regard, Al-Zahra hospital holds the maximum BOR with 86.92 per cent and the minimum BOR was attributed to Taleghani hospital at 68.44 per cent (P<0.001). Study findings indicate that BOR in neonatal wards is greater than prenatal wards. On the other hand, BOR in Al-Zahra is greater than Taleghani (P<0.001), whereas BOR trend shows an increasing pattern in both hospitals. CONCLUSION: Results of this study showed that the performance of Al- Zahra Hospital is better than Taleghani Hospital. These two hospitals are similar in different aspects except Al-Zahra is under a board of trustees and Taleghani is not. We should also consider that Al-Zahra Hospital has more facilities than Taleghani.