Barriers and enabling factors for utilizing physical rehabilitation services by Afghan immigrants and refugees with disabilities in Iran: a qualitative study.

INTRODUCTION: Individuals with a migrant background often underutilize physical rehabilitation services (PRS) compared to the host population. This disparity is attributed to various barriers, including limited access to information, language barriers, illiteracy, and cultural factors. To improve PRS utilization by Afghan immigrants and refugees in Iran, it is crucial to identify these barriers and enabling factors. In response, this study explored the barriers and enabling factors for utilizing PRS among Afghan immigrants and refugees with disabilities in Iran. METHODS: This qualitative study was conducted in Iran between January and March 2023. Participants were selected through convenient and snowball sampling. Individual, semi-structured interviews were carried out both in face-to-face and online formats. Data analysis occurred concurrently with data collection, using the directed content analysis approach. RESULTS: Findings from our research indicate that common barriers to PRS utilization among Afghan immigrants and refugees include insufficient insurance coverage, high service costs, expensive transportation and accommodation, limited knowledge about Iran's health system, inadequate awareness of available supports, restricted access to PRS in remote areas, impatience among PRS providers, fear of arrest and deportation, a lack of trust in modern treatments, stringent immigration rules, high inflation rates limiting the ability to pay for PRS, and limited social support. On the other hand, several enabling factors were identified, such as strengthening insurance coverage, utilizing the capacities of charities and NGOs, providing information about available services, promoting respectful behavior by healthcare providers towards patients, facilitating cultural integration, and increasing immigrants' awareness of available services and eligibility criteria. CONCLUSION: The barriers and enabling factors uncovered in this study offer valuable insights into the complexities surrounding PRS utilization by Afghan immigrants and refugees with disabilities in Iran. Understanding and addressing these factors is essential for developing targeted interventions and policies that can improve access and utilization, ultimately leading to enhanced health outcomes for this vulnerable population.

Barriers and facilitators to reducing low-value care for the management of low back pain in Iran: a qualitative multi-professional study.

INTRODUCTION: Low back pain (LBP) is a prevalent musculoskeletal disorder with a wide range of etiologies, ranging from self-limiting conditions to life-threatening diseases. Various modalities are available for the diagnosis and management of patients with LBP. However, many of these health services, known as low-value care (LVC), are unnecessary and impose undue financial costs on patients and health systems. The present study aimed to explore the perceptions of service providers regarding the facilitators and barriers to reducing LVC in the management of LBP in Iran. METHODS: This qualitative descriptive study interviewed a total of 20 participants, including neurosurgeons, physiatrists, orthopedists, and physiotherapists, who were selected through purposive and snowball sampling strategies. The collected data were analyzed using the thematic content analysis approach. RESULTS: Thirty-nine sub-themes, with 183 citations, were identified as barriers, and 31 sub-themes, with 120 citations, were defined as facilitators. Facilitators and barriers to reducing LVC for LBP, according to the interviewees, were categorized into five themes, including: (1) individual provider characteristics; (2) individual patient characteristics; (3) social context; (4) organizational context; and (5) economic and political context. The ten most commonly cited barriers included unrealistic tariffs, provider-induced demand, patient distrust, insufficient time allocation, a lack of insurance coverage, a lack of a comprehensive referral system, a lack of teamwork, cultural challenges, a lack of awareness, and defensive medicine. Barriers such as adherence to clinical guidelines, improving the referral system, improving the cultural status of patients, and facilitators such as strengthening teamwork, developing an appropriate provider-patient relationship, improving the cultural status of the public, motivating the patients, considering an individualized approach, establishing a desirable payment mechanism, and raising the medical tariffs were most repeatedly stated by participants. CONCLUSION: This study has pointed out a great number of barriers and facilitators that shape the provision of LVC in the management of LBP in Iran. Therefore, it is essential for relevant stakeholders to consider these findings in order to de-implement LVC interventions in the process of LBP management.

Exploring the landscape of health technology assessment in Iran: perspectives from stakeholders on needs, demand and supply.

BACKGROUND: The evaluation of health technologies plays a crucial role in the allocation of resources and the promotion of equitable healthcare access, known as health technology assessment (HTA). This study focuses on Iran's efforts to integrate HTA and aims to gain insights into stakeholder perspectives regarding capacity needs, demand and implementation. METHODS: In this study, we employed the HTA introduction status analysis questionnaire developed by the International Decision Support Initiative (iDSI), which has been utilized in various countries. The questionnaire consisted of 12 questions divided into three sections: HTA need, demand and supply. To identify key informants, we conducted a literature review and consulted with the Ministry of Health and Medical Education (MOHME), as well we experts in policy-making, health service provision and HTA. We selected stakeholders who held decision-making positions in the healthcare domain. A modified Persian version of the questionnaire was administered online from September 2022 to January 2023 and was pretested for clarity. The analysis of the collected data involved quantitative methods for descriptive analysis and qualitative methods for thematic analysis. RESULTS: In this study, a total of 103 questionnaires were distributed, resulting in a favourable response rate of 61% from 63 participants, of whom 68% identified as male. The participants, when assessing the needs of HTA, rated allocative efficiency as the highest priority, with a mean rating of 8.53, thereby highlighting its crucial role in optimizing resource allocation. Furthermore, healthcare quality, with a mean rating of 8.17, and transparent decision-making, with a mean rating of 7.92, were highly valued for their impact on treatment outcomes and accountability. The importance of budget control (mean rating 7.58) and equity (mean rating 7.25) were also acknowledged, as they contribute to maintaining sustainability and promoting social justice. In terms of HTA demand, safety concerns were identified as the top priority, closely followed by effectiveness and cost-effectiveness, with an expanded perspective on the economy. However, limited access to local data was reported, which arose from various factors including data collection practices, system fragmentation and privacy concerns. The priorities of HTA users encompassed coverage, payment reform, benefits design, guidelines, service delivery and technology registration. Evidence generation involved the participation of medical universities, research centres and government bodies, albeit with ongoing challenges in research quality, data access and funding. The study highlights government support and medical education as notable strengths in this context. CONCLUSIONS: This study provides a comprehensive evaluation of Iran's HTA landscape, considering its capacity, demand and implementation aspects. It underlines the vital role of HTA in optimizing resources, improving healthcare quality and promoting equity. The study also sheds light on the strengths of evidence generation in the country, while simultaneously identifying challenges related to data access and system fragmentation. In terms of policy priorities, evidence-based decision-making emerges as crucial for enhancing healthcare access and integrating technology. The study stresses the need for evidence-based practices, a robust HTA infrastructure and collaboration among stakeholders to achieve better healthcare outcomes in Iran.

Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach.

INTRODUCTION: Iran is host to one of the world's largest and longest-standing refugee populations. Although Iran has initiated a basic health insurance scheme for refugees throughout the country since September 2015, the population coverage of this scheme is very low, and various factors have caused a significant percentage of refugees to still lack insurance coverage and often face financial hardships when receiving health services. In response, this study aimed to understand barriers to insurance coverage among refugees in Iran and propose effective policies that can address persistent gaps in financial protection. METHODS: This qualitative study was conducted in two phases. First, a review of policy documents and interviews with participants were conducted to investigate the common barriers and facilitators of effective insurance coverage for refugees in Iran. Then, a systems thinking approach was applied to visualize the common variables and interactions on the path to achieving financial protection for refugees. RESULTS: Findings showed that various factors, such as (1) household-based premium for refugees, (2) considering a waiting time to be eligible for insurance benefits, (3) determining high premiums for non-vulnerable groups and (4) a deep difference between the health services tariffs of the public and private service delivery sectors in Iran, have caused the coverage of health insurance for non-vulnerable refugees to be challenging. Furthermore, some policy solutions were found to improve the health insurance coverage of refugees in Iran. These included removing household size from premium calculations, lowering current premium rates and getting monthly premiums from non-vulnerable refugees. CONCLUSIONS: A number of factors have caused health insurance coverage to be inaccessible for refugees, especially non-vulnerable refugees in Iran. Therefore, it is necessary to adopt effective policies to improve the health financing for the refugee with the aim of ensuring financial protection, taking into account the different actors and the interactions between them.

Financing of health services for undocumented immigrants in Iran: common challenges and potential solutions.

INTRODUCTION: Iran is host to one of the largest urban refugee populations worldwide, about two million of whom are undocumented immigrants (UIs). UIs are not eligible to enroll in the Iranian health insurance scheme and have to pay out-of-pocket to access most health services. This increases the likelihood that they will delay or defer seeking care, or incur substantial costs if they do seek care, resulting in worse health outcomes. This study aims to improve understanding of the financial barriers that UIs face in utilizing health services and provide policy options to ensure financial protection to enhance progress towards UHC in Iran. METHODS: This qualitative study was conducted in 2022. A triangulation approach, including interviews with key informants and comparing them with other informative sources to find out the complementary findings, was applied to increase data confirmability. Both purposive and snowball sampling approaches were used to select seventeen participants. The data analysis process was done based on the thematic content analysis approach. RESULTS: The findings were explained under two main themes: the financial challenges in accessing health services and the policy solutions to remove these financial barriers, with 12 subthemes. High out-of-pocket payments, high service prices for UIs, fragmented financial support, limited funding capacity, not freeing all PHC services, fear of deportation, and delayed referral are some of the barriers that UIs face in accessing health care. UIs can get insurance coverage by using innovative ways to get money, like peer financing and regional health insurance, and by using tools that make it easier, like monthly premiums without policies that cover the whole family. CONCLUSION: The formation of a health insurance program for UIs in the current Iranian health insurance mechanism can significantly reduce management costs and, at the same time, facilitate risk pooling. Strengthening the governance of health care financing for UIs in the form of network governance may accelerate the inclusion of UIs in the UHC agenda in Iran. Specifically, it is necessary to enhance the role of developed and rich regional and international countries in financing health services for UIs.

The role of Iran's context for the development of health technology assessment: challenges and solutions.

Health technology assessment (HTA) is a comprehensive and structured evaluation that aims to analyze the potential impacts of health technologies, including medical devices, diagnostic tools, pharmaceuticals, and public health interventions. Its purpose is to provide policymakers with evidence-based information to inform decisions related to the utilization and implementation of these technologies. HTA allows for the comparison of various scenarios related to a technology across a wide range of factors. This can aid in the creation of an essential drug list and health benefits package that is tailored to the actual needs of the community within a given healthcare system. In the present paper, we review the role of Iran's context for the development of HTA, in terms of challenges and solutions.

The association of patient-reported social determinants of health and hospitalization rate: A scoping review.

Introduction: The interplay between social determinants of health (SDOH) and hospitalization is significant as targeted interventions can improve the social status of the individuals. This interrelation has been historically overlooked in health care. In the present study, we reviewed studies in which the association between patient-reported social risks and hospitalization rate was assessed. Method: We performed a scoping literature review of articles published until September 1, 2022 without time limit. We searched PubMed, Embase, Web of Science, Scopus, and Google Scholar to find relevant studies using terms representing "social determinants of health" and "hospitalization." Forward and backward reference checking was done for the included studies. All studies that used patient-reported data as a proxy of social risks to determine the association between social risks and hospitalization rates were included. The screening and data extraction processes were done independently by two authors. In case of disagreement, senior authors were consulted. Results: Our search process retrieved a total of 14,852 records. After the duplicate removal and screening process, eight studies met the eligibility criteria, all of which were published from 2020 to 2022. The sample size of the studies ranged from 226 to 56,155 participants. All eight studies investigated the impact of food security on hospitalization, and six investigated economic status. In three studies, latent class analysis was applied to divide participants based on their social risks. Seven studies found a statistically significant association between social risks and hospitalization rates. Conclusion: Individuals with social risk factors are more susceptible to hospitalization. There is a need for a paradigm shift to meet these needs and reduce the number of preventable hospitalizations.

Health policy analysis in Eastern Mediterranean region using a health policy triangle framework: Historical and ethical insights from a systematic review.

Background: Health policy can be defined as an agreement and consensus on a health-related program and set of actions taken to achieve the goals expected by programs in the area of policy. Policy analysis involves a wide range of methods, techniques, and tools in a way to reach awareness of the impacts of the developed and implemented policies. Whereas policy analysis in developed countries has a long history, in developing countries, it is instead in its first developing stages. Our paper aimed to collect systematically the studies using health policy triangle framework in doing analysis in one of the health policy issues in the Eastern Mediterranean region organization. Methods: To conduct our literature search, ISI/Web of Science, PubMed/MEDLINE, Embase, The Cochrane Library, Global Health Database, Scopus, as well as Google Scholar from 2003 up to June 2020 were systematically mined. To evaluate the methodological quality of the included studies, the Critical Appraisal Skills Program checklist was used. Results: We selected 30 studies, conducted between 2011 and 2020. According to the findings of these studies, in the Eastern Mediterranean region, organization region, and the role of evidence-based research in policy-making has been repeatedly emphasized, but its use in health program decision-making has been limited, and health research systems in Eastern Mediterranean region organization are still under scrutiny. There is still a gap between evidence-based research in health systems and its use in policy-making. Discussion: Based on the present systematic review, studies based on policy analysis should focus on all the elements of health policies and provide evidence to inform decisions that can strengthen health systems, improve health and improve existing inequalities.

Toward good governance for the prosthetics and orthotics sector in Iran: Evidence from a qualitative study.

BACKGROUND: Prosthetics and orthotics (P&O) services are essential health services whose desired provision is considered as prerequisite to achieving universal health coverage. However, the P&O sector is sometimes not audited and governed, leading to groups that receive and offer the services to face challenges for benefits in Iran. OBJECTIVES: To identify common challenges of governance for the P&O sector and provide some potential policy recommendations to strengthen it. STUDY DESIGN: Qualitative study. METHODS: This study was conducted using semistructured in-depth interviews with prosthetists and orthotists (n = 13), P&O academicians (n = 6), and healthcare policy-makers (n = 8). The interview guide was also established based on 10 dimensions of the Framework for Governance of Healthcare System. RESULTS: Challenges identified included no legislation on P&O services, insufficient government support, uninformed policy-makers, and lack of interest by powerful stakeholders. In addition, nontransparent policy-making, inadequate distribution of workforce across the country, and lack of insurance coverage for P&O services were also raised as other challenges. The respondents identified the need for clear legislation to inform policy-makers and to seek advocacy from the government. CONCLUSIONS: The governance of the P&O sector in Iran has faced with a number of challenges that have made it unable to respond to existing demands desirably. Hence, it is important and necessary to adopt effective and comprehensive policies to reduce current challenges and barriers and improve the governance for P&O services.

Stewardship of physiotherapy services in Iran: common pitfalls and policy solutions.

Physiotherapy (PT) is a key component of the rehabilitative health strategy and an effective approach to the management and treatment of a wide range of health conditions. However, it remains underdeveloped and poorly implemented in many national health systems. Previous studies show that weak stewardship of rehabilitation services is, among others, a significant barrier to equitable access to services and supports in many parts of the world, including in Iran. This study investigated the common pitfalls and potential policy solutions to improve the stewardship of PT services in Iran from the perspective of key stakeholders. Semi-structured interviews were conducted by telephone, via the internet, and in face-to-face sessions in Iran with a purposive sample of health planners and policy decision-makers, university professors, rehabilitation managers, and physiotherapists. In total, 30 individuals agreed to participate. Participants identified several pitfalls across the six dimensions of stewardship: 1) strategy formulation; 2) inter-sectoral collaboration; 3) governance and accountability; 4) health system design; 5) policy and regulation; and 6) intelligence generation. In addition, several policy options and solutions to address critical deficiencies in the system were suggested to improve the stewardship of PT services. The study identified challenges and pitfalls affecting the stewardship of the PT sector in Iran as perceived by key stakeholders. Participants' insights can inform deliberative dialogue processes, agenda-setting, and strategy formulation to support the development, expansion, and implementation of PT services.

Prioritizing solutions to incorporate Prosthetics and Orthotics services into Iranian health benefits package: Using an analytic hierarchy process.

INTRODUCTION: Health benefits package (HBP) is regarded as one of the main dimensions of health financing strategy. Even with increasing demands for prosthetics and orthotics (P&O) services to approximately 0.5% of the world's population, only 15% of vulnerable groups have the chance to make use of such benefits. Inadequate coverage of P&O services in the HBP is accordingly one of the leading reasons for this situation in many countries, including Iran. AIMS: The main objective of this study was to find and prioritize solutions in order to facilitate and promote P&O services in the Iranian HBP. STUDY DESIGN: A mixed-methods (qualitative-quantitative) research design was employed in this study. METHODS: This study was conducted in two phases. First, semi-structured interviews were undertaken to retrieve potential solutions. Then an analytic hierarchy process (AHP) reflecting on seven criteria of acceptability, effectiveness, time, cost, feasibility, burden of disease, and fairness was performed to prioritize them. RESULTS: In total, 26 individuals participated in semi-structured interviews and several policy solutions were proposed. Following the AHP, preventive interventions, infant-specific interventions, inpatient interventions, interventions until 6 years of age, and emergency interventions gained the highest priority to incorporate in the Iranian HBP. CONCLUSION: A number of policy solutions were explored and prioritized for P&O services in the Iranian HBP. Our findings provide a framework for decision- and policy-makers in Iran and other countries aiming to curb the financial burdens of P&O users, especially in vulnerable groups.

Physical rehabilitation financing in Iran: a policy analysis using Kingdon's multiple streams.

BACKGROUND: Adequate financing is a crucial function, securing that physical rehabilitation services (i.e., physiotherapy, occupational therapy, prosthetics and orthotics) are available with no financial hardship. Like many other countries, despite the adoption of various policies and strategies in recent decades, Iran enjoys no desirable physical rehabilitation financing (PRF). Accordingly, this qualitative study aimed to explore the PRF-related strategies and issues as well as their impacts on relevant policies in Iran. METHODS: An analysis of PRF-related policies was conducted in Iran using semi-structured interviews and policy documents review. Purposive and snowball sampling techniques were employed to select key informants, including health-policy makers, civil society, rehabilitation-policy makers, university professors, and practitioners. Thematic analysis was used to analyze the collected data. The analysis was framed within Kingdon's multiple streams. RESULTS: The hindering factors for desirable financing were weak insurance coverage, lack of sustainable financial resources, fragmented financing, lack of split between provider and financer, high-cost of physical rehabilitation services, low engagement of relevant experts in policy-making processes, and corrupt activities. In the policy stream, the following factors were highlighted: involvement of sustainable financial resources, the use of external revenue sources, allocated resources' earmarking, the integration of the current funds to have better pooling, the use of incentive and timely payment mechanisms, the implementation of strategic purchasing principals, and the employment of effective rationing strategies. Moreover, parliament support, changes in administrations, international effects, pressures from interest campaigns and NGOs, and international sanctions were found as factors affecting the politics stream. CONCLUSION: The study findings revealed that a variety of national and international factors affect PRF-related issues in Iran. The recently enacted laws indicate that the PRF policies have already been on the national health political agenda. The study reflected the multifaceted nature of barriers to optimal PRF in Iran.

Global health diplomacy: a solution to meet the needs of disabled people in Yemen.

People with disabilities (PWD) are one of the most vulnerable groups in society during armed conflicts. According to the statistics, four million persons with disability live in Yemen. Lack of access and the use of rehabilitation services make PWD unable to retrieve their social and economic roles, which would have substantial negative impacts both on their families and community. The conflict escalation, an increase in the number the of displaced, COVID-19 pandemic, an increase in non-communicable diseases, and the exacerbation of poverty and malnutrition have rapidly enhanced the population at risk of disability in Yemen. Accordingly, effective and comprehensive approaches such as global health diplomacy (GHD) should be considered to meet the emerged needs. GHD seeks to address the common challenges in the global health system by involving all key stakeholders and establishing negotiations and diplomatic dialogue among official actors. Given the presence of various regional and international actors in Yemen and the examples of the successful use of GHD under conflict and post-conflict conditions in Iraq and Afghanistan, the use of diplomacy is crucial to respond to the needs of PWD in this war-torn country appropriately.

Physical rehabilitation in Iran after international sanctions: explored findings from a qualitative study.

BACKGROUND: Although the main aims of sanctions are the political and economic pressures on governments, literature has demonstrated the harsh effects of sanctions on the general public, especially on the patients, poor and disabled people. Since the international sanctions regime negatively affected almost all dimensions of Iran's health sector, this qualitative study was conducted to investigate the situation of the physical rehabilitation sector after these sanctions. METHODS: This qualitative study was conducted from January 2019 to June 2019 in Iran using Skype, telephone, and face-to-face in-depth semi-structured interviews. Purposive and snowball sampling approaches were used to identify the participants. Also, framework analysis approach was applied to analyze the collected data. RESULTS: In total, 38 individuals including health policy-maker, faculty member, rehabilitation expert, Physiotherapist, Occupational therapist, and Orthotist/Prosthetist, were involved in the study. Based on our findings, a number of challenges facing the Iranian physical rehabilitation sector during the international sanctions period included: 1) socioeconomic challenges (inadequate funding, rising inflation rate, high unemployment rate, catastrophic expenditures, and inappropriate employment status of practitioners); 2) education challenges (decreased international collaboration and shortage of training devices and materials); 3) international challenges (rising issues in accessing services for patients from neighborhood countries); and 4) service delivery challenges (shortage of raw materials for producing the orthoses and prostheses, hardening of the importing the needed equipment, inappropriate infrastructures, and impossibility to use external assistance). CONCLUSION: After international sanctions, the Iranian physical rehabilitation sector has faced considerable multifaceted challenges. Therefore, the international community must be aware of the situation and be concerned about the irreparable consequences.

Financing of physical rehabilitation services in Iran: a stakeholder and social network analysis.

BACKGROUND: Inadequate financing is one of the major barriers in securing equitable access to high-quality physical rehabilitation services, without imposing financial hardship. Despite this, no sufficient attention has been paid to physical rehabilitation services and no specific financial resources have been allocated to such services in many countries including Iran. Owing to the fact that effective decision- and policy-making requires identifying possible stakeholders and actors and their characteristics, in the current study a stakeholder analysis and also a social network analysis (SNA) was conducted to identify the potential stakeholders and also their characteristics involved in physical rehabilitation financing (PRF)-related policies in Iran. METHODS: The present study was performed in two phases. Firstly, semi-structured interviews and relevant document review were conducted to identify the stakeholders. Then, the position, power, interest, and influence of each stakeholder were determined using a web-based questionnaire. Secondly, SNA approach was utilized to map and visualize the interactions among stakeholders. RESULTS: The findings showed that there are different stakeholders in PRF-related decision- and policy-making processes in Iran. In addition, the position, power, interest, and influence level of the identified stakeholders were varied. Moreover, although some stakeholders, like the Ministry of Health and the parliament have the highest level of power and position, they lack sufficient interest to participate in PRF-policies. Furthermore, SNA demonstrated that social network density was low, which indicates the lack of proper collaboration and interaction among the stakeholders. CONCLUSION: As many powerful and influential stakeholders had low interest levels to warrant participate in the FPR-related decision- and policy-making processes in Iran, employing careful and effective strategies, that is ongoing negotiations, receiving advocacy, and making senior managers and policy-makers aware can be helpful.

Assessing Iran's health system according to the COVID-19 strategic preparedness and response plan of the World Health Organization: health policy and historical implications.

BACKGROUND: The role of health systems in the management of disasters, including natural hazards like outbreaks and pandemics, is crucial and vital. Healthcare systems which are unprepared to properly deal with crises are much more likely to expose their public health workers and health personnel to harm and will not be able to deliver healthcare provisions in critical situations. This can lead to a drammatic toll of deaths, even in developed countries. The possible occurrence of global crises has prompted the World Health Organization (WHO) to devise instruments, guidelines and tools to assess the capacity of countries to deal with disasters. Iran's health system has been hit hardly by the COVID-19 pandemic. In this study, we aimed to assess its preparedness and response to the outbreak. METHODS: The present investigation was designed as a qualitative study. We utilized the "COVID-19 Strategic Preparedness and Response Plan" devised by WHO as a conceptual framework. RESULTS: The dimension/pillar which scored the highest was national laboratories, followed by surveillance, rapid response teams and case investigations. Risk communication and community engagement was another pillar receiving a high score, followed by infection prevention and control and by country-level coordination, planning and monitoring. The pillars/dimensions receiving the lowest scores were operational support and logistics; case management; and points of entry. DISCUSSION: The COVID-19 pandemic has represented an unprecedent event that has challenged healthcare systems and facilities worldwide, highlighting their weaknesses and the need for inter-sectoral cooperation and collaboration during the crisis. Analyzing these experiences and capitalizing on them, by strengthening them,will help countries to be more prepared to face possible future crises.