A SWOT analysis of the development of health technology assessment in Iran.

BACKGROUND: Health systems need to prioritize their services, ensuring efficiency and equitable health provision allocation and access. Alongside, health technology assessment (HTA) seeks to systematically evaluate various aspects of health technologies to be used by policy- and decision-makers. In the present study, we aim to identify strengths, weaknesses, opportunities, and threats in developing an HTA in Iran. METHOD: This qualitative study was conducted using 45 semi-structured interviews from September 2020 to March 2021. Participants were selected from key individuals involved in health and other health-related sectors. Based on the objectives of the study, we used purposive sampling (snowball sampling) to select individuals. The range of length of the interviews was between 45 to 75 minutes. Four authors of the present study carefully reviewed the transcripts of interviews. Meanwhile, the data were coded on the four domains of strengths, weaknesses, opportunities, and threats (SWOT). Transcribed interviews were then entered into the software and analyzed. Data management was performed using MAXQDA software, and also analyzed using directed content analysis. RESULTS: Participants identified eleven strengths for HTA in Iran, namely the establishment of an administrative unit for HTA within the Ministry of Health and Medical Education (MOHME); university-level courses and degrees for HTA; adapted approach of HTA models to the Iranian context; HTA is mentioned as a priority on the agenda in upstream documents and government strategic plans. On the other hand, sixteen weaknesses in developing HTA in Iran were identified: unavailability of a well-defined organizational position for using HTA graduates; HTA advantages and its basic concept are unfamiliar to many managers and decision-makers; weak inter-sectoral collaboration in HTA-related research and key stakeholders; and, failure to use HTA in primary health care. Also, participants identified opportunities for HTA development in Iran: support from the political side for reducing national health expenditures; commitment and planning to achieve universal health coverage (on behalf of the government and parliament); improved communication among all stakeholders engaged in the health system; decentralization and regionalization of decisions; and capacity building to use HTA in organizations outside the MOHME. High inflation and bad economic situation; poor transparency in decisions; lack of support from insurance companies; lack of sufficient data to conduct HTA research; rapid change of managers in the health system; and economic sanctions against Iran are threats to the developmental path of HTA in Iran. CONCLUSION: HTA can be properly developed in Iran if we use its strengths and opportunities, and address its weaknesses and threats.

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.

Quality Assessment of Services in Primary Healthcare in Iran: A Systematic Review and Meta-analysis.

Background: Primary healthcare (PHC) plays an important role in achieving universal health coverage (UHC). The SERVQUAL instrument is the tool for evaluating the quality of services in the health sector. The main purpose of this study is to evaluate the quality of services provided in PHC in Iran using the SERVQUAL instrument. Materials and Method: We searched eight databases from January 2000 to September 2021. We analyzed the mean of various SERVQUAL instrument items using the DerSimonian-Laird approach via a random model with 95% confidence interval. Also, we used I2 to evaluate the heterogeneity of the studies. Results: Finally, 17 studies were chosen for analysis in the present study. There were 8,767 study participants, out of which 8,237 were female and 530 were male. The mean dimensions of perception were as follows: Tangibles = 3.71, reliability = 4, responsiveness = 3.79, assurance = 3.83, and empathy = 3.86. For the expectation, the mean dimension were: Tangibles = 4.46, reliability = 4.46, responsiveness = 4.36, assurance = 4.36, and empathy = 4.36 respectively. The total gap quality between perception and expectation was -0.53. Conclusion: All dimensions of quality based on SERVQUAL were negative, and the quality of service in PHC is not satisfactory. Therefore, policymakers must adopt serious and effective programs to improve services in this area. We also recommend that quality management of services in PHC in Iran should move toward comprehensive optimization in all areas, and quality in this area should be a priority.

The effect of COVID-19 on public hospital revenues in Iran: An interrupted time-series analysis.

BACKGROUND: The "Coronavirus Disease 2019" (COVID-19) pandemic has become a major challenge for all healthcare systems worldwide, and besides generating a high toll of deaths, it has caused economic losses. Hospitals have played a key role in providing services to patients and the volume of hospital activities has been refocused on COVID-19 patients. Other activities have been limited/repurposed or even suspended and hospitals have been operating with reduced capacity. With the decrease in non-COVID-19 activities, their financial system and sustainability have been threatened, with hospitals facing shortage of financial resources. The aim of this study was to investigate the effects of COVID-19 on the revenues of public hospitals in Lorestan province in western Iran, as a case study. METHOD: In this quasi-experimental study, we conducted the interrupted time series analysis to evaluate COVID-19 induced changes in monthly revenues of 18 public hospitals, from April 2018 to August 2021, in Lorestan, Iran. In doing so, public hospitals report their earnings to the University of Medical Sciences monthly; then, we collected this data through the finance office. RESULTS: Due to COVID-19, the revenues of public hospitals experienced an average monthly decrease of $172,636 thousand (P-value = 0.01232). For about 13 months, the trend of declining hospital revenues continued. However, after February 2021, a relatively stable increase could be observed, with patient admission and elective surgeries restrictions being lifted. The average monthly income of hospitals increased by $83,574 thousand. CONCLUSION: COVID-19 has reduced the revenues of public hospitals, which have faced many problems due to the high costs they have incurred. During the crisis, lack of adequate fundings can damage healthcare service delivery, and policymakers should allocate resources to prevent potential shocks.

Recommendations to improve insurance coverage for physiotherapy services in Iran: a multi criteria decision-making approach.

BACKGROUND: High toll of traffic-related injuries, climate change, natural disasters, population aging, as well as chronic diseases have all made considerable demands on receiving physiotherapy services in Iran. Nevertheless, there is an assortment of complications facing utilization of such services, particularly poor insurance coverage. Therefore, the present study investigated and identified gaps in insurance coverage in order to inform future policy reforms and the design of a more comprehensive and universal benefits package for physiotherapy services in Iran. METHODS: This project was carried out in Iran, using a mix-methods (viz. qualitative-quantitative) approach. Within the first phase, a qualitative study was completed to find policy recommendations. Such recommendations were then prioritized through the Analytical Hierarchy Process (AHP), in the second phase, based on effectiveness, acceptability, cost, fairness, feasibility, and time. RESULTS: Within the first phase, a total number of 30 semi-structured interviews with health policy-makers, health insurers, faculty members, rehabilitation experts, and physiotherapists were completed. Several policy recommendations were also proposed by the study participants. Following the second phase, prioritized recommendations were provided to promote stewardship (e.g., informing policy-makers about physiotherapy services), collection of funds (e.g., placing value-added taxes on luxury goods and services), pooling of funds (e.g., moving allocated resources towards insurance (viz. third-party) mechanism), purchasing (e.g., using strategic purchasing), and benefit package (e.g., considering preventive interventions) as the main components of insurance coverage. CONCLUSION: The study findings provided a favorable ground to improve insurance coverage for physiotherapy services in Iran. As well, decision- and policy-makers can place these recommendations on the agenda in the health sector to protect population health status, especially that of groups with disabilities.

A policy analysis of agenda-setting of Brucellosis in Iran using a multiple-stream framework: health policy and historical implications.

BACKGROUND: Brucellosis, a major zoonotic disease, is highly present in Iran, especially in Lorestan province. The aim of this study was to understand the issues related to Brucellosis utilizing the multiple streams framework. METHODS: A two-step method was adopted: 1) assessment of brucellosis-related documents and 2) interviews with stakeholders. As a first step, all documents related to Brucellosis were reviewed at provincial and national levels. Policy documentation on health issues included the consultation of guidelines, rules and regulations, websites, reports, books, guides, and conferences. These documents were collected by referring to specialized centers, institutions, and organizations. In the second step, semi-structured interviews were conducted to determine the burden of disease with actors and stakeholders involved with the brucellosis program in the Lorestan province. More in detail, physicians, healthcare workers, managers, policy- and decision-makers were selected for interviews. RESULTS: The problem stream was characterized by: 1) high prevalence of the disease, 2) traditional livestock production, 3) unsafe animal slaughtering, 4) centers for the sale and distribution of non-authorized dairy products, 5) raw milk and 6) traditional unsafe dairy products consumption, 7) incomplete livestock vaccination, 8) lack of knowledge of Brucellosis, 9) neighboring countries with high prevalence of Brucellosis, 10) lack of livestock quarantine, and 10) nomadic immigration. The policy stream was characterized by 1) primary healthcare networks, 2) guidelines, 3) medicines, insurance, and 4) diagnostic services. Finally, the political stream was characterized by: 1) support of the University of Medical Sciences, 2) sponsorship by the Ministry of Health and Medical Education, 3) Health transformation plan, and 4) Working Group on Health and Food Security in Lorestan. CONCLUSION: This study examined the brucellosis-related agenda setting: if different issues are taken into consideration, it can be perceived as a health priority.

Financial Protection Indexes and the Iranian Health Transformation Plan: A Systematic Review.

Background: On May 5, 2014, the Iranian Ministry of Health and Medical Education launched the Health Transformation Plan (HTP) as a major healthcare reform to curb out-of-pocket (OOP) expenses and protect people from catastrophic health expenditures (CHEs). Therefore, in this study, we conducted a comprehensive literature search with the aim of systematically investigating the impacts of HTP on OOP and CHE after the implementation of the plan. Method: Web of Science, PubMed, Scopus, Embase, and Iranian bibliographic thesauri and repositories such as MagIran, Elmnet, and Scientific Information Database were searched. Studies published between May 2014 and December 2020 that reported the impact of HTP on the financial indicators under investigation in this study (OOP and CHEs) that were conducted in Iran. Estimated pooled change both for OOP and CHEs was calculated as effect size utilizing meta-analytical techniques. Also, heterogeneity among studies was assessed with the I2 statistics. Results: Seventeen studies were included, nine of which evaluated the OOP index, six studies assessed the CHEs index, and two studies examined both the OOP and CHEs indexes. The OOP was found to decrease after the implementation of the HTP (with an estimated decrease of 13.02% (95% CI: 9.09-16.94). Also, CHEs experienced a decrease of 5.80% (95% CI: 3.85-7.74). Conclusion: The findings show that the implementation of HTP has reduced health costs. In this regard and in order to keep reducing the costs that many people are unable to pay, the government and other organizations involved in the health system should provide sustainable financial resources in order to continue running HTP. However, there remain gaps and weaknesses that can be solved through discussion with all the actors involved.

The Impact of the Social Distancing Policy on COVID-19 Incidence Cases and Deaths in Iran from February 2020 to January 2021: Insights from an Interrupted Time Series Analysis.

Background: In December 2019, a viral outbreak occurred in China, and rapidly spread out worldwide. Due to the lack of immediately available vaccines and effective drugs, many policy- and decision-makers have focused on non-pharmacological methods, including social distancing. This study was aimed at assessing the effects of the implementation of this policy in Iran, one of the countries most affected by COVID-19. We conducted a quasi-experimental study, utilizing the interrupted time series analysis (ITSA) approach. Methods: We collected daily data between February 20, 2020 and January 29, 2021, through governmental websites from 954 public hospitals and healthcare settings. The Iranian government launched the social distancing policy on March 27, 2020. Statistical analyses, including ITSA, were carried out with R software Version 3.6.1 (London, UK). Results: During the study period, 1,398,835 confirmed incidence cases and 57,734 deaths occurred. We found a decrease of -179.93 (95% CI: -380.11 to -20.25, P-value=0.078) confirmed incidence cases following the implementation of the social distancing policy, corresponding to a daily decrease in the trend of -31.17 (95% CI: -46.95 to -15.40, P-value=0.08). Moreover, we found a decrease of -28.28 (95% CI: -43.55 to -13.01, P-value=0.05) deaths, corresponding to a daily decrease in the trend of -4.52 (95% CI: -5.25 to -3.78, P-value=0.003). Conclusion: The growth rate of confirmed incidence cases and deaths from COVID-19 in Iran has decreased from March 27, 2020 to January 29, 2021, after the implementation of social distancing. By implementing this policy in all countries, the burden of COVID-19 may be mitigated.

Mapping Research Trends of Universal Health Coverage From 1990 to 2019: Bibliometric Analysis.

BACKGROUND: Universal health coverage (UHC) is one of many ambitious, health-related, sustainable development goals. Sharing various experiences of achieving UHC, in terms of challenges, pitfalls, and future prospects, can help policy and decision-makers reduce the likelihood of committing errors. As such, scholarly articles and technical reports are of paramount importance in shedding light on the determinants that make it possible to achieve UHC. OBJECTIVE: The purpose of this study is to conduct a comprehensive analysis of UHC-related scientific literature from 1990 to 2019. METHODS: We carried out a bibliometric analysis of papers related to UHC published from January 1990 to September 2019 and indexed in Scopus via VOSviewer (version 1.6.13; CWTS). Relevant information was extracted: the number of papers published, the 20 authors with the highest number of publications in the field of UHC, the 20 journals with the highest number of publications related to UHC, the 20 most active funding sources for UHC-related research, the 20 institutes and research centers that have produced the highest number of UHC-related research papers, the 20 countries that contributed the most to the research field of UHC, the 20 most cited papers, and the latest available impact factors of journals in 2018 that included the UHC-related items under investigation. RESULTS: In our analysis, 7224 articles were included. The publication trend was increasing, showing high interest in the scientific community. Most researchers were from the United States, the United Kingdom, and Canada, with Thailand being a notable exception. The Lancet accounted for 3.95% of published UHC-related research. Among the top 20 funding sources, the World Health Organization (WHO), the Bill and Melinda Gates Foundation, and the National Institutes of Health (NIH) accounted for 1.41%, 1.34%, and 1.02% of published UHC-related research, respectively. The highest number of citations was found for articles published in The Lancet, the American Journal of Psychiatry, and the Journal of the American Medical Association (JAMA). The top keywords were "health insurance," "insurance," "healthcare policy," "healthcare delivery," "economics," "priority," "healthcare cost," "organization and management," "health services accessibility," "reform," "public health," and "health policy." CONCLUSIONS: The findings of our study showed an increasing scholarly interest in UHC and related issues. However, most research concentrated in middle- and high-income regions and countries. Therefore, research in low-income countries should be promoted and supported, as this could enable a better understanding of the determinants of the barriers and obstacles to UHC achievement and improve global health.

Effect of COVID-19 on the Number of CT-scans and MRI Services of Public Hospitals in Iran: An Interrupted Time Series Analysis.

Background: In February 2020, the Ministry of Health and Medical Education in Iran announced the first case of COVID-19. The aim of this study was to investigate the impact of COVID-19 on the number of CT-Scans and MRI services in public hospitals in western Iran. Methods: We collected CT-scans and MRI services data from 18 public hospitals via Vice-Chancellor Office, Lorestan University of Medical Sciences from January 2017 to February 2021. Interrupted time series analysis (ITSA) was conducted to assess the impact of COVID-19 on CT-Scans and MRI services. More specifically, ITSA was conducted using ordinary least squares regression with the number of CT-Scans and MRI services per 1,000 registered persons per month as dependent variable. Results: At the beginning of the observation period, the monthly rate of CT-Scans was constant (p for trend = 0.267) at 291.9 (from 95%CI 240.5 to 343.4) per 1,000 registered patients. The first case of COVID-19 coincided with an abrupt increase by 211.8 (from 95%CI 102.9 to 320.7) per 1,000 patients. Thereafter, the trend of CT-Scans did not change (p=0.576) compared to the pre-pandemic period. The rate of MRI services was 363.5 per 1,000 per registered patients per month (P = <0.0001) with a slightly decreasing trend (coefficient=-5; 95%CI, -6.9 to -3.1). Conclusion: The findings of this study showed that crises such as COVID-19 can affect the service delivery process. Health policymakers and decision makers should work to prevent potential reductions in health care during events such as COVID-19.

Strategic planning, components and evolution in zoonotic diseases frameworks: one health approach and public health ethics.

Zoonotic diseases are seen as a major public health concern. Routes of the rapid transmission of zoonotic diseases and the economic damage they cause to communities are all reasons why health institutions and systems need to pay more attention to these diseases. Strategic planning is one of the important tasks of policymakers in every organization and system. It is a very reliable and useful tool for leading all kinds of organizations, including health organizations. Countries with clear policy plans have succeeded in controlling and reducing zoonotic diseases. Such countries used appropriate strategic planning and pursued annual goals to control and prevent diseases. Three important steps (strategy development, strategy implementation and strategy evaluation) should be considered in developing a strategic planning for controlling and prevention of zoonotic diseases. Health systems need to develop strategic planning in order to upgrade their capabilities in combating zoonotic diseases. These programs must be flexible, in line with the one health approach, based on the current needs, and aligned with the new challenges faced with health systems. The strategic planning is directly related to national and international policies, organizational goals and missions, dynamism, degree of complexity, and organizational structure of each country's health system.

One health approach to tackle brucellosis: a systematic review.

BACKGROUND: Brucellosis is the most significant and common bacterial zoonosis and is recognized as a re-emerging and neglected disease. Tackling zoonosis is very important for the health and the economy. One Health is an approach characterized by the integration of human and animal health, plants, and ecosystems and encourages joining local, national, and global multidisciplinary efforts to achieve optimal levels of health and collaboration among different disciplines to address complex health problems. OBJECTIVES: The present study aimed to review published scientific literature related to the use of the One Health approach to tackle human brucellosis. METHODS: Web of Science (WoS), PubMed, Scopus, The Cochrane Library, and Embase databases were searched from inception until 30 January 2020. The reference lists of all relevant papers were hand-searched. Two authors extracted data from published studies independently. The Joanna Briggs Institute tool was used to assess the quality of studies. RESULTS: Of 2297 studies, 10 studies were deemed eligible, which were conducted between 2013 and 2019. Studies were performed in Uganda, Malta, Serbia, Greece, Mongolia, Azerbaijan, Israel, India, Ethiopia, and the USA. All studies suggested that brucellosis is still a major public health problem and that the most important aspect of the One Health approach is the interdependence of humans, ecosystems, and animals .Some studies have focused on livestock vaccination as the most effective way to prevent disease, and others have focused on the biology of Brucella infection and its transmission patterns. Some studies have pointed to the effectiveness of the One Health approach in all the phases of disease management as well as to its role in reducing health costs. CONCLUSION: The success of the approach depends on the willingness of the decision-makers to implement the necessary policies. Due to the heterogeneity of current practices, and organizations involved in One Health approach-based programs, it will be incomplete without proper planning. To better implement the approach, strategies should be appraised and disseminated by experts and relevant stakeholders.

Ensuring adequate health financing to prevent and control the COVID-19 in Iran.

On February 19th 2020, the Iranian Ministry of Health and Medical Education (MoHME) has announced the first 2 cases of SARS-CoV-2, a novel emerging coronavirus which causes an infection termed as COVID-19, in Qom city. As such, the Iranian government, through the establishment of the "National Headquarters for the management and control of the novel Coronavirus", has started implementing policies and programs for the prevention and control of the virus. These measures include schools and universities closure, reduced working hours, and increased production and delivery of equipment such as masks, gloves and hygienic materials for sterile environments. The government has also made efforts to divulge high-quality information concerning the COVID-19 and to provide laboratories and hospitals with diagnostic kits and adequate resources to treat patients. However, despite such efforts, the number of cases and deaths has progressively increased with rising trends in total confirmed cases and deaths, as well as in new daily cases and deaths associated with the COVID-19. Iran is a developing country and its economic infrastructure has been hit hardly by embargo and sanctions. While developed countries have allocated appropriate funding and are responding adequately to the COVID-19 pandemics, Iran has experienced a serious surge of cases and deaths and should strive to provide additional resources to the health system to make healthcare services more accessible and to increase the fairness of that access. All relevant actors and stakeholders should work together to fight this disease.

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.

Universal Health Coverage to counteract the economic impact of the COVID-19 infection: current practices and ethical challenges.

In late December 2019, the first case of an emerging coronavirus was identified in the city of Wuhan, Hubei province, in mainland China. The novel virus appears to be highly contagious and is rapidly spreading worldwide, becoming a pandemic. The disease is causing a high toll of deaths. Effective public health responses to a new infectious disease are expected to mitigate and counteract its negative impact on the population. However, time and economic-financial constraints, as well as uncertainty, can jeopardize the answer. The aim of the present paper was to discuss the role of Universal Health Coverage to counteract the economic impact of the COVID-19 infection. Appropriate financing of the health system and ensuring equitable access to health services for all can, indeed, protect individuals against high medical costs, which is one of the most important goals of any health system. Financing profoundly affects the performance of the health system, and any policy that the health system decides to implement or not directly depends on the amount of available funding. Developed countries are injecting new funding to cope with the disease and prevent its further transmission. In addition to psychological support and increased societal engagement for the prevention, control, and treatment of COVID-19, extensive financial support to governments by the community should be considered. Developed and rich countries should support countries that do not have enough financial resources. This disease cannot be controlled and contained without international cooperation. The experience of the COVID-19 should be a lesson for further establishing and achieving universal health coverage in all countries. In addition to promoting equity in health, appropriate infrastructure should be strengthened to address these crises. Governments should make a stronger political commitment to fully implement this crucial set of policies and plans.