What may encourage or deter health services utilization by people living with or at the risk of HIV/AIDS in special health centers? Qualitative evidence from a stigmatized community.

BACKGROUND: Behavioral Diseases Counseling Centers (BDCCs) and Vulnerable Women's Counseling Centers (VWCCs) in Iran are the main peripheral centers that offer educational, counseling, diagnostic, preventive, curative and protective services to individuals living with or at high risk of contracting HIV/AIDS and female sex workers respectively. Due to the social stigma surrounding HIV in Iran, this study aims to identify the factors that may hinder or encourage HIV/AIDS patients and women with risky sexual behaviors from visiting these centers. METHODS: Conducted in 2023, this qualitative study involved individuals visiting BDCCs and VWCCs in two western provinces of Iran, Ilam and Kermanshah. The study participants included 21 health staff members working in BDCCs and VWCCs and 20 HIV/AIDS patients and vulnerable women with unsafe sexual behaviors referring to these centers. Purposive, snowball and maximum variation sampling techniques were applied to interview the participants. Interviews were conducted between January 5th and May 21st, 2023, using a semi-structure guideline. Interviews were transcribed and content analysis approach was applied to analyze data using MAXQDA20 software. RESULTS: According to the findings, the barriers and facilitators of visiting specialized centers for HIV/AIDS patients and vulnerable women were categorized into three main categories, 10 subcategories and 35 sub-subcategories including: Medical and operational processes (4 subcategories and 12 sub-subcategories), mutual interactions between the personnel and visitors (people living with and at the risk of getting HIV/AIDS) (3 subcategory and 13 sub-subcategories), and physical characteristics of the centers (3 subcategories and 10 sub-subcategories). CONCLUSIONS: To improve the performance of BDCCs and VWCCs and encourage people living with and at the risk of contracting HIV/AIDS to visit these centers regularly, health policy makers should consider modifying clinical processes, physical features, personnel behaviors and visitors' concerns raised by the interviewees and the issues identified in this study.

Classification and focus comparison of health financing frameworks: A scoping review.

OBJECTIVE: The purpose of this study is to review the current frameworks for understanding and assessing health financing and draw out the dimensions of conceptual frameworks. METHODS: This scoping review was conducted using the five stages of Arksey and O'Malley's framework. We reviewed all published peer-reviewed literature indexed in PubMed, SCOPUS, and Embase from 2000 up to 2021 for inclusion. RESULTS: We identified 21 frameworks developed to assess financing in the health system. We classified frameworks by grouping them into: frameworks focusing on health financing as a constituent of health system and frameworks focusing on health financing only. We classified health financing frameworks further into three main groups according to the general commonalities among them. These three groups are as follows: (1) frameworks providing general recommendations for improving health financing system regardless of sources of financing, (2) frameworks focusing on improving the performance of health insurance schemes, and (3) frameworks focusing on managing public health financing. CONCLUSION: Despite being diverse, various health financing frameworks offer synergistic views to the health financing system and provide a comprehensive picture of the health financing system. These frameworks can help policy makers decide which framework is more appropriate to start with based on their local contextual features and the changes they are going to bring about in their health financing system.

Causes and consequences of quack medicine in health care: a scoping review of global experience.

BACKGROUND: The field of health has been facing challenges with fraudulent practices and the prevalence of "quack medicine". Many cases have given rise to this issue. Therefore, this study aims to comprehensively investigate and categorize the causes and consequences of quack medicine in the healthcare. METHODS: A scoping review, using the 5 stages of Arksey and O'Malley's framework, was conducted to retrieve and analyze the literature. International databases including the PubMed, Scopus, Embase and Web of Science and also national Iranian databases were searched to find peer reviewed published literature in English and Persian languages. Grey literature was also included. Meta-Synthesis was applied to analyze the findings through an inductive approach. RESULTS: Out of 3794 initially identified studies, 30 were selected for this study. Based on the findings of this research, the causes of quackery in the health were divided into six categories: political, economic, socio-cultural, technical-organizational, legal and psychological. Additionally, the consequences of this issue were classified into three categories: health, economic and social. Economic and social factors were found to have a more significant impact on the prevalence of quackery in the health sector. Legal and technical-organizational factors played a crucial role in facilitating fraudulent practices, resulting in severe health consequences. CONCLUSION: It is evident that governing bodies and health systems must prioritize addressing economic and social factors in combating quackery in the health sector. Special attention should be paid to the issue of cultural development and community education to strengthen the mechanisms that lead to the society access to standard affordable services. Efforts should be made also to improve the efficiency of legislation, implementation and evaluation systems to effectively tackle this issue.

Understanding conflicts of interest in rational drug prescription in a developing country: A stakeholder analysis, healthcare guidelines and ethical public health issues.

Background: Rational drug prescription (RDP) is one of the main components of the healthcare systems. Irrational prescribing can bring about numerous negative consequences for the patients and governmental agencies. This study aims to analyze the involvement of stakeholders in rational drug prescribing, their position (opponent or proponent), and the rationale behind it. Methods: This was a qualitative study conducted in 2019. Semi-structured face-to-face interviews were conducted with 40 stakeholders. Purposive and snowball sampling techniques with maximum heterogeneity were adopted to select the interviewees. Data was analyzed by MAXQDA software using thematic approach. Results: Iranian Food and Drug Administration employs the highest authority on the rational prescribing policy. Although the Ministry of Health and Medical Education, the Social Security Organization as one of the main health insurance organizations, pharmaceutical companies, and the Medical Council of the Islamic Republic of Iran, are among agencies that have great authority to improve rational prescribing, they fail to act professionally as they have conflicting interests. Remarkably, the Iran Food and Drug Administration, insurance organizations, family physicians, and patients, highly support the rational prescribing policy while the pharmaceutical companies display the least support for it. Conclusions: To make the prescription and using drugs more rational, policy makers should focus on different sources of conflicts of interest that different actors have. They should devise legal, behavior and financial policies accordingly to lessen or at least neutralize these conflicting interests, otherwise achieving RDP would be impossible in short and long terms.

Socioeconomic inequality in self-rated health and its determinants: an Oaxaca blinder decomposition in Ilam, West of Iran during 2023.

AIM: To determine inequality and decompose it's in Self-Rated Health (SRH). METHOD: This population-based cross-sectional study was undertaken on the entire population of the city of Ilam, Iran, in 2023. Multi-stage stratified cluster random sampling with proportion-to-size approach was used to select the participants. Oaxaca-Blinder decomposition technique was used to show the amount of inequity in SRH and to decompose of the gap of SRH between the poor and the rich group of participants. RESULTS: 1370 persons participated in the study. The 59.38% of participants stated good SRH status and just 8.86% of participants had poor SRH status. The results of the Oaxaca-Blinder decomposition revealed a considerable gap (15.87%) in the poor status of SRH between the rich and the poor. A large proportion (89.66%) of this difference was described by explained portion of the model. The results of decomposition showed that economic status was directly responsible for explaining 27.98% of overall inequality gap between rich and poor people. Moreover, hopelessness to future (32.64%), having an underlying disease (18.34%) and difference in the education level (10.71%) were associated with an increase in inequality disfavoring the poor. CONCLUSION: For people suffering from underlying disease, it is suggested to devise policies to improve access to/and remove healthcare utilization barriers. To address hopelessness to future, it is recommended to carry out further studies to reveal factors which affect it in more details. This can help policy makers to formulate more realistic and evidence-informed policies on order to lessen the current socioeconomic inequity in SRH.

Criteria for the selection of complementary private health insurance: the experience of a large organisation in Iran.

BACKGROUND: Expenses related to employee's health benefit packages are rising. Hence, organisations are looking for complementary health financing arrangements to provide more financial protection for employees. This study aims to develop criteria to choose the most appropriate complementary health insurance company based on the experience of a large organisation in Iran. METHODS: This study was conducted in 2021 in Iran, in the Foundation of Martyrs and Veterans Affairs to find as many applicable criteria as possible. To develop a comprehensive list of criteria, we used triangulation in data sources, including review of relevant national and international documents, in-depth interviews of key informants, focus group discussion, and examining similar but unpublished checklists used by other organisations in Iran. The list of criteria was prioritised during focus group discussions. We used the best-worst method as a multi-criteria decision making method and a qualitative consensus among the key informants to value the importance of each of the finalised criteria. FINDINGS: Out of 85 criteria, we selected 28 criteria to choose an insurer for implementing complementary private health insurance. The finalised criteria were fell into six domains: (i) Previous experience of the applicants; (ii) Communication with clients; (iii) Financial status; (iv) Health care providers' network; (v) Technical infrastructure and workforce; (vi) and Process of reviewing claims and reimbursement. CONCLUSION: We propose a quantitative decision-making checklist to choose the best complimentary private health insurance provider. We invite colleagues to utilise, adapt, modify, or develop these criteria to suit their organisational needs. This checklist can be applied in any low- and middle-income country where the industry of complementary health insurance is blooming.

Explore of the reasons of irrational prescribing in Iran: A qualitative study.

Background: Irrational prescribing is highly prevalent in Iran, and it is under the impact of different factors. Objective: This research aims to recognize the reasons for Irrational prescribing in Iran. Methods: A qualitative approach and a conventional content analysis were employed to perform this research. The research community includes some experts and key specialists in medication prescribing. Semi-structured interviews were used for data collection. The intentional sampling method was applied, and theoretical saturation was reached by conducting 40 interviews with experts. The data analysis process was done following the steps suggested by Graneheim and Lundman. Results: Four main categories and 12 subcategories appeared after analyzing the data. The main categories are organizational and management factors, legal factors, cultural factors, and economic factors. Conclusion: Irrational prescribing can be prevented by reforming the referral system, overseeing pharmacies and physicians, raising public awareness and correcting their misconceptions about the medications, and creating an appropriate mechanism for pricing and selling medicines.

Preferences of people in choosing a family physician in rural areas: a qualitative inquiry from Iran.

BACKGROUND: Creating a stable and long-term relationship called 'longitudinality' between the population and general practitioners is crucial for the family physician program. The constant change of family physicians (FPs) can deteriorate longitudinality. This study aims to reveal what factors people usually consider when choosing a new FP or changing their current FP. METHOD: A qualitative study with a thematic analysis approach was carried out in Ilam province, Iran, in 2019. Purposeful sampling with a maximum variation strategy was followed to select the key informants. We did 34 interviews with following groups: patients (rural residents); FPs; and experts from Iran Health Insurance Organization, Ilam University of Medical Sciences, and Health Network Development Center. Data were analyzed using a thematic analysis to identify and contextualize the preferences of people in choosing a FP in rural areas. All the processes related to data coding and emerging themes were carried out using MAXQDA 2012 software. RESULTS: The content of the interviews was categorized into 2 main themes, 6 sub-themes, and 39 codes. The first theme was 'family physician characteristics' including four sub-themes: general behaviors, social and physical characteristics, professional expertise, and pharmaceutical prescriptions. The second theme was 'health center' consisting of two sub-themes including location and physical features and properties of the health center. CONCLUSION: Some of the factors extracted from the interviews may have a different effect on the choice of people with different demographics. For instance, patients may have different ideas about the age, gender, years of medical practice, and finally, language and origin of the birthplace of FPs. Quantitative studies are needed to rank the factors identified in this study according to their significance for choosing FP and reveal patients' preferences for each factor.

Economic evaluation of laboratory diagnostic test types in Covid-19 epidemic: A systematic review.

BACKGROUND: Corona 2 virus (SARS-CoV-2) is known as the causative agent of COVID-19 disease; the World Health Organization (WHO) declared it an epidemic on March 11, 2020. The Joint Guidelines of the Centers for Disease Control and Prevention (CDC) and the WHO including social distancing, the use of face masks, emphasis on hand washing, quarantine, and using diagnosis tests have been used widely, but the value of diagnostic interventions to prevent the transmission of SARS-CoV-2 is unclear. We compared the economic evaluation of different laboratory diagnostic interventions with each other and also with implementing the conservative CDC & WHO guidelines. MATERIAL AND METHODS: Electronic searches were conducted on PubMed, Embase, Science Direct, Scopus, Cochrane Library, Web of Knowledge, NHSEED, NHS Health Technology assessment (CRD), and Cost-Effectiveness Analysis Registry databases. Related articles were reviewed from January 2020 to the end of November 2021. RESULTS: Out of 1791 initial studies, 13 articles had the inclusion criteria. According to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, ten studies were of excellent quality, and the remaining two studies were of very good quality. Most studies were cost-effectiveness analysis studies. The entered studies had different time horizons. Diagnostic tests reviewed in the studies included real-time polymerase chain reaction (RT-PCR) test, immunoglobulin G (IgG) & Antigen, point of care tests. Although polymerase chain reaction (PCR) testing improves the quality of life and survival for patients with infected Covid-19 based on its greater effectiveness compared to standard protection protocols, due to the high cost of this intervention, it has been considered a cost-effective method in some countries. CONCLUSION: Since most studies have been conducted in developed countries, it unquestionably does not make sense to extend these results to low-income and developing countries. Therefore further studies are required in low-income and developing countries to evaluate the cost-effectiveness of laboratory-based diagnostic methods (RT-PCR) of covid-19 in variable prevalence of infectious cases.

District health network policy in Iran: the role of ideas, interests, and institutions (3i framework) in a nutshell.

BACKGROUND: District Health Network (DHN), one of Iran's most successful health reforms, was launched in 1985 to provide primary health care (PHC), in response to health inequities in Iran. The present study aims to use interrelated elements of the 3i framework: ideas (e.g., beliefs and values, culture, knowledge, research evidence and solutions), interests (e.g., civil servants, pressure groups, elected parties, academians and researchers, and policy entrepreneurs), and institutions (e.g., rules, precedents, and organizational, government structures, policy network, and policy legacies) to explain retrospectively how (DHN) policy in Iran, as a developing country, was initiated and formed. METHODS: A historical narrative approach with a case study perspective was employed to focus on the formation and framing process of DHN. For this purpose, the 3i framework was used as a guideline for data analysis. This study mainly searched and extracted secondary sources, including online news, reports, books, dissertations, and published articles in the scientific databases. Primary interviews as a supplementary source were also carried out to meet cross-validation of the data. Data were analyzed using a deductive and inductive approach. RESULTS: According to the 3i framework, the following factors contributed to the formation of DHN policy in Iran: previous national efforts (for instance Rezaieh plan) and international events aiming to provide public health services for peripheral regions; dominant social discourses and values at the beginning of the Iranian revolution such as addressing the needs of disadvantaged and marginalized groups, which were embedded in the goals of DHN policy aiming to provide basic health services for deprived people especially living in rural and remote areas. Besides, the remarkable social cohesion and solidarity among people reinforced by the Iran-Iraq war were among other factors which contributed to the formation of participatory plans such as DHN (ideas). Main policy entrepreneurs including Minister of Health, his public health deputy and two planners of DHN with similar and rich background in the public health field and sharing the same beliefs (interests) which subsequently led to creation of tight-knit policy community network between them (institutions) also accelerated the creation of DHN in Iran to great extent. Political support of parliamentary representatives (interests), and formal laws such as principles of Iran Constitution (institutions) were also influential in passing the DHN in Iran. CONCLUSIONS: The 3i framework constituents would be insightful in explaining the creation of public health policies. This framework showed that the alignment of laws, structures, and interests of the main actors of the policy with the dominant ideas and beliefs in the society, opened the opportunity to form DHN in Iran.

Investigating the effect of health transformation plan on the public hospitals performance indicators; a case study from Iran.

BACKGROUND: Health systems need constant changes and reforms in their structure to adapt to changing conditions and meet the needs of society. One of the fundamental changes in the health system of Iran is the health transformation plan (HTP), the effects of which must be examined from different aspects. Therefore, the purpose of this study is to investigate the effect of HTP on the performance indicators of public hospitals in Yazd city, Iran. METHODS: This cross-sectional study was carried out in all public hospitals in city of Yazd. Six performance indicators were examined monthly and in two time periods of 12 months before and 12 months after the implementation of Health Transformation Plan (HTP). The data was analyzed by SPSS software program version 22, using the paired T-test, and the Interrupted Time Series (ITS) model. FINDINGS: Findings showed that the performance indicators of the studied hospitals have improved after the implementation of the HTP. According to the ITS model, the implementation of HTP did not have a significant effect on the level and trend of the bed rotation distance, average length of stay and the ratio of surgical operations to bed indicators. However, it had a statistically significant effect on the level and trend of mortality and hospitalization rates. Moreover, the implementation of HTP had a significant effect on the level of the bed occupancy rate, but did not have a significant effect on the trend of this indicator. CONCLUSION: Based on the research findings, all the selected indicators changed to some extent after the implementation of HTP, which showed the effect of this plan on the performance of hospitals. However, not all indicators were statistically significant as the findings sub-section revealed.

HIV/AIDS policy-making in Iran: A stakeholder analysis.

INTRODUCTION: The present study aims to identify and analyze HIV/AIDS stakeholders in Iran. METHODS: This qualitative stakeholder analysis was conducted in 2018 nationwide, both retrospectively and prospectively. Purposive sampling was applied and followed by snowball sampling until data saturation. Data were analyzed using framework analysis. Also, MAXQDA (Version 11) and Policy Maker software (version 4) was applied. FINDINGS: A total of 44 stakeholders were identified and categorized into 23 active and 21 inactive stakeholders. The Ministry of Education and Iran Broadcasting have moderate participation in this regard. Supreme Council of Health and NGOs have low participation. The Ministry of Health (MoH), State Welfare Organization, Blood Transfusion Organization, and the State Prisons are interested in HIV/AIDS policymaking. The MoH is the main body responsible for the stewardship of HIV/AIDS in Iran but does not have enough authority to handle the issue. CONCLUSION: Considering multidimensional nature of HIV/AIDS, there are many stakeholders regarding HIV/AIDS control. The process of HIV/AIDS -policy making is fragmented in Iran. Despite multiple active and potential stakeholders in this field, there is no integrated system to involve all stakeholders in the process of HIV/AIDS policy-making. Therefore, given the importance of the issue, an upstream entity is needed to coordinate and mobilize all stakeholders associated with managing and controlling HIV/AIDS.

The experiences of merging health insurance funds in South Korea, Turkey, Thailand, and Indonesia: a cross-country comparative study.

BACKGROUND: Fragmentation in health insurance system may lead to inequity in financial access to and utilization of health care services. One possible option to overcome this challenge is merging the existing health insurance funds together. This article aims to review and compare the experience of South Korea, Turkey, Thailand and Indonesia regarding merging their health insurance funds. METHODS: This was a cross-country comparative study. The countries of the study were selected purposefully based on the availability of data to review their experience regarding merging health insurance funds. To find the most relevant documents about the subject, different sources of information including books, scientific papers, dissertations, reports, and policy documents were studied. Research databases including PubMed, Scopus, Google Scholar, Science Direct and ProQuest were used to find relevant articles. Documents released by international organizations such as WHO and World Bank were analyzed as well. The content of documents was analyzed using a data-driven conventional content analysis approach and all details regarding the subject were extracted. The extracted information was reviewed by all authors several times and nine themes emerged. RESULTS: The findings show that improving equity in health financing and access to health care services among different groups of population was one of the main triggers to merge health insurance funds. Resistance by groups enjoying better benefit package and concerns of workers and employers about increasing the contribution rates were among challenges ahead of merging health insurance funds. Improving equity in the health care financing; reducing inequity in access to and utilization of health care services; boosting risk pooling; reducing administrative costs; higher chance to control total health care expenditures; and enhancing strategic purchasing were the main advantages of merging health insurance funds. The experience of these countries also emphasizes that political commitment and experiencing a reliable economic growth to enhance benefit package and support the single national insurance scheme financially after merging are required to facilitate implementation of merging health insurance funds. CONCLUSIONS: Other contributing health reforms should be implemented simultaneously or sequentially in both supply side and demand side of the health system if merging is going to pave the way reaching universal health coverage.

Iran health insurance system in transition: equity concerns and steps to achieve universal health coverage.

BACKGROUND: Equity, efficiency, sustainability, acceptability to clients and providers, and quality are the cornerstones of universal health coverage (UHC). No country has a single way to achieve efficient UHC. In this study, we documented the Iranian health insurance reforms, focusing on how and why certain policies were introduced and implemented, and which challenges remain to keep a sustainable UHC. METHODS: This retrospective policy analysis used three sources of data: a comprehensive and chronological scoping review of literature, interviews with Iran health insurance policy actors and stakeholders, and a review of published and unpublished official documents and local media. All data were analysed using thematic content analysis. RESULTS: Health insurance reforms, especially health transformation plan (HTP) in 2014, helped to progress towards UHC and health equity by expanding population coverage, a benefits package, and enhancing financial protection. However, several challenges can jeopardize sustaining this progress. There is a lack of suitable mechanisms to collect contributions from those without a regular income. The compulsory health insurance coverage law is not implemented in full. A substantial gap between private and public medical tariffs leads to high out-of-pocket health expenditure. Moreover, controlling the total health care expenditures is not the main priority to make keeping UHC more sustainable. CONCLUSION: To achieve UHC in Iran, the Ministry of Health and Medical Education and health insurance schemes should devise and follow the policies to control health care expenditures. Working mechanisms should be implemented to extend free health insurance coverage for those in need. More studies are needed to evaluate the impact of health insurance reforms in terms of health equity, sustainability, coverage, and access.

What are the potential advantages and disadvantages of merging health insurance funds? A qualitative policy analysis from Iran.

BACKGROUND: In countries with health insurance systems, the number and size of insurance funds along with the amount of risk distribution among them are a major concern. One possible solution to overcome problems resulting from fragmentation is to combine risk pools to create a single pool. This study aimed to investigate the potential advantages and disadvantages of merging health insurance funds in Iran. METHODS: In this qualitative study, a purposeful sampling with maximum variation was used to obtain representativeness and rich data. To this end, sixty-seven face-to-face interviews were conducted. Moreover, a documentary review was used as a supplementary source of data collection. Content analysis using the 'framework method' was used to analyze the data. Four trustworthiness criteria, including credibility, transferability, dependability, and confirmability, were used to assure the quality of results. RESULTS: The potential consequences were grouped into seven categories, including stewardship, financing, population, benefit package, structure, operational procedures, and interaction with providers. According to the interviewees, controlling total health care expenditures; improving strategic purchasing; removing duplication in population coverage; centralizing the profile of providers in a single database; controlling the volume of provided health care services; making hospitals interact with single insurance with a single set of instructions for contracting, claiming review, and reimbursement; and reducing administrative costs were among the main benefits of merging health insurance funds. The interviewees enumerated the following drawbacks as well: the social security organization's unwillingness to collect insurance premiums from private workers actively as before; increased dissatisfaction among population groups enjoying a generous basic benefits package; risk of financial fraud and corruption due to gathering all premiums in a single bank; and risk of putting more financial pressure on providers in case of delay in reimbursement with a single-payer system. CONCLUSION: Merging health insurance schemes in Iran is influenced by a wide range of potential merits and drawbacks. Thus, to facilitate the process and lessen opponents' objection, policy makers should act as brokers by taking into account contextual factors and adopting tailored policies to respectively maximize and minimize the potential benefits and drawbacks of consolidation in Iran.

Correction to: Combining health insurance funds in a fragmented context: what kind of challenges should be considered?

In the original publication of this article [1], there are two corrections.

Combining health insurance funds in a fragmented context: what kind of challenges should be considered?

BACKGROUND: Iran's Parliament passed a Law in 2010 to merge the existing health insurance schemes to boost risk pooling. Merging can be challenging as there are differences among health insurance schemes in various aspects. This qualitative prospective policy analysis aims to reveal key challenges and implementation barriers of the policy as introduced in Iran. METHODS: A qualitative study of key informants and documentary review was conducted. Sixty-seven semi-structured face-to-face interviews were conducted, with key informants from relevant stakeholders. Purposive and snowball sampling techniques were used for selecting the interviewees. The related policy documents were also reviewed and analyzed to supplement interviews. Data analysis was conducted through an existing health financing World Bank framework. RESULTS: This study demonstrated that for combining health insurance funds, operational challenges in the following areas should be taken into account: financing mechanisms, population coverage, benefits package, provider engagement, organizational structure, health service delivery and operational processes. It is also important to have adequate cogent reasons to "the justification of the consolidation process" in the given context. When moving towards combining health insurance funds, especially in countries with a purchaser-provider split, it is critical for policy makers to make sure that the health insurance system is aligned with the policies and Stewardship of the broader health care system. CONCLUSIONS: Implementation of major reforms in a health system with fragmented insurance schemes with different target populations, prepayment structures, benefit packages and history of development is inherently difficult, especially when different stakeholders have vetoing powers over the proposed reforms. Solving the differences and operational challenges in the main areas of health insurance system generated in this study may provide a platform for the designing and implementing merging process of social health insurance schemes in Iran and other countries with similar situations.

So Near, So Far: Four Decades of Health Policy Reforms in Iran, Achievements and Challenges.

The Islamic revolution of 1979 in Iran emphasized social justice as a pillar for development. The fundamental steps towards universal equitable access to high-quality healthcare services began with the creation of the Ministry of Health and Medical Education (MoHME) and the nationwide establishment of primary healthcare (PHC) network in 1985. Now, in the 40th anniversary of the Islamic revolution, the history of health system development in Iran is characterized by constant policy changes; i.e. structural and procedural transformations. Ever since and despite the imposed 8-year war with Iraq and continuous unfair sanctions against the country, noticeable progress has been achieved in the health system that has led to better population health including among others: self-sufficiency in training health workforce; advances in public health and medical sciences; establishment and expansion of health facilities within the hard-to-reach areas aiming to enhance equity in access to needed healthcare services; domestic production of most medicines and medical equipment; and meaningful expansion of health insurance coverage. These have led to admirable improvement in public health indicators; i.e. maternal mortality, child mortality, life expectancy, and vaccination coverage. Despite achievements, there still remain challenges in health financing, protecting the public against high expenditure of medical care, establishment of referral system and rationalization of service utilization, provision of high quality healthcare services to all in need, and conflict of interest in health policy making, all of which may hinder the goal to reach "universal health coverage", identified as the main goal of the health system in Iran by 2025. Recently, the MoHME began structural and functional reforms to boost societal efforts and enhance intersectoral collaboration to address social determinants of health, improve actions for prevention and control of non-communicable diseases and other social health problems. Drawing upon the World Health Organization (WHO)'s "six building blocks" model, this article presents an analytical description of the main health policy reforms during the last four decades after the Islamic revolution in Iran, divided by each decade. Learning from the historical reforms will create, we envisage, a better understanding of health system developments, its advances and challenges, which might in turn contribute to better evidence-informed policy making and sustainable health development in the country, and perhaps beyond.

Stakeholders analysis of merging social health insurance funds in Iran: what kind of interests they may gain or lose?

Iran passed a Law in 2010 to merge all existing health insurance funds physically together. This stakeholder analysis aimed at revealing that what benefits the stakeholders might lose or gain as a result of merging health insurance schemes in Iran, which make them to oppose or support it. This was a qualitative study conducted in 2014. Sixty semi-structured face-to-face interviews were conducted. Purposive and snowball samplings with maximum heterogeneity samples were used for selecting interviewees. Government is not willing to undertake more financial commitment. Existing health insurance schemes like Social Security Organization and minor well-resourced health insurance funds and also worker unions are unwilling to lose their financial and organizational autonomy, to share their benefits with other less privileged groups, or face likely financial challenges in running their health facilities like hospitals. Top managers and workforces are worried to lose their job, salary, or organizational positions. Ministry of Cooperation, Labour, and Social Welfare does not want to lose its control on health insurance schemes. Ministry of Health and Medical Education and Iran Health Insurance Organization are among actors that support the insurance funds merging policy. Successful implementing of consolidation requires taking into account the interests of different stakeholders.