Iranian Journal of

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Background and Objectives: Out-of-pocket (OOP) expenditure is one of the main indicators in health financing, indicating risk pooling and risk spreading. This study aimed to calculate the total health expenditure (THE), the THE per capita and share of OOP in each province from 2008 to 2014.

Methods: The present cross-sectional study was done by collecting provincial health expenditure data from public and private organizations during 2008-2014. The data were approved by board of trustees or board of directors in each organization. The relevant data on household health expenditures were collected from the Statistical Centre of Iran, as well.

Results: Even though the absolute monetary value (IRR) of OOP in the study years showed an increase, it decreased from 51.9% in 2008 to 40.6% in 2014 in terms of share. The absolute monetary value (IRR) of THE and THE per capita increased about 3.5 times in all provinces. So, during the study years, Tehran and Sistan and Baluchistan Provinces had the highest and lowest absolute monetary values (IRR) in THE per capita and this difference increased from 2.12 million Rials in 2008 to 10.56 million Rials in 2014.

Conclusion: Although the share of OOP decreased in all provinces in the country during the study years, it is still far from the objective of the national development plans (30% OOP). In order to improve the study indices and reduce the provincial inequity, it is suggested to put more emphasis on prepaid-based mechanisms, insurance system improvement, and equitable distribution of financial resources should be compatible with the deprivation of the area and its infrastructures.

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Background and Objectives: Health insurance would guarantee people security against disease and health problems. Given the key role of health insurance in achieving the goals of justice and reducing the out-of-pocket payment, this study aimed to evaluate the performance of Iran health insurance using the DEA model in 2014.

Methods: This was a cross sectional study. The study population included all Iran health insurance organizations. DEA input and output criteria were selected by targeted library and documentary review and the data were collected accordingly. The determinants of efficiency were evaluated using liner regression.

Results: The mean technical, management, and scale efficiency of Iran health insurance head offices was 0.593, 0.761, and 0.721, respectively. Considering the findings, the capacity of efficiency promotion at these head offices was approximately 41%. Regarding technical efficiency, 5 head offices had the maximum efficiency (1), 7 head offices had efficiency between 0.5 and 1, and 19 head offices had efficiency less than 0.5. In addition, the variables of population and total number of institutions had a significant impact on efficiency.

Conclusion: Based on defined variables, input oriented AP-DEA model was appropriate. The results showed a great capacity for increasing technical efficiency in the Iranian health insurance organizations which could be increased by benchmarking efficient and reference organizations and also adjusting their input. For this purpose, downsizing and agility of the Iranian health insurance organizations based on the e-government clause are proposed for administrative system reform.

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Background and Objectives: One of the fair financial protection indexes in monitoring health systems is estimating impoverishment due to health care expenditure. The aim of this study was to measure the percentage of households impoverished due to out-of-pocket(OOP) payments in Iran provinces during2008-2014.

Methods: The present retrospective descriptive study was conducted based on data from Household Income and Expenditure Survey in both rural and urban households. The proportion of households that moved below the poverty line after deducting health care costs was calculated. The poverty line for urban and rural areas was calculated based on household food expenditure. To show the provincial dispersion of the index during this period, the coefficient of variation(CV) was used. Mann-WhitneyU test and descriptive statistics were used to analyze the data.

Results: Golestan, North Khorasan, and Kerman had the highest impoverishment rate due to OOP Moreover, Alborz, Tehran, and Bushehr had the lowest impoverishment rate due to OOP. In all the study years, the average impoverishment due to OOP was significantly higher in rural areas compared to urban areas. Provincial dispersion CV for this index did not have a constant trend.

Conclusion: The results of this study provide valuable evidence for policy-makers to estimate the impact of OOPs on household impoverishment. In order to reduce impoverishment due to OOP, supportive targeted interventions for vulnerable and low-income households, especially rural households, in addition to decreasing the share of OOP, are essential, such as developing health subsidies and improving insurance service packages.

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Background and Objectives: Productivity and efficiency are the most important and the most common mechanisms of evaluation and measurement of the performance of an enterprise including the Social Security Organization. In the past decades, performance evaluation of various economic sectors has been attractive to researchers in different disciplines. Thus, the aim of this study was to measure the efficiency of the direct treatment section of treatment management units of Social Security Organization by data envelopment analysis method. 

Methods: This descriptive- analytic study was conducted to measure the efficiency of the direct treatment section of treatment management units of Social Security Organization through the data envelopment analysis (DEA) method in 2014. Data and relevant statistics were collected from the Statistical Center of Social Security Organization. The Deap2.1 software was used to calculate the efficiency and the EMS software was used to calculate the super efficiency. Then, the hypotheses of the research were studied using the Stata software.

Results: The average technical efficiency, managerial efficiency, and scale efficiency in 2014 was 0.924, 0.992, and 0.932, respectively. Twelve decision making units (DMUs) had the maximum technical efficiency (1), 16 DMUs had technical efficiency between 0.8 and 1, and 3 units had technical efficiency less than 0.8.

Conclusion: This study introduces a functional pattern to managers of Social Security Organization that enables them to have more accurate planning for the development and saving of resources.

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Background and Objectives: Catastrophic health expenditure (CHE) is a key indicator for measuring  households' financial protection in the health system. This study was conducted to measure the incidence and intensity of CHE in Iranian provinces 2008-2014.

Methods: When the out-of-pocket (OOP) spending of each household amounts to at least 40% of the household's capacity to pay, it is called a catastrophe. The incidence of CHE in Iranian provinces was estimated using the data obtained from household-expenditure-and-income-surveys. The intensity was calculated as the average extent to which OOPs exceeded the 40% threshold. Descriptive statistics and Mann-WhitneyU test were used for data analysis. The index of disparity(ID) was also calculated for geographical disparities across the provinces.

Results: On average, the lowest and highest CHE incidence and intensity were seen in Fars and South Khorasan provinces respectively. However, the highest and lowest rate for CHE households that actually experienced catastrophe at the 40% threshold belonged to Fars and Kurdistan provinces. The incidence of CHE in rural was more than urban areas. ID of CHE incidence for targeted amount was high and had no constant trend.

Conclusion: CHE incidence had a remarkable difference in different provinces and in the rural area compared to the urban area. Due to the importance of this index in promoting health financial protection, like indexes such as OOP, its distribution in rural and urban areas as well as in different provinces is considerable. It requires a structured format to identify the disadvantaged and low-income groups and provide financial-support and insurance for them.

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Background and Objectives: Universities of medical sciences play a vital role in promoting population health and without a doubt, their performance should be measured and evaluated.

Methods: The study was a mixed method study (consecutive combination) and the universities were examined by census. In the qualitative phase of the study, by examining the documents and focused group discussions, the basic framework of the performance evaluation model and its associated challenges were elicited. Then, the policies, objectives, and strategies related to each dimension were extracted and finally, key indicators were selected. Finally, by running Analytic Hierarchy Process method, the weight of dimensions and their key aspects were calculated and the model was implemented.

Results: BSC was designed in accordance with the universities. In this model, four main aspects including population health, services, finance, and development were identified. Then, by reviewing the documents, key policies and strategies, key policies and criteria, primary and secondary strategies were extracted. 13 key indicators were chosen as the final indexes. Moreover, 3 main challenges and 11 secondary challenges were identified. The results of the AHP-BSC model indicated that categorizing (ranking) universities had an impact on their functional status.

Conclusion: The main challenge for evaluating the performance of universities was the presence of a logical connection between policies, strategies, and criteria to have comprehensive and concise indexes for evaluation and ranking.

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Background and Objectives: Efficiency measurement can be used for all decision-makers and planners for useful resource allocation. Social Security Organization as a health service provider, provides part of health care services in indirect sector. This study aimed to assess the performance of provincial units of Social Security Organization in the indirect health services sector.

Methods: This descriptive analytical study was conducted based on the available data of Social Security Organization in 2014. To assess efficiency and super-efficiency, the DEA-VRS and Anderson-Peterson rating model were used, respectively. Factors affecting the efficiency was evaluated using multivariate regression.

Results: The primary efficacy analysis showed that 61% of the provincial units of Social Security had maximum efficiency. Average efficiency was 0.94. After super-efficiency analysis, it was found that Markazi and Kerman provincial units were the most efficient and the most inefficient units, respectively. Additionally, none of the variables had a significant impact on the efficiency.

Conclusion: Evaluation of the general performance of provincial units reflected the good state of technical efficiency in the indirect health service sector. On the other hand, the scale efficiency of inefficient units compared with managerial efficiency had a higher share of inefficiency. Optimum performance can be achieved through modification of managerial practices for optimal utilization of resources and factors.

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Background and Objectives: Timely access to required health services without any financial hardship is necessary to achieve public health. Therefore, the aim of present study was to review the policies and plans adopted in the health financing system.

Methods: The qualitative study with a policy research approach reviewed upstream laws, policies, and plans in Iranian health financing. Then, by holding seven focused group discussions with 28 participants who represented various stakeholders, financing policies and programs were identified. Using framework analysis, the data were coded and categorized.

Results: In response to health financial protection indexes improvement, policies and plans in this field were defined in 10 themes and 4 categories: resources collection, resources management and pooling, resources allocation, and strategic purchasing of health services. The most important policies and plans were integration of insurance funds, increasing sustainable financial resources and targeted allocation of subsidies, services priority setting, establishment and improvement of a performance-based payment system with emphasis on integration of the professional element in the public and private sectors.

Conclusion: There is no gap for documented laws and policies in the Iranian health financing system. The main barriers are the method of implementation and adequate commitment to laws that have created major difficulties in relation to financial protection. Resolving these barrierrs requires sufficient political support and a common understanding between stakeholders at different levels of policymaking and implementation and designing programs based on the infrastructures.

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Good governance promotion in the health sector needs effective policies and evidence-based decision making. Using efficient and effective information is an important issue so that planners will not be confused amid many figures and numbers and also the main problem will not be marginalized. Hence, having a common language and consensus between policy makers and decision makers about the cycle (collecting and processing information, analysis, and judgment) and decision-making tools (criterion, indicator, index, and variable) is an initial and crucial step in evidence-based decision making. The main challenge for creating such an information system is the lack of a common language among scientific and executive experts; so the aim of this study was to provide a perspective of the concept of decision-making and the main components of its cycle and tools and to review these concepts in health care financing system.

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Governance and leadership are seen as the most important function in the realization and promotion of community health. This two components through legislation must identify present situation, determine the desirable situation, provide infrastructures and implementation mechanisms and in accordance with stated policies and planning, they should apply necessary monitoring and control. In this regard, the most important challenge is a comprehensive and evidence-based identification and analysis, which can consider all functions in relation to the objectives at a general and coherent glance and assess the functions of the health system.

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Background and Objectives: One of the issues affecting the health sector is the presence of regional inequalities. The purpose of this study was to evaluate the trend of inequality in the distribution of human resources and health facilities in the health sector of Iran.
 
Methods: In this study, inequality in the distribution of human resources and health facilities in the health sector was assessed using the Gini coefficient in 2006, 2011, and 2015. The variables included human resources (6 indicators) and health facilities (10 indicators). Data were collected from the Statistical Center of Iran and the Statistics and Information Technology office of the Ministry of Health. For a Gini coefficient less than 0.35, 0.35-0.5, 0.5-0.6, more than 0.6 indicated relatively balanced inequality, relatively unequal inequality, high inequality, and very high inequality, respectively.
 
Results: The maximum Gini coefficient belonged to radiographic centers (0.61) and the minimum was Behvarz (0.23). In human resources indicators, inequality decreased over the study years from 0.57 to 0.27. However, inequality showed a slight increase in Behvarzes from 0.24 to 0.26. Among the facilities indicators, the Gini coefficient of urban health centers, health care facilities, beds, and radiology centers decreased from 0.45 to 0.31, whereas other indicators had an increasing trend from 0.24 to 0.59. In the private sector, there was a high inequality (0.5 to 0.61).
 
Conclusion: Eliminating inequalities in the distribution of health sector resources can help to improve justice in health outcomes. Therefore, policymakers should be pay more attention to eliminating inequalities.

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The human approach to health and identification of the factors affecting it over time has changed. Understanding these approaches is helpful in promoting policymaking and good governance can be helpful in the health sector. Biomedical, psychological, health promotion, health determinants, health in all policies and one health are the most important health approaches that have emerged in different years in order. Each of these approaches has many challenges and strengths. Documents and studies show that although these health approaches have been inconsistently addressed in Iran, no specific doctrine has been define to guide the health policies. Therefore, in practice, what seems to be that a biomedical approach to health is the dominant approach in Iran's health system.

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Background and Objectives: Improving the efficiency and productivity of the higher education, especially in the field of research on health sciences, is one of the characteristics of sustainable development in today's societies. This study aimed to measure the efficiency and productivity of Iran's Medical Sciences Universities (MSU) in the research function.
Methods: In a descriptive study, the research function of fourty five MSUs in Iran was evaluated using data envelopment analysis (DEA) method and Malmquist index in 2010, 2013, and 2016 years. Measurement of both efficiency and Malmquist index was developed and modeled based on the assumption of variable returns to scale (VRS) and output-oriented. Also, the ranking of efficient units was done using Anderson-Patterson's model.
Results: The mean research efficiency was estimated to be 0.86. Findings of Malmquist index showed that between 2010 and 2013, there was a 6% growth in the productivity; while the performance of universities had a 12% drop in research function from 2013 to 2016. Also, the average total productivity during two periods is 0.96, indicating 4% reduction in research efficiency which technology efficiency growth has dropped by 8% and other components of total productivity had a positive growth.
Conclusion: The results of the study showed that universities do not work efficiently and average productivity has been decreasing which was mainly due to a decline in the efficiency of technology, which despite the development of technology in recent years could be the result of the lack of effective use of it.
 

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Background and Objectives: Research plays an important role in solving health problems in the community. One main mission of higher education institutions is developing research tailored to the needs of the community by providing equal and fair opportunities for research sectors. The present study aimed to measure inequality in the rea of research in Iranian medical sciences universities.
Methods: In this descriptive study, the Gini Coefficient (GC) was used to measure inequality from 2010 to 2016. The indexes included the number of published papers, citations, citation per paper, self-citation, Scimago Journal Rank (SJR), Source Normalized Impact per Paper (SNIP), Citescore, Hirsch
(h-index), number of faculty members, number of students, and educational and research budget. Stata 14 software was used for data analysis.
Results: During the study years, the GC of SJR, SNIP, and Citescore varied from 0.65 to 0.73, 0.62 to 0.73, and 0.61 to 0.72, respectively. In addition, The GC of international papers, total articles, self-citation, citation per article, Hirsch index, and total citations varied from 0.62 to 0.70, 0.56 to 0.66, 0.22 to 0.27, 0.12 to 0.28, 0.33 to 0.39, and 0.57 to 0.72, respectively. The GC of the number of faculty members and budget ranged from 0.26-0.40 and 0.34-0.67, respectively.
Conclusion: Inequality in self-citation and citation per article was relatively fair, while Hirsh and the number of faculty members had intermediate inequality. Other indicators had a high and very high inequality. To reduce inequality, developing of the balanced research infrastructures in medical universities is recommended.

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Background and Objectives: Human resources is a key factor in achieving the Millennium Development Goals. Lack of indicators and standard tools for monitoring and evaluating human resources may cause limitations in achieving these goals. This study was done to develop evaluation indicators of human resources in the health sector.
Methods: The present study was carried out using the Delphi technique to extract the indicators of human resources evaluation in 2017. To conduct this study, three independent stages including a review of theoretical concepts, preparation of initial indicators of human resources evaluation, and consensus building were undertaken. The data were collected by a panel of 12 experts and representatives of related organizations in three rounds, with a scorecard designed to score from 1 to 10. In each round, the indexes that attained at least 8 out of 10 by two thirds of the experts were confirmed in the final model.
Results: In the first stage, 220 indicators were identified. The final model of human resources evaluation had 45 indicators in 11 main criteria. Four criteria were accepted at the stage of entrance to job market, (qualified applicants for health education, accreditation, capacity and outsourcing of health education institutions, approval and licensing). Five criteria were confirmed during the work (main indicators of availability and distribution, activity, productivity of labor force, waste and renewal, desirable governance on the information system of labor). Two criteria were accepted at the exit stage (transfer and withdrawal).
Conclusion: Despite the complexity of the human resources assessment, three different stages of the life cycle of the workforce (input, active labor force and output) should be considered for evaluation and monitoring. The indicators presented in this study make it possible to assess and monitor the health workforce.
 

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Background and Objectives: The higher education system plays an important role in the socio-economic development of the country due to its mission in training the required human resources. Therefore, performance evaluation of different sectors of higher education is of great importance. The present study was conducted to evaluate the educational efficiency and productivity changes of Iranian medical sciences universities.
Methods: This descriptive study was conducted in 2011, 2014, and 2017 to evaluating the performance of 43 Iranian medical universities using Data Envelopment Analysis and output oriented approach. In addition, productivity changes were measured using the Malmquist index. For this purpose, Deap 2.1 software was used. The Anderson Patterson Model and EMS software were also used to rate the units accurately.
Results: The average educational efficiency of medical universities was 0.97 in the study years. The average total productivity based on the Malmquist Index was 1.05, and educational productivity of the universities showed an average growth of 5% over the study years. This growth was 1% from 2011 to 2014 and 10% from 2011 to 2017.
Conclusion: The results of the study showed the acceptable efficiency of the education sector of Iranian medical sciences universities. Moreover, a positive increasing trend was observed in the productivity of the education sector during the study years. Further research using quality and quantity measures are necessary to assess the educational performance of medical universities more accurately.

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Background and Objectives: Quantitative and qualitative improvement of human resources inequality have a significant effect on achievement to health system goals. The purpose of this study was to investigate the trend of geographic, supply, and gender distribution inequality of human resources of the Ministry of Health and Medical Education (MOHME) in Iran.
Methods: In this descriptive study, the trend of human resources of the Ministry of Health during the years 2009-2015 was investigated based on gender, level of education, and type of employment. In order to study the inequality, Lorenz curve and Gini coefficient index were used. Data were collected from the Human Resources Office of the Deputy of Management Development and Resources of the MOHME and analyzed by Excel 2013 and Stata-14 software.
Results: In the present study, women had the highest portion with a growth rate of 6.66% in 2015 and a Gini coefficient of 0.29 except in 2011. The highest and lowest growth rate compared to the base year in 2010 was related to specialist doctors (83.12) and general practitioners (-19.61), respectively. The lowest and highest Gini coefficient was related to the associate degree (0.26) and subspecialty (0.45), respectively.
Conclusion: The present study was the first study to investigate the trend of changes in the human resources characteristics of the MOHME at a national level. Since this study only considered the quantity of the trend of human resources changes, it is recommended that the quality of human resources be investigated in the future studies.              

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Background and Objectives: A significant portion of the total health expenditure is related to medicines. Evaluation of medication system indicators forms a basis for modifying the consumption pattern and cost containment. Therefore, the present study was conducted to investigate the trend of medication consumption indicators in Iran.
Methods: In this descriptive-cross-sectional study, medicine consumption per capita was calculated based on the medicine type, medicine form, and treatment category. The data were extracted from the Pharmacological Statistics of the Food and Drug Administration and the Statistics Center of Iran between 2012 and 2015. Catzung categorization was used for treatment categories. Data were analyzed using descriptive statistics and annual growth index by Excel 2013 software.
Results: During the study years, the highest medicine consumption per capita was related to metformin 500 (18.52), ranitidine 150 (15.45), and adult cold (15.29). The highest average consumption per capita in different treatment categories was related cardiac medications (97.65). The lowest and highest growth rates were related to glibenclamide 80 with -12% in 2014 and metformin 500 with 16.9% in 2013, respectively. Tablets were the most widely used form of medicine.
Conclusion: According to the results, medicine consumption per capita in Iran is higher than developed countries. Cardiac and diabetes medications have a high consumption per capita in Iran compared to other medications. Therefore, in order to rationalize drug prescription, strengthening the clinical evaluation system is recommended by developing and implementing clinical guidelines for common and high-cost diseases.

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Background and Objectives: Access to equal educational opportunities is one of the fundamental rights in each country, and elimination of inequalities, especially in the higher education system, is one of the most important priorities. This study aimed to measure educational inequality in the medical sciences sector in Iranian provinces.
Methods: In this study, educational inequality in medical sciences was measured using the Gini coefficient. The study indexes included the number of students, faculty members, staff, majors and educational budget. Data were analyzed using Stata 14 software.
Results: During the study years, the Gini coefficient of the number of female students, male students, and faculty members showed a more or less decreasing trend from 0.51 to 0.46, from 0.53 to 0.46, and from 0.59 to 0.53, respectively. However, the values of inequality in the number of personnel working in educational sector and educational budget showed a slight increasing trend from 0.49 to 0.50 and from 0.53 to 0.54, respectively. According to the academic majors, the lowest Gini coefficient was related to non-continuous bachelor’s degree that varied from 0.13 to 0.17, and the highest value was related to fellowship degree ranging from 0.66 to 0.69 in the study years.    
Conclusion: Despite reduced inequality in some educational indicators, there is a high inequality in the number of academic majors of some postgraduate degrees, number of students by gender, and educational budget, which requires policy makers to focus more on balanced distribution of educational infrastructures among provinces to provide equal educational opportunities.

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Concurrent with globalization, some changes have been created in the performance of the universities in developed countries that have turned them into a power source for economic development. In this study, generation changes of Iranian universities in the health sector were analyzed by the layer analysis (CLA) framework. The results showed that the status of universities in Iran is moving from the first and second university generations (i.e. education and research oriented) to the third generation (wealth creation). Too much concentration on indexes such as expert human resources training and number of papers and citations in the Iranian universities has led to stagnation in litany and structural layers. Obtaining scientific authority and technology development requires fundamental evolutions of sciences in deeper layers such as Islamic world view, governance of valuable contexts and evolution in the relationship among higher education and the research and technology system with other sectors.