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: 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: 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: 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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Background and Objectives: Different governance approaches have various definitions and systems about health. The purpose of this study was to compare the appropriateness of the health system performance with the ideology of the selected countries.
Methods: In this comparative study, liberal countries (America, Canada, France), social countries (Russia, China, Cuba) and mixed countries (Sweden, Norway, England) were selected purposefully. Data were obtained from World Bank and WHO’s published documents and discourse literature studies. Causal layered analysis framework was used for data analysis.
Results: Comparison of health indicators showed that mixed countries were in a better position than the other two groups. The health system’s stewardship of the liberal, mixed, and social countries were decentralized, semi-centralized, and centralized, respectively. Discourses of the liberal states were based on the capitalist economy, with lack of reliance on natural resources. Socialist countries, a socialist economy system emphasizes the use of natural resources. In these countries governmental involvement is maximum. Mixed countries have a constitutional monarchy government and benefit from both of these approaches to create welfare based on the ideology of liberalism and the welfare state approach.
Conclusion: Mixed countries with appropriate economic- social conditions, semi-centralized structure of service delivery, suitable financing system, and regional and local management of services (highlighting the role of municipalities), have better health status than other countries. The ideology of the countries forms the social, economic, and political structures as well health. Iran should consider various layers of metaphor, discourse, casual structures, and litany for redesigning 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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Background and Objectives: Urban family physician program(UFPP), a program for improving equity in access to, financing, and quality of health services, is piloting in two provinces of Fars and Mazandaran, Iran since 2012. This study aimed to examine the association between the implementation of program and financial protection measures.
 
Methods: This cross-sectional, ecological study was performed on aggregated data of financial protection measures and some independent variables in the above provinces from 2008 to 2015. At first, the Lasso regression model was used for selecting independent variables affecting financial protection indexes. After adjusting the selected independent variables, in separate models, the association between the UFPP and financial protection measures, as outcome variables, was examined using a backward linear regression model.
 
Results: The percentage of households facing catastrophic health expenditure(CHE) in the years of UFPP implementation was 1.82% higher than the years before implementation(P<0.05). This increase was 1.37% in rural areas. the percentage of medical impoverishment in the two provinces increased by 0.83% during the implementation years than the years before(P<0.05). Finally, no significant relationship was observed between UFPP implementation and the Kakwani index and out of pocket payment(as % of total health expenditure) in the two provinces(P>0.05).
 
Conclusion: Despite the achievements attained by UFPP in improving physical access to health services, it seems that this program has had no success in improving financial protection measures and equitable health care financing. However, further research is warranted in this regard.

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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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Health and human rights are two inseparable and interrelated elements, whose provision and assurance enhance welfare in any society. Definition of welfare, human rights, and health as indicators of welfare development is controversial which is done in accordance with different approaches and discourses. Although the WHO definition is currently the only definition of health agreed upon by the member states of the Organization, it has been subject to criticism by the international society. In general, the most important criticisms include ambiguity, ideality, limitlessness, lack of comprehensiveness, lack of weighting to aspects of health, being non-operational, reductionism, and lack of a precise definition of the normal condition and disease. These criticisms would expose health systems to some challenges such as increased expectations of people, rapidly growing health expenditure, inconsistent expansion of technology-based systems, increased vulnerability to corruption, and equity and efficiency issues. Identifying and examining these criticisms can lead to a more informed decision to redefine health according to the favorable and context-sensitive discourse of the health doctrine in each country. This short review briefly describes the context and the most important criticisms of the WHO definition of health. Eventually, some policy suggestions are presented for redefining health according to Islamic-Iranian discourse.

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One of the main functions of the health systems in each country is health services delivery which includes a wide spectrum of four levels. The first level includes the reduction of disease prevalence, the second level includes early detection, screening and timely treatment. In the third level, we have rehabilitation and relief services, and finally the fourth level is reducing and controlling unnecessary medical interventions. Health services delivery should encompass all of the health needs of each population in the form of these levels. The focus on just one level leads to a reduction in the importance of other levels, and disrupts comprehensive services delivery. It is obvious that, paying attention to the prevention levels can have a significant impact on reducing the later costs and consequences. At present, the provision of services at different levels of Iran's health system is not balanced, and the promotion of these services requires more attention from health policymakers. The health system of Iran is more focused on treatment and medical services and there are many challenges such as poor stewardship and disadvantages of integrated systems in the rehabilitation, relief and palliative services.
 

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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: 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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Background and Objectives: In the late 2019, the SARS-CoV-2 virus was identified as the cause of an outbreak of acute respiratory illness known as the COVID-19, which began to spread in the world very quickly. Preventive measures have been a significant issue in preventing the spread of COVID-19. This rapid review study was conducted to summarize selected countries' preventive policies and strategies in the East and Southeast Asia, including China, South Korea, Japan, Vietnam, and Singapore, during the COVID-19 epidemic.
 
Methods: In this rapid review study, the Scopus, PubMed, Embase, and Web of Science databases were searched. The keywords applied in the search strategy were primary health care, public health, prevent* and plan, policy, program, initiative, intervention, measure, and COVID-19 in addition to the name of each country. Furthermore, we searched the World Health Organization (WHO) and the United Nations Development Program (UNDP) websites to retrieve more key sources as grey literature. The relevant data were extracted from the final studies and categorized.
 
Results: After screening, 33 studies met the inclusion criteria. Dominant measures implemented in these countries were categorized into different categories including communication and information, physical distancing, quarantine, monitoring, and testing axes.
 
Conclusion: Education and information, extensive testing and screening, contact tracing, isolation of infected and suspected cases, and observance of physical distancing has been very effective in reducing Covid-19 transmission and its mortality.

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Background and Objectives: Fair financial protection against health expenditures is one of the most critical goals of health systems. This study was conducted to investigate the most appropriate threshold for measuring the exposure to catastrophic health expenditure (CHE) in Iran.
 
Methods: The present study was conducted using 2018 national household income and expenditure data of the Iran statistics center. The occurrence and intensity of the households' exposure to CHE at different thresholds and for economic quintiles was measured using two World Health Organization (WHO) and World Bank (WB) methodologies. The most appropriate threshold for each methodology was also determined using the Kappa statistics adaptation estimation.
 
Results: The occurrence of households’ exposure to CHE was 3.02% and 8.51% in urban households and 4.66% and 9.22% in rural households, respectively. According to asset quintiles, the highest occurrence was in the first quintile and the lowest in the fifth quintile. In addition, the results of adaptation estimation based on Kappa statistics showed that a threshold of 40% in the WHO methodology and 25% in the WB methodology were the most appropriate thresholds.
 
Conclusion: The results showed a relatively high rate of exposure to CHE. CHE occurrence was also more in poorer households, and common thresholds were the most appropriate thresholds for estimating CHE.

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Background and Objectives: The spread of COVID-19 in the world has had adverse effects on all aspects of people´ life and social and economic development of the communities. The current study was conducted to determine the knowledge, attitudes, and practices toward COVID-19 in the general population of Qazvin province. 
 
Methods: This cross-sectional study conducted on 1223 people above 15 years in Qazvin province between December and January 2020. We used multistage stratified random sampling to select the participants from urban and rural health centers. The questionnaires were completed by the patients as well as through phone interviews. The questions included demographic information and knowledge, attitude, and practice toward COVID-19. 
 
Results: In total, 1223 subjects with a mean (standard deviation) age of 35.6 ± 12.2 years participated in this study. The scores of knowledge, attitudes, and practice were 68%, 72% and 91%, respectively. The lowest score of knowledge was related to awareness of common symptoms of the disease (6%). Forty-two subjects believed they observed the principles of disease prevention. A distance of 2 meters was observed by 50.3%. The scores of knowledge (P=0.007) and practice (P=0.028) increased with age, and the scores of knowledge (P<0.001) and attitude (P=0.001) increased and decreased with an increase in the education level, respectively. Males had significantly lower knowledge (P=0.002) and practice (P<0.001) scores. Moreover, rural residents had higher attitude scores compared to urban residents (P=0.002).
 
Conclusion: The results suggest that the general population of Qazvin province had desirable knowledge, attitude and practice towards COVID-19 at the time of the epidemic.

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Background and Objectives: low utility of health care services is one of the main determinants of not achieving desired health indicators in urban areas. This study aimed to investigate the barriers and facilitators of receiving health services from health centers in Kerman city, Iran.
 
Methods: This study was a qualitative study with a content analysis approach conducted in 2020. After selecting health centers with the experience of desirable or low utility services, purposive sampling continued until information saturation. A total of 78 staff members, recipients, and non-recipients of services citizens were interviewed semi-structured and face-to-face at health centers. All interviews were recorded and coded manually and then reviewed and analyzed using directional content analysis.
 
Results: The essential services for children and mothers, free services, and service providers' behavior were mentioned as facilitators of referral. Distance and physical factors, knowledge of different types of services, preference of private centers, time access, view of people on regular visits to centers, addresses and telephone numbers registered in the system, responsiveness to health needs, fear of disease disclosure, lack of human resources in the centers, and service providers' behavior, were among the barriers of visiting the centers.
 
Conclusion: According to the results of this study, an accurate understanding of the under-coverage people's views and perceptions can help national and local planners and policymakers design the necessary strategies to increase the use of health services in urban health centers.