Journal of School of Public Health and

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Background and Aim: Economic evaluation of health interventions is critical for efficient allocation of resources. The aim of this study was to critically review empirical studies on the cost-benefit of health interventions published over the last 40 years.

Materials and Methods: This study was carried out by searching seven  databases (PubMed, Cochrane Database of Systematic Reviews, Web of science, Science Direct, Scopus, Springer Link, and SID) using appropriate keywords to find articles on the cost-benefit of health interventions published during 1975-2015. All the relatedretrieved articles were analyzed after quality assessment using a valid check list.

Results: A total of 33studies on the cost-benefit of health interventions during the last 40 years were included in the review; 39%, 37%, 21% and 3%of the studies had been conducted in Asia, America, Europe and Africa, respectively. The subjects dealt with in most ofthe studies (79%) were related to immunization, education, healthy nutrition and use of health technologies. Further analysis of the data showed mental health education, healthy nutrition, use of safety equipment while driving, vaccination, diagnostic and screening tests, and oral and dental healthto have considerable clinical and economic benefits.

Conclusion: The number of studies on the cost-benefit analysis of health interventions is increasing. Preventive and promotive interventions can help planners and policy-makers to better utilize the limited resources in the health sector aiming at promoting health of the people.

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Background and Aim: Quality management, as an organizational strategy, helps enhance hospital effectiveness and efficiency. This study aimed to examine the effect of a quality management model on the efficiency of the respiratory intensive care unit in Labafijejad Hospital, Tehran in 2013-14.
Materials and Methods: This was a participatory action research conducted  in  the respiratory intensive care unit in Labafijejad Hospital, Tehran in 2013-14. A quality improvement team was formed to implement the quality management system and promote working processes.  The team identified and standardized working processes, determined the quality goals for the processes, and improved the processes based on the 10-stage Mosaddeghirad Quality Management model. Performance indicators of the unit  (bed occupancy, bed turnover, and bed interval rates;  patient average length of stay in the ward) were calculated and compared before and after the intervention.
Results: Implementing quality management brought about an increase of 2.8% and 19.2% in bed occupancy rate and bed turnover rate, respectively, as well as a decrease of 14.1% in patient average length of stay and a decrease of 35.6% in bed interval rate in the respiratory intensive care unit of the hospital.
Conclusion: Implementing quality management can increase the efficiency of the respiratory intensive care unit of a hospital. A suitable quality management system and the commitment of the hospital manager and staff can result in enhancement of efficenicy in a hospital.
 

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Background and Aim: Hospital accreditation is a systematic external evaluation of a hospital’s structures, processes and results (outputs/ outcome) by an independent professional accreditation body using pre-established optimum standards. This study aimed to examine the relationship between accreditation and hospital performance. In addition, the most important accreditation constructs affecting hospital performance were identified and ranked.
Materials and Methods: This descriptive, correlational and cross-sectional study was conducted using the data related to accreditation scores and nine performance indicators of 121 hospitals in 2014 and 123 hospitals in 2015 in Tehran province, Iran. Shannon entropy method was used for calculating the weights of the hospital indicators. Then, Feature Selection method in data mining was used to explore the relationship between accreditation scores and hospital indicators. Data were analyzed using IBM SPSS Modeler software. Analyses were carried out at the 0.05 significance level
Results: The mean of hospitals’ accreditation scores were 61.98% and 69.56% in 2014 and 2015 respectively. All performance indicators except the number of outpatients were increased in 2015 compared to 2014. There was no significant difference in the scores between 2014 and 2015 data. Hospitals’ accreditation scores were not associated with their performances. However, accreditation scores of leadership and management; accident and emergency; and procurement departments had the most effect on hospitals’ performance.
Conclusion: Accreditation was not correlated with hospital performance. Thus, improving accreditation system including standards, methods and surveyors and using quality management strategies in hospitals are necessary for improving hospital’ performance.
 

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Background and Aim: Burn injuries cause severe devastating losses and early death. Care and treatment of burns patients is very costly. The purpose of this study was to calculate the economic burden of care and treatment of burn injuries in a hospital in Ahvaz, Iran.
Materials and Methods: This descriptive and cross-sectional study was carried out in 2015 in Taleghani Hospital, Ahvaz, Iran. A total of 315 patients participated in the study. Data was collected, using a valid and reliable questionnaire, through interviews with patients or their relatives on the day of discharge and examining their medical records. Data analysis was done using standard statistical tests and the SPSS (V.22) software.
Results: The mean total cost of care and treatment of an inpatient with burns was 117,071,803.00 Iranian Rials (equivalent to US$ 4,063.00), the mean daily cost being 8,501,946.00 Iranian Rials (equivalent to US$ 295.00). Direct medical costs, direct non-medical costs and indirect costs accounted for 94.1%, 1.4% and 4.5% of the total cost, respectively. The patients’ out-of-pocket payment was 7.7% of the total direct costs. Surgery, drug and diagnosis costs accounted for the largest fraction of the total treatment cost.
Conclusion: The total cost of care and treatment of burns patients in the hospital is very high, imposed on patients, their relatives, government and health insurance companies. The government and insurance companies should provide financial protection to facilitate the process of care and treatment of burns patients.
 

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Background and Aim: Iran is experiencing a very fast population ageing, ranking 3^rd globally in terms of pace of population ageing. The increase in the elderly population has been accompanied by an increase in demand for health services. A knowledge and understanding of the utilization of health services by the elderly are essential for resource allocation and health planning. This study aimed to investigate the utilization of in-patient services by the Iranian elderly and explore its determinants.             
Materials and Methods: This study was a secondary analysis of the data of a cross-sectional National Study on the Utilization of Health Services in Iran, including 22470 households across the country. The study population was people aged 60 years and over, the sample size being 8205 individuals selected by stratified random sampling from provinces, towns and villages. A questionnaire was used to collect information on the need of the individuals to hospitalized services during the last one year and receiving the required services and analyzed using multilevel logistic regression to identify the factors related to the utilization of inpatient health services.            
Results: Of the 8205 participants, 1411 (17%) reported that they needed in-patient services at least once during the previous year, about 93% of whom referred to a hospital, of whom about 1288 (97%) finally had finally received the required services. The factors related to inpatient service utilization were age (p=0.03) and having insurance status (p<0.001), such that the older individuals and those with no insurance, although they had higher inpatient service needs, received less services. The most important cause of dissatisfaction in the towns was related to the behavior of nurses and non-physician personnel and in villages long waiting time for receiving a service.  Finally, the most important causes being not willing to be hospitalized were the high service cost and no health insurance coverage.
Conclusion: The older people and those with no insurance should be priority groups in health service utilization policy-making and planning, so that they can access and receive better services. The causes of low inpatient service utilization and dissatisfaction should be taken into consideration seriously by health service providers and managers.                  

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Background and Aim: Good governance results in better health outcomes for the society thorugh improving health system performance. The governance of Iran health stsyem faces some challenges. Hence, this study aimed to propose and verify a model for strengthening Iranian health system governance.
Materials and Methods: This descriptive study was conducted in 2016 using the Delphi method. A health governance model with six dimentions including sturucture, communication, regulation, policy making and planning, stewardship and evaluation and accreditation has been proposed. Then, the proposed model verified using 25 Iranian healthcare experts’ opinions in two rounds.
Results: Developing an integrated health system model comprising health system enablers and results, downsizing and reducing the number of directorates in ministry of health,determining basic principles for regulation, enhancing communication with other external organizations affecting people health, using more evidence in policy making and planning, developing a strategic plan and national health policy, enhancing leadership, management and stewardship; and developing comprehensive systemic standards for evaluation and accreditation of healthcare organizations are recommended to enhance the effectiveness and efficiency of Iran health system governance.
Conclusion: Iran health system governance faces numerous challenges. Using successful countries’ experience and internal health care experts’ opinions help to reduce the current challenges and achieve health system goals.
 

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Background and Aim: The health system financing is the process of collecting, pooling and managing financial resources and purchasing healthcare services. Health financing plays an important role in achieving the health system goals and objectives specially universal health coverage. The aim of this study was to strategically analyze the Iranian health financing system and recommend strategies to strengthen it.
Materials and Methods: Using the scoping review method, all published studies about the strengths, weaknesses, opportunities and threats of the Iranian health financing system were searched in eight databases including "PubMed", "Scopus", "Science Direct", "Embase", "ProQuest", "SID" and "Magiran", as well as the "National Database of Medical Science Theses" and two search engines, namely, "Google" and "Google scholar". Finally, 29 studies were selected and analyzed using the framework analysis method and MAXQDA software. 
Results: Extended health insurance coverage, reduced out-of-pocket payments following the national health transformation plan, and increased healthcare tariffs were the strengths of the Iranian health financing system. On the other hand, regressive financing, high out-of-pocket payments and increased number of health insurance companies were the weaknesses of Iran’s health financing system. Political sanctions, financial crises and increased healthcare demands were the threats, while supportive laws, the NGO’s financial support, increased number of health care organizations and modern technologies were among the important opportunities for the Iranian health financing system. Increasing the health system financial resources through prepayments, structural and policy unification of health insurance system, health service tariff reform and enhancing health system efficiency and healthcare services quality are essential to strengthen the Iranian health financing system.
Conclusion: The Iranian health financing system is not resilient and faces several challenges. The health system policy-makers and senior managers should adopt the recommended strategies to strengthen the national health financing system.

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Background and Aim: The realist review has been introduced to review and synthesize the evidence related to the implementation of complex healthcare interventions. This method interprets the results of an intervention by explaining the causal relationships between the intervention and the results. This study aimed to explain the methodology of realist review in the health system.
Materials and Methods: This study was conducted using the scoping review. The following databases were used to find articles using appropriate search strategies and relevant key words: Pubmed, Scopus, Science Direct, and Embase electronic databases, as well as Google Scholar and Google search engines. Finally 49 articles were selected (in the period between January 1990 and December 2020) for review.
Results: The realist review is a theory-based approach to synthesize evidence related to the complex interventions, explaining the reasons for the successes or failures of interventions based on the causal relationships between the interventions, contexts, mechanisms and outcomes. A protocol was introduced to conduct a realist review composed of three phases ─ explaining, development and correcting the intervention program theory ─ and including seven steps of determining research questions; explaining the initial program theory; developing search strategies; collecting, evaluating and selecting evidence; synthesizing evidence; modifying the initial theory; and making suggestions. In addition, the structure of a realist review article was described and a checklist for evaluation of a realist review study was introduced.
Conclusion: The realist review is a suitable method for reviewing the complex health system interventions, explaining how an intervention relates to the results obtained. A realist review explains how, under what conditions and for whom a health and therapeutic intervention works.

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Background and Aim:  The health financing system is the process of collecting, pooling and managing financial resources to purchase health services. Sustainable financing of the Iranian health system is crucial for achieving universal health coverage. The purpose of this study was to identify strategies for sustainable financing of the Iranian health system.
Materials and Methods:  This study was conducted using the scoping review in 2020. The following databases and search engines were searched systematically between 21.03.2002 and 21.09.2020 to find studies related to sustainable financing strategies for the Iranian health system: PubMed, Web of Science, Scopus and Embase, Magiran, Iranmedex and SID databases, and two search engines; i.e., "Google" and "Google scholar”. Finally, 47 studies were selected and analyzed using the MAXQDA software and the framework analysis method.
Results: A total of 40 strategies were identified for strengthening the sustainability of Iran's health financing system, which were grouped into three categories: collecting funds, pooling funds and purchasing health services. The most frequently cited strategies for sustainable financing of the Iranian health system were the following: increasing the health share of gross domestics product, expanding tax revenues, pre-payment methods of health financing, strengthening public-private partnership, increasing the efficiency of the health system, reducing health system costs, consolidating insurance funds, eliminating insurance overlaps, value-based health service tariffs, optimizing health services support packages, and fixed payment methods based on  the performance of the health service providers.
Conclusion: The Iran's health financing system must be strengthened in such a way as to make it possible to collect, pool and manage sufficient financial resources to be used to purchase health services for the people to ultimately ensure universal health coverage leading to the promotion of the public’s health.

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Background and Aim: The Primary Health Care (PHC) system is the most comprehensive, equitable and efficient way to promote people's health and social welfare by providing preventive, curative, rehabilitative and palliatvie services in a place close to where people live and work. Iran's PHC system faces challenges that limit its effectiveness and efficiency. The aim of this study was to identify strategies to strengthen Iran's PHC system.
Materials and Methods: A realistic review method was used in this research. Published articles on strategies to strengthen the PHC system between 1978 and 2019 were searched in eight databases and Google scholar search engine. Finally, 29 articles were found to be eligible for inclusion in this study; framework analysis was done using the MAXQDA-10 software. 
Results: Twenty-nine strategies were identified for strengthening the PHC system. A well designed PHC system is one with the following characteristics: realistic goals and appropriate strategies  equipped with necessary resources, organized in multidisciplinary teams that provide comprehensive and quality health services (intervention program), with strong governance and leadership, financing, work force, equipment and medicines, information systems and robust health services delivery processes and well adpated to the external environment (context). Such a PHC system will increase healthcare providers’ satisfaction and commitment, as well as the  patients’ trust, participation and satisfaction (the mechanism) and, finally, promotes, restores, and maintains the people health (result).
Conclusion: A strong PHC system is a pre-requisite for strengthening a health system. Various strategies such as strengthening management and leadership, improving organizational structure and culture, improving the information system, empowering human resources and increasing population coverage can lead to an improved PHC system. Historical, social, cultural and economic factors affecting the health system should be considered in redesigning and stregtening a PHC system.
 

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Background and Aim: Occupational injuries are an important human resource management challenge with negative effects on employees and organizations. A knowledge of the prevalence of occupational injuries is the first step in eliminating or reducing them. The aim of this study was to determine the prevalence of occupational injuries among financial employees of hospitals affiliated to Tehran University of Medical Sciences.
Materials and Methods: This was a cross-sectional questionnaire survey conducted in 2019 in 13 hospitals of Tehran University of Medical Sciences using a valid questionnaire to gather data. A total of 162 questionnaires were randomly distributed among the financial staff of the hospitals, but only 147 subjects completed the questionnaires. Data were analyzed using the SPSS statistical software.
Result: Analysis of the data showed that 52.6% and 50.2% of the financial staff of the hospitals were suffering from physical and mental occupational injuries, respectively. Most of the occupational physical injuries were related to headache, neck pain, back pain and visual impairment, and most of the occupational psychiatric injuries were stress and anxiety. Female and single employees experienced significantly more occupational injuries. Working in a sitting position for a long time, lack of proper equipment operation, lack of safety and health facilities, insufficient training and carelessness of staff were the causes of musculoskeletal injuries.
Conclusion: About half of the hospital financial staff were found to suffer from occupational injuries. Occupational injuries had had direct and indirect costs for the employees and the hospitals. Hospital managers should plan and implement measures to eliminate or reduce occupational injuries at an individual, group, and organizational level.
 

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Background and Aim: Primary health care is a holistic approach that aims to maximize people's health and well-being as quickly as possible in their immediate living environment. The primary health care system is the first point of contact of the people with the health system. Therefore, increasing its resilience will play a significant role in controlling and managing pandemics. This research aimed to identify strategies to strengthen the resilience of the primary health care system in the Covid-19 pandemic.

Materials and Methods: This study was conducted using the scoping review method. Using appropriate keywords search was done on the subject of the study in PubMed, Web of Science, Scopus, SID, Iranmedex and Magiran databases and Google and Google Scholar search engines. Finally, after screening and reviewing the titles, abstracts and texts of the retrieved documents, 36 articles were selected and strategies to strengthen the resilience of the primary health care system in the Covid-19 pandemic were extracted from them.
Results: A total of 48 strategies/solutions were extracted to strengthen the resilience of the primary health care system, categorized into 6 groups, namely, governance and leadership, financing, human resources, medicines and equipment, health information systems, and health service delivery. Among the most frequently solutions mentioned were the following: Dynamic and accountable leadership, using valid research evidence in policy-making, contingency planning, increasing inter-sectoral cooperation, advocacy for health policies, community involvement, sustainable financing, recruiting additional staff and training and supporting them, providing sufficient stocks of medicines and diagnostic kits, developing and modernizing public health information systems, facilitating people's access to health centers, continuing to provide health services, and increasing the community’s health literacy.
Conclusion: The structural and process components of the primary health care system including "governance and leadership", "financing", "staff", "equipment, vaccines and medicines", "information" and "health care delivery" should be strengthened in a coordinated manner in the primary health care system to be prepared for future epidemics.
 

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Background and Aim: The health financing system is "the process of collecting, pooling and managing financial resources and purchasing healthcare services”. Iran's health financing system is facing challenges. The aim of this study was to evaluate the Iranian health financing system.        
Materials and Methods: This descriptive study retrospectively evaluated the health financing system of Iran between 2000 and 2019 using archival data. Data were collected from the World Bank website and analyzed using the Excel software.
Results: Iran's health expenditure per capita increased by 3.7% annually between 2000 and 2019 and reached $868 (purchasing power parity) in 2019. Iran's total health expenditure increased from $32 billion in 2000 to $72 billion (purchasing power parity) in 2019 (5.9% annual increase). Iran accounted for about 0.6% of the world total health expenditure in 2019. In that year about 6.7% of the country's gross domestic product was spent on health, the global average being 9.8%, while the general government health expenditure (% of the then current health expenditure) in Iran and the world were 49.5% and 59.8%, respectively. Out-of-pocket expenditure (% of the then current health expenditure) decreased in the last decade in Iran, reaching 39.5% in 2019, compared to 18% worldwide.
Conclusion: Iran’s health system costs are increasing at a faster rate than the growth of its Gross Domestic Product (GDP). The country’s health expenditure (% of GDP) and, as a result, the general government health expenditure (% of general government expenditures) has decreased and out-of-pocket expenditure (% of current health expenditures) has increased. Therefore, reforms should be implemented to strengthen the country's health financing system.
 

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Background and Aim: Surgical site infection (SSI) is an infection that occurs within 30 days after surgery and involves the skin and subcutaneous tissue of the surgical incision. It is one of the most common nosocomial infections which, in addition to endangering lives of the patients, increases the heath care expenditures in the health system. The objective of this study was to estimate the cost of surgical site infections in hospitals.
Materials and Methods: This was a case-control study conducted in a teaching hospital in Kashan, Iran in 2017 to find information about direct hospitalization costs of surgical site infections. Detailed information about the hospiutalization costs of case and control patients was extracted using patient records and the hospital information system software.
Results: Out of all the patients 115 (1.04%) experienced an SSI. The median additional direct medical cost was US$ 2577 and US$ 1034 for the case and control in-patients, respectively (p <0.001). The cost of treating SSI was US$ 1543 per patient. The direct hospitalization costs were 2.5 times greater for patients with an SSI than for those without an SSI.  Further analysis of the data showed that the cost of SSI was related to the patient's age, duration of surgery and length of hospital stay before infection.
Conclusion: Surgical site infection treatment costs imposes high costs  on the patients, health insurance companies and the hospitals. Therefore, hospitals managers should design and implement interventions to reduce surgical site infections.
 

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Background and Aim: Health system financing is the process of collecting, pooling, and allocating financial resources to maintain, restore or promote the health of the people. Developing countries face many challenges in mobilizing, managing and allocating health financial resources. The aim of this study was to identify sustainable financing methods in developing countries.
Materials and Methods: This study was conducted using the scoping review. All the studies related to health system financing methods in developing countries were searched in the English electronic databases (i.e., Pubmed, Scopus, Science Direct, and Web of science), Persian electronic databases (i.e., Magiran, Iranmedex, and SID) and Google Scholar and Google search engines using appropriate keywords. Finally, 94 suitable documents were selected and analyzed using the framework analysis method and MAXQDA software.

Results: Forty-two methods were identified to strengthen the sustainability and resilience of the health financing system in developing countries; these methods were grouped into three categories: collection and management of financial resources, pooling of financial resources and purchasing of health services. The most frequently used solutions to strengthen the sustainability of the health financing system in developing countries were as follows: expanding social health insurance plans, integrating multiple health insurance plans, strengthening public-private partnerships, establishing a robust referral system, imposing taxes on harmful commodities, using perspective fixed payment methods, defining needs-based health service packages, promoting donors’ contributions, and reforming health service tariffs.

Conclusion: The health financing system in developing countries should be strengthened. The financial reforms of the health system should be accompanied by reforms in providing health services to make possible efficient and effective results. Health policymakers and senior managers should strengthen the governance of the health financing system at the macro level. In addition, healthcare managers should increase the efficiency and reduce resource wastage by strengthening budget capacity and financial management at the micro level.