Developing a framework for the monitoring and evaluation of the Health Transformation Plan in the Islamic Republic of Iran: lessons learned

Background: Monitoring and evaluation of health system reforms are essential to ensure the achievement of their objectives. The latest heath sector reform in the Islamic Republic of Iran, namely, the Health Transformation Plan (HTP), was launched in 2014 and the country is embarking on the HTP to achieve universal health coverage (UHC).

Aims: The study aimed to develop the most appropriate monitoring and evaluation framework for the HTP in accordance with national and global goals and priorities, and to identify data gaps in its monitoring and evaluation.

Method: A case study and evidence-based approach was applied to develop the monitoring and evaluation framework. The model that was proposed jointly by the World Bank and the World Health Organization for monitoring and evaluation of UHC was used as the basis for the potential list of the indicators and key policy documents were reviewed, accordingly. The framework formulation process was carried out through a series of meetings with experts and senior managers working at the Ministry of Health and Medical Education, whose perspectives on the frameworks functionality and usage were regarded as valuable. The final draft was presented to policy-makers for input and approval.

Results: A data mapping revealed that at least nine national surveys were required to obtain the indicators for effective monitoring. At the time of framework designing, many indicators were not available or had not been updated for several years due to lack of available and appropriate data sources.

Conclusions: Results indicated that the country’s health information system had many information gaps that should be filled to enable the tracking of UHC goals and measuring the success of the plan. Applying the proposed framework would increase the comparability of the country’s health indicators at the global level and specify a path to successfully achieve the objectives of the reform

Barriers to Health Service Utilization Among Iranian Female Sex Workers: A Qualitative Study / 예방의학회지

OBJECTIVES: In most countries around the world, sex work is an illegal activity. Female sex workers (FSWs) in Iran hide their identities, and they are known to be a hard-to-reach population. Despite free access to HIV testing, fewer than half of FSWs receive HIV testing. The purpose of this study was to characterize the reasons for which FSWs do not seek testing at drop-in centers (DICs) and voluntary counseling and testing (VCT) centers in Iran. METHODS: A qualitative study was conducted in 2016. The participants were 24 FSWs who received services at VCT centers and DICs for vulnerable females in the north of Iran and 9 males who were the clients of FSWs. In this study, we made use of purposive sampling and carried out a thematic analysis. RESULTS: We found 4 major and 6 minor themes. The major themes were: fear of being infected (with HIV), stigma, indifference, and knowledge. CONCLUSIONS: Despite the significant efforts made by the government of Iran to establish and expand DICs for vulnerable females, the number of FSWs receiving services at these centers has not been very considerable. Consequently, by introducing and implementing training programs for peer groups, it may be possible to take steps toward establishing strategic programs for the control and prevention of HIV/AIDS.

Physicians' retention rate and its effective factors in the Islamic Republic of Iran

Background: Migration of physicians from less developed countries to affluent ones has become as one of the major concerns of human resource policy-makers. This leads to problems such as inequity in the distribution of physicians, lack of physicians in less developed areas, as well as an excess of the health workforce in developed environs. Thus, policy-makers aim to increase retention of physicians in their places of origin.

Aims: This study aimed to find those effective factors for the retention of physicians in the Islamic Republic of Iran.

Methods: 30 569 records of public sector physicians in 2016 were gathered from the Ministry of Health and Medical Education database, and the retention rate of each province was calculated. Geographic information system [GIS] was used to show retention in each province, and linear and logistic regression analysis were used to determine the effective factors for physicians' retention in the country.

Results: There was a significant relationship between per capita gross domestic product of each province and its retention rate of physicians [OR = 1.56], retention rate of family physicians [OR = 7.38], and retention rate of specialists [OR = 1.59]. In addition, relationships were significant for the human development index [all physicians [OR = 1.22], family physicians [OR = 2.36], and specialists [OR = 1.23]]. Married physicians, higher paid physicians, and those who worked in headquarters and clinics showed greater willingness to stay in their area of origin.

Conclusions: Physicians' retention rate is dependent on both macro and microlevel factors.

Healthy and Unhealthy Dietary Patterns Are Related to Depression: A Case-Control Study

OBJECTIVE: Major depressive disorder is the leading cause of disability around the world. The relationship between depression and dietary patterns has been reported in a few studies but with controversial results. This study aimed to investigate this relationship in an Iranian population. METHODS: In our study, 330 depressed patients (cases) and healthy people (controls) (1:2) were individually matched according to age, sex and area of residence. New cases of depression were recruited from two psychiatric clinics in Tehran. Interviewers went to each patient's residential area, and invited qualified individuals to participate in the study as controls. Food intake over the past year was collected using a validated semi quantitative food frequency questionnaire. Dietary patterns were determined by the principal components method. Binary logistic regression was used to test the effect of dietary patterns on depression. RESULTS: We identified two major dietary patterns by using factor analysis: the healthy and unhealthy dietary patterns. We categorized the scores of these patterns to quartiles. After adjusting for non-depression drug use, job, marital status, children number, and body mass index, the relations of depression and quartiles of two dietary patterns are significant (p=0.04 & p=0.01, respectively). Compared with participants in the lowest quartile, those in the highest quartile had significantly lower odds ratio (OR) for depression in healthy dietary pattern, and higher OR for depression in unhealthy dietary pattern. CONCLUSION: This study indicates that healthy and unhealthy dietary patterns may be associated with the risk of depression. The results can be used for developing interventions that aim to promote healthy eating for the prevention of depression.

Estimating economic burden of cancer deaths attributable to smoking in Iran in 2012

Background: There is a broad consensus among health policy-makers that smoking has a significant impact on both heath system and society. The purpose of this study was to estimate the economic burden of major cancer deaths caused by smoking in Iran in 2012

Methods: Number of major cancer deaths due to smoking by sex and age groups in 2012 was obtained from GLOBCAN database. The life expectancy and retirement age were used to estimate years of potential life lost [YPLL] and cost of productive lost attributable to smoking, respectively. Data on prevalence of smoking, relative risk of smoking, life expectancy table, annual wage and employment rate were extracted from the various resources such as previous studies, WHO database and Iranian statistic centers. The data analysis was conducted by Excel software

Results: Smoking was responsible for 4,623 cancer deaths, 80808 YPLL and $US 83,019,583 cost of productivity lost. Lung cancer accounts for largest proportion of total cancer deaths, YPLL and cost of productivity lost attributable to smoking. Males account for 86.6% of cancer deaths, 82.6% of YPLL and 85.3% of cost of productivity lost caused by smoking

Conclusions: Smoking places a high economic burden on health system and society as a whole. In addition, if no one had been smokers in Iran, approximately two out of ten cancer deaths could be prevented

Inequality of leprosy disability in Iran, clinical or socio-economic inequality: an extended concentration index decomposition approach

Despite significant reduction in global disease prevalence, leprosy still has a high rate of disability while its determinants are unfair and many of them are amendable. The objective of this study was to measure inequality of disability in leprosy in Iran. This was a cross-sectional study [2006-2007] on all living people affected by leprosy registered in W. Azerbaijan province health center, Western North of Iran. The outcome of the study was the socio-economic inequality considering presence or absence of grade 2 disability [G2D] based on the WHO classifications. An extended concentration index decomposition approach was used for analysis. Among 452 cases, 65.3% were male and 67% were affected by the multi bacillary type. Overall G2D was 65.3%. The estimated Concentration Index was -0.0782, showing presence of pro-poor socio-economic inequality of G2D, while extended CI estimation [v = 5] was -0.163. Achievement index with coefficiently = 5] revealed that G2D mean was 16% more than classic mean in the poorest group. The result of decomposition of the existing inequality revealed that, some of the determinants such as receiving mono-therapy, education, urbanization, and bacillus calmette ; guerin [BCG] vaccination had shared contribution [67.4%, 61.8%, 59.2%, and 57.5% respectively]. This study provided new perspective for the health j system to leprosy control considering the significant gap between; rich and poor [inequality] regarding G2D disability, and its effective elements in socio-economic strata. Some effective actions can be considered to reduce the scale of existing inequality

Constructing pragmatic socioeconomic status assessment tools to address health equality challenges

A key challenge for equality evaluation and monitoring, mainly in developing countries, is assessing socioeconomic status [SES] of individuals. This difficulty along with low technical competency, have resulted in many health information collected in these countries which are devoid of suitable SES indices. However, simplifying data collection requirements for estimating economic parameters seems to guarantee their wide adoption by survey and health information system [HIS] designers, resulting in immediate production of equity-oriented policy-relevant information. The goal of this study is obtaining adequate number of variables, which their combination can provide a valid assessment of SES in Iranian population. The data source was Living Standards Measurement Study of Iran [2006]. Data of 27,000 households on the ownership of 33 household assets was used for this analysis. Households of this study were divided into 5 groups in terms of SES status using principle component analysis. Then selection was made among the 33 variables so that a combination with minimum necessary number for obtaining SES status is reached. Agreement of the new combination [including minimum number of variables] with full variable combination [including all 33 variables] was assessed using weighted kappa. A minimum set of six variables including having kitchen, bathroom, vacuum cleaner, washing machine, freezer and personal computer could successfully discriminate SES of the population. Comparing this 6 item-index with the whole 33 item-index revealed that 65% of households were in the same quintiles, with a weighted kappa statistics of 0.76. For households in different quintiles, movement was generally limited to one quintile, with just 2% of households moving two or more quintiles. The proposed simple index is completely applicable in current Iran's society. It can be used in different survey and studies. The development is quite simple and can be done on a yearly basis using the updated National level data. Having such standardized simplified and up to date SES indices and incorporating them into all health data sources can potentially ease the measurement and monitoring of equity of health services and indices

Research's practice and barriers of knowledge translation in Iran

Knowledge Translation is a process that includes synthesis, dissemination, exchange and application of knowledge to improve the health, services and products In this study we have attempted to examine the knowledge translation practice and its perceived barriers on the universalities and research institutes [research sector] in Iran. Both qualitative and quantitative approaches were used. In the quantitative section, a questionnaire had prepared for this study was completed by 88 authors country wide from randomly selected papers. In the qualitative section 13 in-depth interviews and 6 focus group discussions were held with managers and policy makers, clinical and health service providers, and researchers. Twenty four percent of the authors had no interaction whatsoever with the target audience. Lack of expectation toward creating change in the target audience, researchers' incentives, low level of trust among researchers and decision makers, absence of a predefined mechanism for delivery of research results and inappropriate research priorities were among the most important barriers identified in the qualitative section. Translation of research findings into some concrete outputs which can affect health of people is not in mandate of researchers and subsequently they are not prepared for this as well. Based on the barriers identified, it seems that the following interventions are necessary: cooperation among policy makers at macro and meso [organizational] level and the research sector; establishing networks for researchers and decision makers in choosing the research topic, priority setting, and building trust among researchers and policy makers

Application of capture-recapture for fine-tuning uncertainties about national maternal mortality estimates

Maternal mortality ratio [MMR] is one of the main indicators of the millennium development goals and its accurate estimation is very important for the countries concerned. The objective of this study is to evaluate the applicability of capture-recapture [CRC] as an analytical method to estimate MMR in countries. We used the CRC method to estimate MMR in Iran for 2004 and 2005, using two data sources: The maternal mortality surveillance system and the National Death Registry [NDR]. Because the data registry contains errors, we defined three levels of matching criteria to enable matching of cases between the two systems. Increasing the matching level makes the matching criteria less conservative. Because NDR data were missing or incomplete for some provinces, we calculated estimates for two conditions: With and without missing/incomplete data. According to the CRC method, MMR in 2004 and 2005 were 33 and 25 in the best-case scenarios respectively and 86 and 59 in the worst-case scenarios respectively. These estimates are closer to the ones reported by United Nations Agencies published in 2010, 38 and Hogan's study, 30 in 100,000 live births in 2005. The MMR estimation by CRC method is slightly different from the international studies. CRC can be considered as a cost-effective method, in comparison with cross-sectional studies or improvement of vital registration systems, which are both costly and difficult. However, to achieve accurate estimates of MMR with CRC method and decrease the uncertainty we need to have valid databases and the absence of such capacities will limit the applicability of this method in developing countries with poor quality health databases

Ethical considerations of community-based participatory research: contextual underpinnings for developing countries

The nature of community-based participatory research [CBPR] poses distinctive ethical challenges. In the absence of organized guidelines, a remarkable amount of researchers' time and energy will be spent tackling these ethical challenges. The study aimed to explore ethical issues and principles potentially arising when conducting CBPR. This qualitative study conducted in CBPR Center of Tehran University of Medical Sciences. Required data were gathered through systematic literature review and semi-structured interviews. Representatives of community, academia, and nongovernmental organizations [NGOs] participated in our study. Ten interviews with representatives of partner organizations, four group interviews with academic staff, and four with representatives of community were conducted. Repeated thematic analysis was used to elicit ethics-related overarching themes from transcribed interviews. As recommendations, these themes were then organized into a set of CBPR-related ethical issues and principles. Four CBPR ethical guidelines [including 173 articles] were selected from a systematic review. Overarching themes relating to ethical principles which emerged from interviews were as follows: Trust, transparency and accountability, equity and inclusion, power imbalance, tolerance and conflict management, and attention to cultural sensitivity. Practical principles that emerged included: Consensus rather than informed consent, ownership of data and research achievements, and sustainability and maintenance of relationships. According to findings and in comparison to international guidelines, the present study put more emphasis on cultural sensitivity and sustainability as CBPR ethical tangles. Community-based participatory research ethical challenges are of the same kind in most parts of the world. However, some discrepancies exist that calls for local scrutiny. Future use and critic of current explored ethical issues and principles are highly encouraged

Socioeconomic inequalities in nonuse of seatbelts in cars and helmets on motorcycles among people living in Kurdistan province, Iran

The aim of this study was to determine the socioeconomic inequalities in nonuse of seatbelts in cars and helmets on motorcycles in Kurdistan Province, west of Iran, 2009. The data used in this study was collected from the data gathered in non-communicable disease surveillance system [NCDSS] in 2009 in Kurdistan. A total of 1000 people were included in this study. The outcome variable of this study was the nonuse of seatbelts and helmets. The socio-economic status [SES] was calculated based on participants' residential area and assets using Principal Component Analysis [PCA] method. The concentration index, concentration curve, and comparison of Odds Ratio [OR] in different SES groups were used to measure the socioeconomic inequalities using logistic regression. In order to determine the contribution of determinants of inequality, decomposition analysis was used. The prevalence of nonuse of seatbelts in cars and helmets on motorcycles were 47.5%, 95%CI [44%, 55%], respectively. The Concentration index was -0.097, CI [-0.148, -0.046]. The OR of nonuse of seatbelts in cars and helmets on motorcycles in the richest group compared with the poorest group was 0.39, 95%CI [0.23, 0.68]. The results of the decomposition analysis showed that 34% of inequalities were due to SES, 47% were due to residential area, and 12% were due to unknown factors. There is a reverse association between SES and nonuse of seatbelts in cars and helmets on motorcycles. This issue must be considered while planning to reduce traffic accidents injuries

Social network size estimation and determinants in Tehran province residents

Network scale-up is an indirect method for estimating the size of hidden, hard-to-count or high risk populations. Social network size estimation is the first step in this method. The present study was conducted with the purpose of estimating the social network size of the Tehran Province residents and its determinants. Maximum Likelihood Estimation was applied to estimate people's network sizes by using populations of known sizes and the scale-up method. Respondents were selected from Tehran province through convenience sampling in 2012. Out of thirteen selected subpopulations with known size, ten had minimum accuracy which used in our analysis. Of the 1029 respondents in this study, 46.7% were male. The social network size of Tehran Province residents was estimated to be 259.1 [CI[95%]: 242.2, 276] based on the ten known populations remained in this study. This size was 291.8 in men and 230.4 in women. Younger people [18-25 years old] had larger network sizes compared to the other age groups [P<0.001]. Our estimation for social network size of Tehran inhabitants was smaller than that previously estimated size for the whole country [c=380]. In addition, we found that the social network of subpopulations was different. This difference means that we need local estimations for sub-populations to improve the accuracy of population size estimation using network scale up method

Quality of life of medical students in Tehran University of medical sciences

This study aims to investigate the quality of life [QOL] of Tehran University of Medical Sciences' [TUMS] medical students at different educational levels and specify the most important factors related to this quality. A sample of 242 medical students was selected randomly, given their number in three educational levels [basic sciences, physiopathology-stager and intern]. The QOL was measured by WHOQOL-BREF. The students obtained average high score in two psychological and environmental health domains, and low score in physical health and social relationship domains. As the educational level of students increased their quality of life decreased at all four domains. At social relationship domain, the female students had overall better situation as compared to males [p=0.009]. The female and male students had opposite condition at the level of basic sciences and internship, in a way that the female students earned higher marks at basic sciences level and the males at internship level [P= 0.008]. The condition of female students in terms of environmental, physical and psychological health became static while their education rose. However, only environmental health of the male students reduced as their education level increased [P= 0.05]. The students were of undesirable conditions in two domains of social relationship and physical health. Internship is a specific level in both groups which has a negative impact on the dimensions of quality of life and naturally needs more care for the students. Married status improved the students' QOL and could moderate the undesired effects of internship

Socioeconomic inequality of non-communicable risk factors among people living in Kurdistan province, Islamic republic of Iran

The most fundamental way to decrease the burden of noncommunicable diseases [NCDs] is to identify and control their related risk factors. The goal of this study is to determine socioeconomic inequalities in risk factors for NCDs using concentration index based on Non-Communicable Disease Surveillance Survey [NCDSS] data in Kurdistan province, Islamic Republic of Iran in 2005 and 2009. The required data for this study are taken from two NCDSSs in Kurdistan province in 2005 and 2009. A total of 2,494 persons in 2005 and 997 persons in 2009 were assessed. Concentration index was used to determine socioeconomic inequality. To assess the relationship between the prevalence of each risk factor and socioeconomic status [SES], logistic regression was used and odds ratio [OR] was calculated for each group, compared with the poorest group. The concentration index for hypertension was -0.095 [-0.158, -0.032] in 2005 and -0.080 [-0.156, -0.003] in 2009. The concentration index for insufficient consumption of fruits and vegetables was -0.117 [-0.153, -0.082] in 2005 and -0.100 [-0.153, -0.082] in 2009. The concentration index for the consumption of unhealthy fat and oil was -0.034 [-0.049, -0.019] in 2005 and -0.108 [-0.165, -0.051] in 2009. The concentration index for insufficient consumption of fish was -0.070 [-0.096, -0.044] in 2005. The concentration index for physical inactivity was 0.008 [-0.057, 0.075] in 2005 and 0.139 [0.063, 0.215] in 2009. In all the cases, the OR of the richest group to the poorest group was significant. Hypertension, insufficient consumption of fruits and vegetables, consumption of unhealthy fat and oil, and insufficient consumption of fish are more prevalent among poor groups. There was no significant socioeconomic inequality in the distribution of smoking, excess weight, and hypercholesterolemia. Physical inactivity was more prevalent among the rich groups of society in 2009. The reduction of socioeconomic inequalities must become a main goal in health-care policies

Disease surveillance and private sector in the metropolitans: a troublesome collaboration

An effective response to health problems is completely dependent upon the capacities of the health system in providing timely and valid information to take action. This study was designed to identify various reasons from various perspectives for underreporting disease by physicians in the private sector in big cities in developing countries setting. In this qualitative study, we used focus group discussions [16 manager], and in-depth semi-structured interviews [7 private physician, 2 experienced policy maker and a researcher]. We used the thematic approach for data analysis. Results were amplified by a comprehensive literature review. Themes were classified in 6 categories: Infrastructure and legal issues, the priority of disease reporting, workflow processes, motivation and attitude, human resources and knowledge and awareness. As the main reasons of under reporting, most physicians pointed out complicacy in reporting process and inadequate attention by the public sector. Managers emphasized instituting legal incentives and penalties. Experts focused on physicians' knowledge and expressed a need for continuing medical education programs. Independent interventions will have little chance of success and sustainability. Different intervention programs should consider legal issues, attitude and knowledge of physicians in the private sector, and building a simple reporting process for physicians. Intervention programs in which the reporting process offers incentives for all stakeholders can help improving and sustaining the disease reporting system

Barrier and facilitators of HIV related risky sexual behavior

This study was conducted to identify the determinants of protective behavior in relation to HIV transmission. Since the risk of transmission is higher among those who have extramarital intercourse, the study sample constituted of such people. We started this study in 2010 and finished it in 2011. Participants were divided into low-risk and high-risk groups. High-risk people included sex workers and those who presented at drop- in centers. interviewers were 18 men and women in low-risk group and 12 men and women in the high-risk group. Data were collected through in-depth interviews and were analyzed using the thematic framework method. In both groups, protective behavior was influenced by willingness to protect, intention or decision to protect, and personal, social, and environmental barriers and facilitators. In terms of willingness, behavior was influenced to preserve sexual pleasure by avoiding condoms. In terms of barriers and facilitators, trust in partner, misperceptions, condom inaccessibility, unplanned sex, fear of contracting the disease, partner's wish, ethical commitments were mentioned by both groups, stigma of condom possession by the low-risk group, and partner's force was mentioned by the high-risk group. Educational programs need to focus on changing the concept that "condoms reduce sexual pleasure". In addition, interventional programs to strengthen factors such as self-efficacy, ethical commitments, faithfulness, and correct beliefs such as undue trust in partner, misconception of being safe, unplanned sex, and the stigma of possessing condoms can be very effective in changing high-risk sexual behavior

Malaria elimination in Iran, importance and challenges

The aim of study is to assess the importance and challenges of Malaria elimination [ME] in Iran's health system. Opinion of experts from Ministry of Health and Medical Education and the chancellors of medical universities affected by malaria were gathered using Focus Group Discussions and in-depth interviews. We asked them about the importance and main challenges of ME in Iran. Main factors on importance of ME were: it's a struggle to reach to equity in the poorest regions of county, prevention of emerging disease in susceptible regions, lowering the cost of control and its effects on the region's socioeconomic condition. Main challenges were Iran's long border with malaria-endemic countries Pakistan and Afghanistan and illegal immigrants, underdevelopment in rural areas, system's insensitivity and diagnosis problem due to reduction of cases. Quantitative and holistic researches are needed for assessing the consequences of ME

Barriers of clinical practice guidelines development and implementation in developing countries: a case study in Iran

Knowledge products such as clinical practice guidelines [CPG] are vitally required for evidence-based medicine [EBM]. Although the EBM, to some extent, has been attended during recent years, no result has achieved thus far. The current qualitative study is to identify the barriers to establishing development system and implementation of CPGs in Iran. Twelve semi-structured, in-depth interviews were conducted with a purposive sample of health policy and decision makers, the experts of development and or adaptation of CPGs, and the experts of EBM education and development. In addition, 11 policy-makers, decision-makers, and managers of the health system participated in a focus group discussion. The analysis of the study data was undertaken by thematic framework approach. Six themes emerged in order of their frequency include practice environment, evidence-based health care system, individual professional, politician and political context, innovation [CPG] and patients. Most of the indications in the treatment environment focused on such sub-themes as regulations and rules, economical factors, organizational context, and social context. While the barriers related to the conditions of treatment environment, service provider and the features of innovation and patients had been identified before in other studies, very little attention has been paid to the evidence-based health care system and politician and political context. The lack of an evidence-based healthcare system and a political macro support are mentioned as the key barriers in Iran as a developing country. The establishment of a system of development and implementation of CPGs as the evidence-based practice tools will not be possible, unless the barriers are removed

Only one third of Tehran's physicians are familiar with 'evidence-based clinical guidelines'

Clinical guidelines have increasingly been used as tools for applying new knowledge and research findings. Although, efforts have been made to produce clinical guidelines in Iran, it is not clear whether they have been used by physicians and what factors are associated with them? Four hundred and forty three practicing physicians in Tehran were selected from private clinics through weighted random sampling. The data collection tool was a questionnaire on familiarity and attitude toward clinical guidelines. The descriptive and analytical findings were analyzed with t-tests, Chi2, logistic and linear multivariate regression by SPSS, version 16. 31.8% of physicians were familiar with clinical guidelines. Based on the logistic regression model physicians' familiarity with clinical guidelines was positively and significantly associated with 'working experience in a health service delivery point' OR = 2.13 [95% CI, 1.17-3.90], 'familiarity with therapeutic protocols' OR = 2.09 [95% CI, 1.22-3.57] and 'holding a specialty degree' OR = 2.51 [95% CI, 1.24-5.07]. The mean overall attitude scores in the 'usefulness', 'reliability', and 'problems and barriers' domains were, respectively, 78.9 [SD = 16.5], 78.9 [SD = 19.7] and 50.4 [SD = 15.9] out of a total of 100 scores in each domain. No significant association was observed between attitude domains and other independent variables using multivariate linear regression. Little familiarity with clinical guidelines may represent weakness in of production and distribution of domestic evidence. Although, physicians considered guidelines as useful and reliable tools, but problems such as difficult access to guidelines and lack of facilities to apply them were stated as well

What must be the pillars of Iran's health system in 2025? values and principles of health system reform plan

Preparing long term reformatory plan for the health system, like other macro plans, requires guiding principles which is according to the values, and as a bridge, connect the ideals and values to the goals. This study was designed with the purpose of explaining the values and principles of health system, and as a pre-requisite to compilation of Iran's health system reform plan at 2025. The document of values and principles of health system reform plan for 2025 was developed by reviewing the literature and receiving the opinions of senior experts of health system, and was criticized in focus group discussion sessions of experts and decision makers. The values of Iran are: dignity of human, the right to maximum attainable level of health, comprehensive health, equity and social cohesion. the principles of this health system include: institutionalizing the ethical values, responsiveness and accountability, equitable access [utilization], prevention and health promotion, community participation, inter-sectoral collaboration, integrated stewardship, benefit from innovation and desired technology, human resources promotion and excellence and harmony. Based on the perception of cultural and religious teachings in Iran, protecting of human dignity and human prosperity are the ultimate social goal. In this sense, health and healthy humans, in its holistic concept [physical, mental, social health and spiritual] are the center and development in any form should lead to the human prosperity in a way that each of the individuals could enjoy the maximum attainable level of health in its holistic meaning and in a faire manner