Factors Associated With Failure of Health System Reform: A Systematic Review and Meta-synthesis / 예방의학회지

Objectives@#The health system reform process is highly political and controversial, and in most cases, it fails to realize its intended goals. This study was conducted to synthesize factors underlying the failure of health system reforms. @*Methods@#In this systematic review and meta-synthesis, we searched 9 international and regional databases to identify qualitative and mixed-methods studies published up to December 2019. Using thematic synthesis, we analyzed the data. We utilized the Standards for Reporting Qualitative Research checklist for quality assessment. @*Results@#After application of the inclusion and exclusion criteria, 40 of 1837 articles were included in the content analysis. The identified factors were organized into 7 main themes and 32 sub-themes. The main themes included: (1) reforms initiators’ attitudes and knowledge; (2) weakness of political support; (3) lack of interest group support; (4) insufficient comprehensiveness of the reform; (5) problems related to the implementation of the reform; (6) harmful consequences of reform implementation; and (7) the political, economic, cultural, and social conditions of the society in which the reform takes place. @*Conclusions@#Health system reform is a deep and extensive process, and shortcomings and weaknesses in each step have overcome health reform attempts in many countries. Awareness of these failure factors and appropriate responses to these issues can help policymakers properly plan and implement future reform programs and achieve the ultimate goals of reform: to improve the quantity and quality of health services and the health of society.

Human resources for health strategies: the way to achieve universal health coverage in the Islamic Republic of Iran

Background: It is impossible to achieve universal health coverage [UHC] without an adequate, competent and motivated workforce.

Aims: The study aimed to describe how the Iranian health sector has formulated its human resources strategies to achieve UHC.

Methods: This was a qualitative study using a conceptual framework approach to content analysis. Primary data were gathered through expert focused group discussions and document analyses. Both transcribed discussions and the selected documents were analysed using in-depth thematic analysis. A conceptual framework from the Global Health Workforce Alliance was used for content analysis and to draft and develop the strategies. The framework suggested five human resources for health [HRH] pathways to achieve UHC aspects structured according to availability, accessibility, acceptability and quality.

Results: Thirty strategies were formulated for Iranian HRH. Eleven of the developed strategies were related to the field of education and training, such as development of new required academic disciplines; balancing university admissions based on workforce requirements; and enrolling local students from deprived and underserved areas. Ten of the developed strategies were structured under the workforce accessibility dimension.

Conclusions: Strategies for HRH were formulated by adopting a comprehensive, scientific and collaborative approach to ensure alignment with the country's health system priorities and Global Strategy on Human Resources for Health to overcome health workforce challenges.

Effect of dual practice on service delivery time by surgeons in the Islamic Republic of Iran: multi-level analysis of a national survey, 2016

Background: One of the work patterns which affects the supply of specialists is the phenomenon of dual practice [DP], i.e., working simultaneously in the public and private sectors. Uncontrolled DP in the surgery health workforce can have adverse effects on access to surgeons, efficiency, effectiveness and quality of surgery services.

Aims: The aim of this article is to examine the impact of DP on service delivery time by surgeons.

Methods: We used a prestructured form to collect data on surgery specialists in all 925 Iranian hospitals. National medical ID codes, council ID codes, first name, surname and father's name were used for data matching. Multilevel linear regression was used to assess the association between DP and study variables, which were recruitment type, faculty status, experience, sex and age.

Results: The 4642 surgery specialists in this study, representing 31.08% of the total number of surgeons identified, spent mean 1.09 [standard deviation 0.33] hours full-time equivalent [FTE] on health care service delivery. Specialists with DP had long service delivery time [beta = 0.427]. Female specialists [beta = –0.049] and full-time specialists [beta = –0.082] spent less time on health care service delivery. Permanent specialists had higher FTE [P < 0.001] and as the population increases, FTE increases [P < 0.05].

Conclusions: Although DP had a direct impact on surgeons' working hours, it seems that a greater share of the difference in working time was used in the private sector services, leading to poor access to surgery services in the public sector. Therefore, it is necessary to develop a systems approach to regulate DP.

Factors influencing medical specialists' dual practice in the Islamic Republic of Iran

Background: Dual practice [DP] is performing several different jobs at the same time and has effects on healthcare services delivery.

Aims: To identify the causes of medical specialists' tendency towards DP in the Islamic Republic of Iran.

Methods: We used a qualitative approach to identify the factors affecting DP in medical specialists in 2016. We used a purposive and outlier sampling method to conduct semistructured deep interviews with 14 key informants. The data analysis was performed simultaneously with data collection using thematic content analysis by MAXQDA [version 10.0]. Interviews continued up to data saturation. The quality of the study was ensured by addressing the criteria of Guba and Lincoln.

Results: The results of the interviews showed six themes and 16 subthemes for specialists' propensity to DP. Major themes included financial incentives, cultural attitudes about professional identity of physicians, experience and academic level of specialists, controlling approaches in the public sector, available infrastructure for responding to the population needs in the public sector, and regional characteristics of health service locations.

Conclusions: Medical specialists' DP is a multidimensional issue, influenced by different factors such as financial incentives, cultural attitudes and available infrastructure. Considering the capacities and conditions of each country, control and management of this phenomenon require regulatory and incentive mechanisms, which in the long term can modify private and public sector differences and increase the willingness of doctors to work in the public sector.