Iranian Health System Response to the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic has created several challenges for countries all over the world. Different countries have taken different measures to fight this pandemic and reduce its challenges depending on their cultural, economic, and social structures. This study aims to understand and explain the Iranian health system's response to fighting the COVID-19 pandemic from the managers' and authorities' perspective. Method: This study is a basic applied research performed under a qualitative approach. In the survey, 30 experts including the managers of health centers and deputies and heads of the Ministry of Health and Medical Education and Medical Universities were selected by purposive snowball sampling and participated in semi-structured interviews from March to May 2020. The researchers explained the actions of the Iranian health system in fighting the COVID-19 pandemic in 2020 by content analysis. Results: As a result, 14 subthemes were found and classified into four major themes, including the informative and regulative actions (two subthemes), administrative and supportive actions (six subthemes), preventive and curative actions (three subthemes), and resource-related actions (three subthemes). Conclusions: Due to its strong health structures, such as urban and rural health networks, various general and specialized hospitals, experienced doctors, and committed health staff, Iran has taken practical actions in fighting the COVID-19 pandemic. However, the findings of this study and its relevant measures can help combat this pandemic in countries with similar social and cultural structures or counter future similar crises.

Presented and prioritizing waste management strategies using SWOT and QSPM approach in two private hospitals in Yazd in 2021.

BACKGROUND: This study aimed to present a strategic waste management in two private hospitals in Yazd using models of the strengths, weaknesses, opportunities, and threats (SWOT) and quantitative strategic planning matrix (QSPM). METHODS: The strengths, weaknesses, opportunities, and threats of the organization was identified according to existing documents and expert team. The internal and external factors were identified by internal factor evaluation (IFE) and external factor evaluation (EFE) matrices. The strategies to improve waste management in two hospitals were presented by comparing internal and external factors. Finally, the attractiveness table was compiled and weighted using the QSPM method to prioritize the strategies. RESULTS: The results demonstrated that 24 strengths, 30 weaknesses, 16 opportunities, and 22 threats were identified. The final score of internal and external factors for hospital A and B were (X: 2.37, Y:1.88) and (X: 2.37, Y: 2.01), respectively. Based on the results, 12 strategies were presented. Finally, the strategy of "the improvement of green management indicators" was implemented as a priority according to QSPM matrix. CONCLUSION: The result of this study duplicated that using the QSPM and SWOT models is assist to present viable strategies to improve the health-care waste management.

Investigating medical tourism development indicators in Yazd Reproductive Sciences Institute: A cross-sectional study.

Background: Payingspecial attention to the development indicators of medical tourism (MT) can lead to the further development of this industry and tourists' satisfaction. Objective: This study aimed to investigate MT development indicators in Yazd Reproductive Sciences Research Institute, Yazd, Iran in 2021. Materials and Methods: In this cross-sectional study, 430 medical tourists referred to the Yazd Reproductive Sciences Institute, Yazd, Iran in 2021 were studied. A researcher-made questionnaire with 46 questions and 10 dimensions was used in both internal and external environments to collect data. The Spearman correlation coefficient was also used to assess the correlation between the quantitative factors. Results: The reliability and validity of the scale were confirmed. The mean ± SD of the advertising and marketing index scored was lower than the other internal environmental indices (15.05 ± 2.16). Also, the economic factors and tourism infrastructure were lower than the other external environmental factors (9.8 ± 1.99, 8.53 ± 2.11, respectively). Conclusion: Given the importance of MT, top managers and relevant authorities should pay close attention to the criteria of advertising, marketing, and tourism infrastructure. MT demand can be improved by increasing the importance of advertising, implementing realistic advertising strategies, and developing adequate urban infrastructure and services.

Catastrophic Health Expenditure before and after of the Implementation of Health Sector Evolution Plan in Iran.

Introduction: One of the fundamental goals of health transportation plan (HTP) in Iran is to improve household's financial protection against catastrophic health expenditures (CHE). The aim of this study was to calculate the percentage of catastrophic health expenditures after implementing the plan and compare it with CHE before the plan for the same households. Methods: Data were collected through face-to-face interviews for 400 households. The CHE was calculated using the WHO approach, and relationships between CHE and the variables (having member ≥65 years old, having member ≤5 years old, having disabled member, economic status, health insurance status, dentistry services usage, and inpatient and outpatient services usage) were examined by the Fisher's exact test. Moreover, the impacts of the variables on CHE were assessed by logistic regression model. Stata version 15 was used for data analyses. Results: The exposure of the households to CHE increased from 8.3% in 2011 to 14.2% in 2020, and percentage of the impoverished households due to health expenditures in 2020 was more than that of the 2011 (4.3% vs 7.5%). The economic status, having members ≥65 years, and using dental and inpatient services were the key factors determining the CHE. The most important determinant affecting the exposure to CHE was dental services utilization in 2011 (92.64) and 2020 (122.68). Conclusion: The results showed a negative incremental change for the households facing CHE in this period. The dental and inpatient services need to be more widely covered by basic health insurance and households having members ≥65 years along with the poor households should be exempted from paying some of the healthcare expenditures for improving their financial protection against CHE.

Explaining the challenges of the Iranian Health System in fighting the COVID-19 pandemic: A Qualitative Study.

Introduction: The COVID-19 pandemic has become a global threat for the general public and health care workers, and it has created major challenges for all healthcare sectors. The challenges created by this disease can vary in different countries depending on cultural, social, and economic factors. The purpose of this study was to explain the challenges of the Iranian health system in fighting the COVID-19 pandemic from the managers' and executive authorities' viewpoints. Methods: The present study was a basic-applied research performed using a qualitative approach. It has studied 30 hospitals and medical centers' managers, deputies of the Ministry of Health, and the universities of medical sciences, which were selected by purposive and snowball sampling with the maximum variety in March-September 2020. Data collection was done through semi-structured interviews and content analysis was used to explain the challenges of the Iranian health system in fighting the COVID-19 pandemic (2020). Results: Most of the interviewees (34%) had a Ph.D. degree, and 40% of the participants were graduated in management and health economy and policymaking fields. Analysis and synthesis of the data collected from the interviews led to the creation of 19 sub-themes and 12 main themes classified into four general scopes: organizational factors, resources, management factors, and other factors. Conclusion: Identifying the mentioned challenges can provide helpful information for the managers and policy-makers to develop appropriate plans, take the necessary measures to resolve the challenges, and use the available resources to provide the most effective services.

The effect of macroeconomic indicators on health-care expenditure in Iran.

INTRODUCTION: A sharp increase in expenditure is one of the challenges of the health system in Iran. Every macroeconomic variable affects health, and if it is disregarded, it will lead to higher macrobudgets. Physical and mental health as well as the use of health services change according to the macroeconomic conditions and business cycles (boom and recession). The present study aimed to determine the effect of macroeconomic indicators on health expenditure. METHODS: This study was descriptive analytical. The required data related to macroeconomic indicators and health expenditure in public and private sectors were collected during 1995-2014. The data were analyzed using the time series models in econometrics, Vector Auto Regression, and Granger causality technique. RESULTS: The results of this study indicated that health expenditure has a positive bilateral relationship with gross domestic production (GDP), gross national production, national income, and national consumption. On the contrary, expenditure has a negative bilateral relationship with liquidity rate and inflation rate. In addition, budget deficit has a negative unilateral relationship with health expenditure while population rate has a positive unilateral relationship with health expenditure. CONCLUSION: The results of this study indicated the increase of health expenditure in Iran that GDP is the most critical determining factor of health expenditure. In general, the total expenditure in the health sector in the world increases when the countries become richer. In line with the increase of resources, innovative financing methods and efficiency improvement are required for providing basic health services in low-income countries.

Hospitals' efficiency in Iran: A systematic review and meta-analysis.

BACKGROUND: Given that the need to pay attention to measuring efficiency is considered as one of the main pillars of improving the level of efficiency in hospitals, so this study was carried out aimed to determine the mean technical efficiency (The technical efficiency is bound by zero and one and a score of less than one means that the theatre is inefficient as it could) score in terms of type and activity of the hospital, input-oriented and output-oriented attitude, returns to scale (In economics, returns to scale and economies of scale are related but different concepts that describe what happens as the scale of production increases in the long run, when all input levels including physical capital usage are variable (chosen by the firm). The concept of returns to scale arises in the context of a firm's production function. It explains the behavior of the rate of increase) in hospitals of Iran using data envelopment analysis (DEA) (DEA is a nonparametric method in operations' research and economics for the estimation of production frontiers. It is used to empirically measure productive efficiency of decision-making units) and stochastic frontier analysis (SFA) (SFA is a method of economic modeling. It has its starting point in the stochastic production frontier models simultaneously introduced by Aigner, Lovell and Schmidt[1977] and Meeusen and Van den Broeck[1977]. MATERIALS AND METHODS: The present study was carried out with a systematic review of all studies conducted on measuring efficiency of hospitals in Iran from March 21, 2001 to December 21, 2017 using DEA and SFA. Eleven databases were searched using appropriate keywords and 470 articles were found and evaluated using a checklist, and finally, 24 articles were entered into the meta-analysis process. Meta-analysis was performed using random effect model and fixed-effect model, and study heterogeneity was investigated using Q-Cochran test and I 2 index. Furthermore, the main reasons of study heterogeneity were identified due to meta-regression. RESULTS: The average technical efficiency score of hospitals using DEA and SFA method was obtained equal to 0.885 and 0.809, respectively. Furthermore, with regard to the DEA method, 0.885, 0.891.0.952 and 0.913 was obtained for input-oriented and output-oriented, general and specialized care hospitals and constant returns respectively. With regard to SFA method, 0.733, 0.664, 0.641, 0.802, was obtained, and the inputs and outputs affect measuring the efficiency. DISCUSSION: In contrast, the DEA method can investigate several input and output simultaneously and is used as an effective and flexible tool in order to measure the efficiency of the hospital. DEA can be easily used for calculating efficiency scores based on the proper selection of input and output indicators. The data envelopment analysis method and different input and output variables have been used in most studies conducted in Iran, and Stochastic Frontier Analysis has been less considered. In the present study, the DEA method in governmental educational hospitals showed a higher efficiency than SFA method in the hospitals under study. But in general, due to lack of optimal efficiency level in the hospital, it is suggested that policymakers determine the hospital efficiency indices in order to evaluate their efficiency from different dimensions. CONCLUSION: The average technical efficiency score of hospitals using DEA and SFA method was obtained equal to 0.885 and 0.809, respectively. Also, the mean technical efficiency score in terms of input-oriented and output-oriented, general and specialized care hospitals and constant returns to scale using the DEA method was obtained equal to 0.885, 0.891.0.952 and 0.913 and using the SFA method, respectively, it was equal to 0.733, 0.664, 0.641, 0.802, and the inputs and outputs affecting measuring the efficiency. There is no significant difference between the mean efficiency score between the two methods, but the data envelopment analysis method is used more. It is suggested that the hospitals efficiency indicators to be determined in order to more accurately evaluate the hospitals efficiency.

Data envelopment analysis for estimating efficiency of intensive care units: a case study in Iran.

Purpose As hospitals are the most costly service providers in every healthcare systems, special attention should be given to their performance in terms of resource allocation and consumption. The purpose of this paper is to evaluate technical, allocative and economic efficiency in intensive care units (ICUs) of hospitals affiliated by Yazd University of Medical Sciences (YUMS) in 2015. Design/methodology/approach This was a descriptive, analytical study conducted in ICUs of seven training hospitals affiliated by YUMS using data envelopment analysis (DEA) in 2015. The number of physicians, nurses, active beds and equipment were regarded as input variables and bed occupancy rate, the number of discharged patients, economic information such as bed price and physicians' fees were mentioned as output variables of the study. Available data from study variables were retrospectively gathered and analyzed through the Deap 2.1 software using the variable returns to scale methodology. Findings The study findings revealed the average scores of allocative, economic, technical, managerial and scale efficiency to be relatively 0.956, 0.866, 0.883, 0.89 and 0.913. Regarding to latter three types of efficiency, five hospitals had desirable performance. Practical implications Given that additional costs due to an extra number of manpower or unnecessary capital resources impose economic pressure on hospitals also the fact that reduction of surplus production plays a major role in reducing such expenditures in hospitals, it is suggested that departments with low efficiency reduce their input surpluses to achieve the optimal level of performance. Originality/value The authors applied a DEA approach to measure allocative, economic, technical, managerial and scale efficiency of under-study hospitals. This is a helpful linear programming method which acts as a powerful and understandable approach for comparative performance assessment in healthcare settings and a guidance for healthcare managers to improve their departments' performance.

Kinetics of biogas production and chemical oxygen demand removal from compost leachate in an anaerobic migrating blanket reactor.

In this study, laboratory anaerobic migrating blanket reactor (AMBR) with four units was used to reduce and remove COD leachate of composting process; it was also used to determine the kinetic coefficients of COD removal and biogas and methane gas production in several different OLRs. The maximum concentration of organic matter entering the reactor was 100,000 mg/L and the reactor was under operation for 319 days. The results showed that the COD removal efficiency of AMBR in all concentrations of substrate entering the reactor was above 80%. First-order model and Stover-Kincannon were used to investigate the kinetics of COD removal via AMBR biological process; in addition, the two models of Modified Stover-Kincannon and Van der Meer and Heertjes were used to check the kinetic constants of biogas and methane gas production. The results obtained from the models showed that the experimental data on COD removal were more consistent with the results obtained from Stover-Kincannon model (R2 = 0.999) rather than with the First-order model (R2 = 0.926). Kinetic constants calculated via Stover-Kincannon model were as follows: saturation value constant (KB) and maximum utilization rate constants (Umax), respectively, were 208,600 mg/L d and 172,400 mg/L d. We investigated the linear relationship between the experimental data and the values predicted by the models; as compared with the values predicted by the First-order model, the values predicted by Stover-Kincannon model were closer to the values measured via experiments. Based on the results of the evaluation of kinetic coefficients of Stover-Kincannon model, with the migration of the leachate flow from unit 1 to unit 4, Umax value has fallen significantly. The values of maximum specific biogas production rate (Gmax) and proportionality constant (GB) obtained from the Stover-Kincannon model, respectively, were 35,714 ml/L d and 42.85 (dimensionless) and value of kinetic constant of Van der Meer and Heertjes (ksg) was 0.0473 ml CH4/mg COD.

Failure mode and effect analysis: improving intensive care unit risk management processes.

Purpose Failure modes and effects analysis (FMEA) is a practical tool to evaluate risks, discover failures in a proactive manner and propose corrective actions to reduce or eliminate potential risks. The purpose of this paper is to apply FMEA technique to examine the hazards associated with the process of service delivery in intensive care unit (ICU) of a tertiary hospital in Yazd, Iran. Design/methodology/approach This was a before-after study conducted between March 2013 and December 2014. By forming a FMEA team, all potential hazards associated with ICU services - their frequency and severity - were identified. Then risk priority number was calculated for each activity as an indicator representing high priority areas that need special attention and resource allocation. Findings Eight failure modes with highest priority scores including endotracheal tube defect, wrong placement of endotracheal tube, EVD interface, aspiration failure during suctioning, chest tube failure, tissue injury and deep vein thrombosis were selected for improvement. Findings affirmed that improvement strategies were generally satisfying and significantly decreased total failures. Practical implications Application of FMEA in ICUs proved to be effective in proactively decreasing the risk of failures and corrected the control measures up to acceptable levels in all eight areas of function. Originality/value Using a prospective risk assessment approach, such as FMEA, could be beneficial in dealing with potential failures through proposing preventive actions in a proactive manner. The method could be used as a tool for healthcare continuous quality improvement so that the method identifies both systemic and human errors, and offers practical advice to deal effectively with them.

Comparing Performance Indicators of Obstetrics and Gynecology Ward at Yazd Educational Hospitals with Expected Limits of Indicators, 2015.

OBJECTIVES: The purpose of this study was to evaluate the performance indicators for obstetrics and gynecology wards in Iran. METHODS: This study was designed as a cross-sectional study and was carried out in obstetrics and gynecology wards of Afshar and Shahid Sadoughi hospitals in 2015. The information required for the performance indicators was gathered through questionnaires, statistical forms, and direct observation. In several tables, performance rating and performance status are presented using the Likert scale index based on the expected limits. RESULTS: According to the results of the categories of input indicators, the bed occupancy rate of Afshar Hospital's obstetrics and gynecology ward was, at 83%, higher than expected (79%), and that in Shahid Sadoughi Hospital (at 69%) was lower than expected. For medicinal methods and nonmedicinal methods of pain alleviation, the index process at Afshar Hospital was much lower than expected (40%). In Afshar Hospital, patient satisfaction at discharge was about 66.74%. CONCLUSION: Effective steps can be taken to improve the input and output criteria: allocating appropriate physical space, examining the reasons for low bed occupancy rate by using complex analytical models, and in order to study the reasons for large number of cesarean section childbirth, it was recommended to place more emphasis on training of pregnant mothers and to inform them about the side effects of cesarean section and advantages of natural childbirth.

Designing Iranian Model to Assess the Level of Health System Responsiveness.

BACKGROUND: Given the rapid pace of changes in community health needs and the mission of healthcare organizations to provide and promote the community's health, the growing need to increase health system responsiveness to people as a key element of observance and fulfillment of justice is felt more than ever. OBJECTIVES: This study was aimed at designing the native model of responsiveness for Iran and to validate the aspects of the proposed model. MATERIALS AND METHODS: Our study had a cross-sectional design and was a validation study performed in 2014. In order to define and identify responsiveness model aspects, the first phase recorded the views of 200 key informants from 19 provinces of Iran. Snowball sampling was used to select experts (based on WHO guideline). Then, the opinions of 18 comments were received from service recipients in the form of three focus group discussions and were analyzed by the frame framework analysis (interviewed recipients were selected using the purposive sampling method). Finally, in order to confirm the model's efficacy, a responsiveness questionnaire with 7 aspects (domains) and 52 indicators (items) obtained from the initial proposed model was answered by 600 members of the selected families in the two provinces of Fars and Yazd. A multi-stage cluster sampling approach was used for the household survey. The results were analyzed by the Confirmatory Factor Analysis (CFA) test and through the use of Lisrel software. RESULTS: Confirmatory Factor Analysis, based on the results of the key informant survey and group discussions, showed that according to quantities of GFI = 0.91, CFI = 0.93, NFI = 0.91, RMSEA = 0.074, SRMR = 0.061 and Hoelter (CN) = 178.54 in outpatient services and where GFI = 0.89, CFI = 0.91, NFI = 0.86, RMSEA = 0.064, SRMR = 0.053 and Hoelter (CN) = 158.93 for inpatient services, seven factors (F) (dignity, informed choice, confidentiality, patient training and informing, access to services, quality of basic amenities, and access to social support) are the main determinants of the responsiveness model and proposed model validity. CONCLUSIONS: Given the comprehensiveness of presented aspects and indicators in this proposed model and its validity test, the aforementioned responsiveness model can be considered a suitable model to use when assessing the levels of health system responsiveness in Iran.

Factors affecting family physicians' drug prescribing: a cross-sectional study in Khuzestan, Iran.

BACKGROUND: Rational prescription is a considerable issue which must be paid more attention to assess the behavior of prescribers. The aim of this study was to examine factors affecting family physicians' drug prescribing. METHODS: We carried out a retrospective cross-sectional study in Khuzestan province, Iran in 2011. Nine hundred eighty-six prescriptions of 421 family physicians (including 324 urban and 97 rural family physicians) were selected randomly. A multivariate Poisson regression was used to investigate potential determinants of the number of prescribed drug per patient. RESULTS: The mean of medication per patient was 2.6 ± 1.2 items. In the majority (91.9%) of visits a drugs was prescribed. The most frequent dosage forms were tablets, syrups and injection in 30.1%, 26.9%, and 18.7% of cases respectively. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and antibiotics were 29.7% and 17.1% of prescribed drugs respectively. The tablets were the most frequent dosage forms (38.6% of cases) in adult's patients and syrups were the most frequent dosage forms (49% of cases) in less than 18 years old. Paracetamols were popular form of NSAIDs in two patients groups. The most common prescribed medications were oral form. CONCLUSION: In Khuzestan, the mean of medication per patient was fewer than national average. Approximately, pattern of prescribed drug by family physicians (including dosage form and type of drugs) was similar to other provinces of Iran.

Technical efficiency of teaching hospitals in Iran: the use of Stochastic Frontier Analysis, 1999-2011.

BACKGROUND: Hospitals are highly resource-dependent settings, which spend a large proportion of healthcare financial resources. The analysis of hospital efficiency can provide insight into how scarce resources are used to create health values. This study examines the Technical Efficiency (TE) of 12 teaching hospitals affiliated with Tehran University of Medical Sciences (TUMS) between 1999 and 2011. METHODS: The Stochastic Frontier Analysis (SFA) method was applied to estimate the efficiency of TUMS hospitals. A best function, referred to as output and input parameters, was calculated for the hospitals. Number of medical doctors, nurses, and other personnel, active beds, and outpatient admissions were considered as the input variables and number of inpatient admissions as an output variable. RESULTS: The mean level of TE was 59% (ranging from 22 to 81%). During the study period the efficiency increased from 61 to 71%. Outpatient admission, other personnel and medical doctors significantly and positively affected the production (P< 0.05). Concerning the Constant Return to Scale (CRS), an optimal production scale was found, implying that the productions of the hospitals were approximately constant. CONCLUSION: Findings of this study show a remarkable waste of resources in the TUMS hospital during the decade considered. This warrants policy-makers and top management in TUMS to consider steps to improve the financial management of the university hospitals.