Relevance of the COVID-19 rapid response system to public health policymaking in Islamic Republic of Iran.

Background: The COVID-19 pandemic has increased awareness of the need for high-quality and timely evidence to support policy- and decision-making in emergency situations. Aims: To describe the experiences of the National Institute of Health Research (NIHR), Islamic Republic of Iran, in adopting evidence-informed policymaking during the COVID-19 pandemic. Methods: During the COVID-19 pandemic, NIHR institutionalized a rapid response system that was backed up by evidence-informed policy- and decision-making. Activities included establishment of a preparedness and response management committee, gathering and providing timely pandemic information to policymakers, establishing a timeline of actions and activities, and a feedback system for policy responses and queries. Results: The COVID-19 rapid response committee addressed the questions of 40 policymakers by synthesizing and analysing evidence and making it available to relevant stakeholders. It developed and disseminated knowledge products to provide relevant information. We identified the need for more timely data and more reliable research evidence for pandemic management. Conclusion: National institutions responding to health emergencies need to take responsibility for establishing and managing a robust rapid response systems that can provide valid and timely evidence to policymakers. Over time, their capacity should be monitored, evaluated and strengthened to adapt and respond appropriately to pandemics, outbreaks and epidemics.

Developing Iranian sub-national primary health care measurement framework: a mixed-method study.

BACKGROUND: Desired health outcomes are more achievable through strong Primary Health Care (PHC). Using comprehensive and scientific tools, decision-makers are guided to formulate better PHC reforms and policies. This study introduces a sub-national framework based on the World Health Organization (WHO) proposed frameworks for the PHC performance measurement. METHOD: By a mixed-method and qualitative approach, the Iranian sub-national PHC Measurement Framework (PHCMF) was developed through a review of the WHO's PHC measurement conceptual framework (for selecting Key Performance Indicators (KPIs)), literature review (academic database), PHC-related national documents, consultations with an advisory committee of national experts (6-meetings), and the Delphi technique for finalizing the framework. RESULTS: The Iranian sub-national PHCMF was finalized with 100 KPIs in three components including Health systems determinants, Service Delivery, and Health system objectives. Based on the result chain domain, most KPIs were related to the output (24 KPIs) and the least were related to the input and the process (9 KPIs). CONCLUSION: Regarding the comprehensiveness of the developed measurement framework due to its focus on all PHC operational levers and key aspects of PHC systems' performance, it can be used as a practical tool for assessing and improving the Iranian sub-national PHC system.

The impact of health reform on poverty estimates in Iran: Implications for monitoring the first goal of Sustainable Development Goals.

INTRODUCTION: Iran launched a series of health reforms called Health Transformation Plan (HTP) in order to improve financial protection and access to health care in 2014. This study aimed to investigate the extent of impoverishment due to out of pocket (OOP) payments during 2011-2016 and to assess the implications of health expenditures to overall national poverty rate before and after the HTP implementation, with a focus on monitoring the first Sustainable Development Goals (SDGs). METHODS: The study relied on data from a nationally representative household income and expenditure survey. Two measures of poverty were estimated in this study: the prevalence (poverty headcount) and the intensity of poverty before and after OOP health payments (poverty gap). Proportion of the population fell into poverty due to OOP spending for health care from total poor population calculated for 2 years before and after the HTP implementation using three poverty lines suggested by the World Bank for global poverty comparison ($1.90, $3.2 and $5.5 per day in 2011 purchasing power parity (PPP) $). RESULTS: Our results indicate that the incidence of impoverishing health expenditures has remained relatively low during 2011-2016. At the 2011 PPP $5.5 daily poverty line, the average incidence rate at the national level was 1.36% during the period. The percentage of population impoverished due to OOP health expenditures increased after HTP implementation, irrespective of the poverty line used. However, the proportion of individuals that pushed further into poverty decreased after HTP implementation. It was estimated that around 12.5% of total poor population fell below poverty line due to paying OOP payments in 2016. CONCLUSION: Although health care costs are not major causes of impoverishment in Iran, the relative impact of OOP spending for health is not negligible. To attain SDG 1, pro-poor interventions that aim to reduce the burden of OOP payments should be advocated and implemented with an inter-sectoral approach.

A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses.

BACKGROUND: Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment. METHODS: We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021. RESULTS: A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process. CONCLUSION: Our findings highlight the need for having holistic approaches to assess community's health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal-assessment of the community health needs assessment impacts.

The Dilemma of Underutilized Health Insurance: A Matched Case-Control Study Investigating Reasons in Iran's Free Universal Health Insurance.

Background: In May 2014, the Iranian government announced it would cover all uninsured Iranians. Despite free-of-charge insurance, the studies found that the coverage still needed to be completed (93%). This study aimed to understand why certain population groups remain without insurance despite the accessibility of free-of-charge coverage. This issue is not unique to Iran; it is prevalent in many other countries where, despite free coverage, not all individuals avail themselves of it, thereby exposing themselves to risks. Methods: In a matched case-control study, 89 non-insured patients were compared with 178 hospital-based controls with health insurance (2:1). The samples were recruited at one of the leading public hospitals in the country (Imam Khomeini Hospital Complex in Tehran) in 2019. Two insured controls were selected and matched for age (± five years) and sex for each person without insurance. A conditional logistic regression was performed to assess the magnitude of effects and the goodness of fit test used to examine the model. Results: Unemployment (Odds Ratio (OR)=8.33, 95% Confidence interval (CI): 1.05-50.0), being single (OR=3.69, CI: 1.18-11.55), low economic status (OR=1.85, CI: 1.02-3.33) and attitude towards performance of health insurance (OR=0.86, CI: 0.75-0.99) were affected not having health insurance. Conclusion: Approaches that cover the entire population may struggle to ensure no one is left without needed services. There is a need for greater focus on vulnerable groups to achieve universal health coverage conscientiously. Moreover, improved services and education can positively shape public perceptions of insurance efficacy, affecting their enrollment choices.

Developing Iranian sub-national Primary Health Care Measurement Framework: a study protocol.

BACKGROUND: Developing an effective system for measurement and improvement of primary health care (PHC) based on the conditions and characteristics of the countries' health systems is one of the World Health Organization (WHO) recommendations. AIMS: This study will aim to develop a framework to assess the Iranian sub-national PHC system performance using the WHO measurement framework for PHC. METHODS/DESIGNS: This is a mix-method study with a triangulation design. The Iranian sub-national PHC Measurement Framework (PHCMF) will be developed through a review of the WHO's PHC measurement conceptual framework (for selecting key performance indicators (KPIs)), literature review (academic database), PHC-related national documents, consultations with national experts, and the Delphi technique for finalizing the framework. The required data for calculating selected KPIs is expected to encompass qualitative and quantitative data. Discussion: Iranian PHC system performance is not measured based on the holistic and scientific framework and international standards. The information obtained from this project will guide managers and policymakers to be aware of the current situation and the success rate of the PHC system in achieving the desired goals, as well as identify strengths and weaknesses of the PHC system and provide the solution to better policy formulation.

Prevalence of Tobacco Use in Adults; 2016 Nationally Representative Household Survey in Iran.

Background: Tobacco use is an established preventable risk factor for many noncommunicable diseases and is considered as an important indicator for monitoring progress towards Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs). This study aimed to determine the situation of tobacco use among Iranian adults using 2016 household survey. Methods: This is a secondary analysis of the data from 2016 nationally representative STEPwise approach to Surveillance (STEPs) survey with a sample size of 31,050. The data on tobacco consumption was gathered using questions incorporated in the survey questionnaire. Results: The prevalence of current tobacco use in Iran was 25.2 % (24.4-25.9) in men versus 4% (3.7-4.3) in women. The prevalence was higher in rural areas and among second wealth group. The prevalence of current daily cigarette smoking was 20.1% (19.4-20.7) in men versus 0.9% (0.8-1.1) in women). Average number of cigarettes per day among current cigarette smokers was 14.5% (14.1-14.9), mean age at start smoking among daily cigarette smokers was 21.6% (21.1-22), and 95.2% (94.4-96) of daily current daily cigarette smokers attempted for cessation during past 12 months. Prevalences of exposure to secondhand cigarette smoke among nonsmokers at homes and workplaces were 23.21% (22.65-23.76) and 18.04% (17.2-18.87), respectively. Conclusions: There was a large difference between the prevalence of tobacco use between men and women (25.2% vs. 4%). Higher prevalences of tobacco use in rural areas and among lower wealth quintiles require more equity-based approaches in tobacco combatting actions.

COVID-19 cases, hospitalizations and deaths after vaccination: a cohort event monitoring study, Islamic Republic of Iran.

Objective: To investigate the incidence of coronavirus disease 2019 (COVID-19) cases, hospitalizations and deaths in Iranians vaccinated with either AZD1222 Vaxzevria, CovIran® vaccine, SARS-CoV-2 Vaccine (Vero Cell), Inactivated (lnCoV) or Sputnik V. Methods: We enrolled individuals 18 years or older receiving their first COVID-19 vaccine dose between April 2021 and January 2022 in seven Iranian cities. Participants completed weekly follow-up surveys for 17 weeks (25 weeks for AZD1222) to report their COVID-19 status and hospitalization. We used Cox regression models to assess risk factors for contracting COVID-19, hospitalization and death. Findings: Of 89 783 participants enrolled, incidence rates per 1 000 000 person-days were: 528.2 (95% confidence interval, CI: 514.0-542.7) for contracting COVID-19; 55.8 (95% CI: 51.4-60.5) for hospitalization; and 4.1 (95% CI: 3.0-5.5) for death. Compared with SARS-CoV-2 Vaccine (Vero Cell), hazard ratios (HR) for contracting COVID-19 were: 0.70 (95% CI: 0.61-0.80) with AZD1222; 0.73 (95% CI: 0.62-0.86) with Sputnik V; and 0.73 (95% CI: 0.63-0.86) with CovIran®. For hospitalization and death, all vaccines provided similar protection 14 days after the second dose. History of COVID-19 protected against contracting COVID-19 again (HR: 0.76; 95% CI: 0.69-0.84). Diabetes and respiratory, cardiac and renal disease were associated with higher risks of contracting COVID-19 after vaccination. Conclusion: The rates of contracting COVID-19 after vaccination were relatively high. SARS-CoV-2 Vaccine (Vero Cell) provided lower protection against COVID-19 than other vaccines. People with comorbidities had higher risks of contracting COVID-19 and hospitalization and should be prioritized for preventive interventions.

Prevalence, awareness, treatment and control of diabetes among Iranian population: results of four national cross-sectional STEPwise approach to surveillance surveys.

BACKGROUND: Diabetes as a leading cause of death imposes a heavy burden on health systems worldwide. This study investigated the trends in prevalence, awareness, treatment and control of diabetes among Iranian population aged 25 to 65 years over 12 years (2004-2016). METHODS: Secondary data analysis was performed using data from a national population-based survey, STEPwise approach to surveillance (STEPS) for non-communicable diseases (NCDs) in four rounds (2004, 2007, 2011, 2016). The sample sizes were 89,404, 29,991, 12,103 and 30,541 individuals, respectively across the country in both rural and urban areas. Data were analyzed using descriptive statistics and a logistic regression model with odds ratio at a significance level of less than 5% with no adjustment for age and sex. Logistic regression was used to identify socio-demographic factors associated with the levels of awareness, treatment and control of diabetes mellitus. RESULTS: The prevalence of diabetes in four rounds was 8.4, 9, 11.1 and 13.2%, respectively. Among people with diabetes, 53.5, 65.6, 70.5 and 82.2% were aware of their condition and 35.9, 42, 46 and 39.6% were treated for this condition, respectively. In four rounds of study, 14.5, 20.8, 20.4 and 18.5% of all diabetic patients had adequate glycemic control, respectively. In the multivariable logistic regression analysis, there was a significant relationship between female gender, age over 40, living in the urban area, being in the third wealth quintile and having health insurance with diabetes prevalence. Female participants were more likely to be aware of the disease. Older participants were more likely to receive treatment and had adequate glycemic control. CONCLUSION: The prevalence of diabetes in Iran has been increasing and despite the great awareness of the disease, receiving treatment and effective control of the disease are suboptimal. While several national policies to improve diabetes screening and care have been passed in recent years, it seems large gaps remain in disease detection and treatment. It is suggested that more attention be paid to the treatment and control of diabetes by NCDs national policies to prevent the growing burden associated with the disease.

The vaccination coverage rate in under-5 children in Nasiriyah, Iraq before and during the COVID-19 pandemic.

OBJECTIVES: This study compared the vaccination coverage rate (VCR) in children under 5 years old in Nasiriyah, Iraq before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This cross-sectional study was conducted in the city of Nasiriyah in southeastern Iraq, with data collected from 79 primary healthcare facilities. This study evaluated the VCR in 3 periods (2018, 2019, and 2020) using multi-level random sampling. Pertinent data were extracted from the vaccination records of 598 children for Bacillus Calmette-Guérin (BCG); pentavalent 1, 2, and 3; measles; and activated oral poliovirus vaccine 1 and 2. Missing data were completed by telephone calls to participants' parents. Logistic regression was applied to compare and estimate the odds ratios (ORs) with 95% confidence intervals (CIs) for the association between VCR and related factors. RESULTS: The data showed the greatest decline in the studied vaccines in 2020. Among the vaccines studied, BCG had the highest rate in all 3 periods (100% VCR) and measles had the lowest rate (83.7%), reaching 63.6% in 2020 (p<0.001). The highest OR among all types of vaccine were found for the pentavalent-3 vaccine among city dwellers and those born in 2020 (OR, 2.67; 95% CI, 1.39 to 5.10 and OR, 2.34; 95% CI, 1.28 to 4.28, respectively). CONCLUSIONS: The VCR for children decreased during the COVID-19 pandemic in Iraq, and new health policies are needed to increase the coverage rate. Improving the knowledge and attitudes of parents, as well as removing barriers or risk factors, can also be effective in improving the VCR.

Global school-based student health survey: country profiles and survey results in the eastern Mediterranean region countries.

BACKGROUND: The increasing prevalence of non-communicable diseases (NCDs) has some major implications on many countries to achieve universal health coverage. This study aimed to investigate the implementation of Global School-based Student Health Survey (GSHS), which is used to assess the risk factors of NCDs among children and adolescents in the eastern Mediterranean region (EMR). METHODS: This study was a meta-analysis and systematic literature review of 2001-2018 published studies, which were found by searching PubMed, Google Scholar, WHO, and CDC databases. In this study, the target group was students aged between 13 and 17 years old. GSHS implementation as well as risk factors of NCDs were compared across different countries. The random-effect model for meta-analysis was considered at 95% confidence interval. RESULT: In the EMR, 19 countries have implemented GSHS at least once following the survey manual (37 surveys). Overall, 201,795 students were included in our analysis. The overall estimation prevalence rateof the overweight was 24.5% (20.6-28.8), obesity was 7.3% (5.4-9.5), insufficient physical activity was 82.4% (80.7-84.1), tobacco usage was 14.3% (10.53-18.67), and smoking was 9.6% (8.1-11.3), respectively. Among those aged 13 to 17 years old, these rates were estimated as 19.8 (13.2-27.3), 9.7 (6.2-14.0), 86.1 (84.1-87.9), 17.8 (11.8-24.7), and 11.5 (9.4-13.8), respectively. CONCLUSION: GSHS has been widely implemented across EMR countries. Using nationally representative data, the results show that more efforts are needed to target the NCDs risk factors among adolescents in the region.

Funding for health policy and systems research in the Eastern Mediterranean region: amount, source and key determinants.

OBJECTIVES: To provide an overview of the current state of funding for health policy and systems research (HPSR) on a national level across the Eastern Mediterranean region (EMR), and to examine the key factors influencing funding for HPSR in the region. METHODS: A multistep approach was employed, involving a documentation review, secondary data analysis and key informant interviews with 30 stakeholders from five countries in the EMR. Findings are presented narratively (and where applicable as percentages). RESULTS: National funding for research and development (R&D) in general, and for health research in particular, has been low in comparative terms and lagging behind at the global scale, while funding for HPSR has been lacking on a national level. None of the 22 EMR countries studied had explicit national funding or a budget line for HPSR. Analysis of funding sources of 1821 published HPSR articles in the EMR (2010-2019) showed that the most notable source was external/international grants (45.6%), followed by university/academia (35.1%), and government (9.5%). Although HPSR publications have been increasing over time, this still falls short of the scale needed for strengthening health systems and informing current transformations in the region. Findings from the interviews identified several factors influencing investment in or funding for HPSR in the EMR. CONCLUSIONS: Many of the EMR's policy priorities are related to health systems, however our research finds that overall investment in health research and HPSR is still low, with limited recognition of the importance of HPSR in the EMR.

How health transformation plan was designed and implemented in the Islamic Republic of Iran?

Following his inauguration in late 2013, President Rouhani aimed to boost quality and equity in the health care delivery system. To fulfill this aim, a set of interventions, called Health Transformation Plan (HTP), were implemented. So far, it has been a heated debate whether HTP breathes a spirit of a new reform. HTP has targeted long-standing historical deficits of the Iranian health system as well as urgent problems, both of which have been, to some extent, resolved. To decrease Out-Of-Pocket (OOP) health expenditures, HTP has presented new financing mechanisms to expand a safety net to Iranian citizens fundamentally. HTP also encompassed interventions to overcome problems in the provision of health care by recruitment of health workforces, establishing new health facilities, and expanding primary health care to urban and peri-urban areas. Furthermore, performance indicators including access, quality, and patient satisfaction have been affected. Given these changes, HTP is entitled to be a health system reform. However, a new agenda within HTP is required so that the Iranian health system can obtain better value for money that is to be spending on it.

An analysis of financial protection before and after the Iranian Health Transformation Plan.

BACKGROUND: Protecting people against the financial consequences of health-care payments is a key objective of health systems. AIMS: We carried out a descriptive analysis of changes in health spending associated with the implementation of the latest health sector reform in the Islamic Republic of Iran, the Health Transformation Plan (HTP). METHODS: The study relied on 2 rounds of data from the Household Expenditure and Income Survey (2014 and 2015). Key indicators of financial protection in health expenditure were estimated. The Kakwani index was used for out-of-pocket (OOP) health expenditure to measure the degree of progressivity in the distribution of such payments. RESULTS: Total OOP per capita health expenditure showed a 2.5% relative decrease in real terms in 2015 compared to 2014. Estimation of the Kakwani index suggested OOP spending became slightly more progressive over the time period of HTP reform. The share of the population facing catastrophic health expenditure also decreased significantly from 2.9% to 2.1% at the national level. However, the incidence of impoverishment due to OOP payments increased slightly between preand post-HTP, from 0.2% to 0.5%. CONCLUSION: Our findings suggest that the new policies have a positive association in improving financial protection against health costs among Iranians, albeit slightly less so for the poor. Future efforts to increase public spending for financial protection would be challenging and should rely on efficiency gains such as a move from fee-for-service to performance- based payment systems and more organized OOP collection mechanisms involving prepayment and risk pooling.

Health Status in the Islamic Republic of Iran, Middle East and North Africa Countries: Implications for Global Health.

BACKGROUND: The aim of this study was to evaluate the health status of the Iranians following the sustainable development goals' (SDGs) introduction and the recent health reform implementation in Iran and to compare with those of the Middle East and North Africa region (MENA) and global average. METHODS: This comparative study used secondary data to investigate socio-demographic and health status indicators. The sources included census, population-based surveys and death registries. Global and regional health status indicators were obtained from international databases including WHO, the World Bank and the Institute for Health Metric and Evaluation (IHME). RESULTS: Life expectancy and human development index improved following the reform implementation. Among causes of death, 74.6% were attributed to non-communicable diseases (NCDs). There was an increasing trend in risk factors for NCDs in Iran, while at the same time neonatal, infant and under-5 mortality rates reduced. Compared to the MENA, Iran has a lower maternal mortality ratio, neonatal, infant, and under-5 mortality rates, and a higher life expectancy. NCDs and road traffic injuries accounted for a larger portion of disability-adjusted life years in Iran compared to the MENA and worldwide. CONCLUSION: Actions against communicable diseases and road traffic injuries are required together with continued efforts to address NCDs. Although based on the results, Iran has relatively high rankings, there is a need to develop a roadmap to accelerate achieving global health goals and SDGs targets.

Evaluating maternal and child health indicators for the Sustainable Development Goals in 2018: what is Iran's position?

OBJECTIVES: Since many Millennium Development Goals (MDGs) were not achieved, countries including Iran-despite achieving some of the MDGs-need regular planning to achieve the Sustainable Development Goals (SDGs) by 2030. This article examines maternal and child health indicators in the early years of the SDGs in Iran relative to several other countries. METHODS: This study was carried out through a secondary analysis of maternal and child health indicators in Iran. The results were compared with data from other countries divided into three groups: countries with upper-middle income levels, countries in the Eastern Mediterranean region, and the countries covered by the Outlook Document 1,404 (a regional classification). Then, the relationship between these indicators and the Human Development Index was investigated. RESULTS: Iran has attained better results than other countries with respect to maternal mortality, family planning, skilled birth attendance, under-5 deaths, incidence of hepatitis B, diphtheria-tetanus-pertussis vaccination coverage, and antenatal care. In contrast, Iran performed worse than other countries with respect to under-5 wasting, under-5 stunting, and care-seeking behavior for children. CONCLUSIONS: Overall, among the 11 indicators surveyed, Iran has attained better-than-average results and seems to be improving. We recommend that Iran continue interventions in the field of maternal and child health.

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.