Designing a health equity audit model for Iran in 2010.

BACKGROUND: Health equity audit, as an alternative solution, is a process by which local partners systematically review inequalities in the patients` health, their access to appropriate services and health system outputs. Then, necessary activities needed in order to have more equitable services are agreed on and these concurrences become the executive scheme and action initiates. Therefore, it is pivotal for health care organizations to pay special attention to this important topic. The objective of the current study was to review the health equity audit model in different countries to gather viewpoints of various involved groups in health sector, particularly health experts, and to offer a practical and appropriate model for health equity audit in Iran.
METHODS: This study adopted applied research approach in two phases. In the first step, this study conducted theoretical health equity audit models in the texts; the experiences of other countries were studied and the most appropriate model for Iranian health system was selected. In the second step, this study employed the Delphi technique. According to the Delphi technique the questionnaire applied in order to gather data and then, the final model was extracted.
RESULTS: Agreeable topics, performing agencies, 6 equity audit stages, and equity indicators under 3 main parts with 16 sub-sections were elaborated and viewpoints of Iranian experts in the above fields were gathered and presented as the proposed health equity audit model for Iran.
CONCLUSIONS: This study reviewed the model of health equity audit for UK and provided a comparative model for health system of Iran with respect to the opinions of academic experts.

Iran's health system furnishing health and treatment services serves in an environment which is expeditiously changing in social, economical and technical aspects and this leads to numerous challenges and tensions.1 There are some current challenges in Iran's health status that can be mentioned; the unfair distribution of medical services, imposed medical tariffs and wandered insured patients, instability in financial support system and inequity in the amounts of insurance premium, high rates of out-of-pocket expenses, the high cost of health care and the subsequently neglecting towards inserting supportive methods for individuals under insurance cover in the community, high cost of visit for deprived classes of society, lack of health policy-making concentration at the Ministry of Health and its distribution among various institutions in the country, distribution of health budget in different authorities rather than spending it just in the Ministry of Health, lack of appropriate increase in per capita treatment rates in the country in line with revenues, and its steep reduction considering price and inflation index are the main ones.2 In response to these problems and challenges caused by the need for equity1 and the importance of a key issue in health provision, the approach to health inequalities becomes obvious.3 Nevertheless measuring health inequality over time and across the countries still remains as a challenge.4

The out-set point for health equity audit is a shared understanding of the differences between health inequality and inequity.5 Health care inequalities refer to differences in access to or availability of facilities and services6 and also differences in health experience and health outcomes between different population groups, according to socio- economic status, geographical area, age, disability, gender or ethnical groups.5

In contrast, health inequity describes differences in opportunities for different population groups which result in unequal life chances, biased access to health services, nutritious food, adequate housing and so on. These can lead to health inequalities.5

The overall aim is not to distribute resources equally, but rather in relation to the need in different groups,6 to reduce avoidable health inequalities and promote equal opportunity to the determinants of good health, and access to health and other services.5

Health equity audit is designed to ensure that equity planners consider equity in their decision making and that the right decisions are made.6 Therefore, health equity audit is a pragmatic policy tool to ensure that services and resources are focused on issues that have the highest impact on health inequalities.7

In order to overcome these health inequalities, in Iran, the government has the duty to prepare the overall program.2 The government's commitment in providing health is due to the fact that individual and community health are correlative and interdependent concepts. On the other hand, promoting community health status have positive effect on increasing production, productivity, employment and ultimately achieving the national development; so the government as the representative of the community must endeavor to provide equity.8

Above points indicate the necessity of applying the model of health equity audit, but unfortunately, although there are many problems in the health sector in Iran and there is an urgent need for performing equity audit, this subject has not been heeded by the experts in the Ministry of Health. Therefore, this study aimed to review the UK health equity audit model, gathering viewpoints of different involved groups in health sector, particularly health experts, and offered a practical and suitable model for health equity audit in Iran.

Methods

This study adopted applied research approach in two phases. In the first step, this study conducted theoretical health equity audit models in the texts, and then, employed the Delphi technique.9

Phase I . Data gathering about other health equity model

This phase was conducted to study the experiences of other countries in this regard and select the most appropriate model for Iranian health system.

The models of health equity audit of Canada, Australia, UK and Switzerland were reviewed and the UK's model for Iranian case was adopted. The UK's health administration system is the same as the current health management system of Iran (e.g., referral system for needy and villagers).10 There is also existence of an equity-oriented health system in UK, considering the importance of preparing and applying specific and practical patterns in health evaluation and principles of the 60-year-old National Health Service (NHS) in UK with the commitment to equal access and treatment for all, regardless of social class, income or status,11 and its positive actions in the field of health equity audit. However, scope of this research included the NHS of UK; and the time scope was from the past to the present. UK's information was collected by using the available on-line data bases, such as library resources and information released by NHS, the electronic databases like Iranmedex, PubMed, Emerald, and Science Direct.

Phase II. Employing Delphi technique

This study applied a questionnaire in order to gathering data.12 Questionnaire was made according to the UK model. It was categorized in four major sections: indicators, equity audit topics, organizations responsible for carrying out equity audit model and health equity audit stages. The validity of the questionnaire was assessed using the collective opinions of top five academic experts and specialists in health sector.

The questionnaires filled up by 18 academic experts including: scholars with a relevant university degree in health care management, members of expert committees, the people who have enough work experiences (at least 5 years) in health institutions, such as the Ministry of Health, Schools of Medical Sciences and Health Care Centers.

Finally, with the aim of achieving consensus on the basic model and converting it to the final model, a revision of the earlier model was done, defects (resulting from the phase II) were removed and the re-revised model was sent to the previous experts who participated in phase II. Once again, their views were collected. This process repeated several times until a concord was achieved and the final model were extracted.

Ethical considerations

Confidentiality of interviews was respected. Overall analysis of results was done without insertion of the names.

Results

A total of 18 academic experts were identified and the questionnaires were distributed among them in university, separately. 17 academic experts provided a positive response towards implementation of health equity audit in Iran, and only one did not provide a direct answer; instead he stated that, we must set concepts, principles and cultural infrastructures of equity first, and then audits may be performed.

Agreeable topics, performing agencies, equity audit stages, and equity indicators in the UK health system were identified and ultimately proposed viewpoints in the above fields were provided and the proposed health equity audit model for Iran was presented as follows.

Discussion

Health equity audit is a tool that enables the identification and redistribution of resources on the basis of need.11 The study results based on expert opinions is that using health equity audit in Iran's health system is valuable: 1. to increase awareness of its application across the country, 2. to document its practical ability in health centers, 3. to increase its acceptance politically, 4. to do self-assessment equity in health centers, 5. to prevent health inequalities in the future, 6. to consider local issues around the country and local population groups with special health needs, 7. to compare health inequalities in similar groups, 8. for focusing on community health issues to identify the cumulative effects of unequal access to services, 9. to ensure that new initiatives and current priorities to reduce health inequalities have been in agreement with the Health Ministry schemes, 10. for the appropriate investment in reducing health inequalities, and 11. for the planning, implementation and evaluation of local interventions.

On the other hand, considering no investigation has been done about health equity audit in Iran and unfamiliarity with this topic, the obvious achievements of the study on identification of equity audit model was focusing on four major sections including indicators, equity audit topics, audit organizations to perform equity and health equity audit stages in UK and ultimately proposing a health equity audit model for Iran.

Since the selection of the topics related to health equity audit is based on the national and local preferences, 28 main axes (with 195 minor axes) in the UK health system were studied.5 Themes such as quitting smoking, stroke, childhood obesity, coronary heart disease, and diabetes were the top five main topics in health equity audit in the UK health equity system.13 In contrast with the 28 main axes above, access to primary care, immunization and vaccination, family planning and contraceptive services, children's health and mental health were proposed as five priority (or primary) axes in Iran.

Since the organizations involved in the health equity audit process of UK are discordant with Iran, just to inform experts, information on the UK was given to them, and 9 organizations which could participate in equity audit process in Iran were listed in the questionnaire. Finally, after considering experts’ comments, suggested items are presented in Table 2. Considering that the Iranian government is the trustee, the result shows that the priority in equity audit for Iran will be with independent organizations.

Table 2

Audit organizations to perform equity in United Kingdom compared with the proposed audit organizations to perform equity agreed by experts in order of preference for Iran

Health Equity Audit steps in the proposed Model for Iran

In Iran according to a gap in the field of health equity, reviewing the health equity audit process, priority is to identify equity profile, identifying the gap and then, reaching an agreement with partners on issues with most dilated gaps; and another stage is to agree on priorities for action, but in UK the priority is to agree on priorities and partners, and preparation of an equity profile and analyzing the data and then identifying the use of evidence for effective local action. It should be mentioned that from the six stages of the health equity audit review, expert comments in the stages 1, 2 and 3, were different from those in the UK model, but their comments were similar to those in the UK model in stages 4, 5 and 6.

One of the important achievements of this study was providing details of the proposed model of health equity audit for Iran for offering better understanding of the equity audit topic and optimizing its capabilities in Iran's health system.

Table 4 contains health equity and health inequality indicators under three main parts: demographic indicators (with 6 sub-sections), community health status indicators (with 7 sub-sections), indicators of health care services (with 3 sub-sections) and samples of UK's and Iran's indicators in the relevant columns were compared. The purpose of this part was to help health practitioners and stakeholders to promote the knowledge of community health status.

Table 4

Comparing sample indicators in United Kingdom health system with those in Iran

Finally, it can be said that, although in Iran the government executes the affairs now, but it could be the responsibility of independent proposed boards to make a plan about, establishing equity and performing stability, reducing social and economic inequalities, reducing the income gap and equitable distribution of income in the country, reducing poverty, deprivation and empowering the poor, through targeted resource allocation and efficient social security payments and subsidies, comprehensive poverty alleviation planning and social equity, and carrying out all activities associated with economic development according to the health equity audit.

Also, to generate relevant evidence and take appropriate actions to tackle health inequities, local authorities need a variety of tools. In order to facilitate a comprehensive understanding of health systems performance, these tools should: 1. adopt a multi-sectoral approach, 2. link evidence to actions, 3. be simple and user-friendly, and 4. be operationally feasible and sustainable.10

Authors believe that future studies on the formation of health equity audit team with attendance of independent proposed boards (citing findings in Table 4) in Iran, conducting independent analytical research about health equity in Iran and ultimately, implementing the model presented on this study and analyzing its results to promote health equity in Iran are necessary.

Authors’ Contributions

SK and SHAHZM contributed equally to design, data collection and review, questionnaire preparation, review and comments by experts and writing the manuscript. Both authors read and approved the final manuscript.

Table 1

Health equity audit topics in United Kingdom compared with the topics agreed by experts for health equity audit in order of preference for Iran.

Table 3

Health equity audit stages in United Kingdom model compared with the health equity audit stages in the proposed model for Iran