Iran health system reform plan methodology.

BACKGROUND: The Ministry of Health and Medical Education of Iran, along with the country movement towards achievements of Iran's Vision 2025 put compilation of the health system reform plan on its agenda. In this article, we are trying to show the method we used for developing this plan and how this method considered the general condition of the country along with maintaining the standards of scientific and technical programs. All steps of this planning are described in the paper and finally we discuss the techniques and the appropriateness of the method compare with the experience of the other countries.

Introduction

Health is an issue that is in transition and undergoes rapid changes. One of the changes is in the pattern and burden of diseases.

We all know that shift in burden of diseases from communicable to non-communicable, the aging of population and many other factors will affect the burden of diseases in future (1). Furthermore one of the most important changes will occur in the field of health related science and technology (2). Today world has become accustomed to these changes, but the significance and complexity of these changes in speed, diversity and mutual influences will be in the tomorrow world (3). In Iran also, health system and science and technology system will be influenced by these changes like other countries, organizations and institutions. These effects can be positive or negative and can happen in different aspects like education, research, diagnosis, treatment and service providing. Around the world different methods for planning of the health systems have been used to become prepared for facing the changes. In general, two approaches are used, reformatory macro strategies approach and gradual reformation (4). In the strategic reformation approach, vast interventions and in more dimensions are required compared to gradual reformations which include several reformation plans. Also three generations of reformation have been accrued in the world. First generation emphasized on reducing the public budget and encouraging private sector, while in the second generation emphasize was on the efficiency of health system management of human resources and decentralization. In the third generation, having a multi-sectorial view, the outputs of health system along with the health care system services were concerned more (3).

The Ministry of Health and Medical Education of Iran, along with the country movement towards achievements of Iran’s Vision 2025 and Iran’s Health Innovation and Science Development Plan, put compilation of the health system reform plan on its agenda. Plan means a long term reformatory program in health system which includes vision, mission, goals, principals and values, policies and national reformation program.

This article is about the method we used for developing this plan and how this method considered the general condition of the country along with maintaining the standards of scientific and technical programs. For providing the method of health system reform plan, along with consultation with the experts and those who were involved in planning of the previous health system reform, we carefully studied the methods used in other countries and their experiences, also we reviewed the policy- making literature, concepts and techniques of foresight to formulate the foundation of methodology and then we consulted with the managers and policy makers and ultimately we reached to a mutual agreement for the method which is shown in Fig. 1.

Fig.1:

Steps of preparing the health system reform Plan

Formation of teams: Formation of three teams, entitled: Steering Committee, Change team and experts team, was advised. These teams was formed based on completing the matrix of stakeholders/acceptance, stakeholders /authority and stakeholders /access and with considering the executional remarks. The Steering Committee was formed with the aim of decision making on the output of the planning process and with the responsibility of following up approval of the outputs at the national level, the Change team was formed for implementing the plan and adding the executional consideration to the decision of experts, and experts team was formed for developing the plan.

Clarifying the Values: the principles and values are the foundation of architecting the system and regulate the association between the components. So it was necessary to clarify them at the beginning of the planning using experts’ opinion and qualitative methodology.

Assessing the external environment: As the reformation plan is for the next 15 years, it is necessary to assess the external environment and the governing trends, using foresight techniques, to identify the forces that influence the health system and control the customers’ behavior, in order to guess possible futures of health system in 2025.

Challenges and opportunities Review: In order to determine the main cause of health system challenges, it was advised to do root cause analysis using Problem Tree Analysis (5 Why technique) and system dynamics modeling.

Identifying Key strategic issues: in order to use limited resources for the best changes in the health system, we need to identify key strategic issues -as the priority areas for action- with the help of information acquired in the previous steps.

Situation Analysis: for designing and selecting the necessary interventions, it is required to have accurate information of each priority areas based on available data.

Setting Goals: Defining goals is very important in the planning process. For this purpose, it was advised to provide a provisional draft of all the objectives by using the information acquired in the previous stages and finalize it with the help of experts and Steering Committee.

Determining the roles of institutions: As all the institutions, which have a direct role in health system are not directly controled by MOHME, therefore it was advised to define the share and roles of each institution for better future inter-sectoral collaboration.

Policy Formulation: It was advised to collect ideas and policy options by using, relevant evidence, and experts’ opinions from all over the country so the steering committee would be able to choose among these options considering values and contextual characteristics.

Policy Assessment: As the future environment is always associated with uncertainty, it was proposed to develop alternative scenarios regarding main drivers and trends. Then the robustness of each policy in each scenario is assessed by using the wind tunnel techniques.

Discussion

The initiation of health system reform is different in each country. In Iran, the main reason was achievement of Iran’s 2025 Vision. The initiation of reform in Australia was with a critical report by the parliament “Blame Game”. This report contained very critical points and severely challenged the government’s performance (5). In US, we can attribute the reformation plan of President Obama to years of efforts of democrats for organizing the unorganized health services in the last decades (6). In Mexico, the health reform was a response to three challenges that public health system was facing means equity, quality and fairness of financial contribution (7). Similar concerns could be seen at the beginning of the health sector reform in other countries in the region(8).In Chile, each round of reformation was initiated after an epidemic which revealed main problems of the health system, except for the reform at the time of Pinochet –privatization and decentralization(9). By looking at the reasons for initiating the reform program in other countries, we can say that they were for responding to a problem and were challenge-based. Opportunity-based orientation and looking to future in horizon of 2025 were the reasons that the methods and tools for shaping the future or foresight was advised for designing the health system reformation plan. Techniques like; scenario development, STEEPV analysis and wind tunnel technique.

Although the reform plans in other countries are designed for a period of time in future, but only England has entered foresight approach in its plan. In England two cases of health system planning have used the foresight approach, the first was in the framework of national comprehensive plan with the subject of Future of England (10) and the second was a plan by NHS with the purpose of estimating the future costs and obtaining more budgets (11).

One of the characteristics of an ideal society in Iran in 2025 is being equity-oriented and fairness of social systems (12). As the health system reform is aligned with 2025 prospective, so it is appropriate to have an especial consideration for values. In the planning process, describing principles and values, is an invitation of all who are involved and planners of health system to think about it and agree with the basic principles and values of the health system in Iran.

In some countries like US, Egypt and Brazil from the beginning, reformation included a very limited field and there was no chance for change in different fields (8, 13–14). In this reformatory plan the whole health system of the country was involved in different stages of the planning to increase the chance of successful implementation.

Nowadays for reformatory planning in social fields like education, welfare, housing and public health, the public policy approach is being used (15). Therefore considering the extent of this project, the public policy making approach was selected rather than management approach. Studies show that strategic planning is used at the level of organization and for 3 to 5 years period of time (16) therefore the foresight approach which its prospective for planning is a period of 10 to 50 years (17), was used more, compared to strategic planning.

For planning the long term developmental programs at the national level, two different approaches are used: the elitist approach which means using limited number of experts and professionals versus pluralistic approach which try to obtain maximum number of opinions of groups, organizations and even peoples (17). The processes in this project are designed in a way that enables using the merits of both approaches. The Steering Committee is made of a few number of stakeholders and health system policy makers is formed with the purpose of decision making and approval of the defined outputs of the plan. The reform team, which is made of middle managers of MOHME and other stakeholders, is responsible to assess the organizational and contextual characteristics and combine them with experts’ opinions. Also this team has the responsibility for the implementation of the plan after its approval. The expert teams, were responsible to prepare the policy options in each priority area using the local and global evidences and their tacit knowledge. Also all medical universities participated in the planning processes and there was opportunity for all experts in the country to make their comments in the project website.

The method has special characteristics such as participatory approach, scenario development, evidence informed policy making and foresight method which will help the produced plan for better implementation. Successful implementation of policies and actions of health reform plan together with Iran’s health innovation and science development plan by 2025(18) will lead to better health and wealth in the country.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.