Ways to improve the current performance of the boards of trustees of medical universities in iran.

BACKGROUND: Establishment of boards of trustees for all universities was legalized in 1988. It is crucial to assess the performance of the boards and to adjust them to the mandates raised by new visions of the country.
METHODS: Subjects were members of boards of trustees and officers in charge of board's affairs at medical universities. Furthermore, a sample of 860 resolutions adopted by the boards was selected to assess the state of their enforcement.
RESULTS: About 70% of the resolutions addressed have been enforced. There is a consensus on focusing on policy-making and high supervision on the objectives of the institutes rather than other areas. Furthermore, ways suggested improving the performance of the boards.
CONCLUSION: Despite the rather high enforcement rate of the resolution in the past ten years, several interventions are suggested to improve the current performance of the boards of trustees and to meet new directions.

Introduction

It is evident that Roman church reformist movement in 16th century used boards of trustees (1). Academic institutes were managed by non-academic individuals appointed by the governments and clerics, aristocrats, law makers and mayors had a major role in this. The composition of the boards of trustees gradually shifted to a more technical one and academic members could dominate in the composition of the boards. Boards of trustees are means to bridge the gap between academia and community.

There have been different approaches to select members of the boards that have been backed to charity or civic nature of the institute. Charity institutes are usually managed by unspecialized board members; this is also followed by private higher education institutes. While, public educational institutes use different ways to designate board members, however, it is unlikely to have faculties of them as members, unless they take part in the meeting without voting right (2).

The first modern higher education institute, School of Political Science, was established about a hundred years ago in Iran under the Ministry of Foreign Affairs. Several other institutes were established afterward such as School of Law, School of Agriculture, Rural Industries and School of Trade (3). All these institutes were managed without a board of trustees. The first board of trustees was included into the constitution of Iran’s National University in 1960 as its highest decision making authority. In 1967, an act was adopted by both Senate and Parliament to form a board of trustees for the University of Tehran.

After Islamic Revolution of Iran, establishment of boards of trustees for universities and higher education institutes was legalized by an Act adopted by High Council of Cultural Reform in 1988. The Act recognizes a wide range of duties for the boards, however, performance of the boards of trustees has not been satisfactory and there have been a lot of policy interferences from high authority organizations that are among the main stakeholders. This could lead to uncoordinated resolutions with legal conflicts and low enforcement potential (4, 5). Studying the challenges and finding solutions to overcome them is an ignored necessity. On the other hand, it is crucial to adjust the performance of the boards to the new mandates raised by some long-term plans developed under Iran 2025 Vision.

The purpose of this study was to assess the current state of performance of the boards of medical education and research institutes and provides the key decision makers with a list of priority challenges to be faced to improve the state.

Materials and Methods

The study was a descriptive one with three components that addressed 52 boards of trustees of medical university or higher education/ research institute under the Ministry of Health and Medical Education. Two components conducted as surveys and addressed the entire board members and officers in charge of related secretariat in each medical university or higher education/ research institute. In another descriptive and cross sectional component, a sample of 860 resolutions randomly selected from a bank of approximately 10100 resolutions adopted between 2000 and 2010 by the boards of all medical universities and education institutes under the Ministry of Health and Medical Education. A questionnaire prepared for each institute to clear out if the related resolution is enforced according to accessible reserved evidence. All sample resolutions were categorized based on the 16 main duties introduced by the Act of Boards of Trustees as well.

Three types of questionnaires were used. The first one was used to assess the level of enforcement according to accessible documents. Resolutions were categorized as “completely enforced”, “partially enforced”, “not enforced” and “unknown”. A separate tool was developed for each university/institute based on the selected sample resolution. There was another tool to collect the opinion of board members about the challenges affecting the performance of the boards and the ways to face them. The third questionnaire was intended to the officers in charge of the secretariats at university headquarters to collect their opinion about challenges they face and improvement approaches they suggest.

Fifty two officers in charge of the secretariat of boards of trustee were trained in a national workshop to precisely respond to the questions on enforcement of sample resolutions through checking entire related documents to each resolution. They were asked to provide a copy of document/s that may show a resolution is enforced or not to let the research team to undertake a double check on partially and completely enforced or not enforced responses. Lack of any physical document was the criterion to consider an “unknown” option.

They were also asked to transfer the questionnaire intended to the board members directly to each addressee and follow up if he filled and returned it to a certain address in Tehran through two consequent telephone contacts after a posted deadline.

The third questionnaire was applied during the national training workshop held to introduce the study for the target officers in Tehran in spring 2010. They worked together in five teams, consisted from a variety of different universities/institute types to provide responses to the questions according to their perceptions and experiences they face in practice.

Results

We received the response to the questions on 797 out of 860 sample resolutions that were investigated to find out whether they have been enforced. Eleven universities/institutes couldn’t provide the response on time. Majority of these resolutions were on collection and expending of earmarked revenues, extra payments of faculty and non-faculty university staff, internal regulations and management procedures for service units and health facilities. The least number of resolutions were on encouraging local supports and private sector partnership that includes money, equipment or physical spaces, and on the content of annual report of chancellors. Table 1 summarized the state of enforcement of investigated resolutions.

Table 1:

State of enforcement of resolutions adopted by boards of trustees between 2000 and 2010

State of enforcement	Frequency n (%)
Completely enforced	560 (70.3)
Partially enforced	45 (5.7)
Not enforced	92 (11.5)
Unknown	100 (12.5)
Total	797 (100)

Participation rate of board members was acceptable and 140 (72%) members, who received the questionnaire, filled it out and returned the completed questionnaire to the study team. There were 4 governor generals and 33 university chancellors among respondents. Forty one percent of the respondents have been member of a board of trustees for a two-year round in the past ten years, 22% twice and 27% more than two rounds have experienced this membership; 10% didn’t respond to the related question. Sixty one percent of the respondents were contributed in just one board in the last ten years. 24.8%, 5% and 2.9% have been member of two, three and more than three boards, respectively.

Table 2 summarizes the prominent opinion of respondents about the question on those who should join to the board composition to improve the performance. However, the following persons have been proposed to join the board with lesser frequencies:

Table 2:

Opinion of board members about designation of new members to improve the performance of the boards of trustees

New members suggested to join the boards	Frequency n (%)
Representative of university faculties	94 (67.1)
Representative of community in the catchment area of the university	81(57.8)
Local senior professors who work for other universities	51(36.4)
Local scholars who have experience of being a university chancellor	25 (17.8)

-Charitable citizens

-Mayors

-Imams of districts

-Deputy Chancellors

-Representative of nurses

-Heads of the university schools

-Representative from judiciary

-Representative from private health sector

-Chancellors of non-medical universities

-Representative of non-faculty staff

-Representative of province Islamic council

-Economists and sociologists

-A local public health expert

Table 3 displays the attitude of the respondents on the performance of the universities/institutes.

Table 3:

Level of satisfaction of the Board members on performance of the boards

Topic	Level
	Very high (%)	High (%)	Moderate (%)	Low (%)	Very low (%)	No response (%)
Level of enforcement of resolutions	10.2	55.5	28.5	2.9	0.7	2.2
Compliance of the current composition of the boards with the Act	8.0	46	36.5	7.3	0.7	1.4
Method of designation of board members	5.8	40.1	40.9	8.8	1.4	2.9
Ministerial supervision on boards	5.8	35.8	40.9	10.9	2.9	3.6
Current executive organization of the boards’ secretariats	13.1	42.3	29.9	11.7	1.4	1.4
How much satisfactory are the board’s duties stated in the Act and Article 49?	13.2	43.1	30.6	8.7	0	5.1
The level to which private sector and local financial supports are mobilized by the boards	0.7	4.4	33.6	43.8	15.3	2.2
Encouraging community participation by the boards to meet the university goals	0.7	5.8	35.7	43.0	12.4	2.2
Efficacy of the Boards’ Act of 1988 in the current situation	2.9	27.7	40.1	21.2	2.9	5.2

Four questions were asked from all 52 officers in charge of board secretariats to collect their opinion about the challenges and solutions to improve performance. They were focused on these areas:

Administration problems of the secretariats. The most frequent challenges stated were lack of organizational chart for the secretariats, lack of budget for overtime payments of the secretariat’s staff, inadequate training programs for the staff, lack of SOPs for the secretariats, relative unavailability of board members, lack of standard working space for the secretariats and rapid changes in reporting forms.

Challenges affecting board performance. Lack of independent decision making by the boards because of the strict control from the Ministry, members with inadequate information to meet their duties, over occupied board members, members who are not local, interrupted attendance of members in the board meetings, avoidance of the boards to get involved in strategic policy-making, frequent change of chancellors, holding the meetings out of university, the attitude of members who designated for more than one board, lack of supervising mechanism on member’s performance, lack of evaluation mechanism for past resolutions, little role of the boards in appointment of chancellors, weak university-board relationship and the current conflict of inspecting organs with Article 49 of the 4th Development Program that allows the boards to make decisions independent to current monetary and employment laws (6).

Some training needs were mentioned to improve the capacity of board members to undertake their job. These are: The organization and terms of reference of the Ministry of Health and Medical Education, Article 49 details, mid- and long-term goals and plans of the Ministry, success keys for boards, essentials of health economy, monitoring and evaluation methods, board-related legislations, budgeting, strategic planning, fund raising skills, skills to improve community partnership, legal aspects of resolutions adopted, social determinants of health, PHC system of Iran, laws and duties related to investigational bodies and current financial and employment guidelines.

Discussion

We could not find any similar network of boards of trustees through review of international literature; however, there was a few studies addressed the function and performance of board of trustees of Iranian non-medical universities. Our study approved this finding that the focus of the boards is on just a part of their legal authority and they do not use their complete capacities and legal authorities (7, 8).

It seems that Iranian boards are systematically ignored their function on making policies and planning that are essential role of their European and American counterparts (7). However, it is now evident that policy making at provincial level, and building capacity for this, is considered as a priority need in the perspective of health policy making improvement in Iran (9).

In spite of the rather high rate of materialization of previous resolutions of the boards of trustees, both board members and technical officers provided us with a long list of challenges and solutions methods to improve the performance of the boards as well as the quality of their resolutions. The role of the boards is significant in meeting Iran 2025 Vision as they are axial in all health reforms (10).

We can divide their suggestions to what should be changed in the structure of the boards and their secretariats and what is needed to be changed at community and national level as follows.

➢ Management of the boards. More strict supervision on activity of board members; increasing the level of accountability of chancellor to the board, frequent meetings between board members and university board of managers; staff and students.

➢ Processes, procedures and standards. Bolding the supervisory position of the board specially in regards with strategic plans of university; holding board meetings in university premises; increasing the number of board meetings (seasonal meetings at least); revision of selection criteria for board members; involving the boards in strategic planning of universities; presenting a progress report by chancellor in every meeting of the board, frequent visits of the board members from university; attendance of officers working at the board’s secretariat in the meetings without voting right; development of a confidentiality protocol for board resolutions and the dissemination policy; using meeting management principles for board meetings; at least two annual joint meetings with university board of directors; considering incentives for board membership, e.g. payments for time spent for meetings; clear process for proposing meeting agenda and efficient and clear reporting and budgeting forms.

➢ Structure. An active secretariat with organizational chart under university; higher level of board independence from national authorities in making decisions; formation of technical committees under secretariat of boards; an effective mechanism to coordinate board’s secretariat with Policy-Making and Provincial Health and Food Safety Council secretariats.

➢ Resources. Establishment of an office for the secretariat and active presence of board members; mobilization of local resources to support board’s decisions; building capacity in board members and secretariat staff; electronic based website for university boards.

➢ Goals. Preparing documented goals and plans for the activity of the boards of trustees. This must include a more supervisory role as strictly suggested (11).

➢ Community and national levels. Providing consultation opportunities to use chancellors’ experiences; introducing the boards to other sectors that have influence on university affairs; annual joint meeting between board members and the Minister of Health; more active participation of the Minister of Health in the board meetings; enhancement of the capacity at Ministerial level to act as a national consulting and supervisory body; promoting competition between the boards; updating the legislation that can affect the performance of the boards including those that should allow to change the composition of the board members; updating the duties and mandates of the boards according to the emerging national strategic plans and visions.

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.