Customers' satisfaction with the Iranian health system reform plan.

BACKGROUND AND AIM: Customer's satisfaction is one of the main goals of the health system because it is effective on the desire of external customers for using the services of the health system and also the quality and quantity of the provided care for the internal customers and eventually the health of the society. Considering the importance of the subject, the present study was designed to determine the customers' satisfaction with the health system reform plan in the field of health.
MATERIALS AND METHODS: Participants in the present content analysis qualitative study were 22 technical and operational managers and 118 health-care providers, and 15 recipients of health services referring to the health centers in Qom; who individually answered the questions of the interview guide. The gathered qualitative data were analyzed using conventional qualitative content analysis.
RESULTS: Customers' satisfaction with the health system reform plan was categorized into six themes of decreased trust of the caregivers, wasting caregivers' time in the health units, increased provision of services to the caregivers, decreased motivation for work, occupational burnout, and a sense of petition in the care providers.
CONCLUSIONS: Although external customers were satisfied with some services of the health system reform such as providing various free services, follow-up the patients, and beautification the environment of the health centers; but there are multiple weaknesses in this plan that would cause dissatisfaction in the external and internal customers. More studies seem necessary to better determine the different aspects of the satisfaction in the caregivers and care. Copyright:

Introduction

Health is a valuable wealth which its maintenance and improvement is one of the most important efforts of everyday life.[1] In general, health does not mean having no illnesses, rather it also includes physical, mental, social, and spiritual peace and welfare which contains multiple and usually complicated determinants and its provision requires a comprehensive and multi-dimensional approach.[2] A healthy human is the axis of constant development and health is essential for humans to benefit from divine blessings; so paying attention to health and making effort for its maintenance and improvement is always considered an important priority.[34]

The main mission of the health system is to improve the health level and fulfill the needs of the people and the society.[1] Revolution in the society needs that health system should respond to it, convert the reform in health-care system to a necessity.[5] On this basis, the occurrence of a reform in the health system of Iran was proposed and after many studies and discussions, eventually, this project was started from May 5, 2016, and is currently being performed with three approaches of financial protection of the patients, establishing justice in accessing health services and improvement of the quality of provided services.[6] Executing this project, like any other project, had its positive and negative effects and determining these effects required periodical assessment and evaluation. Evaluating the performance of the health system could provide in-time and relevant information to the performance of the health system for the decision-makers. This information would lead to the awareness of the managers and policy makers and would provide the conditions for monitoring the movement toward national goals and relevant policies. On the other hand, in-time monitoring and evaluation of the justifications could provide evidence for guiding the reform.[7]

Various studies have been conducted, nationally and internationally, about the effect of the reform plan on the health sector indices. For example, Kheiri et al. stated that the reform plan had a positive effect on decreasing patients’ costs, increasing the rate of vaginal delivery, improving the hospitals’ services and lingering physicians’ stay in deprived areas and in general, this plan has been successful in Iran.[8] Dehghan et al. evaluated the performance of the health reform plan from the viewpoint of the managers of the university hospitals of Yazd province in 2015 and showed that the goals of the health reform plan have been desirably achieved, but the outcome of some of the guidelines of the health reform was not as expected.[9] Results of the study by Yardim et al. in Turkey also showed that the execution of the reform plan has led to the financial protection of the patients against high costs of health.[10] According to the results of the study by Van Der Wees et al. in Massachusetts, justification of the health cares in Massachusetts has been associated with improvement of the health condition and has led to more use of the health services, especially by the more vulnerable groups of the society.[11]

Paying special attention to the customers and their satisfaction would guarantee the necessity of successfully performing a plan and its continuity. Health Reform Plan is also not an exception.[1213] According to the reports by the National Association for Health Researches, it seems that general population of Iran is satisfied with this health reform plan and their satisfaction has gradually increased during the 1st year of its execution.[12] However, results of the study by Hashemi et al., that has compared the patients’ satisfaction before and after the establishment of the health reform plan, have revealed that patients’ satisfaction with therapeutic-care measures has been decreased and after execution of the plan, less time has been spent for visiting the patients and providing health recommendations to the patients.[14] In the study of Shariati et al., most of the participants (patients and their family) were satisfied with the execution of the Health Reform Plan, but most of the nurses were not.[15] Furthermore, Bastani et al. in their study concluded that, despite all its benefits, Health Reform Plan has some defects and shortcomings in some aspects that have caused dissatisfaction in caregivers; therefore, it requires periodical monitoring and evaluation.[16]

Customers’ satisfaction is one of the main goals of the health system because it affects the desire of the foreign customers for using the services of the health system and also the quality and quantity of provided health services for the internal customers and eventually the health of the society. Considering the importance of the subject and lack of studies about customers’ satisfaction with the Health Reform Plan in the field of health, the present study was conducted to determine the customers’ satisfaction with the Health Reform Plan in the field of health.

Materials and Methods

The present study was a qualitative research which was conducted using content analysis method to determine the customers’ satisfaction with the Health Reform Plan in the field of health in Qom. Study environment included health-care centers affiliated with the health deputy of the Qom University of Medical Sciences. Participants in the study were technical and operational managers, and health-care providers affiliated with the health deputy of the Qom University of Medical Sciences and clients who referred to the health-care centers. Operational and field managers were enrolled in the study trough census sampling method. Hence, by referring to the health deputy of the Qom University of Medical Sciences, the researcher requested all the operational and field managers to express their views on the challenges of the health services reform in the health domain and the solutions to resolve them. Finally, 22 operational and field managers participated in this study. Using the convenience sampling method, healthcare providers and clients of health care centers were included in the study. In overall, 118 health-care providers (midwife, health education expert, psychologist, nutritionist, physician, dentist, environmental health expert, and male health caregiver) and 15 clients answered the interview questions. The sampling continued until data saturation. The inclusion criteria involved the willingness to participate in the study and the ability to express individual perspectives and experiences. The exclusion criteria were only the decision to discontinue the participation in the study.

Experiences and viewpoints of the participants about satisfaction with the Health Reform Plan were gathered using personal interviews and semi-structured questionnaires. Data were gathered using individual interviews and using a semi-structured questionnaire include the following questions: What are the challenges of the Health Reform Plan in the field of health in your opinion? What are the advantages of the Health Reform Plan in the field of health in your opinion? Are you satisfied with Health Reform Plan in the field of health? More exploratory questions were asked based on the answers of the participants to these questions.

The gathered data were analyzed using qualitative content analysis and inductive analysis approach. For this purpose, immediately after recording each interview, the researcher prepared a word by word transcription of the interview. The provided text was then read line-by-line to determine the important sentences and phrases, which were underlined and their essence was labeled (coding). Then, the similar codes were merged and categorized to form the subcategories. Subsequently, they were named based on the ideas they had covered. The subcategories were compared with each other, and in the case of similarity, they gathered together, leading to the appearance of the main categories. Furthermore, the manuscripts of the participants were collected and analyzed. Sampling continued until no new codes were achieved from data analysis.

Trustworthiness and rigors

By using diversity in the selection of the participants, the review of the handwritten documents by the participants, we attempted to increase the credibility of data. The reliability was confirmed recoding the transcribed interviews another colleague. In addition, the transferability of data was achieved by completely and constantly recoding the researcher's activities about data gathering and analysis.[17]

Observing ethical considerations

During the process of the study, necessary permissions (No. p/34/11924, ir.muq.REC.1395.104, September 28, 2016) and recommendations were obtained and presented to the participants. The goals and method of the stud were explained to the participants, and they were assured that the texts of the interviews were kept anonymous and their information would remain confidential. In addition, informed consent was obtained from the participants for enrollment in the study and recording the interviews. The participants were assured that they were free to withdraw from the study at any desired time.

Results

Data of the resent study were categorized into 165 codes, 16 categories, and 6 themes which are presented in Table 1.

Table 1

Customers’ satisfaction with the health reform plan in the field of health in the city of Qom from the perspective of managers, clients, and care providers

Theme	Category
Decreased trust of the care givers	Providing simple and common services
	Providing concurrent services to multiple care givers
	Confusion of the care givers
	Inexperienced care providers
	Frequent changes in the care provider
	Ineffective communication between care providers and care givers
Wasting care givers’ time in the health units	The need for frequent referral
	Unnecessary referrals
	Increased waiting time for care receiving
Increased provision of services to the care givers	Providing free services
	Providing various services
	Patient’s follow-up
	Beautification the environment of the health centers
Decreased motivation for work	Working to maintain the occupational position
	Lack of occupational security
Occupational burnout	Heavy workload
	Psychological damage
	Physical damage
The sense of petition in the care providers	Injustice
	Being forced to fulfill unrealistic expectations
	Not profiting from occupational advantages

From the viewpoints of the participants, customers’ satisfaction with the Health Reform Plan in the field of health was categorized into six main themes including decreased trust of the caregivers, wasting caregivers’ time in the health units, increased provision of services to the caregivers, decreased motivation for work, occupational burnout, and a sense of petition in the care providers. These themes are explained in the following:

Decreased trust of the caregivers

Providing simple and common services, providing concurrent services to multiple caregivers, confusion of the caregivers, inexperienced care providers, and frequent changes in the care provider, and ineffective communication between care providers and caregivers, are some of the factors that could decrease the caregivers’ trust in the health system.

Providing simple and common services

Caregivers were dissatisfied with not receiving specialized therapeutic services in the health units and believed that the health services that are currently being provided are simple and common and would not fulfill their therapeutic needs

“Their physicians have low levels. Because right now, I know that if I would take this drug, I would be better. But when I come here, my time would be wasted… but for prescribing tests and drugs for our insurance, it is good”

Providing concurrent services to multiple caregivers

Due to providing various services by care providers and presence of a number of care providers in one room, caregivers of different ages and with various diseases would be visited by one care provider or different care providers in one room. This would cause discomfort and concern for the caregivers and would also violate their privacy

“When they see that the same person who performs sputum culture and vaccination, also performs pregnancy examination and is not even a midwife, they would prefer to go to specialized centers and this would cause induced demand and dissatisfaction.”

Confusion of the caregivers

Care providers are graduates of different majors of the Health Ministry who have been trained through short courses for providing different health cares. In the past system, each caregiver would have provided the services that were in line with the job description of their major. But in the new system, the caregivers’ job description would be defined based on the approved packages in the Health Reform Plan. When the caregivers go to health units, they would search for the experts in their required field, according to their past experiences, for example, they would look for a midwife to receive pregnancy cares, but such titles could not be found in the health units, and they would face a general title of health-care provider which they do not know its field of expertise and its skills. This would lead to the confusion and distrust of the care givers

“People are dissatisfied and always complain; they do not know the abilities of the care providers.”

“The care givers always ask the reception where the midwife is. The reception was asked to say that we do not have a midwife. The care givers would get very upset and would discontinue their pregnancy and other midwifery cares at the health unit and would prefer to go to private centers.”

Inexperienced care providers

After the execution of the Health Reform Plan in Qom metropolis, many new workforces were employed in the health units and centers for providing health services, and many of them had no experience in the field of providing health services. On the other hand, many of their duties were not in line with their trainings and major's job description, and they had no experience and knowledge in this field. This caused an interruption in the quality of the provided services and distrust of the caregivers

“They are not experienced, or professional. Because I think they have been newly recruited.”

Frequent changes in the care provider

Caregivers were upset with frequent changes in the providers of services which interrupted the process of establishing the relationship and trust between the caregivers and the care providers

“They have changed frequently. Once there was a physician who was really good but he left soon, He might have not been here even for 1 month”

Ineffective communication between care providers and caregivers

The caregivers were dissatisfied with the insufficient amount of time that was given to them and not receiving answers for their questions by the care providers.

“One thing that should be noted is that the physician's examinations should be improved. They should give more guidance. However, we are spending a lot of time for coming here. So, I preferred to go to a private physician now.”

Wasting the care givers’ time in the health units

Caregivers were dissatisfied with the need for repeated visits, unnecessary referrals, and increased waiting and service providing time.

The need for frequent referral

Considering the time-consuming nature of presenting the care packages to the caregivers; sometimes, the caregivers would have to go to the health unit repeatedly to receive the services which would lead to their discomfort and dissatisfaction

“Care giver's time would greatly be wasted and sometimes they even have to repeated come to the health unit and this would cause dissatisfaction.”

Unnecessary referrals

Although many of the disorders could be diagnosed, followed up, treated or referred to the specialist, by the caregivers, the caregivers have to refer the cases to a general physician, and this would waste the caregivers’ time and lead to their dissatisfaction

“In most of the cases, the diagnosis, measures and treatment were in the competent field of the midwife; but we have to refer all the cases to the physicians and get confirmation. This would waste the time and money of the care givers, and every day, we see that the care givers are dissatisfied.”

Increased waiting time for care receiving

Recording the information in the Sib System is time-consuming, and it has increased the required time for providing services and also the waiting time for the caregivers and consequently their dissatisfaction.

“A mother once came in a hurry who was pressured by her husband who said that how much is really needed for injecting a vaccine; but the system wants us to give the statistics, many questionnaires should also be filled, then we have to hear care givers cursing and swearing, because injecting a vaccine takes a long time.”

Increased provision of services to the caregivers

Providing free services, providing various services, patients’ follow-up, and beautification the environment of the health units, were some of the services that the caregivers were satisfied with.

Providing free services

Providing free health cares were one of the important advantages of the health services that attracted people and caregivers mentioned it in their interviews

“Visiting the physician is free, the tests that should be performed have very low costs for them; this is very good for the low-income and vulnerable population.”

Providing various services

Developing various health-care packages and providing health services to different groups of the society including men and women of different ages is another strong advantage of this plan

“Consultant, physician,… most of the services that I need is provided here. They have a service which is called ambassadors of health, and I am a member too, which usually have a class once a month.”

Patients’ follow-up

In cases, where the patients require follow-up, the care providers would contact them and follow-up the process of diagnosis and treatment to make sure that the patients have not abandoned the process of their disease's treatment and diagnosis

“You know, we, the housewives, do not think of ourselves. If the caregivers would not follow us up, we would forget ourselves. I usually forget the time that I should come, here, and thank God, they would follow up my process.”

Beautification the environment of the health centers

Considering the program of hoteling and beautification the environment of the health centers in the Health Reform Plan, caregivers were satisfied with the clean and beautiful physical environment of the health centers.

“… a clean place…”

Decreased motivation for work

Working to maintain the occupational position and lack of occupational security have decreased the motivation of the care providers.

Working to maintain the occupational position

One of the caregivers mentioned that since the criteria for evaluating the function of the care providers is the recorded documents in the system and the quality of the provided services would not be considered, the care providers would mainly focus on recording the documents in the system to maintain their occupational position

“Everybody think of themselves and how not to lose their occupational position; patients’ health and attention at work have lowered to zero because documentation is all that matters.”

Lack of occupational security

Agreeing on 1-year contracts with the care providers, that had no guarantee for being extended, especially among corporate forces, the fear of getting fired, hesitate for continuing the cooperation, and uncertainty about the continuity of the Health Reform Plan were some of the reasons that were mentioned by the care providers for lack of occupational security and not working with their heart

“Lack of occupational security for the personnel of the Health Reform Plan in the field of health (1-year contracts with no support from the government)”

“The contractors say that if you have any complaints from the costumers, your salary would be decreased, whether it is right or wrong.”

Occupational burnout

Health-care providers mentioned that they are prone to physical and mental damages due to heavy workload and its related difficulties and stress.

Heavy workload

Shortage in the service providing personnel, the large number of the caregivers, and variety of the health packages for each caregivers that increases constantly, logging the information into the system and the necessity for answering multiple and various questions on the system are some of the reasons that would increase the workload of the care providers.

“Healthcare providers, these poor creatures of God, are not philosophers, they should accurately evaluate every individual from tip to toe and know everything too.”

“There are a lot of letters and instructions that come out every day and say that these should be done and etc… and performing all of these programs are the duty of the poor caregivers. The higher authorities do not think whether what they want is rational and could be done or not.”

Psychological damage

Neglecting humane side of the caregivers, constant changes in the instructions, threats, and pressures, work stress, imposing various responsibilities, repeated monitoring and creating inter-major tension are some of the factors that would threaten the mental health of the care providers

“I have no doubt that the effects of the physical and mental pressures of this plan (variety and high number of the cares and the heavy workload) would soon cause different diseases such as MS in the care providers due to its stress and turbulence.”

Physical damage

Not paying attention to the principles of ergonomics, long hours of work, and the necessity of constant working with the computer could be associated with several physical damages for the care providers.

“The heavy works that they perform and the disadvantages of using the system on the body parts including eyes, hands, waist, and neck.”

The sense of petition in the care providers

Injustice, the necessity to fulfill unrealistic expectations, and not profiting from occupational advantages were some of the factors that the care providers had complaints about

Injustice

Significant difference in payments, injustice in division of the duties, changing title of midwives and health experts into health-care providers and in the contrary, providing specialized services by the experts in nutrition, psychology and …, disproportion between the workload and the payments of the care providers, being monitored by irrelevant experts, discrimination between governmental and private centers, and lack of difference between the payments in the deprived areas and privileged areas, were some of the cases that health-care providers mentioned as the examples for discrimination and injustice

“The significant difference between the payments of the physicians and other care providers would cause discouragement in the personnel. Physicians’ fee (karaneh) is 100% while other would receive 20% at most. A Minimum difference of 80% for doing work, is discouraging and injustice.”

“Nurses practically have no work to do during the day, maybe they have about 1–2 injections/week; but anyway, they would receive their salary and that is a waste of money.”

Being forced to fulfill unrealistic expectations

Being forced to gain skill and knowledge beyond their graduated major, being forced to gain extensive skill and knowledge by passing short-term courses, putting the responsibility of all the cares and providing the service packages on the caregivers, the necessity to create a file for every person who lives in the area under the coverage of the center, and the necessity to perform statistical analysis and extracting the indices by the care providers, where some of the examples that the care providers mentioned as unrealistic expectation

“According to the contract that we have signed, we are obliged to perform whatever they ask us.”

Not profiting from occupational advantages

Providers of services in the private section had complaints about not receiving holiday and severance payments and not receiving their salary in accordance with the rules of the Bureau of Labor.

“Not receiving payments based on the rules of Bureau of Labor for employees”

“Lack of holiday and severance payments”

Discussion

Customers’ satisfaction with the Health Reform Plan in the field of health was categorized into six main themes of decreased trust of the caregivers, wasting caregivers’ time in the health units, increased provision of services to the care givers, decreased motivation for work, occupational burnout, and a sense of petition in the care providers. In the study of Benkaskit and Sarlema that was titled “why people are dissatisfied with the health services?,” the reasons for caregivers’ dissatisfaction were categorized into three groups of defects in health system, defects in providing and quality of the services, and defects in the attitude, skills, and performance of the physicians. The most important reasons for dissatisfaction in each group were respectively the high costs of the services, the long waiting lines, and lack of attention from the physicians.[18] In the study of Ghanbari et al. also, participants mentioned cases such as a shortage in the budget, the dissatisfaction of the personnel, lack of facilities and appropriate environment, heavy workload and the discrimination between the care providers that was caused by this plan.[19] Mortazavi et al. gathered the opinions of the beneficiaries of the Health Reform Plan in Khorasan through a qualitative study. The challenges were categorized in seven subcategories of false referrals of the patients to the health centers; increased workload of the personnel; insufficiency of the infrastructures for executing the Health Reform Plan; the chance of increased medical malpractice, the chance of disrupted relationship between the therapist and the patient, and the chance of decreased quality of the provided service due to the increased workload; and the concern about continuity of the Reform Plan.[20] Due to customers’ dissatisfaction from occupational burnout, wasting caregivers’ time, and defects in the quality of the services in almost studies, attention to causes and solutions of challenges is necessary.

Providing simple and common services, providing concurrent services to multiple caregivers, confusion of the caregivers, inexperienced care providers, and frequent changes in the care provider, and ineffective communication between care providers and caregivers, are some of the factors that could decrease the caregivers’ trust in the health system. In the study of Alidadi et al., not paying attention to the ethics and spirituality, disproportion between the provided packages and the needs of the patients, lack of independence and authority for the patients to choose the type and method of their treatment, and being inaccurate in preserving the patients’ secrecy were mentioned as the challenges of the Health Reform Plan.[21] In the present study, caregivers expected to receive specialized therapeutic and diagnostic services in the health centers, each caregiver would be assigned a separate room, and the privacy of the patients would be respected, the specialty and major of each care provider would be clear and they would provide their service on its basis, and experienced and fixed care providers would be employed for providing the services.

Caregivers were dissatisfied with the need for repeated visits, unnecessary referrals, and increased waiting and service providing time. In the study of Wright et al., the most important reason for caregivers’ dissatisfaction was the long waiting time. He suggested that the caregivers’ dissatisfaction with the long waiting time could be decreased through establishing appropriate communication during the waiting time, emotional support, providing sufficient information, and presence of competent caregivers.[22] Golmakani et al. also mentioned the increased number of false referral of the patients to the health centers and disrupted the relationship between the therapist and the patient as the challenges of the Health Reform Plan.[20] To resolve these challenges, participants in the study suggested that the number of unnecessary referrals to the general physicians should be justified and the number of caregivers covered by each care providers and unnecessary cares should be decreased.

According to the results of the present study, providing free services, providing various services, patients’ follow-up, and beautification the environment of the health units were some of the services that the caregivers were satisfied with. In contrary, results of the study by Hashemi et al., that was aimed to compare the level of caregivers’ satisfaction in the emergency ward of the Shohadaye Tajrish of Teharn before and after the establishment of the Health Reform Plan, showed that satisfaction with provision of education before and after discharge from the hospital, the condition of the hospitals’ rooms, the cleanness of the lavatories, in-time examination by the physicians, spending time and attention during examination, recommendations related to the improvement and well-being of the patients, the condition of financial considerations, and also level of clarity of the health sections and ethics considerations was significantly decreased;[14] this probably might have been due to the higher rate of visits to the hospitals. In addition, in the study of Alidadi et al., qualitative and quantitative improvement of the provided services, increasing the public access to the health services, increasing the number of hospitals’ beds, and upgrading and repairing rusty centers, were mentioned as the opportunities of the Health Reform Plan.[21] On these finding, the quality of services, free services, and pleasant environment are important factors that should be noticed by policymakers.

The lack of motivation, working to maintain the occupational position and lack of occupational security had caused the care providers to lose their motivation for work. Although lack of occupational motivation has not been mentioned in other studies, in the study of Ghanbari one of the mentioned challenges for the Health Reform Plan by the participants was predicting the crisis in financial resources and shortage in efficient human resources in the future.[19] Also, in the present study, one of the concerns of the participants was a discontinuity of the Health Reform Plan due to the shortage of financial resources or changes in the government. Participants in the study of Alidadi et al. also emphasized on periodic and unplanned decisions and inappropriate policy-making as the challenges of the Health Reform Plan.[21] Participants’ recommendations for resolving these challenges included monitoring and evaluation of the care providers’ performance based on the quality of the provided services and establishing trust about the occupational future of the care providers.

Health-care providers stated that they have experienced physical and mental damages due to their heavy workload and its related difficulties and stress. In line with the results of the present study, in the study of Bastani et al., the physicians were mostly dissatisfied with the increased number of patients and the patient's behaviors toward them, the quality and quantity of the medical facilities and equipment at their workplace, and their payments. The nurses and personnel were also mostly dissatisfied with the increased number of the patients and their low income.[16] Participants in the study of Ghanbari et al. also mentioned the imposed heavy workload on the hospitals’ personnel as one of the most important challenges and believed that the imposed workload on the health system has not been proportionate to the predicted workforce.[19] To resolve these challenges, participants suggested that the humane aspects and needs of the care providers should be more attended, the load and hours of work should be planned based on the personnel's abilities, and ergonomic standards for creating a safe working environment for the personnel should be respected.

Injustice, the necessity to fulfill unrealistic expectations, and not profiting from occupational advantages were some of the issues that the care providers were dissatisfied with. Participants in the study of Alidadi et al. were dissatisfied with discrimination and the distance between physicians and nonphysician personnel, inequality in providing the needs of the physicians and nonphysician personnel, and inequality of the payments between the personnel.[21] Nakhaei et al. also reported dissatisfaction with the workplace as the most important dissatisfaction of the nurses with the Health Reform Plan.[23] In this regard, the requests of the care providers included increased payments and fair payments in accordance with individuals’ workload, gradual increase of the care packages, fair distribution of the workload among the care providers, assigning the duties based on the care providers’ specialties, and applying the rules of the Bureau of Labor for corporate and contract staff.

Limitations

The lack of access to some of the experts and key individuals in this field was one of the limitations of the present study.

Conclusions

Results of the present study showed that, although caregivers are satisfied with some aspects of the Health Reform Plan in the field of health including providing free and various services, follow up the patients and beautification the environment of the health centers, this plan still has many weaknesses; which have caused the dissatisfaction of the caregivers and care providers. Considering that the satisfaction of the customers could affect the desire of the foreign customers for using the provided health services and also the manner of providing the services by the care providers, performing similar studies and presenting the results to the policymakers for justifying the Health Reform Plan seems necessary.

Financial support and sponsorship

This work was supported by the Research Deputy of Qom University of Medical Sciences (P/34/11924).

Conflicts of interest

There are no conflicts of interest.