Investigating the service provision challenges by healthcare providers in selected comprehensive health centers.

INTRODUCTION: The healthcare program has opponents and supporters with its multiple policies and also its difficult implementation, which requires that its barriers and problems be addressed comprehensively and extensively. This study was conducted aimed to determine the service provision challenges by healthcare providers, from their point of view, in selected comprehensive health centers of Isfahan.
MATERIALS AND METHODS: The present study is a descriptive-analytic one. One-hundred and ninety-seven healthcare providers were selected by census sampling method from the population of female healthcare providers in Isfahan comprehensive health centers in 2017. The data collection tool was a researcher-made questionnaire in the field of individual-professional, managerial-organizational, and executive challenges. Data analysis was done by repeated measures ANOVA and post hoc test.
RESULTS: The findings indicated that there was a significant difference between the mean score of individual-professional, managerial-organizational, and executive challenges (P < 0.001) from the point of view of healthcare providers. According to least significant difference post hoc test, the mean score of individual challenges was significantly lower than that of managerial and executive challenges (P < 0.001). However, there was no significant difference between the mean score of managerial-organizational and executive challenges (P = 0.46).
CONCLUSION: Based on the results, healthcare providers have put forward several challenges during the implementation of the healthcare program. Meanwhile, executive and managerial challenges have been considered more than individual challenges. Considering that this could lead to improper service provision to the clients, the role of policymakers in this program to remove obstacles and to provide satisfaction to healthcare providers is emphasized. Copyright:

Introduction

In today's world, health outlooks have wider prospects, and people's expectations and attention to safety, quality, and justice have increased, so requests for a responsive health system have also increased.[1] In this regard, the Ministry of Health, Treatment and Medical Training as a healthcare provider in the country, with regard to its general tasks and missions and upstream documents, has considered the health reform plan with three approaches of people's financial protection, establishing equity in access to health services, and also improving the services’ quality.[2] The plan has been implemented since 2013 in three phases of marginal areas, urban informal settlements, and then in urban centers.

One member assigned to this team was a person with bachelor degree in family health care, who is a person with an academic and professional background in one of the fields of family health, public health, nursing and midwifery and becomes a multitasked professional called the family healthcare provider after passing a 147 h course. This person is required to use population census results, to identify population composition, to screen in order to determine the health level of people, and to provide a service package to her covered households during childhood, adolescence, youth, middle age, and old age. In fact, the expert/professional in family health care is responsible for follow-up and continuity of services. Currently, the plan is being implemented for young graduates, and even for earlier employees of the mentioned fields who have already been employed under their professional titles, in all provinces of the country.[3] The only concern is the high activity volume of these experts, their multitasking, and consequently, providing some nonspecialized services by them.[4]

It is clear for everyone that before this, all the professionals that are currently referred to healthcare provider in the health reform plan, have been highly effective in their professional career position and played a very effective role in increasing the care quality and the effectiveness of health interventions.[5] The most manifest activity of healthcare providers is the care of pregnant women, and all their efforts are to promote the valuable indicator of maternal and newborn health.[6] Over the past years, with these capable and effective health service providers, there has been no concern over the implementation of the country policy plan for raising birth, the promotion of safe and physiological childbirth, and even managing high-risk pregnancies, despite the rising marriage age, and the cost-effectiveness of their activities was evident to all.[7]

However, is the mother-care process the same as the former, with the provision of health care by health care providers and a multitasking approach? And whether healthcare providers do other service-related activities properly for all age groups is questionable, since it is believed that service providers should be able to provide opportunities to their covered groups in order to promote and improve the quality of life at the right time and through prevention of inevitable complications, reducing disability and adding supportive services to meet the expectations of clients.[8] Bria Seran et al. in Indonesia argue that taking measures such as care for the elderly, schools special plan and following up patients with tuberculosis and malaria by midwives takes 50% of their time and prevents them from performing their core services.[4]

Mahdian and Jahangard in their overall review of health reform plan, concluded that the main challenges in this plan were increased workload and shortage of workforce.[9] In his study, Aghababaean Dehaghani stated that with this human resources quantity and this job description in the health reform plan, the team will not be able to meet the goals set.[10]

The researcher has closely observed different views on the planning and provision of health services by healthcare providers and how services are provided by them. Some consider this plan suitable for job creation, and some believe that it is unsuitable due to weakening the professional position. In addition, there are some who oppose the plan, by expressing the concern that the implementation of it faces the service provision to the mothers to deficiencies.

On the other hand, it is clear to everyone that it is better to use pilot plans to eliminate defects and shortcomings in order to ensure the compliance of any applicable health plan, since the use of the pilot plan leads to better results and prevents further problems compared to sudden implementation of the plan.[11]

Making a change in the system requires awareness, participation, and cooperation, and paying attention to the views of stakeholders and people who are most likely to be affected by the change is also of great importance.[12] Unfortunately, the service provision by the healthcare provider was implemented suddenly, after the start of the pilot plan, without being reviewed and monitored.

Since the sudden change in the system could potentially lead to undesirable consequences, the unsolvable problems of the program, including managerial or executive ones, have left a lot of known and unbeknown things in the minds of managers, experts, and even service providers. On the other hand, there is no proper analysis of the views of the planners and implementers of this kind of service provision, and the most research has been done in the area of treatment and in the hospital.

However, for the reasons mentioned, there are many discussions and challenges regarding the health care program. In this regard, the researcher, as a midwife who is actively and continuously present in comprehensive health centers, has closely witnessed the concerns, confusions, and healthcare providers’ overbargaining on service provision to the social strata, and the passage of time over the past years has not been able to solve their problems. Therefore, it seems appropriate to know the views of healthcare professionals and healthcare providers so that health policy-makers can solve the challenges by employing the best practices. This study was conducted to determine the challenges of service provision by healthcare providers in comprehensive health centers.

Materials and Methods

This is a descriptive-analytic study conducted in 2017. The statistical population consisted of all female healthcare providers of Isfahan comprehensive health centers and their affiliated centers. Sample size was 171 according to the equation: n = Z2 (S2)/d2. For more accuracy and risk of loss of 20%, the sample size was considered 205.

Healthcare providers were also selected by a simple census from the applicants. Of these, 8 individuals answered the questionnaires incompletely. The final sample size was 197. The conclusion criteria were satisfaction and interest in participating in the study and having at least 2 years of employment in the health sector.

The data collection tool was a researcher-made questionnaire that was designed in four sections following the study of authoritative domestic resources and online libraries. These sections included a demographic information questionnaire on healthcare providers consisting of 6 multichoice questions, a questionnaire on individual–professional challenges, containing 16 items with Likert 5 options scale, from strongly agree to strongly disagree, a questionnaire on managerial–organizational challenges, consisting of 31 with Likert 5 options scale, from strongly agree to strongly disagree, and questionnaire on executive challenges, containing 30-item Likert 5 options scale, from strongly agree to strongly disagree. The questionnaires were completed by the self-report method after receiving the informed consent from the research units. Content and face validities were used to determine the questionnaire validity. The questionnaires were distributed to 15 faculty members of the Department of Midwifery of Isfahan University of Medical Sciences, and one manager and two experts from the health center of the province, and then, structural and content reforms were made based on their suggestions. The internal consistency index (Cronbach's alpha) was used to calculate the questionnaire reliability, which was more than 0.8 for all three questionnaires. Data were analyzed by repeated measures ANOVA and post hoc test using SPSS Version 18 (SPSS Inc., Chicago, IL, USA, SPSS) software. The code of ethics for this research is IR.MUIREC.13963043.

Research findings

The results indicated that of a total of 197 healthcare providers participating in the study, the highest frequency (48.2%) was related to those who were educated in midwifery and the least frequent (2.5%) was for those who were educated in nursing. The results also showed that of a total of 197 healthcare providers participating in the study, the most frequent (59.9%) belonged to those with a bachelor's degree and the lowest frequency (6.1%) related of those with a master's degree. In addition, the type of employment of most healthcare providers (53.5%) was permanent, and only 1% of them were employed by staffing plan [Table 1].

Table 1

Frequency distribution of the discipline and degree, type of employment, and length of service for healthcare providers

Variable	Discipline	N (%)
Discipline	Midwifery	95 (48.2)
	Public health	46 (23.4)
	Family health	43 (21.8)
	Nursing	5 (2.5)
	Other disciplines	8 (4.1)
Degree	Assistant	67 (34)
	Bachelor	118 (59.9)
	Masters	12 (6.1)
Type of employment	Permanent	106 (53.8)
	Contractual	8 (4.3)
	Temporary to permanent	81 (41.1)
	Staffing plant	2 (1)
Length of service (years)	2-5	67 (34)
	6-10	18 (9.1)
	11-15	21 (10.7)
	>15	91 (46.2)

SD=Standard deviation

Repeated measures ANOVA test showed that the mean score of individual–professional, managerial–organizational, and executive challenges of healthcare providers were significantly different (P < 0.05). Furthermore, the mean score of individual–professional challenges was significantly lower than the mean score of organizational–managerial and executive challenges (P < 0.001). However, there was no significant difference between the mean score of organizational–organizational and executive challenges (P = 0.46) [Table 2].

Table 2

Mean score of individual-professional, managerial-organizational, and executive challenges from the viewpoint of healthcare providers

Challenge name	Score, mean (SD)	Repeated measures ANOVA test
		F	P
Individual-professional challenges	73.33 (15.17)	26.17	<0.001
Managerial-organizational challenges	80.63 (17.67)
Executive challenges	79.11 (16.12)

The LSD post hoc test indicated that the mean score of individual-professional health challenges of healthcare providers was significantly lower than the mean score of their managerial-organizational-management and executive challenges (P<0.001). However, there was no significant difference between organizational-management and executive challenges (P=0.46). SD=Standard deviation, LSD=Least significant difference

Five items related to individual–professional, executive, and managerial–organizational challenges that are the most frequent among respondents are also given in Table 3.

Table 3

Frequency distribution of the most contingency in the questionnaire related to individual-professional, managerial-organizational, and executive challenges

	n	Mean (SD)
5 items related to individual-professional challenges with the most frequency
Everyone likes to be known at work as having a discipline in accordance with his/her job	196	3.5918 (0.66928)
Health care providers consider the amount of service they are expected to be more than their capabilities	195	3.4410 (0.94179)
Individuals do not feel good about graduates of different disciplines with a common title who play a role	195	3.2769 (0.96069)
Personal desire and interest are essential for adopting a healthcare provider job	196	3.2602 (1.07114)
The individuals’ motivation to serve as a healthcare provider has been reduced	195	3.2410 (1.01451)
5 items related to managerial-organizational challenges with the most frequency
The plan to provide all services by a multitasked health care provider is not a good policy	197	3.6650 (0.70670)
The cost of providing healthcare services by healthcare providers is not anticipated	196	3.5561 (0.79866)
Potential limitations and shortcomings in service provision by healthcare providers is not anticipated	197	3.4772 (0.78619)
The number of healthcare providers is not determined by scientific standards	193	3.4249 (0.89315)
The multiplicity and simultaneity of changes in the field of health (Integrated Health System (SIB), healthcare providers, etc.) have caused disruptions in service provision	193	3.4249 (0.85135)
5 items related to executive challenges with the most frequency
Extensive workload and multitasking of health care providers cause their job burnout	196	3.7755 (0.59967)
The high workload and working hours cause individuals to be exhausted and thus disturb the service provision	197	3.6650 (0.73501)
Spending too much time to record and document by healthcare providers reduces the time needed to service provision	197	3.6497 (0.65009)
The enough private space for service provision by healthcare providers to all people in different age groups is not foreseen	196	3.6276 (0.75042)
The threat of dismissal or displacement of the workplace in response to the dissatisfaction of healthcare providers causes them to be indifferent	195	3.6000 (0.78254)

In this table, numbers 196, 195, 193. are among the total number of 197 people, despite 197 individuals, due to these individuals responding to related questions. SD=Standard deviation

Discussion

As is evident, most healthcare providers are midwives, and most of them are permanently employed. Considering that the mean score of three challenges of individual (70.33), executive (79.11), and managerial (80.63) is 76.69 of 100, and it is a high score, it can be said that midwives has the highest frequency among healthcare providers and so a large percentage of this score is related to their concerns. Of course, it should be noted that these concerns are formally and informally obvious in their writings on websites and virtual space and have attracted the attention of public medical community.

However, today the names of people who have been considered as forerunners in the midwifery position due to the type of their employment for many years have changed, and they see themselves as having no professional identity. However, the major capabilities of these service providers are in line with the protection of the health of the two vulnerable groups of mothers and children, and in many countries, including Iran, the provision, maintenance, and promotion of health of these two groups is a national priority.[13] These people have been and are the main owners of their careers in policymaking and decision-making to promote the health of vulnerable groups of society.

In their study, Pourkazemi et al. suggested that midwives seek to resolve the existing challenges to midwives’ management positions to improve their professional status so that appropriate policies and decisions can be made to promote the midwifery profession.[14] In their examination on barriers related to midwifery profession development, Shaban et al. concluded that factors such as the lack of understanding of midwifery status in the society and the dominance of the physicians in the health system were effective in not recognizing midwives and their lack of motivation.[15] Sullivan et al. in Australia have identified job satisfaction following facilitating their conditions by healthcare policymakers as one of the most potentially influential factors in staying midwives in their careers and stated that job satisfaction results in more enjoying the activity area and being proud to be employed in midwifery.[16]

According to the present study and the above ones, it is clear that midwives are not only interested in preserving their titles and position but also in developing and expanding this profession by creating managerial posts, because the owners of this profession are trying to promote the health of vulnerable groups and in this regard, they are always and everywhere responsible for the health system. As a result, their concerns are not far-fetched. Changing their title to healthcare provider has created challenges for them in different areas.

Based on the results of repeated measures ANOVA test, the mean score of individual–professional challenges, managerial–organizational, and executive healthcare providers was significantly different (P < 0.05). The least significant difference (LSD) post hoc test indicated that the mean score of individual–professional challenges of healthcare providers was significantly lower than the mean score of managerial–organizational and executive challenges (P < 0.001), but the mean score of managerial–organizational and executive challenges was not significantly different (P = 0.46). This suggests that from the viewpoint of healthcare providers, individual–professional challenges were less important than managerial–organizational and executive challenges, and there was no difference between managerial–organizational and executive challenges.

In reviewing the most important items related to managerial–organizational challenges, multiple responsibilities, high workload, and professional concerns caused by the lack of clear policies in this regard are considered, and domineering management style in plan implementation and threats to proposers and critics to be fired have increased the vulnerability of these people. Regarding these results, it must be mentioned although the focus on employing these individuals as healthcare providers has led to the elimination of the professional status of all four health team groups, namely midwife, public health, family health, and nursing, and removing the name of these individuals and assigning duties to people other than them have caused dissatisfaction, frustration and indifference in this plan, but what is worse for healthcare providers is a big barrier due to the high workload and the multiple activities on the path to service provision and promotion of women's health in this country that has caused confusion and distrust of clients, as well as inappropriate provision for these people. In this regard, we also realize the violation of the principle of resistance economic in the field of health with a careful attention to the details of the problems, because each of these individuals are the most appropriate and cost-effective health care and service providers, and investing in these human resources is one of the best investments to improve the health indicator.[17] As a result, not benefiting from these individuals’ services in appropriate job positions leads clients to more expensive services in the private sector, and in the long term, their continuous referring to the private sector is also decreased or stopped due to the lack of affordability.

The lack of attention of managers to solve the problems relate to this plan and not taking into account the lack of coordination between workload and salaries also indicate their authoritarian management, because in this management model, the authorities impose their orders arbitrarily on employees. They order and employees are forced to obey them. In this case, managers do not see themselves as obliged to identify the employees’ job problems and analyze these problems[18] and in the event of disturbance in their work fields, punish or replace them. Therefore, it seems that reduced motivation and considering this challenge in different areas by healthcare providers is also largely originated by inattention from managers and authorities.

Kheyri et al. studied the implementation of six programs for health reform plan based on the main indicators of each program from the viewpoint of treat monitoring experts. In this study, they stated that several reasons, such as lack of availability of some managerial and executive infrastructures, inadequate training, lack of human resources, increased load of patients referring to healthcare centers, and increased the problem load of health centers, are among the problems of healthcare providers.[19] Darabi et al. in their study titled “Opinions of the Stakeholder of the Health Reform Plan” stated that there is a possibility drop in the quality of service provision due to increased workload.[20]

Therefore, according to the results of this study and the above-mentioned ones, it can be said that multitasking, except in the case of precise prediction of its problems, has no place in the healthcare system because a healthy and high-quality service provision is affected by these deficiencies. Hence, the service provision in every person's job area, along with friendly team cares with respect to the field of activity of each discipline, is the only way to achieve success in the path of service provision to all society strata, especially mothers and infants.

The strength of this study was that it was done for the first time in Iran and its weakness was that it was performed solely on female healthcare providers. In this regard, it is recommended that such research be carried out on male and female healthcare providers.

Research limitation

Fear of losing job position in healthcare providers during presenting their opinion while completing the questionnaire and therefore its impact on the way of responding is the limitation of this study.

Conclusion

As is evident, healthcare providers have put numerous challenges, and they say this more in the area of organizational management of the ministry. Furthermore, according to their point of view, these problems create problems that can lead to inappropriate service provision. In this regard, the role of this plan policymakers in overcoming the barriers and challenges of this type of service and providing satisfaction to healthcare providers is emphasized. Given that the main role and task of healthcare providers is to maintain and promote the health of a wide range of vulnerable groups of society (mothers, women, and children), and accepting that this may done by a graduate in the midwifery in a better way, and as we see that the majority of healthcare providers are midwives, it can be concluded that henceforth, midwives should play a role in protecting and promoting the health of mothers, apart from healthcare providers and under the title midwives, to improve the health of these two vulnerable groups.

This research is the result of a research project no. 396433 of the Research Department of Isfahan University of Medical Sciences.

Financial support and sponsorship

This study was financially supported by, Isfahan University of Medical Science.

Conflicts of interest

There are no conflicts of interest.