Integrated framework to improve health policy implementation in the way of Iran 2025 vision: Bridging policy to practice gap in developing countries.

INTRODUCTION: Health policymaking seems simple; in practice, but, it is very complex. However, this study aimed to provide a framework to bridge the gap between policy and action in order to present an interconnected model for developing countries.
MATERIALS AND METHODS: This was a qualitative study. Using desk search, different models were searched from various scientific databases for formulation of an integrated policy-making framework. In next stage, the identified National upstream documents were analyzed to achieve existing policymaking evidence. Then to determine the validity of the initial model and to gather the views of key experts, two Delphi rounds were used. The tool used in Delphi method was a 9-point Likert questionnaire that was sent to the experts via E-mail.
RESULTS: This model, by employing integrated chain of visions and strategic targeting of ultimate aims on the one hand and expected key functions and support functions for generating output (operational goal) on the other, provides an extensive operable insight being influenced by human-Islamic principles and values, social, technological, economic, environmental, and political for strategic as well as operational managers./Policy makers.
CONCLUSION: This framework consisted of general, strategic, and executive levels. It creates the needed institutional and structural capacity to achieve a comprehensive health approach for all laws and policies to control social factors affecting health, improve health situation, and promote the health of citizens. Copyright:

Introduction

Health is a simple concept. However, the definition of policy-making and execution of policies is not simple; there are many obstacles.[1] There are several different models which are used to define health. Using holistic model, World Health Organization (WHO) (1948) defined health as a complete physical, psychological, and social well-being, and not just the absence of illness or disability; in 1984, it transformed “health as a state” to a dynamic model in which health was introduced as a process.[23]

The health of people has always been one of the main concerns of governments. It is one of the sovereignty goals and civil rights of all countries, including Iran. The community health impact on just and sustainable development.[45] This development will be possible if government take into account the factors affecting health. This approach will strengthen political discourse on health, its determinants, and responsiveness to health outcomes.[6] The WHO defines public health policymaking as “including health at policy-makers” agenda at all levels and departments, directing policymakers to get aware of outcomes of their decisions on health, and accepting health-related responsibilities.[7]

According to WHO, the government is responsible for directing health system. The Ministry of Health has the main responsibility; it should determine orientations, policies, and strategies, impact on behavior of actors at inside and outside of health department, monitor, organize, and guide the efforts, and develop national health actions.[68] The health system consists of individuals, units, resources, interdepartment joint plans, and executive actions at various fields; its main goal is to promote the physical, psychological, and social health of people within the framework of national policies.[9] To achieve their general goals, the health systems manage the provision of services, guidance and governance, financing, human resources, information, medicines and vaccines, health products, and physical facilities to provide individual and group services, evidence, and policies to reform individual, organizational, environmental, and social determinants of health.[10] The health systems have been trying to improve their performance by discovering and understanding changes in environment and recognizing diverse needs. In this regard, many have benefited from legislation capacities and documents to achieve this goal. However, the correct execution of these policies is important. Since development is possible through successful execution, the policymaking and its execution are important. However, the studies indicate that the development policies and plans usually face obstacles in their execution and in practice, they are not executed satisfactorily.[11]

The Ministry of Health and Medical Education was established in 1985 for optimal use of medical facilities to provide health care and welfare and medical education and research.[12] As the trustee of health system, numerous macro policies such as Iran's Perspective Document 1404, comprehensive scientific plan, general policies for reforming administrative system, health, population, science, and technology are provided as framework for decision-making and roadmap for organization of health system of Iran.[13] Since most senior decision-makers are not familiar with technical literature of policymaking and planning and express their intentions in policy documents in a variety of ways, it is necessary to find a suitable model for translating, removing overlaps, and implementing policies.

Some models have been proposed to bridge the gap between policies and operations.[14] The logical model is a usual framework to reach this goal but this model is a one-way linear model;[1516] however, the relationship between elements in health plans is more complicated than this linear relationship; this limits the use of logical models in evaluation of complex interventions. Compared to logical models, the system thinking is a way of examining system widely. According to WHO's recent publication, the system thinking may provide powerful methods to identify and resolve health system challenges and is an important factor in strengthening health systems.[17]

The knowledge translation chain model is one system model which has been suggested in recent years as a functional model for making health-related operational decisions.[18] Bridging the gap between what they know and what they do, this model triggers an operational policymaking for policy-makers.[19] The knowledge translation ensures that the decisionmakers at all levels of health system (consumers, patients, experts, managers, and policymakers) use research evidence to validate health decisions.[20] The policy conceptual analysis framework explicitly clarifies this concept and pave the way for wide research activities and development of research tools to identify barriers, facilitators, and execution arrangements.[21]

However, this study aims to provide an executive framework for stakeholders to understand various general policies and tasks of Ministry of Health, Medical Education, and Medicine. Hence, the strategic policymakers in parliament and executive policy-makers may take advantage of them in their decision-makings without overlapping. Then, it will be more likely to become successful in tackling barriers to health development in Iran.

Materials and Methods

This was a qualitative study. Conducting desk search in Google search engine, different methods of describing, analyzing, and improving health systems were searched in health policy-making and planning journals and international health organizations' databases. Considering comprehensiveness, simplicity, and applicability criteria, the research team selected value chain patterns, health system control knobs, building blocks of WHO, and knowledge translation model. Using mixed approach, then, a framework was drafted for determining the future status of Iran's health system and transforming policy-making items into executive plan. Through focused group discussion with a group of health experts, the drafted model was modified, completed, and finalized.[22]

In next step, the identified National upstream documents were analyzed to achieve existing policy-making evidence. The document analysis is a systematic approach to evaluate (electronic or printed) documents and like other analytical methods in qualitative research, it needs to examine data and interpret them to achieve meaning, understanding, and creating knowledge. In general, the documents include writings and images which are collected by researcher.[2324]

The health system policy documents were collected through scientific databases and electronic portals of related organizations. In addition, the manual search of official published reports and existing policy documents was conducted through participation at organizations. The researcher-made questionnaire was used to extract the data from documents. The content of collected data was analyzed manually. The extracted policy items were put into formulated framework. The Delphi technique was used twice to validate primary model and get aware of opinions of experts, informers, and key policy-makers to reach a collective agreement. The first and second rounds of Delphi were conducted with 30 and 15 experts, respectively. A questionnaire (9-point Likert scale) was used as research tool in Delphi method; it was sent to experts by E-mail. This questionnaire consisted of initial proposed model and its components. To analyze the data obtained from Delphi Technique questionnaire, the options with a score of more than 7 were accepted and the options with median 4–7 entered second stage. The options with scores <4 were deleted.

Finding

The selected models of value chain, health control knobs,[25] building blocks of WHO, and knowledge translation model were used to create a framework for mapping the future road map of health system of Iran and transforming policies into integrated and coordinated executive decisions [Figure 1]. This model, by employing integrated chain of visions and strategic targeting of ultimate aims on the one hand and expected key functions and support functions for generating output (operational goal) on the other, provides an extensive operable insight being influenced by human-Islamic principles and values, social, technological, economic, environmental, and political for strategic as well as operational managers./Policy makers.

Figure 1

Decision-making framework for execution of health system policies

Social, technological, economic, environmental, political, and value mega-trends
Vision/general policyGoal or Impact:Life expectancyHealthy life expectancySatisfactionSocial-financial protectionQuality of lifeWealth (share in GDP/GNP)Social capital/happiness	Promoting Health Indicators (Sustainable Development, Public Health Coverage, Social Determinants of Health)	Iran considers human prosperity in all human societies as its idealA developed country which have first place in economic, scientific, and technology areas in region with Islamic and revolutionary identity,Inspires Muslim world and have constructive and effective interaction in international relations;Have health and well-beingComprehensive health and healthy human approach (spiritual, mental, physical, mental/emotional and social health)Promoting health indicators to achieve first place in Southwest Asia.Promoting life expectancy Having a young, healthy, and dynamic community	Target populations:
Strategic Policy/Strategic objectiveDiseasesRisk factors: Obesity, diabetes, hypertension, high cortisol		Providing health and prevention of social harms (especially addiction, divorce, marginalization, urban critical points, and moral corruption), accidents, and diseasesFertility and childbearing healthIncreasing fertility rateInfertility treatment for men and womenImproving health of families, especially fertility and increasing childbearing
Executive Policy/Program objectiveGeneticsLifestyle (nutrition, smoking, exercise, sleep, life skills, etc.)Environment (water, air, soil, etc.)Socio-economic determinants		Realizing health and healthy human approach in all laws, executive policies, and regulationsReducing health hazards and pollutions based on valid scientific evidence.Providing healthy nutrition, improving lifestyle in terms of nutrition (with the help of traditional medicine doctrines).Strengthening and promoting Iranian-Islamic lifestyle to counteract the undesirable Western lifestyles, informing people of their rights and social responsibilities.Increasing awareness, responsibility, capability and active participation of individual, family, and society in provision, maintenance, and promotion of health.Ensuring food security, social security, equal opportunity, decent distribution of income, solid foundation of family, being away from poverty and discrimination, and benefiting from desirable environment.Assigning appropriate facilities for mothers especially during pregnancy and lactationSpatial and geographic re-distribution of population, proportional to biological capacityPrevention of environmental pollution
Output/product/service/operational objective	Health service: educational, research, health (public health - health promotion, prevention), treatment and rehabilitation/prevention priority, organizing counseling system, teaching life and communication skills, and providing counseling services/physical and emotional care (elderly)
	Evidence health impact assessment)	Policy
Main function (service delivery)	Evidence Based Practice
	Traditional medicine	Modern medicine
	Achieving scientific authority in science, technology, and medical services and turning Iran into a medical pole of Southwest Asia and Islamic world.Strengthening the social security system, health and care services and medical care for reproductive and childbearing health
Support function	Provision of health products (medicines, vaccines, supplies, and medical equipment) with high quality and international standard.	Providing physical resources
	human resources generation: targeted, health-based, based on community needs, responsive and equitable	Production of information and science and technology with innovation system approach.
	Stewardship: Stewardship of health system by Ministry of Health and Medical Education. Health resources management through insurance system with collaboration of other centers and institutions.	Financing: Health insurance (health), therapy/service package/tariffing services/strategic purchasing of services/paying based on quality of performance
	Control Knobs: macro organization (separation of duties, financing and provision of services in health/establishment of regionalization with priority of health promotion services and their prevention and integration into medical education system), regulation and enforcement (modifying and completing monitoring systems, monitoring and evaluation to ensure legitimate protection of rights of people and patients/promoting decision-making and action based on scientific findings/preparing health plan for macro development plans/food, water, air, sports facilities, safe food products along with observing national standards and regional and global criteria), gathering and pooling the financial resources (transparency of income-expenditure-activity) (share of gross national product and general government subsidy/subsidy of health sector/imposition of tax for harmful goods and services), payment system, encouragement and incentives for stakeholders (providing positive incentives for service providers).
	Science and Technology: Establishing a new Islamic-Iranian civilization for national development, creating justice, and inspiring the World Having competent, educated, healthy, and educated people in school of Islam and scientists in top ranks in the world; capable to produce and develop science and technology and use its achievements; Leading in knowledge and technology with scientific authority in the world. Science and technology as empowering, productive, and coordinated with environment and spiritual, physical, psychological, and social health of community (Information technology, bio, nanotechnology, micro/oil and gas field, nuclear, dispatching human to Space)
Humanistic-Islamic principles and values: Religious democracy, social justice, legitimate freedoms, maintenance of human dignity and rights/ethics, priority of public interest to individual and group interests, strengthening the spirit of co-operation, participation, and responsibility in scientific community and institutions related to it/elements of national (Iranian, Islamic, revolutionary) identity, and promotion of social consensus and convergence

The documents which determined the goals and orientations of health system (i.e., Constitution, Iran's Perspective Document 1404, Iran's document of comprehensive scientific plan, and general policies related to health system) were identified, analyzed, and placed in framework. According to Figure 1, Iran is struggling to promote the human prosperity of entire human society and tries to be at first economic, scientific, and technological place in Southwest Asia region with Islamic and Revolutionary identity, inspire Muslim world, and interact constructively and effectively in international relations, and develop social well-being. To achieve first place in region in terms of health indicators, Iran has included the realization of health and healthy human approach in all laws, executive policies, and regulations. All four dimensions of health (namely, physical, psychological, social, and spiritual) are considered by policy-makers. Increasing fertility rate and prevention from accidents and diseases and social damages such as addiction, divorce, marginalization, urban critical points, and moral corruption are among the strategic goals. Reducing health hazards and pollutions, especially environmental pollution, providing healthy nutrition, improving lifestyle in terms of nutrition and responsibility, and capability and active participation of individuals, family, and society in provision, maintenance, and promotion of health are among the most important executive policies. Updating health services including education, research, health (general health-health promotion and prevention) services, treatment and rehabilitation, and production of credible scientific evidence to adopt effective health policies are among the expected outcomes. Undoubtedly, the health system's supporting functions for producing such products should be changed in terms of structure and process according to policy tasks. In these documents, the developed human is determined to be healthy, motivated, responsive, religious, patriotic, law-abiding, active, responsible, selfless, believer, satisfied, conscientious, disciplined, committed to prosperity of Iran, and proud of being Iranian. The target groups include youth, young couples, mothers (especially during pregnancy and lactation), individuals at work age, individuals in rural and marginal areas, and oppressed people[26272829].

Discussion

Today, the reforms in health system revolve around policy reforms. Any reform in health system structure should be followed by policy reforms; that is, the aims and direction of policies determine the reforms at structure of health system and its functions.

The presented model illustrates the route of health system in line with intentions of senior policy-makers in three general, strategic, and executive levels. As a macro social supertrend, the comprehensive health approach necessitates the cover of all causes of diseases and continuous improvement of health outcomes along a range of dimensions of health promotion, prevention, treatment, and rehabilitation and reduces inequity in health. This approach should be supported by government actions on upstream health-related social factors;[30] this is seen in model.

Focusing on health determinants, the emphasis is shifted from planning, investing, and providing health services to a wider range of political, economic, social, and environmental factors which have more effects on people health.[31] The socioeconomic policies are the most important determinants of health and the macroeconomic policies affect health and health inequities.[32] The determination to integrate social determinants in health care system,[33] including them in routine health assessments, considering social problems as a part of care plan for individuals, and using health information technology to collect information on health-related social factors to improve policies and practices[34] indicate the importance of considering social factors affecting health in all laws, regulations, and executive policies and the role of technology as one of the functions supporting the health system in National Perspective Plan.

The policies should be designed as manageable and controllable and have dynamic relationship with around environment. The health policy is just one of components of social policy and should be designed and implemented alongside other social policies. In all policies, the health is a collaborative approach to improve the health of all individuals by integrating decision-making considerations in all policymaking sectors and areas.[35] The health strategies also work at several levels and their effects go beyond health outcomes; other departments achieve health outcomes without interfering in health sector.[36] The transparent goals and perspectives explained in model, powerful leadership in health system and government, legal support through reviewing health laws, and establishing a supportive structure are the prerequisite of realizing health in all policies.[37] Creating the needed institutional and structural capacity and determination and follow-up at government's highest levels to realize comprehensive health approach in all policies are steps toward controlling social factors affecting health, improving health status, and improving desired health of all citizens.

This framework introduces justice, fairness, solidarity, transparency, accountability, and sustainability as its ethical values. The actions in model include governance and policymaking, participation and work, empowerment of individuals and communities, health reforms, research and evidence, monitoring, and reporting and evaluation as a response to threats to health and economic growth of Iran in future.[38] According to the WHO model, stewardship and its functions directly effects on health systems' goals and outcomes such as accountability, effectiveness, quality, accessibility, coverage and safety, while, it is evident by national and international documents and policies that it has been facing an indirect effects of health systems analysis approaches on health sectors' outcomes and aims. Framework of public health critical functions also is being used in health sector assessment.[3940]

The WHO's value-based health policymaking framework determines the strategic health goals of Europe as more justice and better governance of health and sets the priorities as investing in health, empowering people, addressing health challenges including infectious and noncommunicable diseases, strengthening community-based health systems, creating capacity for general health and emergency preparedness, care and response, and creating flexible societies and supporting environments.[41]

Focusing on disadvantaged people is one of the important issues in health system policies. Since the legal and policy documents in health sector did not mention the creation of a good relationship between authorities for protecting poor and disadvantaged people in accessing health services, there is an inconsistency and overlap between tasks in this area.[42] Unfortunately, poor people do not have adequate access to health services.[434445] Directing health policies and practices towards poor and needy people may reduce inequity in accessing to health services.

In order to execute the policies outlined in this framework, the prerequisites should be determined for preparation at executive level and removal of barriers. The Australian National Audit Office has determined eight building blocks for successful execution of policies: governance (whole of government approach or policy in all policies), risk management (early detection and management of risks of policy execution), involvement of stakeholders (determining goals for identification of stakeholders), managing conflicts and interactions using their information, planning, resource mobilization (workforce and required skills), financial resources and systems, monitoring, and review and evaluation through active involvement of stakeholders. This report considers the powerful leadership, comprehensive approach, accurate processes, efficient use of resources, and paying attention to execution at each stage of policy design as necessary prerequisites for successful execution. The government awareness of risks involved in execution phase, setting default answers to deal with them, and using the experience of executives in designing policies are important.[46]

More recently, scholars have moved beyond the general claim that “ideas matter” to study how they matter and how they implemented. As argued in other articles, however, the recent multiplication of ideational studies in political science and related disciplines cannot hide the relative neglect of policy implementation within that scholarship. The mismatch (or the harmony) between the ideas associated with a particular policy and the assumptions of the actors tasked to implement it can directly impact the implementation process, and policy development in general.[4748]

The Analysis of Determinants of Policy Impact model determines the levers of influence or determinants of success or failure of policymaking process and adoption of strategies for successful execution of policies as: consistency of goals, commitments (policymakers' professional duties and institutional arrangements of policymaking system and its target community), resources (capabilities of policymakers and their respective organizations such as their personnel and their financial resources), and opportunities (organizational opportunities including new decision-making structure, political opportunities including cooperation between different political sectors, and public opportunities including support of society and media).[4950] Considering this approach, taking steps for proper institutional organization of executives and their active engagement, assigning sufficient resources for execution, predicting challenges and threats, and taking advantage of opportunities should be included in policymakers' agenda for executing policies.

Conclusion

Finally, it is important to note that the health sector alone is not able to create an excellent level of health and well-being for people; this goal requires national solidarity and awareness and social participation. Focusing more on role of people in promoting health, utilizing community capacity to improve health and its components, attracting support for increasing attention to role of health in improving economic growth, considering health in all macroeconomic and social policies, integrating health-related social components in care provision plan provided by health system, and collaboration of other health institutions and organizations to improve the health of society within the health policymaking framework which is provided in this study will help to improve the health of all Iranians and will provide health services for all people. One of the most important innovations in this research is the comprehensive integration of policy and planning literature in the model. The research team, by systematic reviewing all available national upstream documents, has attempted to delineate a comprehensive insight into supreme politicians' priorities and concerns through a concise framework for health system planners working at different industry levels and positions.

Furthermore, research limitations include the inability to access the policy development details such as exact debates and discussions during meetings and the process of formulating general policies in the upstream document to better understand policymakers' intentions. In addition, the resultant framework was solely based on the scientific and practical experiences of the research team synthesized according to different planning patterns; thus, there is room for possible human error.

Financial support and sponsorship

This study is a partial of a PhD thesis approved and supported by Iran University of Medical Sciences (Grant No:. IUMS/SHMIS_1395/9321557003).

Conflicts of interest

There are no conflicts of interest.