An Evidence-Informed and Key Informants-Appraised Conceptual Framework for an Integrated Elderly Health Care Governance in Iran (IEHCG-IR).

PURPOSE: Population ageing has been steadily rising in Iran and in the over 60-year-old population, the ratio increased from 5.4% in 1986 to 8.6% in 2016 which represents an increase of 4.3 million over the past three decades. The inevitable impacts of a growing elderly population on the demand-side of the health care provision (HCP) equilibrium call for an urgent revision of the current arrangements of the Iran's National health care system (INHS). The main aim of this study was to scrutinize the best available scientific evidence on the international integrated elderly health care governance (HCG) models to revamp health care practice and policy-making processes in Iran.
MATERIALS AND METHODS: This multiphasic study consists of a scoping review of existent HCP modalities for the elderly population worldwide, and the disposition of an optimal HCP scheme for the elderly population and its application for the detection of the gaps in Iran. The final stage includes a Delphi-based consultation and consensus process which was reciprocated in three rounds and the key subjects were requested to give their judgment on the eventuated HCP layout designed to serve the ageing Iranian population.
RESULTS: The yielded model (IEHCG-IR) included four dimensions consistent with the four levels of prevention along with social support services. The structure and feasibility of the preliminary framework were approved by 83.6% of the study participants.
CONCLUSION: The study findings could have important implications for future policy making in the INHS and the suggested healthcare framework for the elderly Iranian population could be a preliminary model for health system re-engineering.

Introduction

Population ageing has been steadily on the rise in Iran during the last 3 decades with considerable socio-economic impacts. The aged population (>60 years old) ratio raised from 5.4% in 1986 to 8.6% in 2016 which represents an increase of 4.3 million in the number of elderly Iranian people over a time span of 30 years.1 This trend of demographic change is expected to continue and by 2040 there will be extensive consequences, especially in the number of chronic health conditions amongst older people. Therefore, it is expected that the need for social and health care services will increase in order to accommodate the changes in patterns of health and illness and this in turn would add a burden of comorbidities on the country’s national health care system.2

The majority of aged people will be admitted to health care centers at some time or other, with multiple chronic conditions. In such situations preventing and treating acute illnesses will require an integrated approach with several methods of assessing, treating, and caring for the aged patients. The integration has been defined as

a discrete set of techniques and organizational models designed to create connectivity, congruence and collaboration within and between the cure and care sectors at funding, administrative and/or provider levels.

The emphasis is on employing a partnership approach to integrate all services together and to ensure that all target groups, particularly the frail and elderly receive health services.3 The required integration must be implemented at different levels of health care provision including the macro level (establishing the general statutory framework by policy maker) meso-level (establishing cooperative relations between organizations) and micro level (in taking initiatives to assure autonomy of health care providers).4

In many developed countries, the majority of older people receive disintegrated and fragmented health care services.5 This is while; an integrated and comprehensive package of health care services is needed to maintain physical, mental and social wellbeing of older people.6 Meager financial and logistic source of health care services, in developing and under developed countries, calls for the effective and efficient use of existing resources to maximize sustainability and responsiveness of the health care systems.7

The Delphi technique includes certain features, such as the existence of an expert panel, the ability of response repetition to questionnaires in limitless rounds and receiving comments from previous rounds, statistical analysis of responses and anonymity of participants. The ability of collecting the ideas and opinions of experts is another advantage of this technique that are far away geographically, at a low cost.8 Delphi technique has frequently been used in a mixed systematic reviews and gap analysis of health care services.9,10

The growing elderly population in Iran and its inevitable impacts on the demand-side of the health care provision equilibrium in coming decades call for an urgent revision of the current policies and health care arrangement in the country’s national health care system (INHS).11 The main assumption is that reorganizing existing frameworks and resources for provision of a more coherent set of health care services for elderly people could respond to the growing pressure of healthcare needs and comorbidities of the aged Iranian population.

The main aim of this study was to scrutinize the best available scientific evidence on the international integrated elderly health care governance (HCG) models to improve health care practice and policy-making. Based on the retrieved evidence an organizational gap analysis was performed to identify the gap between the status quo health care policies and organizational settlements in Iran and a proposed optimal health care delivery armamentarium applicable for the elderly population.

Materials and Methods

A combination of three steps including the best available scientific evidence reviews, selecting evidence for input parameters and the model structures, gap analysis and consensus reaching process (CRP) on components of a conceptual model for the provision of elderly healthcare in Iran and qualitative verification of the drafted model by cross-examination of the comments made by the experts to justify their validation as well as their suggestions for improvement12,13 were utilized to guide the development of the framework (IEHCG-IR).

Phase 1: Scoping Review of Current Health Care Provision Modalities for the Elderly Population

An extended literature search was performed using relevant MeSH terms (health, social care, care, case management, integrated care, ageing, aging, aged, older, elderly, senior, geriatric) and their Persian equivalents in PUBMED, Cochrane library, Proquest, Ovid Medline and Science Direct to retrieving scientific evidence concerning the health care models, synopses of organizational mandates and policy reports and also research activities geared towards the introduction of conceptual or ideal-typical frameworks (at macro level) to meet the needs of elderly people worldwide that were published before May 2019. Hand searching (Google Scholar and related fields’ websites) was also performed to find grey literature and evidence that was not recognized in database searching to find the aged people targeted routine health care delivery arrangements and policies in Iran, webpages of the Iranian Ministry of Health and Medical Education and relevant uploaded electronic reports were also scrutinized (Figure 1).

Figure 1

Flowchart of the publications’ selection process: consolidation of research evidence to find gap in elderly health care governance (HCG) in Iran.

The identified scientific evidences were assessed by the two authors (MA and AS) for relevancy according to the inclusion criteria, that is, quantitative and qualitative reports in English or Persian that discussed components of a theoretical model for elderly health care provision. The publications referring to challenges, effectiveness or efficiency assessment of health care systems or publications that had focused on consumer satisfaction were excluded. The study data synthesis was carried out in descriptive form by summarizing the extracted data about the components of an optimal health care delivery plan for their exploration in a preliminary draft of health care provision model for the elderly Iranian population. The outlined model was conceived based on a gap analysis to identify the main areas of concern and imbalance in HCG to meet the elderly Iranians’ health needs. The simple checklist approach was utilized in the gap analysis methodology to list the types of health care/services that are granted for older people in other countries of the world but not provided for the aged Iranian population.

Phase 2: Disposition of an Optimal Health Care Delivery Scheme for the Elderly Population

The identified dimensions and components of health systems that had been explicitly arranged to cover older population health needs were screened and a conclusive framework was devised as a gold standard presumptive scheme for comparison and gap analysis purposes. The underpinned core structure was employed to compare the existing INHS’s health care provision policies and running programs in serving the country’s aged population.

Phase 3: Exploration of Key Informants’ Perspectives on a Purposed Gold Standard Health System Arrangement to Serve the Elderly Population

The Delphi technique was utilized to examine a selected group of key subjects’ perspectives including INHS’s elderly health care chief officers along with gerontology, elderly health and public health specialists regarding the adapted presumptive gold standard health care system scheme with regard to its comprehensiveness and feasibility for possible application in Iran.

The approached subjects were all provided with an outline of the key questions and questioned regarding what they perceived to be suitable components and the arrangement for a conceptual EHCG model for Iran. Due to their work experience and having knowledge about INHS’s current hurdles in providing the required healthcare for the country’s elderly population, they were assumed to be legitimate candidates for becoming members of the advisory panel in the Delphi rounds.

The adapted model had four main dimensions to cover preventive, medical, rehabilitative and the daily life support needs of the aged population.

The study participants were asked to give their opinions on the blueprint of the aimed gold standard framework to provide the required healthcare for the elderly population of Iran. The respondents were requested to express their sentiments about the necessity and feasibility of each individual component of the drafted model on a 5-point Likert-type scaling option (from strongly disagree to strongly agree). They were also encouraged to comment on and give their recommendations about any item within the pondered schema or add to the assumed items if they came to the conclusion that neglected elements existed. The Delphi-based consultation and consensus reaching process was reciprocated in three rounds and in the final round the study subjects were urged to give their judgment on the eventuated version of the healthcare provision layout.

The study protocol was assessed and approved by the institutional level Medical Ethics Board of Trustees (MEBoT) within the Tabriz University of Medical Sciences (approval number: 5-4-8098-93-09-05).

Results

The literature search for recognition of admissible scientific evidence yielded 67 studies from mainly developed and economically affluent countries including 34 from the USA,14–47 2 reports from Australia,48–50 10 documents from Canada,51–60 1 from China,61 3 from Denmark,5,62,63 5 from England,64–68 1 from Finland,69 2 from France,70,71 2 from Greece,72,73 3 from Sweden,4,74,75 2 from Japan,76,77 and 2 from Italy.78,79

Among the identified publications a wide range of suggested components for a comprehensive EHCG were tabulated that can be classified in four prevention levels, that is, primordial, primary, secondary and tertiary. The provision of primary healthcare in 14 documents, certain types of secondary level health services in 17 reports, the provision of a list of definite tertiary level rehabilitation services in 3 publications and delivery of different kinds of social support care in 12 records were assumed to be essential for elder people. A combination of healthcare services in all four levels of prevention were also elucidated in 42 documents. Thorough scrutiny of the retrieved scientific evidence resulted in a comprehensive priori list of healthcare components that had been prompted to best meet old peoples’ aggravating health care requirements. The list included explicit health care/services based on their inherent nature, that is, preventive and medical care/services, rehabilitative and social support services (Table 1).

Table 1

Inherent Nature and Explicit List of the Elderly Health Care/Services Retrieved from Consolidation of the Global Scientific Evidence

Inherent Nature of Care/Services	Providing Organization/Institution	Types of Care/Services
Preventive & medical care/services	INHS/NGOs/Charities/Private profitable sectors	Healthy lifestyle education
		Screening for prevalent elderly diseases
		Home health care facilities
		Day hospital services
		Vision and dental care
		Mental health services
Rehabilitative	IWO/NGOs/Charities	Rehabilitation services (physiotherapy, occupational/speech therapy)
		Day care and residential home facilities
		Provision of assistive devices (hearing aids, glasses, wheelchairs, walkers)
Social support	Governmental or public pension funds/IWO/NGOs/Charities/IKRF	Financial aids/loans to build, buy or lease a house or a required medical equipment.
		Sport and exercise facilities
		Subsidizing intercity transportation
		Financially supporting elderly care centers
		Financially supporting recreational activities
		Payments of pension/living costs
		General/supplementary health insurance
		Volunteer agencies’ programs

Abbreviations: INHS, Iranian National Health System; NGOs, Non-Governmental Organizations; IWO, Iranian Welfare Organization; IKRF, Imam Khomeini Relief Foundation.

Intensive review of existing empirical evidences for dimensions and types of elderly healthcare or services in Iran also yielded an elucidated list (Table 2) besides the routine healthcare or social support services that are currently provided to the country’s general population. The routine healthcare for the elderly population in Iran across the primordial, primary and secondary prevention levels includes nutrition education, screening and treatment of common diseases that are provided in rural and urban healthcare centers. The proposed healthcare, however, does not cover all the country’s aged people especially in the urban areas and provides only minimal treatment in the catchment areas of health centers. A number of elderly healthcare centers have also been established in recent years to provide mainly primary and secondary level health care services to the elderly in the major cities of the country but the workforce’s unfamiliarity with old peoples’ specific health needs, due to their irrelevant or insufficient educational backgrounds and also the inadequate number of health centers for the elderly to cover all or the majority of the country’s elderly population is another burdensome obstacle.

Table 2

Inherent Nature and List of the Provided Explicit Elderly Health Care/Services in Iran

Inherent Nature of Care/Services	Types of Care/Services
Preventive & medical care/services	Peer to peer education
	Recruitment of volunteer health workers
	Immunization against common elderly diseases
	24 hour hotline counseling
	Home health care facilities
	Daycare facilities
	Night care facilities
	Day hospital services
	Vision and dental care
	Mental health services
	Assistance to obtain durable/specialized medical equipment(s)
	Tele & mobile health/medical services
	District nursing services
	Specialist dementia service
	Limited medical services such as podiatry care
Rehabilitative	Institution-based rehabilitation
	Hospice care
	Ergo therapy programs
	Mobile rehabilitation
Social support	Chore services (assistance with housekeeping, bathing, grooming, etc.)
	Pension payment/fee waivers for healthcare/social services
	Assisted living facilities
	Transporting facilities to attend medical/health care centers
	Reimbursement scheme for elderly health/geriatric services
	General/supplementary health insurance
	Durable medical equipment and pharmacy benefits
	Congregate housing/domiciliary homes
	Recreational services
	Legal and financial counseling
	Custodial nursing home care
	Respite care
	Volunteer agencies’ programs
	Access to reading/audiovisual materials/informal socialization events
	Access to exercise/sport facilities
	Provision of space in public places for resting or taking a nap
	Funeral or mourning services
	Senior errand services
	Wireless alarm system
	Specialized services to isolated/lonely elderlies

Conventional home health care services for elderly people,25–28,51 volunteers who train to gain from their abilities in healthcare provision in order to serve elderly people,41 the provision of active healthcare,41 the provision of physical activity facilities,5,54,68 meal services,5,62,63 immunization against common diseases in the elderly76,77 and free or subsidized healthcare services20,26,29,31,68 are among the list of facilities that are scheduled in mostly developed countries for the ageing population but they are not currently available for the elderly Iranian population.

Comparison of the already scheduled health and health-related services for the aged Iranian population (Table 2) and constituents of an intended comprehensive package of healthcare retrieved from the consolidation of available international evidence (Table 1) yielded a tenable preliminary model of healthcare for elderly Iranians. The model was sent to a group of key subjects in a three-round Delphi procedure to obtain their comments about the applicability of the model in Iran and about possible revision that could be done for the model integrity. Among the 22 approached subjects only 19 agreed to participate in the study (response rate 82.6%). The model components were kept if the majority of the respondents (>50%) were in favor of necessity and feasibility of each individual component. Based on the participants’ comments minor revisions or amendments were also made in the model constructs to best fit with the INHS’s capacities and weaknesses, eg, in the arranging of a multidisciplinary healthcare team in health centers, the setting-up of inpatient and outpatient care centers to provide 24 h health and social care and shortages of required expertise in middle and upper policy-making levels in fulfilling health care needs of the country’s growing elder population. The eventuated version (Figure 2) was agreed in the final stage by 83.6% of the participants.

Figure 2

Schematic diagram of a comprehensive model of healthcare provision for older people: based on the consolidation of empirical scientific evidence and Iranian key informants’ perspectives.

Discussion

This study aimed at highlighting the gap which exists in the provision of healthcare to the elderly Iranian population and suggests a proposed comprehensive model of care to be adapted in Iran. Applying a multi-method design, the researchers tried to base their suggested model of care on sound scientific evidence and assess its feasibility according to the national key subjects’ prospects.

The yielded framework in fulfilling the healthcare needs of the elderly Iranian population (IEHCG-IR) included four dimensions consistent with the four levels of prevention; that is, primordial and primary care, secondary and tertiary care dimensions along with social support services as indicated in Figure 2.

The current identified shortcomings in the INHS to respond to the elderly population health needs include lack of dedicated programs for regular health checkups, immunization against common infectious diseases prevalent in old age, screening for major old age morbidities, eg, cardio vascular disease, cancers, diabetes and neuropsychological impairments, rehabilitative daycare and hospital-based services, home visits, clinical and home-based psychological assessments, transportation facilities, payment of pension and caregiver support services reflect the pathway of change required.

Many of the mentioned services are already provided in developed countries Greece,72 USA,21,24,36,45 Sweden,80 Australia,49 and Denmark,5 with greater emphasis on preventive home visits, further cooperation across care providing organizations and mobilizing national-level resources for an integrated community-based care provision.

Iran is a transitional country with a rapidly growing population of old people. The current arrangements for elderly-specific care provision in the country suffer from patchy mid and upper level organizational policy formulation. Most of the provided care for elderly people in Iran is institution based (health centers, clinics and hospitals) and little investment goes towards integrated community-based initiatives. Therefore, due to the gaps in the provision of all required health and social care for the elderly Iranian population especially in relation to the services that are categorized in primordial and primary prevention levels, considerable pressure and demanding workloads are exerted on healthcare staff in healthcare centers or hospitals by those elderly patients that have encountered complicated but preventable health problems.81

Based on the current empirical data about half of the hospital beds are occupied by elderlies worldwide especially by those in the range of over 85 years old.82 Such a pattern of hospital bed occupation could be devastating for resource-limited countries and cause a lack of sufficient beds available to serve other age groups hospital-based healthcare needs. Thus, planning and the provision of a comprehensive package of care for elderly people could not only answer old peoples’ needs but at the same time could lead to cost-effectiveness and a better availability of constrained healthcare facilities to whole populations. This is even pivotal in the resource-limited countries of the world. Chronic disease-induced need for long-term hospitalization, uncontrolled psycho-cognitive impairments and bedsores in old people are examples of complications that might put extra pressure on health systems within the general constraint of limited financial resources. This is while, empirical international evidence exists to set up an integrated community-based healthcare services for elderly people that could lead to better allocation of resources and an overall better healthcare outcome.

The willingness of older people to live independently83,84 and its positive psychosocial impacts further herald the importance of a comprehensive community-based healthcare framework for this sub group of populations and the required revisions that must be planned for maximum repercussion of the healthcare system cost-effectiveness.

Access to the required healthcare by all and especially by vulnerable subgroups of the population is a universal theme which is highlighted in many national and international plans of actions. The study findings revealed that the current healthcare structure and policies in Iran are failing to adequately fulfill the old population’s health needs. The INHS suffers from inadequacy in providing equitable healthcare services to a sizable subgroup of the country’s population; therefore, access to the required and sometimes live-saving care for the ageing Iranian population could be overwhelming. This gap might even be wider for those old people who live in deprived and marginalized areas of the country. The difference could represent inherent social inequality in distinct geographical regions of the country which may inadvertently marginalize old people due to intrinsic inaccurate health policies.85 The embedded malformed policies in healthcare systems could lead to unequal distribution of health and therefore deepening of healthcare inequalities. The synergistic interplay between financial constraints and the absence of sound policy-making procedures leads to a trajectory shift in the country’s health system priorities.

This study finding must be interpreted with caution due to certain limitations. First, cross-sectional design of this study only represents current available data in relation to a comprehensive model of healthcare provision for elderly adults. The wide range of expertise the study respondents had in the Delphi stage of the study might cast uncertainty on the study findings since; there is the probability of different interpretations of the proposed model of care provision for elderly Iranian people and its feasibility in practice. The applied paper-based self-reporting of the key subjects’ prospects could potentially be another source of bias in this study due to our inability to attain the subjects’ details about the idea about the model and its interpretation on the suggested dimensions. Due to logistics and time restraints, an overall prospect of the Iranian key subjects (policy makers, scholars, health care managers …) was assessed in this study about feasibility of the devised theoretical model for application in care provision to the country’s elder population. A multi-dimensional future study is required to cluster all features of an ideal health care provision model (that includes financing, delivery model, human resources) relative to infrastructure and socio-economic circumstances of the country.

The possibility of identification bias due to missing important original studies in the scoping review of the literature and interpretation bias due to tendency of the researchers to inappropriately analyze the study data for gap analysis based on a priory default mindset should not be ruled out completely in this study either.

Conclusion

The study findings could have important implications for future policy making in the INHS and the suggested healthcare framework for the elderly Iranian population could be a preliminary model for health system re-engineering. Previous international evidence addressed the importance of an integrated and comprehensive healthcare system in responding to old peoples’ healthcare needs. The available evidence, however, was not translated into knowledge to pursue an evidence-informed decision making process in the INHS to obtain the healthcare rights of the elderly Iranian population. A higher level of organizational commitment, evidence-informed policy interventions and intersectional collaboration is needed in order to have a more equitable healthcare system in Iran. Further research is recommended to investigate organizational and infrastructure barriers in the establishment of an integrated healthcare governance to respond to elderly Iranian populations and those of countries similar to Iran.