A roadmap for implementing general policies of resistance economy in the Isfahan Universities of Medical Sciences.

CONTEXT AND AIMS: The country development can be promoted through applying policies of the resistance economy in the health system and universities. Therefore, this paper aimed to provide a scientific analysis of resistance economy policies and providing a roadmap for their implementation in the field of health care of Isfahan University of Medical Sciences.
MATERIALS AND METHODS: This is a qualitative study. The basis, general purposes, and strategies of the resistance economy were extracted from the review of the policy of the resistance economy with a political research approach. Then, effective programs and indicators to achieve the goals of the resistance economy were proposed by holding 10 sessions of a centralized group discussion. Finally, the implementation of the resistance economy in the deputies of the University of Medical Sciences was approved by these programs and indicators along with other components and Delphi questionnaire to 30 experts. Framework analysis and descriptive statistics were used to analyze the data from the group discussion and the Delphi stage, respectively.
RESULTS: Implementation of general policies of resistance economy in the field of health and treatment of Isfahan University of Medical Sciences with eight thematic bases, 39 goals, 54 strategies, and 98 programs and indicators were approved by experts. The eight areas of people-centered, economic growth, economic justice, support for internal services, economic flexibility, economic stability, economic influence, and economic health were identified as the thematic bases of communicative policies of the resistance economy in the field of health.
CONCLUSION: The implementation of resistance economy policies entails planning in the long run, culture-building, appreciating the resistance economy in health issues, cooperation, and synergy among different institutions, restructuring the education system at different levels of the health system, and entrepreneurship training. Copyright:

Introduction

Iran's economic system is a vulnerable economic system, and in the past few years, the word “economic resistance” or “economic resilience” has been added to our economic literature due to the intensification of economic sanctions.[1] Economics resistance means identifying areas of pressure under the current sanction conditions and then attempting to control and inactivate them in an idealized manner, turning these pressures into opportunities. Inevitably, it required macroeconomic stability, social development, public participation, and rational and thoughtful management as prerequisites.[2] In other words, a resistance economy is defined as the capacity of an economy to improve or adapt to the effects of exogenous shocks.[3] Therefore, resilience-based planning requires addressing any disruptive factors of sustainable growth and selecting strategies that minimize the risks and uncertainties of achieving goals.[4]

In Iran, the general policies of the Resistance Economy with a jihadist, flexible, opportunity-generating, endogenous, progressive, and extravagant approach were notified on 2014–2018 within twenty-four paragraphs by the Supreme Leader, aiming at providing dynamic growth and improving the resistance Economics indicators and achieving the goals of the 20-year perspective document.[5] Resistance economy policies as a documented system are backed theoretically and legally supported.[6] Resistance economy policy packages often have a long-term view and are designed to support long-term goals.[7] In other words, these policies are not unique to the current state of the country, but are a long-term strategy for the country's economy and can be complemented and adapted to the various conditions that may arise at any time. What has been requested by the supreme leader in this announcement is to provide the appropriate context and opportunity for the role of the people and all economic actors by preparing the necessary rules and regulations and formulating a roadmap for different areas.[8] According to the topic of resistance economics, the role of different sectors of the country in this field is very important and it is expected that all sectors play their role well in solving problems. In Iran, however, resilience issues are more confined to the field of psychology, engineering, and urban management, and only to some extent have some government agencies discussed economic resilience. That is while the importance of resilience in development, literature is increasing day-by-day and neglecting it will be detrimental to the country.[91011] Therefore, the health system of the country as one of the development infrastructures of the country is a high-risk industry due to its working nature and structural, physical and technological complexities.[12] Therefore, health-care structures must cope with risky situations by increasing their flexibility, which means the same goals of a resistance economy.[1314] Implementing resistance economy policies in the health system and universities can promote the general development of the country, as the resistance economy can improve the efficiency and effectiveness of the health system and academia, and this efficiency will also affect other elements of the country's economy management.[1516]

In view of the above, despite the importance of the subject of resistance economics, there is still no clear understanding of the concept of resistance economics, especially in the health field. Therefore, by determining the contribution of the health system in the resistance economy, the necessary background for reinforcement and resilience against various internal and external risks affecting the components of resources and consumption in different areas of the health system of the country should be provided. In this regard, for implementation of the goals and policies of the resistance economy, an integrated tool in the health field is required. A tool that, while respecting security considerations and removing vulnerabilities in the health system, provides principled management at all levels of strategic, operational, and executive health structures. Therefore, this article aims to provide a scientific analysis of resistance economy policies and provide a roadmap for their implementation in the field of health care of Isfahan University of Medical Sciences (MUI) in 2020.

Materials and Methods

The present study is a qualitative study in which document review method, group discussion and Delphi method was used as required in each step of the work. This study is categorized in the applied class based on the results, and is among cross-sectional studies in terms of time. In this study, first the axes related to health care were extracted from the issued policies of the resistance economy by the research team.

The research population was all key experts in the field of health care in MUI with maximum diversity (in terms of age, education, employment status, and executive background). Due to the fact that in the present study, participants’ knowledge was important for providing data, objective-oriented sampling, and based on sampling from individuals was important.

In continue, the details of the work of each step of the study are explained.

Step 1: Identifying the capacity of the healthcare sector in implementing resistance economy policies

First, 24 clauses of the issued policies of the resistance economy were examined using the document review method and policy research in the expert meetings of the research group members, and the clauses related to the field of health care were extracted based on the in-depth study method. Brief and practical definitions about the basic concepts of each policy clause were then determined and various issues raised in these policies were identified. Subsequently, the strategic objectives of each one of the policy clauses were identified by the members of the research team by rereading the text of the policy.

Step 2: Initial identification of examples related to resistance economy policies about healthcare

At this step, the necessary permits were firstly obtained from MUI and the necessary coordination was made with the participants to conduct a group interview. This step of the study involved collecting the views of the experts using a focused group discussion method. At this step, 55 experts were invited to participate in the group discussion, out of which 49 individuals (89%) participated in the group discussion sessions. The 49 experts were among the staff of the University of Medical Sciences (including 10 experts from the department of health, 15 experts from the department of treatment, 10 experts from the department of food and drug, 7 experts from the department of development, and 7 experts from the department of education and research). The group discussion sessions were held as face-to-face by a supervisor (M. F AND M. R) for “Introducing the question and topics discussed”, a facilitator (Y. MT) for “helping experts to respond the questions” and a secretary as “meeting coordinator and curriculum”. At the beginning of each session, the supervisor provided some explanations to the participants about the objective and method of the study. Group discussion sessions were structured using a guide and done separated by each policy clause. In the first session of the group discussion, the experts were asked to mentions the plans and indicators effective in the field of health care at the University of Medical Sciences to achieve the objectives and strategies of each clause of the resistance economy policy. Effective examples and components were proposed with the method of brainstorming by the experts to achieve the objectives and strategies of each clause of the resistance economy about health care at the university of medical sciences. The content of the group discussion was recorded by the consent of the participants and the conversations and brainstorming continued until data saturation. In total, for each group of different areas of the university staff, 244 min group discussions were held. Each focus group discussion with an average time of 45–60 min was held at Faculty of Management and Information of MUI. Participants used the review method to increase the accuracy of the data. The review process was such that the researcher provided a summary of his notes and perceptions to the participants for recommendations in the second group discussion. It should be noted that before the start of the study, the guide questionnaire, which was designed in the form of questions appropriate to the study objectives, was examined in two interviews as a pre-test in terms of the reliability of the questions, the time required to implement the questions and discuss them and the its problems were eliminated so that the questions could be understood by the participants. By identifying commonalities and differences of the recommendations among the experts, a preliminary draft of effective plans and indicators in the field of health care of the University of Medical Sciences to achieve the objectives and strategies of each policy clauses of the resistance economy were identified.

The frame analysis was used to analyze the data of this step. In the frame analysis, the policies of the resistance economy were divided into eight classes based on thematic objectives. The strategies and objectives of each category subject were extracted by rereading the policy clauses of the resistance economy and set as a framework for continuing the research. Then, the plans and indicators obtained from the recommendations of the experts in the group discussion sessions were separately coded and selected, and a relationship was established between the codes and the objectives of each of the policy clauses. By holding the next group discussion session, the codes were reviewed and agreed on. It is necessary to explain that the present research is not an explanatory and inferential research. Here, the policy of resistance economy has been available, and finally, plans and indicators for achieving the policies of resistance economy about health care is extracted based on people's recommendations.

Step 3: Final approval of examples related to resistance economy policies about healthcare

At this step, a questionnaire was designed based on the initial draft and presented to the experts to determine the necessity and appropriateness of the proposed plans and indicators. This questionnaire was sent to 30 qualified academic experts through E-mail or in person for approval. Three follow-ups were conducted as E-mail or phone call by a researcher to increase the rate of response to the questionnaire. After collecting 25 distributed questionnaires (83% response rate), content validity index (CVI) and content validity ratio (CVR) were calculated for each item. CVI is calculated by aggregating the corresponding scores for each item that scored “related but needs revision” and “fully related” divided by the number of specialists. To determine the CVR, experts were asked to examine each plan based on the three-part spectrum of “necessary, useful but not necessary, not necessary.”[17] The scores obtained in the questionnaire were entered in the SPSS software version 21. The second step of Delphi questionnaire was also sent to the participants of the first step and by collecting 25 questionnaires and analyzing them, plans and indicators related to each of the resistance economy policies to implement in the field of health care of MUI was approved.

Descriptive statistics (frequency distribution tables and mean ratios) were used to analyze the data of this step. Based on the responses provided, CVI and CVR indicators were calculated for each indicator. Plans and indicators with CVI and CVR scores above 0.7 were selected and entered into the model. Plans and indicators with a CVI and CVR score of 0.4–0.7 entered the second step of Delphi, and plans and indicators with a CVI or CVR score of 0–0.4 were removed from the model.

Step 4: Identifying beneficiary departments

At this step, the beneficiary domains of the university were determined to implement each of the final plans through documentary review and interviews with relevant experts.

Determining the content validity of all aspects of the subject matter was identified based on expert discussion sessions. Content indicators were used in the Delphi steps to determine the content validity. Sufficient time was provided for proper communication and real understanding of the data between experts so as increase the breadth and depth of the data. Issues of difficulty level (difficulty in understanding phrases and words), appropriateness (appropriateness and desirable relevance of phrases to the dimensions of the questionnaire), and ambiguity (the possibility of misinterpretations of phrases or the presence of failures in the meanings of the words) were examined. Finally, examples inconsistent with the subject of the research was identified and eliminated or modified. Regarding reliability, quoting Ahmadi et al.'s study, “even if similar information or questions are given to panelists, obtaining the same results is not certain,” so in this study, as in other Delphi studies, reliability cannot be examined.

Inclusion criteria of this study are: 1-Policymakers, faculty members, and beneficiaries in the field of healthcare who are familiar with the meaning and policies of resistance economy (or) experts who have educational and research knowledge in the field of resistance economy; 2-Having enough desire and time to attend meetings; 3-Having a background in the field of staff at the University of Medical Sciences. Furthermore, exclusion criteria of this study were the inability and unwillingness of the experts to continue cooperation at any step of the research.

The ethical considerations in this study were the willingness to participate in the meetings, the observance of the principles of confidentiality of information, and the acquisition of informed consent. Individuals were also assured that their individual words are not reflected anywhere and that recommendations were made only in groups. It should be noted that this research is registered in MUI with the code of ethics of IR. MUI. REC.1396.3.527.

Results

The results of the first phase of the research

In the first phase, out of 24 clauses of the resistance economy policies, 19 clauses were related to the field of health. Clauses of resistance economy were determined in terms of thematic communication and were classified by the researchers in eight thematic areas of people-centered, economic growth, economic justice, and support for internal services, economic resilience, economic stability, economic influence, and economic health. Furthermore, at this step, by reading the text of the resistance economy policies, 39 strategic objectives and 54 strategies were identified. Tables 1-8 describe the objectives and strategies of each of the 19 clauses of the resistance economy.

Table 1

Proposed policies and plans of the resistance economy in the field of people-centered at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive units
1	1. Entrepreneurship development, 2. Maximizing participation of all communities in economic activities	Facilitating and encouraging collective cooperation	Participating nongovernmental organizations	Rial amount of funding from non- governmental organizations	0.7	0.76	1st round	Social deputy
		Providing conditions and activation of all facilities and financial resources and human and scientific capital of the country	Using and attracting resources from other organizations	Rial amount of foreign capital and charitable donations	0.73	0.87	2nd round	Deputy of development
		Increasing income for low- and middle-income classes	Implement a performance-based payment system for low-income personnel	Income ratio of low- and middle-income classes to high income classes	0.76	0.72	1st round	Deputy of development
		Increasing the role of the low- and middle-income classes	Forming and strengthening staff cooperatives	Number of staff cooperatives formed	0.73	0.73	2nd round	Deputy of development
20	Creating added value, production, wealth, productivity, entrepreneurship, investment and employment	Reinforcing Jihadist culture	Services to deprived areas by the help of Jihadist groups	Effectiveness of jihadist groups	0.73	0.73	2nd round	Deputy of treatment Deputy of health
			Participatory management to serve deprived areas with project period rules	Effectiveness of planning forces	0.73	0.87	2nd round	Deputy of treatment Deputy of health
		Awarding the resistive economy badge to individuals with outstanding services in the field	The process of selecting and awarding special badges to qualified health service providers	Number of decent people in the field of resistive economics	0.8	0.8	1st round	Deputy of development

CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

Table 8

Proposed policies and plans of the resistance economy in the field of economic health at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive Units
19	Moving towards a transparent and healthy economics	Preventing measures, activities and areas for corruption in the health sector	Preventing physicians from participating in Para clinics	Frequency of complaints about physicians’ participation in Para clinics	0.73	0.73	2nd round	Deputy of treatment
			Preventing the impact of sales agents and pharmaceutical companies	The rate of complaints about the influences of sales agents on prescribing	0.92	0.84	1st round	Deputy of food and drug administration
			Monitoring unofficial payments	The amount of informal payments in terms of number and amount of Rials	0.92	0.88	1st round	Deputy of treatment
23	Market control	Transparency and lubrication in the distribution and pricing system in the health system	Updating and monitoring tariff and pricing system style	Complaints about non-compliances with tariffs	0.73	0.73	2nd round	Deputy of treatment
			Adjusting budget allocation and budget reporting	Analytical chart of budgetary control and monitoring	0.92	0.84	1st round	Deputy of development
			Transparency and accountability of pharmaceutical and equipment companies in drug and equipment distribution	Average time of distribution of medicines and equipment needed by centers from time of request to delivery	0.73	0.87	2nd round	Deputy of development Deputy of food and drug administration
			Strengthening auditing of health centers	Internal and external audit scores of health centers	0.73	0.76	1st round	Deputy of development
		Updating practices for monitoring health care organizations	Regular visits (periodic and accreditation) and follow-up of health centers	Score of health centers on regulatory visits	0.73	0.87	2nd round	Deputy of treatment Deputy of health
			Monitoring and sharing statistics and information	The amount of each of the performance indicators of health centers			1st round	Deputy of treatment Deputy of health
			Issuance/renewal of principal agreement	Number of principal agreement licenses issued			1st round	Deputy of treatment
			Originality control, tracking and tracking of all health goods in the country	The amount of contraband			1st round	Deputy of food and drug administration
			Dealing with violations	The extent of violations and complaints resolved			1st round	Deputy of treatment Deputy of health Deputy of food and drug administration

CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

The results of the second phase of the research

By identifying commonalities and differences of the recommendations among experts, 243 initial plans in the field of health and medical sciences were identified to achieve the objectives and strategies of each clause of the resistance economy policies.

The results of the third phase of the research

Of the 198 plans proposed, 67 were accepted in the first step of Delphi and were considered as final plans, and 81 were removed. Fifty plans entered the second step of Delphi. In the second step of Delphi and the analysis of its results, 31 plans were approved and 19 plans were rejected. In general, in the steps of Delphi, out of 198 initial identified plans, 98 were identified as priority and final plans for implementation in the fields of health care of MUI. The results of the priority plans, access indicators, and the unit responsible for implementing the plans are shown separately in each clause of the resistance economy in Tables 1-8. It should be noted that due to the large number of plans, only plans that have been accepted by experts in the Delphi steps are mentioned in the tables.

In the following, the subdomains and themes of each of the clauses of the resistance economy policy are described.

List the topics of policies and plans related to the field of people-centered

Customers and stakeholders in the health system have a special place in advancing the goals of the health system. In the health system, as in other organizations and industries, for any major social change to happen, the presence of a huge mass of people is needed. The policies, plans, and indicators of the priority plan to achieve the field of people-centered are presented in Table 1.

List of topics of policies and plans related to economic growth

Economic growth consists of labor, physical capital, and human capital. Human capital in the economic literature also includes education, health, skills, experience, and other capital that increase labor productivity and thus increases economic growth.

As shown in Table 2, by rereading the text of the resistance economy policies, issues such as: improving the economic position of the university, achieving the first rank of knowledge-based economy in the region, improving the share of health and export services and knowledge-based services and increasing productivity in the health economy are placed in the axis of economic growth. The policies, plans, and indicators of the priority plan to achieve the field of economic growth are presented in Table 2.

Table 2

Proposed policies and plans of the resistance economy in the field of economic growth at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive Units
2	1. Promoting the University’s economic standing, 2. Achieving first rank knowledge-based economy in the region, 3. Improving the share of health services and export and knowledge-based services	Advancement of knowledge-based economy	Creating knowledge-based health companies, especially in the pharmaceutical field	The number of knowledge-based products produced in the health field	0.73	0.73	2nd round	Deputy of food and drug administration Deputy of research and technology
		Implementation and administration of a comprehensive scientific map of the country	Implementation of a comprehensive scientific map of the country in the field of health	Percentage of University Performance in Implementation of Comprehensive Scientific Map Indices of the Country	0.73	0.73	2nd round	All deputies
		Organizing the National Innovation System	Activating a new system of innovation in the field of health	The number of proposals implemented	0.76	0.72	1st round	All deputies
3	Productivity growth in the health economy	Reinforcing factors	Equipment Technology Evaluation	Amount of equipment purchased based on HTA results	0.84	0.84	1st round	Deputy of development Deputy of education
			Planning workforce required	Input-output ratio of workforce	0.73	0.76	1st round	Deputy of treatment International affairs office
			Establishing maintenance mechanisms	Rate of abandonment of human resources	0.76	0.76	1st round	Deputy of development
		Empowering the workforce	Personnel training	Personnel training per capita	0.73	0.76	1st round	Deputy of development
		Strengthening the competitiveness of the economy	Development of tourism capacity	Health tourism revenue per region	0.73	0.76	1st round	Deputy of treatment
		Creating a platform for competition between regions and provinces	University ranking in global scale	University ranking on a global scale based on comparisons of universities’ economic performance	0.73	0,93	2nd round	International affairs office
		Using a variety of capacities and capabilities	Deployment of land use plans	The extent of land use observations in the development of universities	0.73	0.73	2nd round	All deputies

HTA=Health technology assessment, CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

List of topics of policies and plans related to economic justice

Economic justice is a situation in which every client and beneficiary of the health system has achieved their right to wealth and income in society. Accordingly, justice in choosing different ways of providing resources, reimbursement of costs and insurance coverage of the community plays an important role in achieving justice and fulfilling the mission of the health system.

By rereading the text of the resistance economy policies, the objectives and strategies of the clauses number four and five of the policies of the resistance economy are placed in the field of economic justice. The policies, plans, and indicators of the priority plan for achieving the field of economic justice are presented in Table 3.

Table 3

Proposed policies and plans of the resistance economy in the field of economic justice at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive Units
4	1. Increasing health services, 2. Increasing employment and productivity. 3. Reducing energy intensity, 4. Promoting social justice indicators	Using the capacity of implementing targeted subsidies	Modifying and strengthening the transformation plan	Audience satisfaction with implementation of transformation plan	0.84	0.84	1st round	Deputy of health Deputy of treatment
			Pay gap correction (income)	Rate of using the one percentage of targeting subsidies to reduce pocket pay in the transformation plan	0.76	0.72	1st round	Deputy of development
			Energy consumption optimization plan	Rial amount of energy bills	0.73	0.76	1st round	Deputy of development
			Referral and grading system	Percentage of specialist doctor visit share through referral system	0.73	0.76	1st round	Deputy of health Deputy of treatment
			Supervising the implementation of a comprehensive and targeted social security system	The extent of insurance coverage	0.87	1	2nd round	Deputy of treatment Deputy of development
5	The fair share of factors in the production to consumption chain proportional to their role in value creation	Promoting entrepreneurship, creativity, skills, training, experience	Improving entrepreneurship	Entrepreneurship Performance Score of university	0.84	0.84	1st round	Deputy of research and technology Deputy of development
		Increasing the share of human capital	Reviewing the value of health care and services	The share of job-related earnings for different jobs in hospital	0.76	0.72	1st round	Deputy of development

CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

List of topics of policies and plans related to self-reliance and support for internal services

Self-reliance and support for internal services may be the main goal of the resistance economy. Every health system in the world must be self-dependent to achieve internal authority. This is even more serious for a country like Iran which is facing sanctions.

By rereading the text of resistance economic policies, it is understood that by achieving the objectives and strategies of clauses six, seven, and 24 of the resistance economy, it is possible to support internal services at the level of MUI. The policies, plans, and indicators of the priority plan to achieve the field of support for internal services are presented in Table 4.

Table 4

Proposed policies and plans of the resistance economy in the field of support for internal services at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive Units
6	Reducing the concentration and dependence on limited and specific countries	Increasing production of essential products	Drug supply and storage	Percentage of drug produced domestically in terms of number and Rial to the total drug consumed	0.76	0.72	1st round	Deputy of food and drug administration
			Production of pharmaceutical raw materials	Production rate of pharmaceutical raw materials	0.72	0.84	1st round	Deputy of food and drug administration
			Supply and storage of capital medical equipment	Percentage of capital equipment domestically produced in terms of number and Rials to total capital equipment	0.73	0.73	2nd round	Deputy of development
			Supply and storage of consumable medical equipment	Percentage of consumable equipment produced domestically in terms of number and Rials to total consumables	0.73	0.93	2nd round	Deputy of food and drug administration
			Vaccine and serum preparation	Percentage of vaccine and serum produced domestically in terms of number and rials to total vaccine and serum	0.72	0.84	1st round	Deputy of health
		Strategic self-reliance	Technology transfer and licensed drug production contracts with reputable companies	Self-sufficiency in drug production, production of consumables and specialized medical services needed	0.72	0.84	1st round	Deputy of food and drug administration
			Preventing entry of similar items and products (fight against trafficking)	The amount of trafficking of health-oriented items and products	0.73	0.76	1st round	Deputy of food and drug administration
			Production of new technologies (nano and advanced drugs)	Self-reliance on medication production and strategic equipment and services required	0.72	0.84	1st round	Deputy of Food and Drug Administration Deputy of research and technology
		Diversification in the basis of supplying imported goods	Supply entries of medicines and equipment	Rate of succession in imported goods	0.76	0.88	1st round	Deputy of Food and Drug Administration Deputy of development
7	1. Providing food security and treatment, 2. Creating strategic reserves	Increase the quantities of raw materials and services in health area	Planning for adequate and continuous production of medicines and equipment	Planning treatment production in line with implementation of treatment development document 2026	1	0.73	2nd round	Deputy of Food and Drug Administration Deputy of development
			Creating strategic stocks of drugs, vaccines, and serum	Level of issuance/extension of principal agreements based on treatment development document	0.92	0.8	1st round	Deputy of treatment Deputy of development
			Inventory of medicines and equipment for investment and consumption	Availability of drugs, vaccines and serum	1	0.8	1st round	Deputy of Food and Drug Administration Deputy of health
			Establish a system of service evaluation and service provider accreditation	Hospital accreditation score (grade)	1	0.73	2nd round	Deputy of treatment Deputy of health
			Control of food products at factory level	Food factories performance audit score	0.8	0.8	1st round	Deputy of health Deputy of food and drug administration
			Recognizing, promoting, developing and institutionalization of traditional medicine	Contribution of traditional medicine to health and food and drug market based on national document of traditional medicinal plants and medicine	0.84	0.76	1st round	Deputy of health Deputy of Food and Drug Administration Deputy of treatment
			Promoting a native optimum food basket	Per capita training for audiences in the development of a desirable native food basket	0.84	0.72	1st round	Deputy of health Deputy of food and drug administration
			Providing essential medicines and equipment	Percentage of in-company medicine and equipment sales to health centers	0.84	0.76	1st round	Deputy of Food and Drug Administration Deputy of development
24	Promoting domestic services	Standard coverage for all internal health services	Establishing a quality control system in health services	Health Service Quality Control Score	0.8	0.8	1st round	Deputy of health Deputy of Food and Drug Administration Deputy of treatment
		Increasing the internal quality of health services	Adherence to national standards and regional and global standards	Standard adherence to in-house pharmaceuticals and equipment	0.92	0.72	1st round	Deputy of health Deputy of Food and Drug Administration Deputy of treatment

CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

List of topics of policies and plans related to economic flexibility

In order to create efficient economic flexibility conditions, the health system needs to be able, on the one hand, to reduce its inherent vulnerabilities and on the other hand, to provide flexibility against external crises and pressures under sanctions.

By rereading the text of the resistance economy policies, the objectives and strategies of clauses eight, twelve, and twenty-two of the policies of the resistance economy are placed in the field of economic flexibility. The policies, plans and indicators of the priority plan for achieving the field of economic flexibility are presented in Table 5.

Table 5

Proposed policies and plans of the resistance economy in the field of economic flexibility at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive Units
8	Consumption management	Implementation of general policies to correct consumption patterns	Establishing and enforcing local laws, guidelines, procedures, and clinical guidelines	The amount of formal cost savings	0.7	0.76	1st round	All deputies
			Demand regulation and suppression of induction demand	Induction demand in hospitals using practitioners’ functional review	0.76	0.7	1st round	Deputy of treatment
			The process of prescribing and taking medication	Percentage of administration and reasonable use of the drug	0.87	0.8	2nd round	Deputy of food and drug administration
			Standardization of care services (self-care and family health literacy)	The effectiveness of self-care programs	0.92	0.84	1st round	Deputy of health Deputy of treatment
			HTA performing	The amount of technology provided based on HTA results	0.76	0.7	1st round	Deputy of treatment
		Promoting consumption of domestic services	Ban on the supply of foreign medicines while domestically produced	Share of imported health goods in household consumption basket	0.76	0.76	2nd round	Deputy of food and drug administration
		Planning for quality improvement	Improving the quality of domestically produced medicines	Internal medicine compliance with international standards	1	0.76	1st round	Deputy of food and drug administration
			Improving the quality of domestic production equipment	The degree of conformity of domestic production equipment with international standards	0.84	0.84	1st round	Deputy of treatment Deputy of development
			Implement quality programs such as accreditation, EFQM, etc.	Hospital accreditation score (grade)	0.87	0.8	2nd round	Deputy of health Deputy of treatment
		Competitiveness	Implementation of lean management	Performance audit score of health centers	1	0.73	2nd round	Deputy of health Deputy of treatment
12	Increasing the strength of the resistance and reducing the vulnerability of the economy	Development of strategic-business links	Engaging and collaborating with the world’s leading scientific and medical centers	Number of agreements, contracts, and projects shared with other target countries	0.87	0.8	2nd round	Deputy of research and technology International affairs office
		Expanding cooperation and partnership with countries in the region and the world
		Economic diplomacy	Third Generation University Development	University performance in establishing third generation university development indicators	0.76	0.7	1st round	Deputy of research and technology Deputy of education
		Regionalism (using the capacities of international and regional organizations)	Engaging and collaborating with advanced scientific and medical centers in the Islamic world and region	Number of agreements, contracts and projects shared with other target countries	1	0.73	2nd round	Deputy of research and technology International affairs office
22	Accessing to offensive power and appropriate actions	Dynamic coordination and mobilization of all facilities in the country	Interaction with the red crescent, welfare organization and other institutions that affect health	Number of mutual agreements, contracts, and projects with the red crescent, the welfare organization and other institutions affecting health	0.92	0.88	1st round	Deputy of health Medical emergency management (deputy of treatment)
			Establishing logical interaction and exchange between different levels of the health system	Number of meetings of provincial governing committees	0.84	0.76	1st round	Deputy of treatment Deputy of health
		Identification and utilization of scientific, technical and economic capacities	Using databases in evaluating organizations	The degree of preparedness for enemy-made crises	0.92	0.88	1st round	Deputy of treatment Deputy of health
			Raising capital and financial backing to tackle sanctions and risks	The amount of Rials raised to counter sanctions and risks	0.73	0.87	1st round	Deputy of development
	Management of economic risks in the field of health	Providing intelligent, active, fast, and timely response plans for internal and external risks and disturbances	Passive defense implementation	Passive defense readiness	0.92	0.72	1st round	Deputy of treatment Deputy of health
		Observing sanctions and increasing costs on the enemy	Conducting research activities in the health system monitoring	Number of research activities in health system monitoring	0.84	0.76	1st round	Deputy of research and development

HTA=Health technology assessment, EFQM=European Foundation for Quality Management, CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

List of topics of policies and plans related to economic stability

Another goal of the health system is to create economic stability and confidence in the future. Therefore, achieving sustainable economic stability and strengthening the health system against the effects of positive and negative shocks is one of the priorities of policymakers in the health system.

As shown in Table 6, by rereading the text of the resistance economy policies, issues such as: meeting the needs of the health economy, stabilizing the health economy, pioneering the strengthening of the real sector, saving public expenditure, and reforming the government's revenue system are placed on the axis of economic stability. The policies, plans, and indicators of the priority plan for achieving the field of economic stability are presented in Table 6.

Table 6

Proposed policies and plans of the resistance economy in the field of economic stability at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive units
9	1. Meeting the needs of the health economy, 2. Health economics stability being pioneer in strengthening the real sector	Comprehensive reform of the financial system	Sustainable financing for the health system	University general budget returns	0.92	0.72	1st round	Deputy of development
			Using and attracting resources from other organizations	Rial amount of foreign capital and charitable donations	0.73	0.73	2nd round	Deputy of development
			Expanding public-private partnerships	Cost savings	0.92	0.84	1st round	Deputy of development
16	Saving public spending in the country	Transformations in structures	Organizational reform	The ratio of labor force to organizational rows	0.72	0.84	1st round	Deputy of development
		Health sector size rationalization (health centers)	HTA	The amount of technology provided based on HTA results	0.73	0.76	1st round	Deputy of treatment
			Leveling services, equipment and facilities	Extent of issuance and extension of principal agreements	0.92	0.88	1st round	Deputy of treatment Deputy of health
			Implementing lean management	The amount of formal cost savings	0.73	0.73	2nd round	Deputy of treatment Deputy of health
			Setting up partnerships between the private and public sectors	Cost savings in public sector spending	1	0.88	1st round	Deputy of development
		Removing parallel and unnecessary bodies (agility)	E-government deployment	Time of responding to correspondences	1	0.73	2nd round	Deputy of development
17	Reforming the state revenue system	Increasing the share of tax revenues	Taxation (timely collection of tax revenues, tax on harmful products and services, tax evasion on doctors’ income)	Compliance with university financial system standards	1	0.73	1st round	Deputy of development

HTA=Health technology assessment, CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

List of topics of policies and plans related to economic influence

The world today is a world without borders and it is impossible to progress in the health system without interacting with other health systems in the Islamic world and elsewhere. Therefore, proper interaction with other health systems should be established through active diplomacy.

By rereading the text of the resistance economy policies, the objectives and strategies of clauses 10 and 11 of the resistance economy policies are placed in the field of economic influence. The policies, plans, and indicators of the priority plan to achieve the field of economic influence are presented in Table 7.

Table 7

Proposed policies and plans of the resistance economy in the field of economic influence at MUI

Clause	Goals	Strategies	Programs	Indicators	CVR score	CVI score	Was Delphi’s round approved?	Responsive Units
10	1. Full and targeted support for export of goods and services, 2. Sustainable expansion of Iran’s share in target markets	Facilitating regulation and expanding incentives	Developing incentives for IPD beds in the hospital	Percentage of variation in export customers	0.92	0.88	1st round	Deputy of treatment
		Expanding health services	Telemedicine for export services	Percentage of exports of medicine, equipment or medical services	0.92	0.84	1st round	Department of Information and Communication Technology Deputy of treatment
			Development of health tourism industry	Health tourism revenue	0.72	0.84	1st round	Deputy of treatment International affairs office
		Attracting foreign investment for export	Attracting foreign capital in production, especially medicine and hospital construction	The amount of foreign capital attracted and the good aid for academic projects	0.92	0.72	1st round	International affairs office Deputy of development
		Diversification of economic ties	Signing contracts with foreign stakeholders	The amount of foreign investment in university projects	0.73	0.73	2nd round	International affairs office Deputy of development
			Creating and strengthening international and regional communications	The amount of foreign investment in university projects	0.73	0.87	2nd round	International affairs office Deputy of development
		Customized planning according to export needs	Attracting international students	The amount of income attracted by international students	0.92	0.88	1st round	International affairs office Deputy of education
			Signing MOU with target countries for export of medicines and equipment	Percentage of exports of medicine, equipment or medical services	0.72	0.84	1st round	International affairs office Deputy of development Deputy of food and drug
			Exporting medical services	Percentage of exports of medicine, equipment or medical services	0.73	0.76	1st round	Deputy of treatment
		Shaping new markets	Building tourism hospitals or health villages in required areas	Number of hospitals with health tourism licenses	0.92	0.72	1st round	Deputy of development
			Licensing health tourism companies	Number of licensed health tourism companies	0.73	0.87	2nd round	Deputy of treatment
		Swap exchanges	Scholarships and study opportunities (sabbatical leaves)	The amount of scholarships and study opportunities in a given period	0.73	0.76	1st round	Deputy of education International affairs office
		Exporting stability procedures and regulations	Managerial stability in implementing upstream export laws and regulations	Percentage of exports of medicine, equipment or medical services	0.73	0.87	2nd round	Deputy of development International affairs office
11	1. Transfer of advanced technologies, 2. Facilitating health services Export of goods and services Supplying essential needs and funding from abroad	Developing the free and special economic zones of the country in the field of health	Establishing international branches in free zones and attracting students, especially noniranian students	Number of international branches registered and established	0.92	0.72	1st round	Deputy of education International affairs office

IPD=Integrated project delivery, CVR=Content validity ratio, CVI=Content validity index, MUI=Isfahan University of Medical Sciences

List of topics of policies and plans related to economic health

One of the most effective objectives for achieving the objectives of the resistance economy in the field of health care was the economic health domain. By implementing appropriate programs in the health system, we should eliminate the opportunity for corruption, reduce the pressures and increase the resistance to corruption, and ultimately bring about economic health in the health system.

As shown in Table 8, by rereading the text of the resistance economy policies, issues such as: clarifying and modifying the economy and market control are placed at the axis of economic health. The policies, plans, and indicators of the priority plan to achieve economic health are presented in Table 8.

In Table 9, the frequency of policies and plans proposed by the resistance economy is presented as a roadmap for implementing the resistance economy policies in the fields of health care at MUI.

Table 9

Implementation of resistance economy policies in the field of health and treatment at MUI

Axes	Policy clause	Objectives	Strategy	The frequency of the proposed plans in the group discussion	The frequency of the proposed plans in Delphi phase
People-centered	One	2	4	14	4
	Twelve	6	2	6	3
Economic growth	Two	3	3	9	3
	Three	1	5	12	7
Economic justice	Four	4	1	9	5
	Five	1	1	7	2
Support for internal services	Six	1	3	16	9
	Seven	2	2	17	8
	Twenty-four	1	2	7	2
Economic flexibility	Eight	1	4	15	10
	Twelve	2	4	8	3
	Twenty-two	2	4	11	6
Economic stability	Nine	3	1	9	3
	Sixteen	1	1	12	6
	Seventeen	1	1	4	1
Economic influence	Ten	2	8	19	13
	Eleven	4	1	4	1
Economic health	Nineteen	1	1	6	3
	Twenty three	1	3	13	9
Total		39	54	198	98

MUI=Isfahan University of Medical Sciences

According to Diagram 1, 98 programs were identified as the final program for implementing the policies of the resistance economy in the field of health and treatment at MUI. The highest frequency of the program was related to the axes of support for internal services and economic flexibility with 19 programs, and the lowest program was related to the axes of people-centered and economic justice with seven programs.

Discussion

The general policies of the resisting economy, in addition to being “general policy” and hence serving as a policy for policy making, have a coherent scientific map of various subject areas and objectives that, if misunderstood, may lead to unfavorable results for the policy maker and even lead to negative results. Therefore, the present study was conducted with the aim of scientific analysis of policies and identifying the most important instances and performance indicators in realization of general policies of resistance economics in the field of health of university of medical sciences. The central question of the paper was “what are the general objectives of the resistance economics which consist of general goals, thematic goals and strategies, and in what forms and indicators can the resistance economics policies be pursued in the field of health?”

In the first step, after rereading the text of resistance economy policies, the eight fields of people-centered, economic growth, economic justice, strategic self-reliance and support for internal services, economic flexibility, economic stability, economic influence, and economic health were identified as general objectives of the issued policies in the in the field of healthcare of MUI. Furtermore, by rereading the text of the resistance economy policies, 39 strategic objectives and 54 strategies were identified. In general, limited studies are done to determine the roadmap for the resistance economy in other industries and organizations, but unfortunately there is no comprehensive plan to implement resistant economy policies in health care.

Seif in his study considered a model of resistance economy to deal with anomalous circumstances. This model has four essential components including economic growth, economic stability, economic justice, and economic flexibility.[18] Whereas, based on the results of the present study, the eight areas of people-centeredness, economic growth, economic justice, strategic self-reliance and support for domestic services, economic flexibility, economic stability, economic influence, and economic health were identified as the overall goals of notified health policy in the field of health care in university of medical sciences. Seif's proposed model had the most similarity to the roadmap for resistance economy in the health department of the university, and most of the elements of this model are seen under similar headings in the roadmap proposed by the present study. In addition, according to the Vaezi and Fadaei study, 10 themes of understanding the importance of strategic management improvement, understanding the importance of resistance economy model, planning and rationalization of management, systematization, development of education, humanism, need orientation, self-sufficiency, entrepreneurship and extraversion were identified as the strategic management components of the Islamic University based on the Resistive Economics Model.[19] The model of the study by Vaezi and Fadai on elements such as self-sufficiency, populism with the axes of supporting domestic production and people-centeredness that are obtained based on the results of the present study is similar. The reasons for the difference in the model of resistance economy in this research with the findings of other researches was that in the present study, rereading of the policy text was used to determine the overall objectives of the resistance economy policies, while in Seif's study the model formulation was done based on research literature. Furthermore, understanding and making a discourse of the concepts of resistance economy may differ based on the research environment and the recommendations of scientific and executive experts.

In the next step, the draft plan was prepared and the roadmap of the implementation of the general policies of the resistance economy in the field of health care of MUI with eight thematic axes, 39 strategic objectives, 54 strategies, and 98 plans was approved by the experts. Based on the results, the most load of the plans to achieve the overall objectives were in the areas of self-reliance and support for internal services with a frequency of 19 plans (19.3%), economic flexibility with a frequency of 19 plans (19.3%) and the lowest load of the plans were the axes of people-centered with a frequency of 7 plans (7.1%) and economic justice with a frequency of 7 plans (7.1%).

By rereading the text of the resistance economy policies, 7 objectives and 6 strategies were placed in the field of people-centeredness. Seven plans were also identified as key plans in this field. One of the indicators of the resistance economy is people-centeredness and people founded economy, and the foundation of the resistance economy comes from the economic behavior of the people.[20] Being popular means that the participation of the classes of the society in economic activities and the circulation of economies is maximized by different classes of the society. In the health system, it is clear that without the support and empathy of the people, the government and the officials of the system, the development of the health system and the objectives of the resistance economy will not be realized. In fact, the role of the people in realizing the policies and plans issued must be uttered in a simple and tangible way.[21]

By rereading the text of the policies of the resistance economy, 5 objectives and three strategies were placed in the field of economic justice. Seven plans were also identified as key plans in this field. Justice is one of the most important social criteria and values in the health sector, which, although its full establishment is impossible even for developed countries, but most societies seek to achieve it in social affairs, including health.[2223] The starting point of economic justice is the observance of civil rights.[24] In the Iranian health system, several measures are always taken to achieve relative justice for the general public, especially the weak and vulnerable classes. In this study, according to the experts, plans such as reviewing the value of health services, referral system, inclusive social security and modifying the payment gap were proposed as effective plans to increase economic growth at the university of medical sciences.

Economic growth with 4 objectives, 8 strategies, and 10 plans was identified as another axis in achieving the policies of the resistance economy in the field of health care of the MUI. A common early empirical approach to examining the effect of health on economic growth involves regressing income per capita growth against initial level of health for a cross-sectional sample of countries, controlling for initial income and other factors believed to influence steady-state income.[25] According to Butkiewicz and Yanikkaya, developing countries need to limit their governments’ spending expenditure and invest in infrastructure to stimulate economic growth.[26] In this study, according to the experts, plans such as creating a knowledge-based company, activating the innovation system, strengthening and empowering factors and developing tourism were proposed as effective plans to increase economic growth at the University of Medical Sciences.

Economic stability is related to the interaction between total supply and demand in the economy. In their study, Briguglio et al. examined the concepts and criteria of economic resistance and economic vulnerability, and considered the four main indicators of strengthening economic resistance as economic stability, microeconomic market efficiency, good governance, and social development.[27] Amiri et al., in their study as estimating the vulnerability and resistance indicators in the Iranian Economy, mentioned economic stability as one of the most important indicators of economic stability.[28] In this study, economic stability with 10 plans was identified as one of the axes in achieving the resistance economy policies in the field of health care.

Economic health with 2 objectives, 4 strategies, and 12 plans was identified as another axis in achieving the resistance economy polices in the field of health care of MUI. Corruption is a phenomenon that is more or less present in all countries, but its type, rate, form, and extent are different in each country.[29] Often, something is violated as a result of corruption, which may be a moral or legal principle or procedure.[3031] Therefore, with the measures taken in the healthcare systems, it is necessary to control the crime-prone contexts and flow the economic health.

Diplomacy and economic influence are other effective and strategic overall objectives of the resistance economy to gain scores in the global economic competition for economic progress. According to the participants’ recommendations, fourteen plans were identified as key plans in this area. Economic influence in the Health Sector is the chosen method of interaction between different stakeholders of the health system to represent, collaborate, resolve disputes, improve health systems, and guarantee the right to health for vulnerable groups.[32] The basic need for economic diplomacy and the conversion of existing sources of economic power into real power is to identify the principles and strategies of diplomacy and economic influence. In the studies of Mohsenzadeh and Danesh Ja'fari, the diversity of countries’ exports and their dependence on a particular commodity are the proper infrastructures for diplomacy and economic influence.[33] Mohammadi Siah Boumi also cited the discontinuance of monopolistic economics and alternative production and exports as goals and foundations of a resistance economy in the field of economic diplomacy.[34] In general, facilitating cross-border trade, improving and enhancing nongovernmental organizations and foundations as health diplomats, globalizing, and enhancing cooperation between low- and middle-income countries contribute to promote economic influence in the field of health.[35] All results were consistent with the results of the present study. Based on the results of the present study, a deep understanding of the target markets of health services helps to increase exports and effective presence in foreign markets. Therefore, it is important to know the real needs and capabilities of the country, as well as to recognize the relative advantage of the country in shaping world trade, and thus the results of the present study are consistent with the above studies.

In the present study, support for internal services and strategic self-reliance with 19 plans was identified as the most important axis in achieving the resistance economy policies in the field of health care at the MUI. According to the results of Hasani and Dehzari's study, a resistance economy is aimed at reducing dependencies and emphasizing the advantage of domestic production and self-reliance.[36] In their research, Mohsenzadeh M also cited the reduction of external dependence and the increase of domestic production as the main foundations of the resistance economy.[37] In addition, Seif[38] and Eidelkhani et al.[39] also cited support for domestic production and strategic self-reliance in resisting economy requirements in their studies. In general, most governments tend to support the production and delivery of domestic services, in particular special products.[40] The results of these studies were in line with the results of the present study. That is because Iran has been experiencing economic crises, technological change, recession, and unemployment in recent years, and thus supporting domestic services and improving the quality of economic services have a significant impact on growth and dealing with economic sanctions.

Economic flexibility is another general objective related to the resistance economy, which was identified by 19 plans as another important axis in achieving the resistance economy policies in the field of health care at the MUI from the viewpoint of the experts. Economic flexibility is a way that organizations can maintain or enhance their flexibility with respect to their workforce, capital goods, natural resources, and location of economic activity after the shock occurs.[41] Economic flexibility has a positive impact on the performance of organizations after a crisis and help organizations maintain their effectiveness in different conditions.[42] To determine the reasonable extent to achieve the ideal economic flexibility in the economic system, the ratio of international trade to Gross Domestic Product (GDP) should be determined.[27] According to Seif's study, economic flexibility strategies include the four elements of deterrence, neutralization, absorption and restoration, and the strategy of dispersal and weakening.[38] Therefore, in the present situation, saving is considered as the driving force in any activity and is of particular importance in the process of economic flexibility of countries.

One of the limitations of the study was that the determination of the plans and executive indicators of the resistance economy policies in each organization are based on its organizational atmosphere and the results cannot be compared with other institutions. However, this program and the relevant specified indicators can be used as a roadmap for other universities of medical Sciences in Iran. Besides, like other qualitative researches, changing the experts may somewhat change the results due to their different understanding. It is suggested to collect information by other methods such as observation and interviews for comprehensiveness. Another limitation of the study was the lack of scientific studies in this field due to the emerging issues of resistive economics in the health issues.

Conclusion

In this study, main goals, thematic goals, strategies, programs, and programmatic indicators of resistance economy policies in the field of health were identified. Resistance economics is not a goal, but it needs to be incorporated into the goals and strategies of policymakers in the health system. The specific and important suggestion of the paper is to identify the programs identified in policymaking to implement health-resistive policies, and to try to act in a balanced way.

Implementing resistance economy policies and achieving its results also requires planning in the long run, building a culture of resistance economics, integrating different sectors and institutions, changing the educational system at different levels of the health system, and training entrepreneurs to implement resilience-driven programs. Finally, implementing programs for a resistance economy is not without cost. Thus, it is suggested that future studies should analyze the cost-benefit of each program to determine the optimal limit of resistance economy.

Financial support and sponsorship

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

Conflicts of interest

There are no conflicts of interest.