The Value Framework Governing Iran's Health System Policy: A Practical Gap.

Background: The value framework governing the health system can guide the policymaking. This study presents a set of values governing the health policies for adopting policies that are in harmony with the ideology of Iran.
Methods: This study was conducted in two phases. In the first phase, using the qualitative approach, Shams et al. framework was adopted to identify values. Identification of health-related national documents (nine documents) was performed purposefully. In the next phase, semi-structured interviews on individual experts in the health system were carried out. The key question was "What values and principles govern the health policy system?" Participants included 15 individuals. Both phases were analyzed based on qualitative content analysis.
Results: In this study, a taxonomy of values governing policymaking is presented. Results show that equity in different dimensions, comprehensive health and a healthy human being, pioneering in health in the region, and accountability are the most important terminal vaqlues. Individual responsibility, government responsibility for health, endogenous and extrinsic economics, fair access, transparency, efficiency, quality and integrity in the supply, development and fair allocation of public health resources, and professional commitment are the most important instrumental values in Iran. Participants believed that, despite the many higher-order documents available, the health system policymaking was not based on a predetermined value. Conclusions: It is not enough to provide a set of values in upstream documents for implementation. It is necessary to specify the relative weight of the reference values in policymaking and their relation to each other in order to apply them in policymaking. Copyright:

Introduction

The Health System in each country always faces new policies or reforms of previous policies to respond to the changing societal needs, to improve health outcomes, and to promote equity.[1] Several factors affect the development of new policies and reform of previous policies, such as available resources, stakeholder experiences, political pressure, habits, traditions, and available evidence.[2]

Usually, policymakers may develop policies at best by merely relying on scientific evidence available and following other countries with regard to the available resources. However, proper governance requires policymaking based on a value framework governing the health system and consistent with the ideology governing that country.[3] This does not mean that evidence-based policymaking and value-based policymaking are inconsistent with each other, but that evidence-based framework and value-based framework together improve the effectiveness of policymaking. In the absence of a referenced value framework, following the policies of other countries, the reference values of other countries become the decision-making reference. Robert Veatch (1985) argued that a deviation from the value framework will cause any targeting, planning, and judging on health-related topics to become a matter of taste if the decision-makers’ values are practically the basis of the health system reform, which will finally lead to instability as well as frequent and tasteless changes in health policies.[4]

Several studies have pointed to the importance of the role of values in decision-making.[5678910] For example, Diane et al. acknowledged that although the past decades have been “greed decades” or “low decades,” we are now entering a new stage and the question is what values guide policymaking.[10] The results indicate that some values in policymaking imply the final result and outcome that are terminal values, and another group of values mediate the realization of the terminal values that are called instrumental values. The instrumental values are usually expressed in health system strategies. The terminal and instrumental values are both considered as content values whose realization can be sought after the implementation of policy options. In other words, provided that policies are developed, adopted, and implemented successfully, policymakers seek first to realize the instrumental values and then achieve the terminal values.[11] In contrast, the realization of process values makes sense during the policy process, or during the policy implementation process. Considering the values of the policymaking process ensures that the policy is developed and approved successfully and qualitatively and considering the values of the policy implementation process ensures successful policy implementation. Although the value framework governing the country plays the most important role in adopting health policies,[11] there has been no identification of the taxonomy of values, which has led to deviations from values in policymaking.[12] In such a case, the evidence of other countries is followed in the best conditions without considering the value framework governing the country. In practice, the same indicators of developed countries are considered as a measure of policy success. This study also presents a set of values governing health policies for adopting the policies that are in harmony with the ideology of Iran.

Methods

The purpose of this study is to extract the values governing Iran's health policy-making system. Since in-depth qualitative research leads to problem recognition, this approach was used in this study by analyzing the content of the higher-order documents related to health and interviewing health system experts. Since facts are generally reflected in policy documents and it is assumed that these documents have been developed based on scientific principles, they are the most valuable means for policy analysis which justifies the extraction of values governing policies.[13] The higher-order documents are national health-related documents published between 1900 and 2020 made publicly available. The selection of documents is purposeful following the four criteria proposed by Jupp namely authenticity (documentation), credibility (accuracy), representativeness (representative of the class documents), and meaning (what it is intended to say).[14] Therefore, the documents studied in this study were evaluated on the basis of these four criteria. The studied population in this study included nine upstream documents such as the Constitution of the Islamic Republic of Iran (A), Act of the Fifth Plan for Social, Economic and Political Development (B), Act of the Sixth Plan for Social, Economic and Political Development (C), the general health policies (D), Comprehensive Scientific Map of the country (E), Map of the evolution of the health system of the Islamic Republic of Iran based on the Islamic—Iranian model (F), Perspective Document of the Islamic Republic of Iran on the 1404 Horizon (G), Comprehensive Scientific Health Map of the country (H), and General Policies of Resistance Economy (I). These documents are among the most important documents related to health and are used as the basis of many decisions and policies. Therefore, the values cited in these documents also represent the whole values governing the health system. After selecting upstream documents, the given documents were studied several times by the research team members and then encoded through a deductive approach based on the concept of the value and its dimensions in health policymaking in a study by Shams et al.[11] In order to ensure the correct placement of values in respective themes, two team members independently encoded and analyzed the content, and finally, in the event of any disagreement, experts were interviewed. After analyzing the content of the texts using MAXDA software, the taxonomy of values was formulated.

At the second stage of the study, individual and semi-structured interviews with health system experts were used. The most central question in the interview was “What values and principles govern the health policy system?” On the other hand, some questions such as “values governing policymaking system in different periods of health system reform” were asked. The interview guidelines were observed to conduct the interview if a list of probes, transition opening, key, ending, and follow-up questions related to the topic were provided, which guided the interview sessions accordingly. Feedback and Reflection were also considered along with the interview.[15] The participants at this stage of the study included 15 individuals, each with different executive work experience and some with work experience in several fields. The participants’ inclusion criteria are volunteering, ability to speak, and experience of the phenomenon. Sandelowski (1995) believed that saturation depends on the researcher's experience,[16] and given that the study results are among the larger study stages conducted by the same team, the researchers had much experience in this field.

In this study, in order to increase the validity, there was a continuous engagement with the research topic and data and a good relationship was established with the participants. The conducted interviews were returned to the participants to ensure that the extracted themes were the same as the content of the interviewee's conversations, after which all versions of the interview were read several times for better comprehension of the data. In order to increase the validity of the study, data analysis and interpretation phases were undertaken by several researchers. In order to establish reliability, we consulted an external auditor to study data with whom an agreement was reached on the process and results, as well as all procedures including accurate recording of the results, where a detailed report of the study was presented. In order to observe the transferability, the results obtained from the present study were shared with professors and other non-research scholars who read the study results, where the similarity of the results was determined. Comparison of the results with previous studies showed its consistency.[17] The inductive approach was used to analyze interview data through MAXDA software.

Results

In order to provide a list of higher-order values and values governing the health system based on nine upstream documents, 219 codes were identified. Accordingly, a larger number of values and principles were outlined in the General Health Policy Document and Health System Evolution Map based on the Islamic-Iranian model [Figure 1].

Figure 1

Number of codes in higher-order documents

Higher-order values of the country

The health system is a complex system, which in turn is a subsystem of a larger system,[18] so the dominant values over the larger system are considered as higher-order values for the health system which include ideological values of each country and the values reiterated in the constitution. The higher-order values refer to terminal values that govern the general policies of each country [Table 1].

Table 1

Terminal values governing the country

Terminal values	Semantic units
Justice [A, D, H]:  Economic justice [F]   Fair distribution of income [B]   Avoidance of poverty [B]  Universal justice [B]  Social justice [B, A]  God’s justice in creation and in law ([A]	Proper distribution of income, avoidance of poverty, universal justice, justice-based nurturing of talents and access for all, especially the oppressed, avoidance of discrimination, rule of law and justice of the Quran
Freedom [D, B]:  Freedom of expression [D]  Freedom of belief [A]  Territorial integrity [A]	There are freedom of opinion, exchange of opinions, and conflict of views (best debate); inquisition is forbidden and no one can be attacked or criticized for having an opinion; treat non-Muslim person with good morality and Islamic justice
Independency [A, H]:  Political [A]  Economical [A]  Social and cultural [A]  Military [A]	Preventing foreign economic domination of the country’s economy, territorial integrity
Pioneer [E, H]:  Competitiveness of economy [F]  Endogenous and exogenous economy [F, E]  Economy based on knowledge and technology [F]  Native pattern of development [B]  National solidarity [B]  Active and inspirational interaction with the global environment [B]	Constructive, active, and leading presence among nations; dynamic and progressive economy; competitiveness of economy, endogenous economy, exogenous economy, and Constructive, active, and leading presence among nations [B, D, H] Leading and dynamic economy [F] economy based on knowledge and technology; developed economy, tailored to its cultural, geographical, and historical requirements; national solidarity; constructive and effective interaction with the world on the basis of the principles of dignity, wisdom, and inspiration; active and effective on the Islamic world by setting the model of democracy

Instrumental values governing the country

The realization of the terminal values in any country depends on the realization of the instrumental values [Table 2].

Table 2

Instrumental values governing the country

Instrumental values	Semantic units
Right observance [C]:	Preserving human dignity and rights, relying on the nature of truth, rationalism, science and freedom, excellence, and balance
Individual right
Ownership [C, H]
Human dignity [A, B, D]
Socialization [C]
Paying attention to Sharia [A, E, D, H]:	Divine revelation and its fundamental role in the expression of laws; resurrection and its constructive role in the human evolution toward God; continuous leadership, and its essential role in the continuation of the Islamic revolution; enjoining good and forbidding evil as the responsibility of all to avoid extravagance on all aspects of the economy, including consumption; prohibition of loss, monopoly, usury, and other prohibited transactions and the ruling of the monotheistic worldview of Islam in all aspects; human perfection, responsibility to God; ethics; public interest priority to individual and group interests; strengthening cooperative spirituality, partnership and responsibility of scientific community and its related institutions; avoidance of oppression; reliance on Islamic, national and revolutionary ethics and values; Jihad culture; family being a fundamental unit in Islam; strong family entity
The Qur’an and Hadith as the Epistemological Source [A]
Hereafter purposefulness [A]
Provincialism [A]
Promoting Islamic behavior [A]
Islamic economy [A]
ruling of the monotheistic worldview of Islam in all aspects [D]
Human happiness [F]
Individual responsibility toward God [A]
ethics, public interest priority to individual and group interests, strengthening cooperative spirituality, partnership and responsibility of scientific community and its related institutions [D]
The need for kindness and charity [C]
Institutionalization of Iranian Islamic Ethical Values [B, C]:
Jihad culture [F]
Family authenticity [A, E, B]
The centrality of the Islamic nation:	Political, economic, and cultural unity of the Islamic world
Political unity of the Islamic world [A]
Economic unity of the Islamic world [A]
Cultural unity of the Islamic world [A]
Social integrity [C] security [B]:	Safe, independent, and robust with a comprehensive deterrent-based defense system of justice
Social
Judicial
Total well-being and health:	Spiritual, physical, mental, and social health of the community, food security, social security for retirement, unemployment, and aging
Spiritual, physical, mental, and social health of the community [D].
food security [B]
social security for retirement, unemployment, and aging [A]
Human capital [H]:	Active, responsible, self-sacrificing, faithful, contented, conscientious, disciplined, spirit of cooperation and social compatibility, committed to revolution and Islamic system and prosperity of Iran and honored to be an Iranian
Active [B]
Responsible [B]
Self-sacrificing [B]
Faithful [B]
Contented [B]
Conscientious [B]
Disciplined [B]
Having a spirit of cooperation and social compatibility [B]
Committed to the Islamic revolution and prosperity of Iran [B]
Honored to be Iranian [B]
Rationality [D]
Gaining people’s trust [C]
Stability In the National Economy [F]
Rule of Law [A]

Content values in the health system

Value-based policymaking requires the realization of terminal values. Among the values mentioned in the higher-order documents, the value of “comprehensive equity in the health system” has been cited more frequently and seems to be the principle final value in the health system.

The realization of terminal values requires the realization of instrumental values. Among the instrumental values, fair access and quality seem to be the central most important instrumental values cited in higher frequency in the documents [Table 3].

Table 3

Terminal and instrumental values governing the health system

Terminal values
Terminal values	Semantic units
Comprehensive equity in health [A, E, C, G, H]  Maximum health as a right [C, H]  Equity in health financing [C]  Fair distribution of health [E, G, C]  Equity in service utilization [C]	Maximum health as a right, equity in health financing, Fair benefit from promoting health, especially in disadvantaged areas, and helping to meet catastrophic health expenditures [G]
Comprehensive health and a healthy human being [E, C, H]  Social solidarity [C]	Health promotion, highest quality of life expectancy for all, comprehensive health, maximum possible health, longest possible life with health and well-being, quality life, and human capital promotion
Pioneering in health [E, H]	Improving health indicators to achieve first place in the region
Accountability [C, E, H]  human dignity [A, B, D, H]	Accountability, accountable, responsible, and accountable, responsibility
Instrumental values
Individual responsibility [C, E]  Government’s responsibility for health [H]  Endogenous and exogenous economy in health [E, F]  Fair access [G, C]  Health services [G, C, E]  Information [C, G]  Food and treatment [B, F]	Creating and strengthening the infrastructure needed to manufacture pharmaceutical products, raw materials, vaccines, bio-products and medical supplies and equipment of international quality and standard, export of goods, fair access to other health services and information, medication coverage, universalization of basic health insurance, comprehensive coverage of basic health services package tailored to community needs and culture, food security and treatment
Transparency [F, C, H]	Fair access to other health services and information
Efficiency [F, E, H]	Efficiency and productivity, efficiency and resource protection
Effective cost [C]
Utilization management [F]
Quality [F, E, G, H]	Quality, providing people with desired health services, transparent information, transparency, performance-based payment, effectiveness, safety, comprehensive and integrated health care, and transparent information
Clinical Quality:
Effectiveness [E]
Safety [C, E]
Comprehensive and integrated health care [E]
Transparent notification [E]
Service quality:
Legal protection of the rights of people and patients [E]
Maintaining integrity in the provision, development and equitable allocation of public health resources [G]
Professional commitment [H]

Process values

Proper policymaking requires the realization of content and process values because without process, values one cannot be sure that content and terminal values will be realized. Process values are rooted in policymaking and implementation, and if these values are ignored, successful policy implementation will face serious problems [Table 4].[11]

Table 4

Process and policy implementation values governing the health system

Process values of policymaking
Values	Semantic units
Promoting decision-making and action based on sound and scientific findings [E]	Responsibility for people to increase health
Intersectoral cooperation [C]
Policy implementation values
Sustainable financing [E]	Responsibility for people to increase health
People’s participation [C]
Intersectoral cooperation [C]

Principles

The principles are fixed, objective, directional, sectoral, self-evident, and self-validating facts that always show the direction as a compass. The principles form the rules of thumb and the basis of the mind of the policymaker during the policymaking process. The principles have different origins. The scientific principles originate from fixed patterns of nature, legal principles originate from laws and regulations, and moral principles originate from instrumental values. Unlike values, which affect decision-making by the intermediating system of criteria and in an analytical framework, the influence of principles on decision-making is usually direct and non-analytical [Table 5].[11]

Table 5

Principles governing the health system

Health attachment for all projects [G]	Prioritizing science and technology responsive to community health needs [H]
Family physician focus on referral system [G, C]	Service leveling [G, C, E]
Strategic purchase of services [G, I]	Declining government enterprises [G, I]
Treatment guides [G, E]	Personnel and physicians [G]
Special treatment and disease [G]	Reducing the dependence of the turnover of health care units on dedicated incomes [G]
Maintain integrity in health knowledge and information management [G, H]	Immediate and unconditional treatment of the victims of traffic accidents [G]
Moral values [C, E]	Prevention-to-treatment priority [C, E, G, F, H]
Updating health and treatment plans [E]	Islamic principles [E]
Prevention of induced demand [E]	Generic plan and national pharmacy system [E]
Priority of public goods over private goods [E]	Health technologies evaluation [E]
Promoting the health and empowerment of veterans and the disabled community of the country [E]	Competitive market for health insurance services [E]
Introducing tax on harmful products, materials, and services [E]	Innovation [H]
Compliance with medicinal pharmacopoeia [I]

After analyzing the content of the interviews with the experts, the question of the status of health policy was first answered and then the barriers to implementing value-based policymaking were identified. Concerning the current state of value-based policymaking, the study participants acknowledged that values framework in the health system (prioritizing values) had not been formulated. As they said, “It cannot be acknowledged as coherent on the basis of what values are politicized, because there is currently no values framework to refer to, and a values framework is a basis of philosophical thoughts. Although the ideology of our country is Islamic, other countries use this ideology, not us.” And there is not even a comprehensive definition of value in the health system. As acknowledged, “The concept of equity has not been defined in different views and in different parties, the main reason being that there has been no attempt to convert values into political schools so that one's approach to a problem is quite different from that of other parties. “ Policymaking is based on the individual values of powerful groups and there is a gap between values governing upstream documents and values governing policy implementation in practice. In policymaking, the interests of the government take precedence over the interests of the people, and “the values are valued by the people, not by health system experts.” The values have become anti-values, and politics is subject to political events, not philosophical or ideological views. At best, the values of international organizations, including the World Health Organization, are considered as irregular and deviated basis in practice.

From the study participant's point of view, the barriers to implementing value-based policymaking fall into four categories: structure, management style, policymaking process, attitude, and disregard for the value burden of evidence.

1-Structure:

- No relationship between seminary and different areas, including the health system

“Sectoral institutions have failed to develop a system of values governing each of the policy areas in order to develop appropriate criteria for operationalizing policies.”

- Lack of legal and administrative frameworks to resolve conflicts of interest

“Conflicts of interest between beneficiary groups have caused the value framework to not be followed. While in other countries, they have been able to somehow resolve the conflict of interest using legal and management frameworks, there is no framework for it in Iran, and if there is any, there is no act on it.”

- Appointing people in sensitive management positions without examining the alignment of individual values with national and organizational values.

2-Management style, policymaking process:

- Pragmatism is the dominant school of politics,

“The current style of policymaking is based on a kind of pragmatism. It has no evidence and no reference values. Rather, the preferences of individuals and groups make policy orientations. So, they do not use evidence or use evidence to justify actions.”

- Lack of systematic relationship between higher-order and other policy documents

- Policymaking is concerned with solving urgent and case problems rather than being engaged in a systemic approach to solving health-related problems:

“The policymaking approach in our country lacks strategic and systemic thinking because policymakers are elected from the executive body and cause sectoral decision-making.”

Others believe that “these policies are nothing more than a means to silence people's complaints.”

- Lack of operationalization of health values

“Although higher-order documents mention values, these values have not been operationalized in the health field.”

- Absence of planning in the community

“Non-planning is prevalent in the community; one of the reasons is that financing does not lead to the accountability of institutions.”

- Lack of a specific trustee in the health system

“The health system does not have specific stewardship, and there is much parallelism in different plans regardless of the values that govern each policy. If a policy is in the right direction, a coincidence has occurred.”

“The values governing the health system policymaking have not been based on one particular rule but on one period of justice, on another period of people's satisfaction, etc., and have been fully tested, and even when justice has been taken into account, we have acted in a justice-based policy and in another anti-justice policy.”

-Multiple interpretations of upstream documents

“The higher-order documents are written in a way that different organizations, based on their own interests and mentality, make different interpretations of sentences. There is no reference to provide a sound interpretation.”

- Lack of proper supervision of the executive power and consequently lack of accountability

- Lack of managerial stability and appointment of managers based on political orientations

“Not only is the management unstable, but policymakers are also subordinated to political relationships, and that depends on where the power pyramid is. Therefore, policymaking does not seem to be very scientific and policies that are developed are inconsistent with Islamic values and in contradiction.”

3-Attitude:

- Commercialization of the medical profession or medicalization

“Medicine has become a business because of its high-income status and all its related industries all over the world have moved in this direction. As the pharmaceutical and equipment industries become a money-making industry, this in effect has caused neglecting the human values.”

- Lack of attention to Islamic ideology in policymaking

“Although some are aware of the effect of values on policymaking, these values are considered at the individual and group levels and less likely to be identified with a reference value framework.”

- Lack of understanding of the importance of policymaking in the health system

- Sectoral vision and short-term thinking of policymakers

“The Health Policy Council could not play an active role in developing a value framework and was only concerned with solving the country's current problems.”

4- Not considering the value burden of evidence

- Lack of use of evidence and/or use of evidence irrespective of its value

“In the health system, either the evidence is not used and problems are solved based on experiences, interests or preferences, or the evidence is used without regard to their value. You may blindly imitate other countries without paying attention to the values that govern their policies and solutions to their problems.”

Discussion

Lack of a value framework leads to reactive, gradual, and partial decision-making, which hardly leads to solving the underlying problems such as inadequate access to health care, high costs, and inadequate quality of care. Without clarifying the values, each policymaker chooses a strategy based on experience, intuition, and personal values, which in turn causes an imbalance in the system. Therefore, explicit values will help to reach an agreement among different policymakers, even at different times, to prevent undue changes in management goals. In addition, the existence of a value framework increases the accountability of the health system to greater adherence to the fundamental values.[19]

Among the studied documents, two documents of the Islamic Republic's Constitution and the Islamic Republic's Perspective Document in the 1404 Horizon indicated more upstream values. These values can be found in the dimension of final values such as justice, freedom, independence, and pioneering and in the dimension of instrumental values such as the observance of rights, observance of Sharia, Islamic nation, social integrity, security, well-being, human capital, rationality, public trust, competitiveness in production, stability in the national economy, and the rule of law. All the studied documents, except for the country's scientific community map and the general policies of the resistance economy, pointed to the content and process values governing the health system. The development map of the health system and general health policies had the greatest contribution to referring to content and process values governing the health system. The values mentioned in these documents are (1) terminal values: widespread justice (including equity in health financing, fair distribution of health, equity in service utilization, and the maximum health as a right), comprehensive health and a healthy human being, pioneering in health, and accountability (including human dignity); (2) instrumental values: individual responsibility, government responsibility for health, endogenous and extrinsic economics of health, fair access, transparency, efficiency, quality and integrity in supply, development and fair distribution of public health resources, and professional commitment; (3) policymaking process values: evidence-based policymaking, and intersectoral cooperation; and (4) policy implementation values: sustainable financing, public participation and intersectoral cooperation. Mostafavi et al.[20] (2016) in a study identified social values for prioritizing health services in Iran and extracted social values in several higher-order documents that can be applied to justice, public participation, transparency, freedom, social integrity, responsibility, and effectiveness cost. However, the present study has mentioned more values that can be assigned to independence, pioneering in health, observance of rights, observance of Sharia, an Islamic nation, security, well-being, rationality, stability, rule of law, individual responsibility, government responsibility, health, and quality. Thus, it seems that the reason for the neglect of some of the values in a study by Mostafavi et al.[20] is the Clark-Wells framework.[8] On the one hand, the Clark-Wells value list does not have the necessary comprehensiveness and the type of values that are grouped together is not homogeneous. For example, equity is a very broad concept and, according to our classification in this study, it is considered as a terminal value, while effectiveness cost or clinical effectiveness is a value that plays a mediating and instrumental role in realizing higher values such as promoting the community health. On the other hand, justice in this study is limited to accessibility and availability of service. However, equity has the broader dimensions mentioned in the present study and access is only one of the means of achieving justice in health. In a study, Rajabi et al.[21] (2013) extracted the values and principles of the 2025 Islamic Republic of Iran health system evolution map based on upstream documents and opinions of health system experts. In this study, values mean goals or social standards or standards accepted by individuals, groups, and community including human dignity (all people should be respected and all people are equal), comprehensiveness of services (physical, mental, and spiritual health), justice, the highest level of health as a right, and social integrity. The principles in this study are the belief, the law, or the driving force behind the actions. The examples of this study include institutionalized ethical values, accountability, responsibility, fair use, prevention, health enhancement, public participation, intra-sectoral cooperation, integrated toilets, the use of desired technology, and improved human capital. It seems that a complete list of values and principles is mentioned in this study, but the point here is that the values and principles in a study by Rajabi et al.[21] are one type and the definition for values and principles is not distinctive, so they could be put forward as a subset of values. In the present study, contrary to values, which influence decision-making through the criterion system and in an analytical framework, the influence of principles on decisions is usually direct and non-analytical.[11] In other words, the principles usually cause a number of policy options to be excluded at the beginning of the work, and other options that are consistent with the principles should be maintained according to the criteria system. In a study by Khayatzadeh-Mahani and Fotaki (2013),[7] two ethical values of justice and individual freedom were examined in practice and it has been stated that in the Iranian health system, the market-oriented view believed individual freedom that is strongly influenced by the medical community. Despite that in many upstream documents including the Constitution and national documents, an equality view governs and justice is emphasized. In the present study, the views of the health system experts on the values that are in practice on the basis of policymakers’ work are sought. The point is that most policymakers believe that, in spite of the many upstream documents available, the health system policymaking is not based on predetermined values, but decisions are often based on individual interests, empirical and based on individual or group interests, not on a value framework in which the importance of each value is known. The experts stated that even when the value of justice in politics was above all the other values, it was due to the favor of the policymaker rather than the value framework that governed Iran. In general, there are various barriers to adherence to the value system, such as structural factors, management style, policymaking process, attitude, and disregard for the value burden of evidence. Therefore, the dominance of a particular group on the health system as a barrier to the implementation of values in practice is consistent with Khayatzadeh-Mahani and Fotaki study. Mostafavi et al.[20] (2016), like this study, pointed to the lack of agreement on the concept of value in the health system and considered it a barrier to the implementation of values. Other countries, such as the US, Canada, Chile, and Colombia[41322] in studies have identified the values that govern the health system, which are not comparable with Iran since the value framework differs in those countries.

Conclusions

In Iran, widespread equity (including equity in finance, equity in service utilization, and the maximum health as a right), comprehensive health and a healthy human being, pioneering in health, and accountability (including human dignity) are the most important final values and values including individual responsibility, government responsibility for health, endogenous and extrinsic health economics, fair access, transparency, efficiency, quality and integrity in the supply, development and fair allocation of public health resources, and professional commitment are the most important instrumental values for the realization of terminal values in the higher-order documents that indicate justice as central to the country's religious values. Considering fundamental values explains why America is the only western country that does not guarantee public access to health care. It is similar to many western European and Canadian countries in terms of cultural, philosophical, and democratic traditions as well as demographics, wealth, and income distribution.[4] Therefore, it is necessary to go a step further and ensure that these values are applied in policymaking, which will not be achieved without determining the relative weight of the reference values in policymaking and specifying the relationship between values.[1222] Determining the relative weight of values can help guide decisions and select the best policy options.

Ethical considerations

Ethical issues (including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

Author's contribution

In the first phase, using the qualitative approach, Shams et al. framework was adopted to identify values. Identification of health-related national documents was performed purposefully by Shams. In the next phase, semi-structured interviews on individual experts in the health system were carried out by Shams and Nasiri. Both phases were analyzed based on qualitative content analysis by Shams and Nasiri and Yazdani.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.