International Journal of Health Policy and Management (IJHPM)

Published by Kerman University of Medical Sciences
As part of the EuroDRG project, researchers from eleven countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their Diagnosis-Related Groups (DRG) systems deal with cholecystectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems. National or regional databases were used to identify hospital cases with a procedure of cholecystectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardised case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained and compared to an index case. European DRG systems vary widely: they classify cholecystectomy patients according to different sets of variables into diverging numbers of DRGs (between two DRGs in Austria and Poland to nine DRGs in England). The most complex DRG is valued at four times more resource intensive than the index case in Ireland but only 1.3 times more resource intensive than the index case in Austria. Large variations in the classification of cholecystectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons, hospital managers and national DRG authorities should consider how other countries' DRG systems classify cholecystectomy patients in order to optimize their DRG systems and to ensure fair and appropriate reimbursement.
Diagnosis-Related Group (DRG) systems across Europe are very heterogeneous, in particular because of different classification variables and algorithms as well as costing methodologies. But, given the challenge of increasing patient mobility within Europe, health systems are forced to incorporate a common patient classification language in order to compare and identify similar patients e.g. for reimbursement purposes. Beside the national adoption of DRGs for a wide range of purposes (measuring hospital activity vs. paying hospitals), a common DRG system can serve as an international communication basis among health administrators and can reduce the national development efforts as it is demonstrated by the NordDRG consortium. © 2015 by Kerman University of Medical Sciences.
Characteristics of registered TB patients in Hamadan province, Iran, 2005-11 
Comparison between investigated variables and gender using Chi-square test 
Trends of TB case-finding in Hamadan Province, 2005-11 
Comparison of age, gender and TB type in registered TB patients between different sources of TB reporting using Chi-square test 
Background: Epidemiological information on tuberculosis (TB) is required to plan control and prevention strategies and to inform service delivery systems. The aim of present study was to determine the epidemiological status of TB in Hamadan Province covering a seven-year period. Methods: In this cross-sectional study all registered TB patients suffering from any form of smear-positive, smear-negative or extra pulmonary from 2005 to 2011 were assessed. Age-adjusted incidence trend was studied. The Cochran-Armitage (C-A) test was used for testing the trends over time. Results: The mean age of TB patients was 57.0 (±21.1), 49.9% were males, 52.8% were aged 61 years or older and 39.7% were rural residents. Previous history of jailed was present in 13 (2.2%) patients and 12 (2.0%) were HIV positive. From all TB patients, 60.8% were smear-positive, 87.6% were new cases, and 87.3% of smear-positive patients were cured cases. Also, 23.6% patients had history of hospitalization for TB. More than half (55.4%) of TB patients were reported by public health system. Age-adjusted incidence rates of all TB cases during 2005-11 was 3.4, 3.2, 3.6, 4.7, 3.3, 4.4 and 7.3 in 100,000 respectively (C-A trend test, P< 0.001). Conclusion: Although, the incidence rate of TB in Hamadan Province is lower than country's average, increasing trend of TB incidence is not concordant with its decreasing trend in Iran. An epidemiological study is required to evaluate risk factors associated with TB to identify ways to decrease the prevalence of TB.
The commentator suggests that it is necessary to extend the classical connotation of global city which focuses much on the functions of controlling global capital and production. Global city should also include the dimensions of the leading role and capacity on health improvements and well-being promotion. The commentator agrees with authors' assessments about Shanghai's substantial progress on health services and health system reform, however, we should pay much attention to the significant inequality of health services between central city and outskirt, and between local residents and non-hukou migrants. The commentator also suggests that future researches could study the successful experiences of Avoidable Mortality (AM) decline and also disease specific AM decline in main global cities, in order to make more effective policy implications and social schemes recommendations for health improvements in Shanghai and in other cities.
Avoidable mortality in London, New York, Paris and Shanghai, ages 0-74, 2000-10 
Leading causes of AM in Shanghai, 2000 
Over the past two decades, Shanghai, the largest megacity in China, has been coping with unprecedented growth of its economy and population while overcoming previous underinvestment in the health system by the central and local governments. We study the evolution of Shanghai's healthcare system by analyzing "Avoidable Mortality" (AM) - deaths amenable to public health and healthcare interventions, as previously defined in the literature. Based on analysis of mortality data, by cause of death, from the Shanghai Municipal Center for Disease Control and Prevention, we analyze trends over the period 2000-10 and compare Shanghai's experience to other mega-city regions - New York, London and Paris. Population health status attributable to public health and healthcare interventions improved dramatically for Shanghai's population with permanent residency status. The age-adjusted rate of AM, per 1,000 population, dropped from 0.72 to 0.50. The rate of decrease in age-adjusted AM in Shanghai (30%) was comparable to New York City (30%) and Paris (25%), but lower than London (42%). Shanghai's establishment of the Municipal Center for Disease Control and Prevention and its upgrading of public health and health services are likely to have contributed to the large decrease in the number and rate of avoidable deaths, which suggests that investments in public health infrastructure and increasing access to health services in megacities - both in China and worldwide - can produce significant mortality declines. Future analysis in Shanghai should investigate inequalities in avoidable deaths and the extent to which these gains have benefitted the significant population of urban migrants who do not have permanent residency status.
The contents of two kinds of policies in Taiwan 
Interviewees in Taiwan 
This article discusses the influence of policies on the development of biopharmaceuticals. We choose the experiences of Taiwan for our empirical study and focus on the evolution between 2000 and 2008; in the period of time the country provides an interesting example for further exploration of biopharmaceutical policies. Among all the policies, the two National Programs (National Research Program for Genetic Medicine and National Science and Technology Program for Biotechnology and Pharmaceuticals) and the Law of Pharmaceutical Affairs showed the contrasting effects on the innovation system of biopharmaceuticals. As a result, the government generated very limited positive influence on the innovation of biopharmaceuticals.
Investments in the extension of health insurance coverage, the strengthening of public health services, as well as primary care and better hospitals, highlights the emerging role of healthcare as part of China's new growth regime, based on an expansion of services, and redistributive policies. Such investments, apart from their central role in terms of relief for low-income people, serve to rebalance the Chinese economy away from export-led growth toward the domestic market, particularly in megacity-regions as Shanghai and the Pearl River Delta, which confront the challenge of integrating migrant workers. Based on the paper by Gusmano and colleagues, one would expect improvements in population health for permanent residents of China's cities. The challenge ahead, however, is how to address the growth of inequalities in income, wealth and the social wage.
Background: Avoidable mortality as an indicator for assessing the health system performance has caught the attention of researchers for a long time. In this study we aimed to compare the health system performance using this indicator in rural and urban areas of one of Iran's southern provinces. Methods: All deaths (29916) which happened during 2004-2011 in Bushehr province were assessed. Nolte and McKee's avoidable deaths model was used to distinguish avoidable and unavoidable conditions. Accordingly, all deaths were classified into four categories including three avoidable death categories and one unavoidable death category. STATA software was used to conduct Poisson Regression Test and age-standardized death rate. Results: Findings showed that avoidable mortality rates declined in both urban and rural areas at 3.33% per year, but decline rates were influenced by Ischemic Heart Disease (IHD) and preventable death categories to treatable death category. Annual decline rate for IHD category in rural and urban areas was nearly the same as 8%, but in preventable death category, rural areas experienced more decreases than urban ones (7% vs 5% respectively). However, decline rate in treatable mortality neither in urban and nor in rural areas was statistically significant. Conclusion: Despite the annual decline in the rate of avoidable deaths, policy making initiatives especially screening and inter-sectoral measures targeting cause of deaths such as colon and breast cancers, hypertension, lung cancer and traffic accidents, can still further decrease avoidable deaths in both areas.
Background: Elimination of suicide attempts is impossible, but they can be reduced dramatically by an organized planning. The present study aimed to survey the suicide trends in Fars province (Iran), during 2004-2009 to better understand the prevalence and status of suicide. Methods: This survey was a cross-sectional study. The demographic data were collected from the civil status registry between 2004 and 2009. Suicide and suicide attempt data were collected of three sources including the affiliated hospitals of Shiraz University of Medical Sciences, mortality data of Vice Chancellery of Health in Fars province and data from forensic medicine. Then, they were analyzed by Excel and SPSS. Chi-square and regression analyses were used for data analysis. Results: During the study, 10671 people attempted suicide, of which 5697 (53%) were women and 4974 (47%) were men. Among them, 1047 people (9.8%) died, of which 363 (34%) were women and 679 (64%) were men. There was a significant relationship between gender and fatal suicide. The mean suicide attempt for both genders was 53 per 100,000 and 49, 57 for men and women, respectively. The trends in the incidence of Suicidal attempts were decreasing. Conclusion: Without implementing effective preventive measures, the health care system in Iran will face a further burden of fatal suicides among young people. Therefore; enhancing the primary health care and specialized mental health services for those with unsuccessful suicide attempts can effectively reduce the burden of suicide.
Relationship between Sexual and Reproductive Health (SRH) and HIV/AIDS-related policies in IRI 
The number of sexual transmission of HIV is increasing globally. Sexual and Reproductive Health (SRH) issues and HIV/AIDS related problems are rooted in common grounds such as poverty, gender inequality, and social exclusion. As a result, international health organizations have suggested the integration of SRH services with HIV/AIDS services as a strategy to control HIV and to improve people's access to SRH services. The aim of this study was to evaluate the relationship between reproductive health and HIV/AIDS services at policy-making level in Islamic Republic of Iran (IRI). This study was conducted in 2011-2 and was a rapid assessment based on guidelines provided by the World Health Organization (WHO), United Nations Programme on HIV/AIDS (UNAIDS), Family Health International Association, and some other international organizations. In this rapid assessment we used different methods such as a review of literature and documents, visiting and interviewing professionals and experts in family health and HIV/AIDS programs, and experts working in some Non-Governmental Organizations (NGOs). Overall, based on the results obtained in this study, in most cases there was not much linkage between HIV/AIDS policies and SRH policies in Iran. Since integration of HIV/AIDS services and SRH services is recommended as a model and an appropriate response to HIV epidemics worldwide, likewise to control the HIV/AIDS epidemic in Iran it is required to integrate HIV/AIDS and SRH services at all levels, particularly at the policy-making level.
Background: Following the implementation of family physician plan in rural areas, the quantity of provided services has been increased, but what leads on the next topic is the improvement in expected quality of service, as well. The present study aims at determining the gap between patients' expectation and perception from the quality of services provided by family physicians during the spring and summer of 2012. Methods: This was a cross-sectional study in which 480 patients who referred to family physician centers were selected with clustering and simple randomized method. Data were collected through SERVQUAL standard questionnaire and were analyzed with descriptive statistics, using statistical T-test, Kruskal-Wallis, and Wilcoxon signed-rank tests by SPSS 16 at a significance level of 0.05. Results: The difference between the mean scores of expectation and perception was about -0.93, which is considered as statistically significant difference (P≤ 0.05). Also, the differences in five dimensions of quality were as follows: tangible -1.10, reliability -0.87, responsiveness -1.06, assurance -0.83, and empathy -0.82. Findings showed that there was a significant difference between expectation and perception in five concepts of the provided services (P≤ 0.05). Conclusion: There was a gap between the ideal situation and the current situation of family physician quality of services. Our suggestion is maintaining a strong focus on patients, creating a medical practice that would exceed patients' expectations, providing high-quality healthcare services, and realizing the continuous improvement of all processes. In both tangible and responsive, the gap was greater than the other dimensions. It is recommended that more attention should be paid to the physical appearance of the health center environment and the availability of staff and employees.
Estimated annual direct medical costs per patient at different stages of the disease in 2012 
Background: One common challenge to social systems is achieving equity in financial contributions and preventing financial loss. Because of the large and unpredictable nature of some costs, achieving this goal in the health system presents important and unique problems. The present study investigated the Household Financial Contributions (HFCs) to the health system. Methods: The study investigated 800 households in Shiraz. The study sample size was selected using stratified sampling and cluster sampling in the urban and rural regions, respectively. The data was collected using the household section of the World Health Survey (WHS) questionnaire. Catastrophic health expenditures were calculated based on the ability of the household to pay and the reasons for the catastrophic health expenditures by a household were specified using logistic regression. Results: The results showed that the fairness financial contribution index was 0.6 and that 14.2% of households were faced with catastrophic health expenditures. Logistic regression analysis revealed that household economic status, the basic and supplementary insurance status of the head of the household, existence of individuals in the household who require chronic medical care, use of dental and hospital care, rural location of residences, frequency of use of outpatient services, and Out-of-Pocket (OOP) payment for physician visits were effective factors for determining the likelihood of experiencing catastrophic health expenditure. Conclusion: It appears that the current method of health financing in Iran does not adequately protect households against catastrophic health expenditure. Consequently, it is essential to reform healthcare financing.
Obstetrical (pregnancy) risk factors in the participants (n=2993) 
The results of three different logistic regression models to determine the association of sociodemographic characteristics with behavioural, obstetrical, and medical risk factors of pregnancy 
Background: To identify the prevalence of behavioural (Pre-pregnancy), obstetrical and medical risks of pregnancy in Iranian women. Methods: A total of 2993 postpartum women who delivered in 23 randomly selected hospitals of six provinces were enrolled in this nationwide cross-sectional study. A structured questionnaire was completed based on interviewees' self-reports and medical record data, consisting of socio-demographic characteristics, behavioural, obstetrical and medical risks, before and during pregnancy. Results: Less than 6.0% had no health insurance and 5.0% had no prenatal visit before labour. Unintended pregnancy was reported by 27.5% of women. Waterpipe and/or cigarette smoking was reported by 7.1% of them and 0.9% abused opiates during pregnancy. Physical abuse by husband in the year before pregnancy occurred in 7.5% of participants. The rate of cesarean section was 50.4%. Preterm birth, low birth weight, and stillbirth were seen in 6.8, 7.7, and 1.2% of deliveries respectively. The most frequent medical risk factors were urinary tract infection (32.5%), anemia (21.6%), and thyroid disease (4.1%). Conclusion: More effort should be devoted by health policymakers to the establishment of a preconception counselling (health education and risk assessment) and surveillance system; although obstetrical and medical risks should not be neglected too.
The world has made a great deal of progress through the Millennium Development Goals (MDGs) to improve the health and well-being of people around the globe, but there remains a long way to go. Here we provide reflections on Rwanda's experience in working to meet the health-related targets of the MDGs. This experience has informed our proposal of five guiding principles that may be useful for countries to consider as the world sets and moves forward with the post-2015 development agenda. These include: 1) advancing concrete and meaningful equity agendas that drive the post-2015 goals; 2) ensuring that goals to meet Universal Health Coverage (UHC) incorporate real efforts to focus on improving quality and not only quantity of care; 3) bolstering education and the internal research capacity within countries so that they can improve local evidence-based policy-making; 4) promoting intersectoral collaboration to achieve goals, and 5) improving collaborations between multilateral agencies - that are helping to monitor and evaluate progress towards the goals that are set - and the countries that are working to achieve improvements in health within their nation and across the world.
The grand challenge in global health is the inequality in mortality and life expectancy between countries and within countries. According to Global Health 2035, the Lancet Commission celebrating the 20(th) anniversary of the World Development Report (WDR) of 1993, the world now has the unique opportunity to achieve a grand convergence in global mortality within a generation. This article comments on the main findings and recommendations of the Global Health 2035.
Characteristics of absconding patients and non-absconding patients 
Analysis of related variables with patients escape using logistic regression 
Characterization of demographic variables and its association with patients absconding in case and control groups 
Patients' escape from hospital imposes a significant cost to patients as well as the health system. Besides, for these patients, exposure to adverse events (such as suicide, self-harm, violence and harm to hospital reputation) are more likely to occur compared to others. The present study aimed to determine the characteristics of the absconding patients in a general hospital through a case-control design in Shiraz, Iran. This case-control study was conducted on 413 absconded patients as case and 413 patients as control in a large general hospital in Shiraz, southern Iran. In this study, data on the case and control patients was collected from the medical records using a standard checklist in the period of 2011-3. Then, the data were analyzed using descriptive and analytical statistics, through SPSS 16. The finding showed that 413 patients absconded (0.50%) and mean of age in case group was 40.98 ± 16.31 years. In univariate analysis, variables of gender [Odds Ratio (OR)= 2], ward (OR= 1.22), insurance status (OR= 0.41), job status (OR= 0.34) and residence expenditure were significant. However, in multivariate analysis significant variables were age (ORadj= 0.13), gender (ORadj= 2.15), self-employment/unemployed (ORadj= 0.47), emergency/admission (ORadj= 2.14), internal/admission (ORadj= 3.16), insurance status (ORadj= 4.49) and residence expenditure (ORadj= 1.15). Characteristics such as middle age, male gender, no insurance coverage, inability to afford hospital expenditures and admission in emergency department make patients more likely abscond from the hospital. Therefore, it may be necessary to focus efforts on high-risk groups and increase insurance coverage in the country to prevent absconding from hospital.
In this commentary, the idea of closing the gap between knowing and doing through closing the gap between academics and practitioners is explored. The two communities approach to knowledge production and use, has predominated within healthcare, resulting in a separation between the worlds of research and practice, and, therefore, between its producers and users. Meaningful collaborations between the producers and users of research could in theory, create the conditions for more situated knowledge production and use, and result in a potential reduction in the evidence-practice divide within a health service context.
The health sector, a foremost service sector in Nigeria, faces a number of challenges; primarily, the persistent under-funding of the health sector by the Nigerian government as evidence reveals low allocations to the health sector and poor health system performance which are reflected in key health indices of the country.Notwithstanding, there is evidence that the private sector could be a key player in delivering health services and impacting health outcomes, including those related to healthcare financing. This underscores the need to optimize the role of private sector in complementing the government's commitment to financing healthcare delivery and strengthening the health system in Nigeria. There are also concerns about uneven quality and affordability of private-driven health systems, which necessitates reforms aimed at regulation. Accordingly, the argument is that the benefits of leveraging the private sector in complementing the national government in healthcare financing outweigh the challenges, particularly in light of lean public resources and finite donor supports. This article, therefore, highlights the potential for the Nigerian government to scale up healthcare financing by leveraging private resources, innovations and expertise, while working to achieve the universal health coverage.
Key Recommendations to Improve Patient Safety for Patients with LEP  
The article by Cheri Wilson, “Patient Safety and Healthcare Quality: The Case for Language Access”, highlights the challenges of providing Culturally and Linguistically Appropriate Services (CLAS) to patients with Limited English Proficiency (LEP). As the US pursues high-value, high-performance healthcare, our ability to meet the needs of our most vulnerable will determine whether we succeed or fail in the long run. With the implementation of the Affordable Care Act (ACA), this is more important than ever before, as it is estimated that the newly insured are more likely to be minority and less likely to speak English than their currently insured counterparts. As such, we must create a safe, high-quality healthcare system for all, especially in this time of incredible healthcare transformation and unprecedented diversity. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals provides a blueprint for achieving this goal, and Massachusetts General Hospital (MGH) is taking action.
This paper aims to provide a description of the need for Culturally and Linguistically Appropriate Services (CLAS) for Limited English Proficient (LEP) patients, an identification of how the lack of CLAS for LEP patients can compromise patient safety and healthcare quality, and discuss barriers to the provision of CLAS.
This commentary is a brief response to Nir Eyal's argument that health policies should not make healthy behaviour a condition or prerequisite in order to access healthcare as it could result in the people who need healthcare the most not being able to access healthcare. While in general agreement due to the shared concern for equity, I argue that making health behaviour a condition to accessing healthcare can serve to develop commitment to lifestyle changes, make the health intervention more successful, help appreciate the value of the resources being spent, and help reflect on the possible risks of the intervention. I also argue that exporting or importing the carrot and stick policies to other countries without a solid understanding of the fiscal and political context of the rise of such policies in the US can lead to perverse consequences.
Background: Road traffic accidents and their related deaths have become a major concern, particularly in developing countries. Iran has adopted a series of policies and interventions to control the high number of accidents occurring over the past few years. In this study we used a time series model to understand the trend of accidents, and ascertain the viability of applying ARIMA models on data from Taybad city. Methods: This study is a cross-sectional study. We used data from accidents occurring in Taybad between 2007 and 2011. We obtained the data from the Ministry of Health (MOH) and used the time series method with a time lag of one month. After plotting the trend, non-stationary data in mean and variance were removed using Box-Cox transformation and a differencing method respectively. The ACF and PACF plots were used to control the stationary situation. Results: The traffic accidents in our study had an increasing trend over the five years of study. Based on ACF and PACF plots gained after applying Box-Cox transformation and differencing, data did not fit to a time series model. Therefore, neither ARIMA model nor seasonality were observed. Conclusion: Traffic accidents in Taybad have an upward trend. In addition, we expected either the AR model, MA model or ARIMA model to have a seasonal trend, yet this was not observed in this analysis. Several reasons may have contributed to this situation, such as uncertainty of the quality of data, weather changes, and behavioural factors that are not taken into account by time series analysis.
McDonough's perspective on healthcare reform in the US provides a clear, coherent analysis of the mix of access and delivery reforms in the Affordable Care Act (ACA) aka Obamacare. As noted by McDonough, this major reform bill is designed to expand access for health coverage that includes both prevention and treatment benefits among uninsured Americans. Additionally, this legislation includes several financial strategies (e.g. incentives and penalties) to improve care coordination and quality in the hospital and outpatient settings while also reducing healthcare spending and costs. This commentary is intended to discuss this mix of access and delivery reform in terms of its potential to achieve the Triple Aim: population health, quality, and costs. Final remarks will include the role of the US federal government to reform the American private health industry together with that of an informed consume.
Factors influencing the implementation of accrual accounting system at KUMS 
The variance is defined by the factors influencing performance. 
Background: Change theories provide an opportunity for organizational managers to plan, monitor and evaluate changes using a framework which enable them, among others, to show a fast response to environmental fluctuations and to predict the changing patterns of individuals and technology. The current study aimed to explore whether the change in the public accounting system of the Iranian health sector has followed Kurt Lewin's change theory or not. Methods: This study which adopted a mixed methodology approach, qualitative and quantitative methods, was conducted in 2012. In the first phase of the study, 41 participants using purposive sampling and in the second phase, 32 affiliated units of Kerman University of Medical Sciences (KUMS) were selected as the study sample. Also, in phase one, we used face-to-face in-depth interviews (6 participants) and the quote method (35 participants) for data collection. We used a thematic framework analysis for analyzing data. In phase two, a questionnaire with a ten-point Likert scale was designed and then, data were analyzed using descriptive indicators, principal component and factorial analyses. Results: The results of phase one yielded a model consisting of four categories of superstructure, apparent infrastructure, hidden infrastructure and common factors. By linking all factors, totally, 12 components based on the quantitative results showed that the state of all components were not satisfactory at KUMS (5.06±2.16). Leadership and management; and technology components played the lowest and the greatest roles in implementing the accrual accounting system respectively. Conclusion: The results showed that the unfreezing stage did not occur well and the components were immature, mainly because the emphasis was placed on superstructure components rather than the components of hidden infrastructure. The study suggests that a road map should be developed in the financial system based on Kurt Lewin's change theory and the model presented in this paper underpins the change management in any organizations.
Sample numbers of household expenditure report
The Kerman Province health expenditure trend according to health functions during 2008–11  
Background: Provincial Health Accounts (PHA) as a subset of National Health Accounts (NHA) present financial information for health sectors. It leads to a logical decision making for policy-makers in order to achieve health system goals, especially Fair Financial Contribution (FFC). This study aimed to examine Health Accounts in Kerman Province. Methods: The present analytical study was carried out retrospectively between 2008 and 2011. The research population consisted of urban and rural households as well as providers and financial agents in health sectors of Kerman Province. The purposeful sampling included 16 provincial organizations. To complete data, the report on Kerman household expenditure was taken as a data source from the Governor-General's office. In order to classify the data, the International Classification for Health Accounts (ICHA) method was used, in which data set was adjusted for the province. Results: During the study, the governmental and non-governmental fund shares of the health sector in Kerman were 27.22% and 72.78% respectively. The main portion of financial sources (59.41) was related to private household funds, of which the Out-of-Pocket (OOP) payment mounted to 92.35%. Overall, 54.86% of all financial sources were covered by OOP. The greatest portion of expenditure of Total Healthcare Expenditures (THEs) (65.19%) was related to curative services. Conclusion: The major portion of healthcare expenditures was related to the OOP payment which is compatible with the national average rate in Iran. However, health expenditure per capita, was two and a half times higher than the national average. By emphasizing on Social Determinant of Health (SDH) approach in the Iranian health system, the portion of OOP payment and curative expenditure are expected to be controlled in the medium term. It is suggested that PHA should be examined annually in a more comprehensive manner to monitor initiatives and reforms in healthcare sector.
Background: Patient satisfaction is one of the vital attributes to consider when evaluating the impact of accreditation systems. This study aimed to explore the impact of the national accreditation system in Lebanon on patient satisfaction. Methods: An explanatory cross-sectional study of six hospitals in Lebanon. Patient satisfaction was measured using the SERVQUAL tool assessing five dimensions of quality (reliability, assurance, tangibility, empathy, and responsiveness). Independent variables included hospital accreditation scores, size, location (rural/urban), and patient demographics. Results: The majority of patients (76.34%) were unsatisfied with the quality of services. There was no statistically significant association between accreditation classification and patient satisfaction. However, the tangibility dimension – reflecting hospital structural aspects such as physical facility and equipment was found to be associated with patient satisfaction. Conclusion: This study brings to light the importance of embracing more adequate patient satisfaction measures in the Lebanese hospital accreditation standards. Furthermore, the findings reinforce the importance of weighing the patient perspective in the development and implementation of accreditation systems. As accreditation is not the only driver of patient satisfaction, hospitals are encouraged to adopt complementary means of promoting patient satisfaction.
A recent International Journal of Health Policy and Management (IJHPM) article by Fadi El-Jardali and colleagues makes an important contribution to the literature on health system strengthening by reporting on a survey of healthcare stakeholders in Low- and Middle-Income Countries (LMICs) about Systems Thinking (ST). The study's main contributions are its confirmation that healthcare stakeholders understand the importance of ST but do not know how to act on that understanding, and the call for collective action by the global community of systems thinkers committed to healthcare improvement. We offer three basic considerations for next steps by this community, derived from our recent work in ST and the related field of Knowledge Translation (KT): resist the temptation to adopt a reductionist approach; recognize not everyone needs to understand ST; and do not wait for everything to be in place before getting started.
Studies investigating fertility decline in developing countries often adopt measures of determinants of fertility behavior developed based on observations from developed countries, without adapting them to the realities of the study setting. As a result, their findings are usually invalid, anomalous or statistically non-significant. This commentary draws on the research article by Moeeni and colleagues, as an exemplary work which has not adapted measures of two key economic determinants of fertility behavior, namely gender inequality and opportunity costs of childbearing, to the realities of Iran's economy. Measurement adaptations that can improve the study are discussed.
The energy boom of the last decade has led to rapidly increasing wealth in the Middle East, particularly in the oil and gas-rich Gulf Cooperation Council (GCC) countries. This exceptional growth in prosperity has brought with it rapid changes in lifestyles that have resulted in a significant rise in chronic disease. In particular the number of people diagnosed with diabetes has increased dramatically and health system capacity has not kept pace. In this article, we summarize the current literature to illustrate the magnitude of the problem, its causes and its impact on health and point to options how to address it.
New HIV infections in key populations at highest risk per 100,000 (with 95% CI); the error bars represent the 95% simulation intervals. The incidence in all groups appears on the right hand side of the figure excluding PWID and their sexual partners. Reprinted with permission from Nasirian et al. (5) 
Despite the fact that HIV epidemic is mainly driven by injection drug use in Iran, partners of People Who Inject Drugs (PWID) have been seriously neglected in terms of effective preventive interventions. Currently, sexual partners of PWID might have access to some harm reduction services at Voluntary Counselling and Testing (VCT) centers; however, their needs have not been effectively targeted and met. Unfortunately, the current programs implemented by the Ministry of Health have overlooked the importance of this population in the course of the HIV epidemic throughout the country. In this policy brief, we are trying to draw the health policy-makers' attention to this overlooked population and while reviewing the advantages and disadvantages of some of the readily available options on the table, come up with a recommended action to tackle this problem. Our recommended action that seems to have had promising results elsewhere in Asia would try to implement preventive interventions targeting this particular population through peer prevention programs.
Decisions in healthcare should be based on information obtained according to the principles of Evidence-Based Medicine (EBM). An increasing number of systematic reviews are published which summarize the results of prevalence studies. Interpretation of the results of these reviews should be accompanied by an appraisal of the methodological quality of the included data and studies. The critical appraisal tool for prevalence studies developed and tested by Munn et al. comprises 10 items and aims at targeting all kinds of prevalence studies. This comment discusses the pros and cons of different designs of quality appraisal tools and highlights their importance for systematic reviews of prevalence studies. Beyond piloting, which has been performed in the study by Munn et al., it is suggested here that the validity of the tool should be tested, including reproducibility and inter-rater reliability. It is concluded that studies as the one by Munn et al. will help to establish a critical understanding of methodological quality and will support the use of systematic reviews of non-intervention studies for health policy making.
We typically think of acutely and chronically mentally ill patients as those who belong in psychiatric hospitals and the latter category of patients belonging in "regular" hospitals, but the intersection of physical and mental illness draws attention to important challenges for policy makers and organizational leaders. This article illuminates some broad trends in the health status of people with mental illnesses, canvasses important features of inequalities suffered by people with mental illnesses, and suggests strategies for systemic reform. Most reform recommendations I offer are in the area of healthcare organization leadership and management. Other key reforms will likely be legislative, regulatory, and insurance-related. Social and cultural reforms in organizational practices and structures will also be critical.
Sample for quantitative phase 
WTP estimates for job attributes, medical and nursing students 
WTP estimates for job attributes, health workers 
Nearly every nation in the world faces shortages of health workers in remote areas. Cameroon is no exception to this. The Ministry of Public Health (MoPH) is currently considering several rural retention strategies to motivate qualified health personnel to practice in remote rural areas. To better calibrate these mechanisms and to develop evidence-based retention strategies that are attractive and motivating to health workers, a Discrete Choice Experiment (DCE) was conducted to examine what job attributes are most attractive and important to health workers when considering postings in remote areas. The study was carried out between July and August 2012 among 351 medical students, nursing students and health workers in Cameroon. Mixed logit models were used to analyze the data. Among medical and nursing students a rural retention bonus of 75% of base salary (aOR= 8.27, 95% CI: 5.28-12.96, P< 0.001) and improved health facility infrastructure (aOR= 3.54, 95% CI: 2.73-4.58) respectively were the attributes with the largest effect sizes. Among medical doctors and nurse aides, a rural retention bonus of 75% of base salary was the attribute with the largest effect size (medical doctors aOR= 5.60, 95% CI: 4.12-7.61, P< 0.001; nurse aides aOR= 4.29, 95% CI: 3.11-5.93, P< 0.001). On the other hand, improved health facility infrastructure (aOR= 3.56, 95% CI: 2.75-4.60, P< 0.001), was the attribute with the largest effect size among the state registered nurses surveyed. Willingness-to-Pay (WTP) estimates were generated for each health worker cadre for all the attributes. Preference impact measurements were also estimated to identify combination of incentives that health workers would find most attractive. Based on these findings, the study recommends the introduction of a system of substantial monetary bonuses for rural service along with ensuring adequate and functional equipment and uninterrupted supplies. By focusing on the analysis of locally relevant, actionable incentives, generated through the involvement of policy-makers at the design stage, this study provides an example of research directly linked to policy action to address a vitally important issue in global health.
Comparison of the same issues from two viewpoints: patients and matrons 
Informed consent is an important part of the patients' rights and hospitals are assigned to obtain informed consent before any diagnostic or therapeutic procedures. Obtaining an informed consent enables patients to accept or reject their care or treatments and prevent future contentions among patients and medical staff. This survey was carried out during 2011-2. We assessed adherence of 33 Shiraz hospitals (governmental and non-governmental) to informed consent standards defined by Joint Commission International (JCI) Accreditation, USA. The questionnaire was designed using the Delphi method and then filled out by hospital matrons. We calculated valid percent frequency for each part of the questionnaire and compared these frequencies in governmental and non-governmental hospitals using analytical statistics. Considering 63% of the hospitals that filled out the questionnaire, no statistically significant difference was observed between the governmental and non-governmental hospitals in adherence to informed consent standards. This study shows a relatively acceptable adherence to standards about informed consent in Shiraz hospitals but the implementation seems not to be as satisfactory.
Monthly costs in € as documented in health insurance records (N = 61) 
Predictors of change over time in self-reported monthly outpatient service costs in € (multiple linear regression) 
There is limited evidence on the course of health service costs before and after psychiatric inpatient treatment, which might also be affected by source of cost data. Thus, this study examines: i) differences in health care costs before and after psychiatric inpatient treatment, ii) whether these differences vary by source of cost-data (self-report vs. administrative), and iii) predictors of cost differences over time. Sixty-one psychiatric inpatients gave informed consent to their statutory health insurance company to provide insurance records and completed assessments at admission and 6-month follow-up. These were compared to the self-reported treatment costs derived from the "Client Socio-demographic and Service Use Inventory" (CSSRI-EU) for two 6-month observation periods before and after admission to inpatient treatment to a large psychiatric hospital in rural Bavaria. Costs were divided into subtypes including costs for inpatient and outpatient treatment as well as for medication. Sixty-one participants completed both assessments. Over one year, the average patient-reported total monthly treatment costs increased from € 276.91 to € 517.88 (paired Wilcoxon Z = -2.27; P = 0.023). Also all subtypes of treatment costs increased according to both data sources. Predictors of changes in costs were duration of the index admission and marital status. Self-reported costs of people with severe mental illness adequately reflect actual service use as recorded in administrative data. The increase in health service use after inpatient treatment can be seen as positive, while the pre-inpatient level of care is a potential problem, raising the question whether more or better outpatient care might have prevented hospital admission. Findings may serve as a basis for future studies aiming at furthering the understanding of what to expect regarding appropriate levels of post-hospital care, and what factors may help or inhibit post-discharge treatment engagement. Future research is also needed to examine long-term effects of inpatient psychiatric treatment on outcome and costs.
Frequency of three factors of DAMA according to its impact based on patients' perspectives 
Background: Incomplete hospitalization is the cause of disease relapse, readmission, and increase in medical costs. Discharge Against Medical Advice (DAMA) in emergency department (ED) is critical for hospitals. This paper aims to explore the underlying reasons behind DAMA in ED of four teaching hospitals in Kerman, Iran. Methods: This was a cross-sectional study in which the samples were drawn from the patients who chose to leave against medical advice from the ED of teaching hospitals in Kerman from February to March 2011. The sampling was based on census. Data were gathered by a self-constructed questionnaire. The reasons for DAMA were divided into three parts: reasons related to patient, medical staff, and hospital environment. The questionnaire was filled out by a face-to-face interview with patient or a reliable companion. Results: There were 121 cases (5.6%) of DAMA out of the total admissions. The main reason of AMA discharges was related to patient factors in 43.9% of cases, while two other factors (i.e., hospital environment and medical staff) constituded 41.2% and 35.2% of cases, respectively. The majority of patients 65.9% (80 cases) were either uninformed or less informed of the entailing side effects and outcomes of their decision to DAMA. Conclusion: In comparison to studies conducted in other countries, the rate of DAMA is markedly higher in Iran. The results revealed that patients awareness of the consequences of their decisions is evidently inadequate. The study suggests a number of recommendations. These include, increasing patient awareness of the potential side effects of DAMA and creating the necessary culture for this, improving hospital facilities, and a more careful supervision of medical staff performance.
In recent times, there has been a growing demand internationally for health policies to be based on reliable research evidence. Consequently, there is a need to strengthen institutions and mechanisms that can promote interactions among researchers, policy-makers and other stakeholders who can influence the uptake of research findings. The Health Policy Advisory Committee (HPAC) is one of such mechanisms that can serve as an excellent forum for the interaction of policy-makers and researchers. Therefore, the need to have a long term mechanism that allows for periodic interactions between researchers and policy-makers within the existing government system necessitated our implementation of a newly established HPAC in Ebonyi State Nigeria, as a Knowledge Translation (KT) platform. The key study objective was to enhance the capacity of the HPAC and equip its members with the skills/competence required for the committee to effectively promote evidence informed policy-making and function as a KT platform. A series of capacity building programmes and KT activities were undertaken including: i) Capacity building of the HPAC using Evidence-to-Policy Network (EVIPNet) SUPPORT tools; ii) Capacity enhancement mentorship programme of the HPAC through a three-month executive training programme on health policy/health systems and KT in Ebonyi State University Abakaliki; iii) Production of a policy brief on strategies to improve the performance of the Government's Free Maternal and Child Health Care Programme in Ebonyi State Nigeria; and iv) Hosting of a multi-stakeholders policy dialogue based on the produced policy brief on the Government's Free Maternal and Child Health Care Programme. The study findings indicated a noteworthy improvement in knowledge of evidence-to-policy link among the HPAC members; the elimination of mutual mistrust between policy-makers and researchers; and an increase in the awareness of importance of HPAC in the Ministry of Health (MoH). Findings from this study suggest that a HPAC can function as a KT platform and can introduce a new dimension towards facilitating evidence-to-policy link into the operation of the MoH, and can serve as an excellent platform to bridge the gap between research and policy.
Mapping of health facilities 
Background: HIV/AIDS and Tuberculosis (TB) are major contributors to the burden of disease in sub-Saharan Africa. The two diseases have been described as a harmful synergy as they are biologically and epidemiologically linked. Control of TB/HIV co-infection is an integral and most challenging part of both national TB and national HIV control programmes, especially in contexts of instability where health systems are suffering from political and social strife. This study aimed at assessing the provision of HIV/TB co-infection services in health facilities in the conflict-ridden region of Goma in Democratic Republic of Congo. Methods: A cross-sectional survey of health facilities that provide either HIV or TB services or both was carried out. A semi-structured questionnaire was used to collect the data which was analysed using descriptive statistics. Results: Eighty facilities were identified, of which 64 facilities were publicly owned. TB care was more available than HIV care (in 61% vs. 9% of facilities). Twenty-three facilities (29%) offered services to co-infected patients. TB/HIV co-infection rates among patients were unknown in 82% of the facilities. Only 19 facilities (24%) reported some coordination with and support from concerned diseases' control programmes. HIV and TB services are largely fragmented, indicating imbalances and poor coordination by disease control programmes. Conclusion: HIV and TB control appear not to be the focus of health interventions in this crisis affected region, despite the high risks of TB and HIV infection in the setting. Comprehensive public health response to this setting calls for reforms that promote joint TB/HIV co-infection control, including improved leadership by the HIV programmes that accuse weaknesses in this conflict-ridden region.
Nowhere are the barriers to a functional health infrastructure more clearly on display than in the Goma region of Democratic Republic of Congo. Kaboru et al. report poorly integrated services for HIV and TB in this war-torn region. Priorities in conflict zones include provision of security, shelter, food, clean water and prevention of sexual violence. In Goma, immediate health priorities include emergency treatment of cholera, malaria, respiratory illnesses, provision of maternal care, millions of measles vaccinations, and management of an ongoing rabies epidemic. It is a daunting task to determine an essential package of medical services in a setting where there are so many competing priorities, where opportunity costs are limited and epidemiologic information is scarce. Non-governmental agencies sometimes add to the challenge via an insidious reduction of state sovereignty and the creation of new levels of income inequality. Kaboru et al. have successfully highlighted many of the complexities of rebuilding and prioritizing healthcare in a conflict zone.
Background: Rational prescription is a considerable issue which must be paid more attention to assess the behavior of prescribers. The aim of this study was to examine factors affecting family physicians' drug prescribing. Methods: We carried out a retrospective cross-sectional study in Khuzestan province, Iran in 2011. Nine hundred eighty-six prescriptions of 421 family physicians (including 324 urban and 97 rural family physicians) were selected randomly. A multivariate Poisson regression was used to investigate potential determinants of the number of prescribed drug per patient. Results: The mean of medication per patient was 2.6 ± 1.2 items. In the majority (91.9%) of visits a drugs was prescribed. The most frequent dosage forms were tablets, syrups and injection in 30.1%, 26.9%, and 18.7% of cases respectively. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and antibiotics were 29.7% and 17.1% of prescribed drugs respectively. The tablets were the most frequent dosage forms (38.6% of cases) in adult's patients and syrups were the most frequent dosage forms (49% of cases) in less than 18 years old. Paracetamols were popular form of NSAIDs in two patients groups. The most common prescribed medications were oral form. Conclusion: In Khuzestan, the mean of medication per patient was fewer than national average. Approximately, pattern of prescribed drug by family physicians (including dosage form and type of drugs) was similar to other provinces of Iran.
Comparison of PV systems in India, Uganda and South Africa with WHO minimum requirements 
Adverse Drug Reaction (ADR) communication channels in Uganda. Abbrivations: NPC= National Pharmacovigilance Centre; NDA= National Drug Authority; PV= Pharmacovigilance; MoH= Ministry of Health. 
Adverse Drug Reaction (ADR) communication channels in South Africa. MCC= Medicines Control Council. 
Pharmacovigilance (PV) data are crucial for ensuring safety and effectiveness of medicines after drugs have been granted marketing approval. This paper describes the PV systems of India, Uganda and South Africa based on literature and Key Informant (KI) interviews and compares them with the World Health Organization's (WHO's) minimum PV requirements for a Functional National PV System. A documentary analysis of academic literature and policy reports was undertaken to assess the medicines regulatory systems and policies in the three countries. A gap analysis from the document review indicated a need for further research in PV. KI interviews covered topics on PV: structure and practices of the system; current regulatory policy; capacity limitations, staffing, funding and training; availability and reporting of data; and awareness and usage of the systems. Twenty interviews were conducted in India, 8 in Uganda and 11 in South Africa with government officials from the ministries of health, national regulatory authorities, pharmaceutical producers, Non-Governmental Organizations (NGOs), members of professional associations and academia. The findings from the literature and KI interviews were compared with WHO's minimum requirements. All three countries were confronted with similar barriers: lack of sufficient funding, limited number of trained staff, inadequate training programs, unclear roles and poor coordination of activities. Although KI interviews represented viewpoints of the respondents, the findings confirmed the documentary analysis of the literature. Although South Africa has a legal requirement for PV, we found that the three countries uniformly lacked adequate capacity to monitor medicines and evaluate risks according to the minimum standards of the WHO. A strong PV system is an important part of the overall medicine regulatory system and reflects on the stringency and competence of the regulatory bodies in regulating the market ensuring the safety and effectiveness of medications. National PV systems in the study countries needed strengthening. Greater attention to funding is needed to coordinate and sustain PV activities. Our study highlights a need for developing more systematic approaches to regularly monitoring and evaluating PV policy and practices. © 2015 by Kerman University of Medical Sciences.
Proportion of health biotechnology firms in SouthSouth and North-South collaborations 
South-South collaboration network in health biotechnology 
The objective of this work is to elucidate various essential drugs in the Brazil, Russia, India, China and South Africa (BRICS) countries. It discusses the opportunities and challenges of the existing biotech infrastructure and the production of drugs and vaccines in member states of the BRICS. This research is based on a systematic literature review between the years 2000 and 2014 of documents retrieved from the databases Embase, PubMed/Medline, Global Health, and Google Scholar, and the websites of relevant international organizations, research institutions and philanthropic organizations. Findings vary from one member state to another. These include useful comparison between the BRICS countries in terms of pharmaceuticals expenditure versus total health expenditure, local manufacturing of drugs/vaccines using technology and know-how transferred from developed countries, and biotech entrepreneurial collaborations under the umbrella of the BRICS region. This study concludes by providing recommendations to support more of inter collaborations among the BRICS countries as well as between BRICS and many developing countries to shrink drug production costs. In addition, this collaboration would also culminate in reaching out to poor countries that are not able to provide their communities and patients with cost-effective essential medicines.
The editorial by Jeremy Shiffman, "Knowledge, moral claims and the exercise of power in global health", highlights the influence on global health priority-setting of individuals and organizations that do not have a formal political mandate. This sheds light on the way key functions in global health depend on private funding, particularly from the Bill & Melinda Gates Foundation. © 2015 by Kerman University of Medical Sciences.
Health systems across the world are concerned with the quality and safety of patient care. This includes investing in research and development to progress advances in the treatment and management of individuals and healthcare organisations. The concept of evidence- based healthcare has gained increasing currency over the last two decades; yet questions persist about the time it takes for new research evidence to find its way into day to day healthcare decision-making. This paper explores the reasons for this apparent gap between research and healthcare practice, management and policy-making. In particular, the paper argues that different meanings attached to the word 'evidence' fundamentally influence the way in which the research-practice gap is conceptualised and subsequent strategies that are implemented to increase the uptake of research.
In a recent editorial in this journal Pierre-Gerlier Forest foretells a coming revolution in health policy based on the synthesis of four conceptual innovations and one technological breakthrough. As much as I agree with the intellectual story told in this editorial I present a more skeptical view of the effect of paradigm shifts on healthcare systems on the ground. I argue that ideas triumph when times are ripe and times are ripe in health policy when payers and providers can find a compromise between the need to value what providers do and their professional autonomy. I also argue that autonomy is a product of the market: patients value autonomy and prefer doctors to insurers.
An active area of public health policy in the United States is policy meant to promote healthy eating, reduce overconsumption of food, and prevent overweight/obesity. Public discussion of such obesity prevention policies includes intense ethical disagreement. We suggest that some ethical disagreements about obesity prevention policies can be seen as rooted in a common concern with equality or with autonomy, but there are disagreements about which dimensions of equality or autonomy have priority, and about whether it is justifiable for policies to diminish equality or autonomy along one dimension in order to increase it along another dimension. We illustrate this point by discussing ethical disagreements about two obesity prevention policies.
The recent report by Barnhill and King about obesity prevention policy raises important issues for discussion and analysis. In response, this article raises four points for further consideration. First, a distinction between equality and justice needs to be made and consistently maintained. Second, different theories of justice highlight one additional important source of disagreement about the ethical propriety of the proposed obesity prevention policies. Third, another point of contention arises with respect to different understandings of the principle of respect for autonomy due to its often-mistaken equation with simple, unfettered freedom. Finally, based on a more robust definition of autonomy, the key issues in obesity prevention policies can be suitably re-framed in terms of whether they advance just social conditions that enable people to realize human capabilities to the fullest extent possible.
War has devastating implications for families, communities, cultures, economies, and state infrastructure. Similarly, the last decade has seen an increase in the number of attacks against health workers in conflict zones and unstable environments. Unfortunately, these attacks have grave consequences for local populations which often rely on foreign aid programs for their health and well-being. As such, this paper will examine why aid-workers have increasingly been targeted for abductions, ambushes, assassinations, and various forms of intimidation. Furthermore, examples of terminated health programs, as well as populations served by current medical and humanitarian interventions, will be provided to impart a sense of magnitude and importance of health programs to the reader. Lastly, suggestions will be presented which could serve to minimize aid-workers' risk and exposure to acts of violence in the field.
Research to improve health systems response on HIV/AIDS. Adapted from Remme et al. 'Defining Research to Improve Health Systems', published November 16, 2010. DOI: 10.1371/journal.pmed.1001000' (8)  
Multi-sectoral HIV/AIDS Strategy within HSS Framework (WHO)  
This paper reviews the essence of effective governance and importance of a multi-sectoral approach in generating health systems response to HIV/AIDS. This comprehensive approach highlights the importance of integrating reproductive sexual health programs and HIV prevention services, including peer education, life skills, and Voluntary Counseling and Testing (VCT), for Prevention of Mother–to-Child Transmission (PMTCT) and reaching out to People Living with HIV/AIDS (PLHA). Research implications for governance of health systems response to HIV/AIDS, integrated youth health policies and high-level political commitment, are emphasized by strategic implications for HIV/AIDS control and followed by a policy thrust on health systems as a strategic plan to achieve sustainability in the fight against HIV/AIDS.
A major constraint to the application of any form of knowledge and principles is the awareness, understanding and acceptance of the knowledge and principles. Systems Thinking (ST) is a way of understanding and thinking about the nature of health systems and how to make and implement decisions within health systems to maximize desired and minimize undesired effects. A major constraint to applying ST within health systems in Low- and Middle-Income Countries (LMICs) would appear to be an awareness and understanding of ST and how to apply it. This is a fundamental constraint and in the increasing desire to enable the application of ST concepts in health systems in LMIC and understand and evaluate the effects; an essential first step is going to be enabling of a wide spread as well as deeper understanding of ST and how to apply this understanding.
Top-cited authors
Ali Mohammad Mosadeghrad
  • Tehran University of Medical Sciences
Sandeep Moola
  • University of Adelaide
Dagmara Riitano
  • University of Adelaide
Karolina Lisy
  • Peter MacCallum Cancer Centre
Zachary Munn
  • University of Adelaide