Explaining the barriers to donor participation in the field of health: a qualitative study

Abstract

Background:

Iran’s health system is facing increasing costs and a lack of resources. Developing the financial participation of donors is one of the ways to strengthen the financial health system.

Objective:

This research was done to explain the barriers to donors’ participation in the field of health.

Method:

This qualitative study was conducted in 2022 using semi-structured interviews with 22 experts, health donors, policymakers, and managers in Iran. The conventional content analysis method was also used for data analysis.

Results:

The review and classification of the interviews showed that the participation of donors in the health system includes four main issues: the incompleteness of legal processes, the lack of continuous communication with the charity, management, and resources problems, and the insufficient awareness of the donors about the problems and needs of the health system and 18 subtopics.

Conclusions:

Donors play an important role in financing, developing resources, providing health services, and financially supporting patients in Iran’s health system. Therefore, by recognizing and removing obstacles to the participation of donors, policymakers and managers of the health system should target the participation of donors with proper planning, organization, guidance, and supervision, and avoid parallel work and waste of resources.

Introduction

Highlights

• Donors play an important role in financing, developing resources, providing health services, and financially supporting patients in Iran's health system.

• By recognizing and removing obstacles to the participation of donors, policymakers and managers of the health system should target the participation of donors with proper planning, organization, guidance, and supervision, and avoid parallel work and waste of resources

• Communication with donors should be maintained continuously

The WHO considers the health system to include organizations, individuals, and actions with the main goal of promoting, restoring, and maintaining people’s health¹. To achieve the set goals, the health system has four duties: governance, financial provision, resource generation, and health service provision². Therefore, the health system includes organizations, groups, and individuals who, in the governmental and non-governmental sectors, engage in policymaking, resource generation, financing, and providing personal and public health services to promote, restore, and maintain people’s health³.

Financing the health system is the management and allocation of revenues for the purchase of health services, which includes the collection of revenues, the accumulation of financial risk, and the allocation and distribution of financial resources at the national and local levels. The goals of the health financing system include increasing people’s access to health services, improving the health of more people, controlling costs, and increasing the efficiency of the health system⁴.

Therefore, the financing systems of the health system by providing financial resources for the provision of health services, reducing the financial barriers to access to health services (reducing the direct payment of patients) and fair allocation and efficient use of financial resources play a significant role in achieving universal health coverage⁵.

In many countries, five methods of public revenues, social health insurance, private health insurance, direct payment of people, and charity are used to finance the health system. Public revenues include the use of a percentage of the government’s public revenues, such as taxes, sales of natural resources, customs revenues, and borrowing in the health sector⁶. In social health insurance, every qualified person (employees and legal workers) must become a member of the social insurance organization and pay the insurance fee to use its benefits. The social insurance fee is usually based on people’s income and is divided between the worker and the employer. In private health insurance, a private insurance organization, in return for receiving insurance premiums from individuals, reimburses their health expenses⁷. The private insurance fee is paid by the individual and may be divided between the individual and his employer, or may be paid in full by the employer. Direct payment is the payment by the patient to the service provider when receiving health services. This method is the most inefficient and unfair method of financing the health system. Finally, the method of public assistance includes the participation of local people or international institutions in paying health expenses. This method plays an important role in financing the health system of countries with very low incomes⁸.

People’s participation in health matters is one of the important issues that should be strengthened and encouraged along with government measures and the country’s development departments⁹, but the evidence shows that these resources are not always used in line with the goals of the health system and the problems. There are many in this field¹⁰. For example, building a hospital by donors regardless of the financial resources for its management leads to the closure and increase of health system problems¹¹. Considering the special position that donors have found in recent years in the financing of hospitals and healthcare centres in the health system, the purpose of the present study was to explain the obstacles to the participation of donors in the health sector of Haji Abad City in Hormozgan.

Method

The present research is of a qualitative type. Semi-structured interviews were used with 22 managers, experts, and specialists of social sciences as well as donors active in the field of health in Haji Abad city of Hormozgan to examine the opinions of experts and collect research data. Purposeful snowball sampling was used to select people. To enrich the findings of the study, different groups of related people were used in the interviews. Like other qualitative studies, the sample size was determined during the work, and interviews with each group of people continued until the saturation of information was reached.

To achieve the goals of the research, first by reviewing the texts and summarizing the opinions of the researchers, the framework of conducting in-depth, semi-structured interviews and using open questions such as “In your opinion, what are the obstacles and problems for greater participation of donors in the field of health?” designed. In the following, by setting a previous appointment and visiting the experts in person, their opinions and views on the subject of the research were collected and recorded in the form of a face-to-face interview. Also, telephone interviews were used to conduct interviews with other participants outside of Tehran. Interviews were recorded to increase accuracy in data collection. During the interview, the demographic information of the interviewees was first asked, and then the necessary explanation was given about the way of the interview and the objectives of the research.

Before starting the research and to gain the credibility of the researcher’s mastery and a general understanding of the subject by using the ideas and guides of the professors, first, some test interviews were conducted. Then, the test interviews were checked by the professors for their accuracy. The text of the conducted interviews was typed and the qualitative content analysis method was used to analyze the data. In general, qualitative content analysis tries to infer and reveal hidden patterns in interviews, observations, and written documents by analyzing concepts, terms, and connections between these concepts. In the conventional approach, the use of predefined classes is avoided and the classes are directly extracted from the data. Content analysis is based on five steps, including conducting the interview immediately after each interview, reviewing the entire interview text for a general understanding of its content, determining semantic units and primary codes, categorizing similar primary codes into more comprehensive classes, and determining latent content done in the data.

Four criteria of credibility, confirmability, dependability, and transferability were used to check the accuracy and reliability of the data. The content of the interviews was checked several times by the researchers to identify the main concepts. The extracted concepts were coded by summarizing the ideas of the researchers and by connecting the codes, classes or main themes were formed. The work was done according to the criteria of qualitative studies¹².

Results

According to Table 1, the findings from the analysis of individual interviews, in the form of four groups, the insufficiency of legal mechanisms, the insufficiency of correct and continuous communication with charity, the obstacles in the field of management and the optimal allocation of resources and insufficient awareness of the priorities, needs, and problems of the health system and 18 categories or main themes were classified.

Table 1.

Obstacles and problems of effective participation of donors in the field of health.

Group	Main floor (main content)	Subclass (subtopic content)
The incompleteness of legal processes	Organizing	Numerous unorganized custodian institutions Weakness of interdepartmental cooperation Weakness of the mechanism of attracting donors’ financial resources
	Planning	Lack of long-term plan at the macro level Lack of strategic plan at the macro level People active in the field of planning are not experts
	Performance	Weakness of the executive mechanism for collecting donations Weakness in identifying and attracting donors Inadequate monitoring of the activities of donors
	Weakness of legislation	Absence of clear rules on how to collect, accumulate and allocate resources Non-fulfillment of obligations by the parties
	Lack of culture building	Cultivation in the field of the importance of the needs and deficiencies of the health system Research in the field of health charity
	Bureaucracy and excessive administrative processes	It takes time to obtain the necessary permits Complex and long administrative processes Legal barriers
Lack of continuous communication with donors	Not giving feedback to donors	Weakness in presenting the results of donors’ spending to them It is not clear where the resources have been spent
	Not motivating donors	Weakness in encouraging and appreciating donors Lack of continuous communication with donors Not informed about the activities of the donors
	Not supporting donors and their activities	Collection of taxes and duties from donors’ activities Lack of allocation of government resources and subsidies to donors’ activities Inappropriate tariff of charity centres
	Distrust of donors	Weak communication between the Ministry of Health and non-governmental and non-profit organizations
	Donors’ personal preferences	Donors’ ethnic and regional feelings Interested in quick things Donors’ neglect of needs and priorities
Obstacles in the field of management and support	Lack of micro resource management	Lack of identification and attraction of small donors Lack of a mechanism to collect the resources of small donors
	Obstacles in the field of management and support	Changing economic conditions of the country Lack of ability to maintain good health Dispersion and unequal distribution of Khi Rin
	Lack of proper management of charity projects in line with effectiveness and sustainability	Poor prioritization of donor resources Lack of needs assessment in spending donor resources
	Lack of transparency	Donors’ expenses cannot be traced
	The financial burden of charitable contributions to the health system	Create induced demand Increasing unnecessary paraclinical services Completion of half-abandoned charitable projects by the government Increase in current expenses for the management of charity projects
Donors’ insufficient awareness of the problems and needs of the health system	Ignorance of upstream documents and leveling	Ignorance of donors about the policies of the Ministry of Health Ignorance of donors about the leveling of services by the Ministry of Health
	Ignorance of donors about the needs of the health system	Donors’ ignorance of the healthcare needs of the region Donors’ ignorance of healthcare inequalities

The incompleteness of legal processes

Organizing

The participants in this research believed that a large number of charitable institutions, the parallel work that is caused by the lack of inter-sectoral cooperation, as well as the attraction of donors’ financial resources, needs to be organized. Participant number 16 believed: “We cannot say that now there is an organization or an established culture, a set of rules that if people want to do a good deed, they should, for example, refer to that authority, state their intention, and the location of the object. Determine the opinion. Unfortunately, there is no suitable mechanism in this way in the country.

Planning

The participants in this research believed that there is no comprehensive, scientific, and macro-level planning for the various elements of the healthcare system’s donors. Participant number 7 believed: “For charitable donations, the strategic plan of 3, 5, or 7 years is necessary to write the annual operational plan.” Also, participant number 20 stated: “The lack of specific planning in the country’s health system to allocate these resources to different sectors of education, research, health, and treatment is considered one of the important obstacles in this field”.

Performance

The results of this research show that the participants believe that due to the insufficient organization, planning, and legal infrastructure in the field of healthy donors, identifying and attracting donors, financing, and informing them is not efficient and effective in practice. Participant No. 22 believed: “Donors should be well identified” and Participant No. 15 stated: “The government cannot attract donors.”

Weakness of legislation

Strengthening and consolidating legal infrastructures and drafting facilitating laws at the national level will lead to efficient and effective participation of donors in the health system. The participants in this research also believed that the weakness of the legislation has caused that in some cases, various elements active in the field of charities not adhere to their commitments. Participant number 10 said: “Laws should be established in the parliament for the mechanism of donors’ sources so that it becomes binding.”

Lack of culture

The participants in this research believed that some donors operate traditionally and are not familiar with the wide range of needs of the health system for financial participation. They considered the lack of magazines related to donors as well as the lack of resources for donors to conduct applied research to solve the problems of the health system as a result of the poor culture in the field of healthy donors. Participant No. 13 suggested: “There is a need to create the culture and provide proper information so that donors play an active role in the field of insuring patients and the needy.”

Bureaucracy and redundant administrative processes

Administrative bureaucracy is one of the other obstacles that stand in the way of donors of the health system, from charity formation to financial participation. In this research, several interviewees believed that there are many legal and administrative obstacles and obstacles in the way of health donors; For example, participant number 6 said: “If a person tells me that he wants to do a good deed, I tell him to go to the donor’s assembly, and after that, he will stop; Because it gets involved in administrative bureaucracies.” Also, participant number 5 stated: “The administrative bureaucracy is too much for donors and they are pushed back”.

Inadequacy of correct and continuous communication with donors

The results of this research show that part of the problems in the field of donors in the health system, which causes the identification and absorption of resources not to be maximal and not spent in the right place, is caused by the incorrect and inappropriate communication of executive and treatment institutions with donors.

The participants believed that the government and the parliament can reduce the distrust of donors in government institutions by enacting laws to support donors and create motivation for more participation in donors. In this context, participant number 21 stated: “Charity hospitals cannot buy their equipment with government currency.” Another complaint of experts in this field was not giving feedback on charity activities. They consider the non-transparency of where to spend resources as one of the existing problems. Participant number 19 said: “Donor wants to give money and wants to make sure that the resources reach certain people, but the current system has not designed this path.”

The personal preferences of donors are another obstacle that sometimes causes resources to be spent in the worst possible place. Participant number 5 stated: “Donor says I want to build only in my city and country” or, “Donor thinks that people will be more comfortable if the city has a hospital.” Also, participant number 3 said: “Some donors want to build a clinic somewhere, but there is no priority for building a clinic there, But the donors persist in their intentions.” Participant number 4 also believed: “If charity works based on its desire, it will cause unfair distribution of resources and bring injustice.”

Problems in the field of management and optimal allocation of resources

The participants in this research believed that the lack of needs assessment on the one hand and the lack of prioritization of needs to spend resources on the other hand cause the partnerships to be ineffective. They also stated that improper management of charitable contributions causes a waste of resources. In this regard, participant number 18 said: “Management of charities should be in the hands of those who are aware of these matters; For example, the manager of the complex should not condemn the hospital that the donor built to be closed!”

Non-sustainability of financial resources, non-continuity of participation, and dispersion are other problems in the field of health charities. Participant number 17 said: “The change in the country’s economic conditions has made donors focus more on their business, and good work is their second priority.” Participant number 11 also said: “The dispersion of donors is high and their distribution is different; In some areas, there is a lot of charity and in some areas, their number is few.

Incomes, expenses, and types of services provided by charities should be clear. Also, in medical centres, the place of spending of the donors’ resources should be clear so that the direction of the resources towards the goals of the donors is tangible. Participant number 2 believed: “One of the problems of donors is the lack of clarification”. Participant number 20 also stated: “If they promise to pay for dentistry, they should be honest and the resources should not be spent on personnel salaries.”

Another problem is the financial burden that charitable contributions bring to the health system. This problem can be seen as a result of the previously mentioned problems and obstacles.

The participants believed that the purchase of equipment to provide paraclinical services can lead to induced demand. Participant number 1 stated: “Some services and equipment are luxury and charity should not enter this field.” Also, this participant believes that the donors only pay the start-up cost and do not pay the running cost of the administration, which causes problems for the government. Participant No. 17 also had a similar opinion and said: “Donor states that he will bear the cost of construction, but the executive and administrative affairs should be with the university. The university is not able to pay the executive and administrative expenses and the hospital remains undecided.”

Inadequate awareness of the priorities, needs, and problems of the health system

The next main obstacle that hinders the efficiency and effectiveness of health donors’ partnerships is their ignorance of priorities, needs, and problems, as well as upstream documents and leveling of services and equipment. The participants believe that although the donors have money, they do not know where to spend it due to ignorance and unfamiliarity with the priorities, and they need advice in this regard. In this regard, participant number 12 said:

“Donors do not have enough health knowledge and they must be convinced to follow the policies of the Ministry of Health.” Participant number 9 believed: “Most of the donors in the field of health and treatment want to build a hospital, but they are not aware of its dimensions and donors do not know that the most important point in hospital activity is to attract specialists, who usually go to the regions They are not deprived”.

Discussion

There are many obstacles and problems in the way of helping ordinary people and donors to the health system, and by recognizing and solving them, the financial resources and contributions of donors can be directed towards the needs of the health system with maximum effectiveness. This research was done to identify the problems and obstacles to donors’ participation in the health system. Countries such as Germany, Australia, Spain, and England have created legal solutions to attract and attract people’s contributions; But in Iran, people have always addressed this issue spontaneously and informally with titles such as endowment and charity⁷. Even though the Association of Health Donors is a popular organization with 220 branches in the field of health, the participants in this research stated that there are many unorganized trustee institutions, and their cooperation and communication with other organizations and bodies are weak. Is. Sometimes even this weak relationship causes parallel work between different institutions; An obstacle that reduces the efficiency and effectiveness of the activities of the donors of the health system. One of the important shortcomings that the participants of Akrami and Abbasi’s research also pointed out was the lack of a coherent and defined institution in the country for charitable affairs, donors, or donor unions^13,14. In Nabatchi and Leighninger research, it has also been mentioned that the lack of regular and organizational planning in ongoing institutions and the lack of specialized human resources in the field of public participation are among the obstacles and shortcomings in public participation¹⁵.

It is necessary to prepare the legal infrastructure in such a way as to facilitate and encourage the maximum participation of donors. The participants in this research considered the weakness of legislation as one of the problems in the field of health charities. In their research, Ziluchi¹⁶ found out that the most important problems in the field of laws and regulations related to charity in Iran’s health sector are lack of comprehensiveness, lack of transparency, strictness, inconsistency of laws and regulations with each other, inconsistency in implementation, facilitation and Not motivating, not providing the financial burden, not fulfilling the government’s obligations in the memorandum of understanding of projects that are built with the participation of donors, or slowness in implementing them, are problems related to the endowment in the field of health.

Another obstacle in front of the health system is making known the importance of the health sector and its shortcomings to the donors. Donors are more interested in the cultural and educational sector, and to attract their participation in the health field, there is a need to inform and inform the donors.

According to the results of this research, one of the other obstacles in the way of donors of the health system is the administrative bureaucracy, in Article 10 of the Law on the Establishment of the Ministry of Health, Treatment, and Medical Education in 1985 to facilitate and speed up the flow of affairs and deal with bureaucracy and redundant procedures. The administration has been mentioned in attracting people’s participation¹⁷. In another research, it is also mentioned that donors tend to be executors and supervisors of the work, but they are not responsible for doing administrative tasks like getting permission¹⁸.

Attracting the participation and commitment of donors, especially in the long term, is always one of the basic challenges of the health system. Trust is the foundation of any contract and transparency is a requirement for its development, and unethical behaviour damages the relationship between the institution and the donors¹⁹. In this study, the experts also pointed out that charity’s lack of trust in various elements involved in the field of health, especially the government, is an obstacle to the participation of charities. The results of Mosadeghrad et al. ¹⁸‘s study in Iran also showed that good communication between institutions and donors helps to maintain financial resources. The results of Eshraghi et al. ¹⁹‘s research showed that the trust of donors has a direct, positive, and significant effect on their commitment to the centres.

The field of participation of donors in the health system is wide and includes prevention, treatment, rehabilitation and well-being, education, and research in the field of health.

Also, the type of contributions can be financial or non-financial¹⁶. The opinions of the participants in this research show that the needs of the health system for participation and financing by donors are not clear, and donors are not aware of the current needs and their extent. On the other hand, the personal interest and tastes of donors also cause the needs and priorities of participation to be neglected. At the world level, the prioritization and allocation of resources in the health system are mostly based on criteria such as cost-effectiveness, disease status, justice, equality, and need²⁰. It is suggested that the Ministry of Health, universities of medical sciences, hospitals, and medical centres define their needs and priorities and inform the be Eshraghi and colleagues’ research showed that the obstacles and shortcomings in public participation include lack of advertising, informing, and encouraging people, lack of awareness among people about the way of participation and its effect, lack of culture in the field of participation, people’s distrust towards some officials. The people’s non-justification from the Shari’a point of view is behind the government credits and defects in the law of free education and the government’s sentiments in the field of public participation¹⁹.

The laws and regulations of the country have emphasized the participation of charities in the health system. In other words, there is a legal capacity to strengthen the participation of charities in Iran’s health system. Therefore, the necessary structures and mechanisms must be created to make maximum use of the created legal capacity. The establishment of the General Administration of Health Charities and Charitable Institutions in the Ministry of Health has played a significant role in identifying and properly organizing health charities and strengthening their participation in the country’s health system. Identifying, guiding, and supporting the capacities of charity affairs and endowments, planning and organizing the use of people’s capacities of Iranians living abroad, and strengthening the participation of philanthropists and charitable institutions in the form of donations, health vows, and voluntary activities were among the duties of this department. Compilation and notification of laws, circulars, and instructions related to the recruitment, management, and control of health charity participation, signing of memorandums between the Ministry of Health and the Organization of Endowments and Charitable Affairs, the Ministry of Foreign Affairs and Iran’s Qarz Al-Hasneh Mehr Bank, approving the amendment of the tariffs of charitable medical centres. The establishment of charitable institutions to support public hospitals and the instructions for placing plaques on the donated property were among the actions of this general administration, which played a significant role in the development of charitable participation in Iran’s health system ⁴.

Managing relationships with benefactors and gaining their trust is very important. Philanthropists want to make sure that their participation in the health sector has valuable results for Daniel. Gaining the trust of donors has a positive effect on their future participation ²¹. Therefore, the managers of hospitals and treatment centres should periodically hold meetings with health charities, report the results of their participation and introduce new areas that require their participation to lead to the continuation of their commitment. Also, appreciation for the participation of health charities is considered an incentive to strengthen their participation. Hospitals are facing a severe lack of financial resources due to the increase in the costs of providing health services. The creation of a hospital-supporting charitable institution plays an important role in attracting donors and organizing and targeting their help to meet the infrastructure, equipment, medical, and support needs of hospitals and facilitates the process of charitable participation in public hospitals.

Conclusion

This research, with an exploratory and descriptive qualitative approach, and using the opinions of managers, experts, and social science specialists, as well as philanthropists active in the field of health in Haji Abad city, Hormozgan, explained the contributions of philanthropists in providing health services in Iran. Also, the analysis of related documents added to the information richness of this research. Health charities directly participate in providing, maintaining, and promoting the health of the people of the society by providing preventive, therapeutic, and rehabilitative services.

Also, they indirectly contribute to the provision of health services by providing support services such as construction, equipping, and repairing hospitals and health and treatment centres, providing health sector resources, education and research in medical sciences, and supporting patients and their families. However, qualitative researches are better to be completed with quantitative research to achieve comprehensive and more applicable results. Therefore, it is suggested that researchers conduct quantitative studies to investigate the level of charitable participation in the provision of health services in Iran.

Limitations

• One of the most important limitations of the current research was the coordination to determine the time of the interview with the experts. Because all of them had busy executive and academic positions and this makes coordination difficult.

• Since only one location (donors of Hajiabad Hormozgan city) was observed, it will be difficult to generalize the data.

• Another limitation of the research is the lack of scientific resources and previous related research. Although this limitation can increase the value of this study in terms of the newness of the subject, on the other hand, it made it difficult for the researcher to use international literature and compare with similar studies, especially in the discussion of results.

Suggestions

• Considering the importance of benefactors’ participation in the health and treatment system of society, it is suggested that charities use modern methods and technologies, including the Internet and virtual space, to attract people’s participation and clarify their performance. One of the suggestions is the use of information technology systems and RFID tags, which help to continuously show the receipt of people’s donations, what goods and services were spent on them, and the delivery of the required code. In this context, it is appropriate for the government and institutions in charge of charities to monitor charities based on their transparency and accountability to the people, their governance, and also their ranking by setting up systems at the national and provincial levels. These systems can show the financial balance sheet of each charity to their benefactors after reviewing and ranking each of the charities using the introduced indicators so that the benefactors and those who are going to provide their money and assets to these charities can understand their financial performance and Also, be aware of the progress of charity projects.

• It is also suggested that officials and policymakers, members of parliament, and all people who can somehow be decision-makers should pay more attention to the importance of the presence and activities of benefactors and charitable institutions and try to facilitate the procedures that cause disruptions in the process of charitable activities.

• It seems that according to the findings of the questionnaire questions and the conducted interviews, as well as the motto of prevention is better than cure, the field of healthcare activities of the health system has been neglected for benefactors and charities, or due to the provision of government services in this area, less charitable public institutions have entered. It seems that in addition to the need for informing and creating a better platform for the presence of benefactors and charities in the field of health and prevention of the health system, it is appropriate to research this issue.

• It is also suggested that due to the high status and the existence of many endowment centres in the country, research in the field of the endowment should be carried out to investigate the sociological factors affecting the act of endowment by benefactors in the health system.

Ethical approval

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Consent

Informed consent was obtained from the participants.

Source of funding

The current study received no funding.

Author contribution

M.M.K. designed the study, collected and analyzed the data, interpreted the results, and wrote and approved the final draft.

Conflicts of interest

The author declares no conflict of interest.

Research registration unique identifying number (UIN)

IRCTID: IRCT2016011826079B5

Guarantor

Masoud Mirzadeh Koohshahi accepts full responsibility for conducting the study.

Data availability

Data are available from authors on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.