Abstract
BACKGROUND:
Older people's health policies suffer from many challenges in Iran. The issue is more highlighted considering the increasing rate of the older population in the country. This study aimed to explore the challenges of older people's health policies in Iran as well as make an avenue for policy responses.
MATERIALS AND METHODS:
This study was a qualitative study that was conducted using conventional content analysis in 2020–2021 in Iran. The purposive and snowball sampling methods were used for semi-structured interviews with 30 selected participants. Data were analyzed through the content analysis approach using Granheim and Landman's five-step thematic method.
RESULTS:
The results of analyzing the data were categorized into four main themes, 16 sub-themes, and 70 final codes. The main themes were executive, policymaking, intra- and inter-sectoral, and environmental challenges.
CONCLUSIONS:
Older people are facing challenges in receiving appropriate and timely care. In order to achieve a wide national policy dialogue for covering all older people's health needs in policy agendas and better formulation and implementation of the policies, it is necessary for Iranian health policymakers to address executive challenges and apply effective strategies.
Keywords: Health policy, health services for the aged, iran, policymaking
Introduction
The world population is increasingly aging,[1] and demographic patterns have changed significantly in all countries recently. Factors such as declined death and birth rates along with migration trends have altered demographic structures and led to population aging.[2] It is estimated that the older population will increase from 11% in 2000 to 22% in 2050.[3]
According to international official forecasts, Iran's population is aging. The UN report warned that Iran would experience the fastest demographic changes in the near future.[4] Such a trend has not only led to inevitable fluctuations among Iranian population policies in recent decades but has also created challenges for policymakers.[5]
As aging increases, responding to the complex needs of the older population becomes more complex, requiring sound and principled policies,[4] and this is one of the rights of the older people.[6] Making a uniform policy for the care of older people through the development of care programs, resource management, and the realization of older people's health objectives should be considered, as well as the management skills of the policymakers.[7]
According to the evidence, older people's health planning and policymaking and the history of political debates on aging are not more than a decade old in Iran, and there is still a lack of real evidence based on the analysis of the country's status to make the right decisions and plans in this regard. Even though older people need care services, little attention has been paid to providing them with health care in policymaking. Considering that aging is a significant phenomenon and affects the formation of care patterns and demands on the healthcare system, it is necessary to take immediate measures by policymakers in this area to effectively deal with this phenomenon in the future.[8]
To the best knowledge of the authors of this article, there was no comprehensive study that analyzed the challenges of older people's health policy-making in Iran. On the other hand, the reasons for conducting the present study qualitatively were that there was not enough knowledge of the subject under study in Iran and that this study could not be carried out through other research methods. In addition, qualitative studies provided a better understanding of phenomena and could explain human experiences, interpretations, and perceptions of life.[9,10] Furthermore, reviewing the studies on health services policies and organizations was better possible through qualitative research, and the researchers sought to understand the perceptions and experiences of policymakers and managers.[3]
To achieve such a purpose, it seems necessary to examine the challenges of older people's health policies in Iran to clarify the current situation for health policymakers and seek appropriate policy responses. A big picture of older people's health policy challenges with appropriate policy responses is achieved to shed light on health policymakers in Iran and similar settings.
Materials and Methods
Study setting and setting
This study was a qualitative study conducted in 2020–2021 in Iran. The research setting included all Iranian Universities of Medical Sciences, geriatric health research centers, the headquarters of the Ministry of Health and Medical Education (MOHME), the Welfare Organization, and the private centers providing geriatric services in Iran.
Study participants and sampling
Considering the research objectives and to gather the round views of the key informants and experts, the study population consisted of policymakers, managers, faculty members, and executive experts in various fields of geriatric health who had relevant scientific or executive backgrounds. Of those, 30 individuals were selected through the purposive and snowball sampling methods [Table 1]. The exclusion criteria were an unwillingness to participate in the study and a lack of mastery over or familiarity with health policy issues and the issues raised in the interview questions.
Table 1.
Demographic characteristics of the participants
| Demographic characteristics | n (%) |
|---|---|
| Gender | |
| Female | 12 (40%) |
| Male | 18 (60%) |
| Marital status | |
| Married | 26 (86.7%) |
| Single | 4 (13.3%) |
| Education level | |
| B.Sc. | 4 (13.3%) |
| M.Sc. | 4 (13.3%) |
| Ph.D. | 22 (73.3%) |
| Managerial experience | |
| 5-10 | 7 (23.3%) |
| 10-15 | 8 (26.7%) |
| 15-20 | 5 (16.7%) |
| 20-25 | 6 (20%) |
| 25-30 | 4 (13.3%) |
| Fields of work related to older people’s health | |
| Ministry of Health | 9 (30%) |
| Welfare Organization | 6 (20%) |
| Universities of Medical Sciences | 6 (20%) |
| Older people’s health Research Centers | 5 (16.7%) |
| Private sector | 4 (13.3%) |
Data collection tools and technique
Semi-structured face-to-face interviews were carried out. The sampling procedure continued until achieving the theoretical saturation in which no new concepts and themes were appeared. It was the level where the continuation of interviews no longer helps to generate new data, all the codes are repeated, and the researcher decides to stop the interview process.[11,12]
To collect the data, a topic guide containing general questions to clarify the research objectives was used. The questions were selected based on the research objectives. The topic guide included main questions and sub-questions [Table 2].
Table 2.
The interview guide of the study
| Main questions | Sub-questions |
|---|---|
| How do you evaluate the policymaking in health promotion for the older people in Iran? | Is the older people’s health promotion policies in Iran are up-to-date and it in line with the world community and the experiences of developed countries? |
| To what expert do policy makers have control over the policy problems in this field? | |
| Do the policy makers in this field have the education or expertise and work and management experience related to health promotion for the older people? | |
| To what expert are the policy makers of this field familiar with the concept of policy making and how to make policy? | |
| what is your opinion about the policy-making process in health care policies for the older people in Iran? | What challenges does the implementation of health promotion policies for the older people in Iran? |
| What is your opinion about the formulation of policies for health promotion policies for the older people in Iran? | |
| Are the older people’s health promotion policies a serious concern for the policy makers in Iran health system? | |
| From your opinion, what are the challenges and strengths of the formulated policies about older people’s health promotion? | |
| How is the implementation of the policies and programs of older people’s health promotion in in Iran? | |
| Is there an evaluation about the implemented policies of older people’s health promotion in in Iran? (Monitoring and evaluation indicators) How is this evaluation done? | |
| Do health policy makers make policies in this field based on evidence-based and documentation? | |
| What contextual factors affect the development and implementation of policies and plans for older people’s health promotion in Iran? | From your opinion, the older people’s health promotion policies in Iran have been formulated according to the existing factors or are they just a copy of the policies of advanced countries in this field? |
| What are the barriers and facilitating factors of older people’s health promotion policies in Iran? | |
| What organizations and institutions are the actors and stakeholders in policy-making and planning of older people’s health promotion policies in Iran? | How do you evaluate the actors and stakeholders in policy-making and planning of the older people’s health promotion policies in Iran? |
| Do you think that private organizations and public institutions have a role in policymaking and planning policies for older people’s health promotion policies? How? | |
| What policies do you suggest to improve the older people’s health promotion policies and what features should these policies have? | What are the challenges and facilitators of older people’s health promotion policies in Iran? |
| What policy requirements should exist in documents and programs related to the health of the older people? |
The time of the interview sessions was predetermined and set with the interviewees on the phone or in person. Each interview lasted 40–55 minutes, depending on the interest and tolerance of the interviewees, and to avoid any possible problems, all the conversations were recorded using two electronic voice recorders.
Data analysis
The data obtained from the interviews were analyzed through the content analysis approach. A conventional content analysis was applied in this study, in which most of the data were obtained through interviews. Granheim and Landman's five-step method was used to analyze the data. The steps were as follows: transcribing the entire interview right away; reading the entire text for a comprehensive understanding of its content; defining semantic units and primary codes; classifying similar primary codes into more comprehensive categories; and determining the main theme using the categories.[11,13]
The data were analyzed once they were collected, that is, just after the end of each interview, its recorded file was listened to several times, and all the interviews were transcribed word for word, following which primary meaningful units were extracted. In addition, after transcribing the interviews, a copy of the text was sent to each interviewee via email to confirm the content of the interview, and after his/her approval, the text data were analyzed. In the next step, primary codes were obtained based on the extracted meaningful units. The final codes were then obtained by classifying and reviewing the initial ones.
Trustworthiness and robustness
The accuracy and validity of the data were assured through Guba and Lincoln's criteria, including credibility, transferability, consistency or dependability, and confirmability.[14] To this end, the peer-check method was applied in such a way that the coding and theme extraction were done by two of the researchers experienced in qualitative research who had no conflict of interest with the subject. They did the job manually using Microsoft Office Word 2019.
Ethics consideration
The participants were provided with necessary explanations of the purpose of the interviews and were assured of the confidentiality of the data and the anonymity of the interviewees. They were also allowed to withdraw from the interview at any time they wished, despite the initial agreement. Then, all the individuals who were fully aware and willing to participate in the study completed and signed a written consent form. This study was approved by the Shiraz University of Medical Sciences Ethics Committee (Code: IR.SUMS.REC.1399.902).
Results
The results of analyzing the data from 30 interviews are briefly presented in Table 3 in the form of 5 main themes, 16 sub-themes, and 70 final codes. The main themes and sub-themes are described below.
Table 3.
Older people's health challenges in Iran
| Theme | Sub-themes | Final codes |
|---|---|---|
| Executive Challenges | Challenges of skilled workforce and appropriate training | Lack of specialized and trained human forces |
| Weaknesses in training human forces | ||
| Weaknesses in providing self-care training to older people | ||
| Lack of policymakers` expertise and experience | ||
| Weaknesses in training formal and informal caregivers | ||
| Challenges of implementing policies | Weaknesses in organization | |
| Poor service quality | ||
| Lack of comprehensiveness in providing care | ||
| Weaknesses in providing specialized services | ||
| Weak performance in the field of treatment | ||
| Weaknesses in integrated execution | ||
| Insurance system inefficiency | Structural weaknesses | |
| Weaknesses in cost coverage | ||
| Weaknesses in service coverage | ||
| The inefficiency of the National Council of the Elderly | Weaknesses in the selection of council members | |
| Low effectiveness of the council | ||
| Weak national document for older people | ||
| Policymaking Challenges | Weakness in policy formulation | Ignoring the facts when formulating policies |
| Inadequate planning in developed policies | ||
| Lack of comprehensiveness in policy formulation | ||
| Developing policies without specialists and older people`s participation | ||
| Lack of attention to the problems of older people subgroups | ||
| Poor content of developed policies | ||
| Lack of attention to infrastructure in policymaking | ||
| Failure to include formal and informal caregivers in policymaking | ||
| Lack of coherence in policy formulation | ||
| Weaknesses in agenda-setting | Weak agenda at the macro-level of policymaking | |
| Lack of attention to older people’s health at policymaking micro-level | ||
| Impact of external factors on policy-making agenda | ||
| Weaknesses in upstream policies | ||
| Stereotypes about aging | Policymakers’ mental stereotypes of aging | |
| Society’s stereotypical view of aging | ||
| Media’s stereotypical view of aging | ||
| The inefficiency of policy evaluations | Defects in evaluation methods | |
| Weaknesses in the evaluation system | ||
| Intra-sectoral and inter-sectoral Challenges | Structural challenges | Structural weaknesses in the Ministry of Health |
| Structural weaknesses at the macro level of policymaking and management | ||
| Economic challenges | Poor budget allocation to geriatric health programs | |
| Effects of the unfavorable economic situation on older people’s life desirability | ||
| Weaknesses in stakeholders’ participation | Weak role of scientific centers in supporting aging health policies | |
| The weak influence of the non-governmental sector on policymaking processes | ||
| Weak participation of older people supporters in policymaking | ||
| Environmental challenges | Weaknesses in older people’s health stewardship | Challenges in the united stewardship |
| Weaknesses in the inter-sectoral leadership | ||
| Weaknesses in the intra-sectoral governance | ||
| Inequity in the distribution of older people’s health care | Discrimination in the health care distribution | |
| Inequity in access to healthcare | ||
| Requirements of older people’s health policies | The need for comprehensiveness in policymaking | |
| The need to create an effective policymaking stewardship | ||
| The need for inter-sectoral cooperation in policymaking processes | ||
| The need to strengthen geriatric health education in policymaking | ||
| The need to strengthen welfare policies | ||
| The need for internationalization in policymaking | ||
| The need to change the form and content of the care delivery | ||
| The need to promote professionalism in the provision of care | ||
| The need to adopt a healthy aging policy in policymaking | ||
| The need to change the structure of the referral system | ||
| The need to strengthen social support for older people in policymaking | ||
| The need for changes in policymaking processes | ||
| Internal factors | Cultural factors | |
| Demographic factors | ||
| Management factors | ||
| Gender differences | ||
| Lifestyle | ||
| Social factors | ||
| Factors related to the physical environment | ||
| Employment of older people | ||
| External factors | International economic sanctions | |
| The role of international organizations |
Executive challenges
Challenges of a skilled workforce and appropriate training
The shortage of older people's health specialists, particularly geriatricians, has caused the health needs of older people not to be addressed specifically. One of the participants said:
“There are very few personnel trained in the field of older people's health. Our country cannot meet the needs of a huge number of old people with a small number of geriatricians and gerontology experts”. (Participant of Ministry of Health)
Challenges of implementing policies
The implementation of older people's health policies in Iran is up and down, and this has led to ignoring the health needs of older people. One of the interviewees said:
“We don't have a proper mechanism for implementing, establishing, and executing health policies in our country. I mean it's very rudimentary and unreliable, and unfortunately, there's a weakness in this field.”(Participant of Older people's health Research Centers)
Insurance system inefficiency
There are many old people in Iran who are not covered by any health insurance organization. In this regard, one of the interviewees said:
“We're very weak in terms of financial protection for the health of older people, and health insurance coverage for older people's health is” very weak as well.” (Participant of Ministry of Health).
The inefficiency of the National Council of the Elderly
The council has not taken any effective practical measures to promote older people's health in the country, and most of the council's resolutions are for the welfare and retirement of older people, but those resolutions have not been implemented properly and effectively. In this regard, an interviewee stated:
“There is no serious cooperation between the members of the National Council of the Elderly, and the laws it passes don't guarantee implementation. The council isn't competent enough and can't play a leading and managerial role at all”. (Participant of Universities of Medical Sciences).
Policy-making challenges
Weakness in policy formulation
The policies formulated so far are not sufficient. Regarding health care centers, there is a lack of appropriate policies as well. One participant stated:
“Aging health policies are developed without considering geographical locations and development as well as facilities of different regions of the country, and aging health policies have been copied from the leading countries in this field without considering the local features of our country”. (Participant of Private sector).
Weaknesses in agenda-setting
Older people's health has not been on the agenda in the Iranian parliament so far. In this regard, a participant stated:
“Older people's health policies aren't appealing to policymakers to pay attention to and seek to develop. Most of the health laws passed in the parliament focus on young people and older people are neglected”(Participant of Older people's health Research Centers).
Stereotypes about aging
Policymakers' views of aging are not based on dynamic, active, and successful aging; instead, they consider older people as ill and disabled persons. In this regard, an interviewer said:
“From the perspective of older people policymakers, there's a classic view of aging that sees aging as the end of life and says we should care for older people, and for our managers, aging means disease.”(Participant of Welfare Organization).
The inefficiency of policy evaluations
There is no comprehensive system for evaluating the health policies for older people in Iran. An interviewer stated:
“Evaluation of geriatric health care programs is just limited to a form and checklist, which isn't really a basic, scientific, comprehensive, and complete monitoring, and the opinions of the service seekers, I mean older people, aren't asked at all” (Participant of Ministry of Health).
Intra-Sectoral and Inter-Sectoral challenges
Structural challenges
The organizational structure of policymaking for older people's health in Iran has major drawbacks. There is no coherent policymaking structure in this field. A participant said:
“In the headquarter MOHME, there's a department in charge of older people's health policies, but in fact, it's just part of its duties and the other part deals with the population, households, and the middle-aged. This limited structure isn't enough” (Participant of Private sector).
Economic challenges
At the macro level of policymaking, such as in government and parliament, budgeting for older people's health has never been a priority. An interviewer stated:
“There's no specific budget for geriatric health services in the country. Unfortunately, the allocation of budgets isn't appropriate neither at the national level nor within the Ministry of Health in particular” (Participant of Older people's health Research Centers).
Weaknesses in the stakeholders' participation
Aging health advocacy associations in Iran have no possibility of lobbying and consulting with older people's health policymakers. One participant said:
“One of the gaps and shortcomings we have in the aging health care policies in the country is that we don't have strong political associations, institutions, and NGOs for older people”(Participant of Universities of Medical Sciences).
Leadership and stewardship challenges
Weaknesses in older people's health stewardship
In Iran, there is no single organization responsible for policymaking on issues related to older people. Regarding the weaknesses in older people's health stewardship, an interviewee said:
“In terms of rehabilitation and disability, the Welfare Organization oversees older people's health, and MOHME supervises the health sector, but neither could develop a real and intelligent plan for the health of older people” (Participant of Welfare Organization).
Inequity in the distribution of older people's health care services
There is great inequity in the distribution of care and health services for older people at various economic, social, and geographical levels. In this regard, one of the participants stated:
“There's inequity in the distribution of geriatric health care services and the quality of services in affluent and disadvantaged areas, as there's also inequity in access to geriatric health care services for older people of different ethnicities in various cities and with different economic, job, political, religious, social, and family status” (Participant of Universities of Medical Sciences).
Requirements of older people's health policies
In providing healthcare for older people, specialization should be considered so that health service providers have relevant specialization and education in the field of geriatric health and medicine. An interviewee said:
“Older people's health policies should have a legal steward defined by the legislature. The one that doesn't dodge his responsibilities! Regarding older people's health care, we should have a ministry or an organization to coordinate the policies so that older people don't have any problems” (Participant of Ministry of Health).
Environmental challenges
Internal factors
Demographic factors or structural population changes in Iran can be considered an important internal factor affecting older people's health policymaking. According to a participant:
“Demographic changes, the ever-increasing older people population that is warning the managers, the burden of the care which is imposed on families, and the burden of the care which is imposed on the health care system are factors that make policymakers pay attention to the older people's health policies” (Participant of Private sector).
External factors
The imposition of international economic sanctions on Iran has had some negative effects on the country's income, creating challenges in the provision of appropriate healthcare for older people and receiving services for them. A participant stated:
“One of the factors that updates the aging health policies is the pressure of international organizations such as the World Health Organization (WHO), and Iran's international commitments. International economic sanctions are another external factor that has strongly influenced aging health policies in our country”. (Participant of Universities of Medical Sciences).
Considering the sensible mutual relationships with the explored themes, a conceptual framework for older people's health policy challenges in Iran is illustrated in Figure 1.
Figure 1.
The conceptual framework of older people's health policies challenges in Iran
According to the present themes and the conceptual framework, a policy response should be prepared in a form of a policy dialogue between Iranian health policymakers and policy implementers and aging healthcare providers as a responder by putting the plans into action [Figure 2]. For this purpose, a policy response from all local stakeholders, including NGOs, health facilities, and hospitals, should be combined with the community's and older people's responses. Such a response from the local and community level moves an upward flow integrating the joint dialogue of organizational stakeholders like the Ministry of Welfare, National council of aging, and MOHME as well as the Parliament to make a wide national policy dialogue for covering all the older people's health needs in policy agendas and better formulation and implementation of the policies.
Figure 2.
Flow of policy dialogue and policy responses for older population healthcare in Iran
Discussion
Executive challenges
Implementation of older people's health policies follows a top-down approach in such a way that the formulation of the policies is done by the policymakers in a centralized manner and is communicated to the operational levels to be implemented. This top-down approach prevents the formation of social participation in policymaking.[15]
Providing health services to older people in Iran is facing the following challenges: a lack of special settings to provide services to older people, such as specialized hospitals, medical centers, or clinics; an accumulation of medical facilities in metropolitan areas; a lack of older people-friendly centers; a lack of prioritization for older people in the treatment queues in hospitals; a lack of relationship between different prevention and rehabilitation levels; a lack of palliative and end-of-life care; lack of attention to annual checkups; and a low quality of home care and daycare centers.[8,16] This result is confirmed in many similar studies as well.[17,18,19,20,21,22] Also, the results of the present study are confirmed by those of the Goharinezhad et al. (2016)[23] and Dehghan Nayyeri et al.'s (2012)[17] studies.
Policy-making challenges
The lack of follow-up and service continuity programs; the lack of relationship between prevention, treatment, and rehabilitation care; the lack of palliative and end-stage care for the final treatment of sick older people; the lack of spiritual health care,[24] the weakness of psychosocial health policies;[18] the lack of general health-oriented policies; the priority of treatment over prevention; and the lack of strategic orientation in older people's health programs are among the main challenges in the development of aging health policies.[8]
Goharinezhad et al.[23] (2016) concluded that there was a challenge in the content of older people's health policies in Iran. They also showed that policymaking for older people's health in Iran included no comprehensive assessment and evaluation of their health. Also, according to Doshmangir et al.[15] (2021), the challenges of policymaking for geriatric health are frequent changes in policymaking laws, structural changes, and the separation of the Welfare Organization from MOHME and continuation of its activities in the Ministry of Welfare.
Intra-sectoral and intersectoral challenges
Collaboration between stakeholders and actors plays an important role in the successful design and implementation of geriatric health care policies. The government cannot meet the diverse health needs of older people on its own, and this population group needs cooperation among the private sector, charities, and municipalities as the actors in this field.[8] Studies have highlighted the lack of inter-sectoral cooperation among the key stakeholders in the field of geriatric health, including MOHME and the Ministry of Welfare.[8,15,23,19,20] Safdari et al.[20] (2016) showed that the lack of an appropriate and independent organizational structure for older people's health had challenged policymaking and support for older people.
Leadership and stewardship challenges
There is a lack of integrated governance in geriatric health policymaking in Iran.[17] The disputes between MOHME and the Welfare Organization and the parallel work of non-professional organizations in older people's health policymaking have significantly challenged older people's healthcare stewardship in Iran.[8] Based on the Goharinezhad (2016) and Safdari (2016) studies' results, there is no permanent and unified stewardship for geriatric health in Iran, and there are disputes between MOHME and the Ministry of Welfare over the stewardship of the provision of geriatric care.[20,23] The results of the Doshmangir et al.[15] (2021) study showed the responsibilities related to older people's health have been assigned to various organizations that do not have proper and coherent cooperation in providing care to this age group. Most older people's health issues exist outside MOHME, and therefore, the Ministry does not have much power to address them. Hence, there is a need for strong inter-sectoral leadership and intra-sectoral governance in this field.
Environmental challenges
Managerial factors are among the internal environmental factors that challenge older people's health policies because the short-term responsibility of managers and management instability cause haste in policymaking and weaken the policymaking system.[21] In the context of Iran, cultural and religious factors play an important role in policymaking for older people while emphasizing respect for them.[15] Personal beliefs, illiteracy (especially health illiteracy), and lack of awareness about the existing health services are among the cultural factors that can challenge aging health policies in Iran.[8] Another factor was gender differences. The previous studies showed that gender was associated with access to geriatric health services, so that older women were significantly more likely than older men to seek health services.[22,25,26,27,28,29] The economic factor was another influential one. The results of the other studies showed the impact of economic factors on older people's health policies and services. They concluded that higher income and better economic status of older people increased their chances of receiving health services.[15,17,23,26,27,30,31,32]
Strengths and limitations of the study
This study examined the perspectives of the managers and policymakers in the field of older people's health policy challenges in the country, including faculty members of universities, executive staff, research centers, the private sector, and various organizations working in different related fields Thus, it provided access to accurate information through a data triangulation process that can guide action and decision-making for policymakers.
However, the present study had some limitations, including the limited time of policymakers and managers of the health system and the executive problems of prior coordination with them, which limited the duration of some interviews. In addition, the results of this study may only be applicable to developing countries with a similar health system.
Conclusions
Older people are facing challenges in receiving appropriate and timely care. In order to achieve a wide national policy dialogue for covering all older people's health needs in policy agendas and better formulation and implementation of the policies, it is necessary for Iranian health policymakers to address executive challenges and apply effective strategies. In addition, efforts to create efficient and capable stewardship with sufficient power should be on the agenda of policymakers and, on the other hand, developed policies should be tried to have comprehensiveness in terms of all areas of prevention, treatment, and rehabilitation for older people. For future studies, the following topics are suggested: examining the challenges of providing primary health care for older people; designing the governance framework for older people's health promotion; and examining the older people's health promotion policymaking process.
Financial support and sponsorship
This research was funded by Shiraz University of Medical Sciences, Shiraz, Iran. The university (as a financing institution) had no role in designing the study, analyzing the data, interpreting the data, and writing the manuscript.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
The present article was extracted from the thesis written by Jamshid Bahmaei and was financially supported by Shiraz University of Medical Sciences grant No. 99-01-07-23064. The authors would like to thank all the health policymakers and managers for their cooperation in conducting interviews and collecting the required data.
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