What must be the Pillars of Iran’s Health System in 2025? Values and Principles of Health System Reform Plan

Abstract

Background:

Preparing long term reformatory plan for the health system, like other macro plans, requires guiding principles which is according to the values, and as a bridge, connect the ideals and values to the goals. This study was designed with the purpose of explaining the values and principles of health system, and as a pre-requisite to compilation of Iran’s health system reform plan at 2025.

Method:

The document of values and principles of health system reform plan for 2025 was developed by reviewing the literature and receiving the opinions of senior experts of health system, and was criticized in focus group discussion sessions of experts and decision makers.

Results:

The values of Iran are: dignity of human, the right to maximum attainable level of health, comprehensive health, equity and social cohesion. The principles of this health system include: institutionalizing the ethical values, responsiveness and accountability, equitable access (utilization), prevention and health promotion, community participation, inter-sectoral collaboration, integrated stewardship, benefit from innovation and desired technology, human resources promotion and excellence and harmony.

Conclusion:

Based on the perception of cultural and religious teachings in Iran, protecting of human dignity and human prosperity are the ultimate social goal. In this sense, health and healthy humans, in its holistic concept (physical, mental, social health and spiritual) are the center and development in any form should lead to the human prosperity in a way that each of the individuals could enjoy the maximum attainable level of health in its holistic meaning and in a faire manner.

Introduction

Over the years, the health system of Iran has undergone many changes. One of the most important and effective changes was developing primary health care system across the country, which was designed forty years ago based on the health status of the society (high burden of infectious and communicable diseases) (1) and was implemented after the revolution because of the social condition of the society and the idealist and equity seeking spirit of people (2).

Integration of medical education in the health service providing system and formation of the Ministry of Health and Medical Education was another major change during these three decays after revolution(3). Currently the health system of Iran has two main characteristics, firstly, it is network based and secondly, the health services providing system has been integrated into educational system.

The above transformation and investment in primary health care system in the form of health networks in the last 30 years, was the cause of a significant progress in health indicators of Iran, in a way that the life expectancy increased from 46.7 years in the year 1981 to 72 years in the year 2007, and non-communicable diseases were controlled effectively (4). Also this reorganization was the reason that Iran achieved a desirable level of maternal and child mortality indicators of millennium development goals (5).

On the other hand, demographic and epidemiological transitions along with the socio-economic condition, resulted in serious challenges for health systems in all developing countries(6, 7), including Iran, and emphasize the need for review of the health system and health programs (8).

Weakness in equitable access to health care, control of increasing cost of services and financial protection of customers, comprehensive and efficient care systems and proper stewardship are among the challenges of health systems, especially in developing countries (9).

This group of problems has been continued due to the reasons like lack of consensus of policy makers about the solutions, insufficient financial resources and low motivated human resources (10). Based on the studies, the dispersion in opinions of policy makers have been recognized as one of the important factors (11). This ambiguity and weakness of regulatory system has lead to a clear gap between proclaimed values in official documents and real values in health professional values in Iranian health system (12).

Root cause analysis of these dispersions brings us to the fact that values, principles and definitions of health, health economics and private-governmental sector relation differs in the mind of the policy makers. Therefore consensus about their definitions can be considered as the first step in reformation of the health care system of Iran (11).

Values are relatively stable propositions of culture, and judge about whatever that has been considered good or bad in the society. They can be found in various forms (idea, word, performance) or in the political debates, with different roles (visualization, secure, sense). In policy making, values are used to make decisions that ultimately determine what is important and visualize what are desirable in a long run (13,14).

The reform plan of health system in Iran, has been designed with the goal of scrutinizing the 2025 vision of the country and drawing the way towards it(15,16); and it is necessary that in the first stage, define the principles and values of the health system, because knowing them leads to a better understanding of decision making (14,17). Presence of a clear framework of values, leads to the improvement of health system reform, in a more rapid and efficient way. With putting a framework of the explicit values in the forefront of reform, the community will be able to make the policy makers accountable for promoting the policies without diluting the basic values. Such a framework can be used as a criterion for evaluating proposals, modifications and provide a vision for the analysis, and is also a benchmark for comparison (13). This study was designed with the purpose of explaining the values and principles of health system reform plan.

Methods

This study was a research in health system done with the method of action research. Considering the studies and previous programs which contain suggestions for a set of health system values, study was designed in two stages, collecting and primary analyzing of these documents and by receiving the views of experts.

Firstly a semi-structured interview was done with 10 prominent health system experts. Purposive sampling method was used to select the experts. Having a previous experience in formulation national health policy and programs and familiar with social and cultural values, were the basic criteria for selecting these experts. They included policy makers, national health consultant, scientific boards and researchers from medical ethic research centers. They were asked about the concept of values and principles, and for introducing some references for compiling principles and values of the health system, references for review of the Iranian-Islamic values and principles, references, for values and principles of health system at the international level and introducing some individuals for interviews or participating in the task forces. The mean time of interview was about 15 minutes.

By considering data of these interviews, four lists were prepared, list of the references proposing principles and values, references for Islamic - Iranian principles and philosophy and references for principles and values of health system in other countries, also, a list of experts was prepared. Then the existing resources were collected and studied and their contents were sub-grouped under three themes, philosophy of ethics, values and principles of the health system.

Based on this analysis, a list of values were provided. To collect the experts’ opinions, two task forces of 15 experts members (selected from the identified expert list) were formed that studies values of the health system for 6 hours. Discussions were guided by two facilitators. Vision of Islamic Republic of Iran in 2025 had the centric roll in discussion. Consensus was the main methods for accepting or rejecting comments. For collecting the data, the discussions were recorded and noted. Finally in group discussions, five titles were agreed upon.

For recognizing health system principles, Delphi method was used. Principles extracted from literature and interviews were distributed between taskforce members via email. They were asked to modify these principles and suggest new ones based on defined values (in the previous stage) and Vision of Islamic Republic of Iran in 2025. Received forms were analyzed quantitatively considering frequency of recommendations and qualitatively by considering not apposition with the sociocultural values and health system values. So first edition of principles of health system was prepared.

The first edition of the above mentioned document was sent by Email to members of the task forces in order to get the opinions. After incorporating the opinions in the document, the second edition was again sent to the same individuals and some of those health system experts that their emails was available and were well-known experts in the health system. The response rate of the task force members was 73% and the response rate of other experts was less than 20%. After receiving the opinions, the documents were presented in several meetings with the Health Policy Council of Ministry of Health, the Supreme Council of the Academy of Medical Sciences and in the meeting of representatives of the deputies of Ministry of Health. After these presentation and correction of the documents, the document was presented in the meetings with the representatives of the universities and also in the task forces of health system reform plan 2025. Disagreements between comments were discussed in core executive committee of “health system reform plan”. In each stage, the modifications were done based on received comments, with considering the frequency of the opinions and the suitability between the opinions, and also in several rounds the modifications were informed to the task force members and their feedbacks were received.

In order to observe the ethical issues, all the recorded sounds and written comments and the emails were kept confidential with the principal investigator (Corresponding author) and in any stage there was no direct or indirect quotation of the participants’ opinion resulting in identifying them.

Results

Five values and 10 principles for the health system reform plan were identified based on the review of literature and group discussion meetings. The following text is the result of this study which is submitted for the approval.

Values of the health system in Iran include:

1. Human dignity: According to the sublime Islamic values, mankind in the arena of creation has a special status and is higher than other creatures. Based on this innate value, all human beings are respectful and are equal and their lives have a special dignity. In the area of health services, this dignity is defined in respect to the rights of Supreme Excellence Truth and others right (both recipients and providers of health services), finds expression in compliance with privacy, confidentiality, right to choose and decide about their own affairs, to avoid injustice, any kind of discrimination and damage and the necessity of humanism and beneficence.

2. Comprehensive health: Health includes physical, psychological, social and spiritual wellbeing and comfort. Health is a gift from God. Achievement of healthy human is for attainment of human perfection as the Caliph of Allah. On the other hand, health has multiple and complex dimensions and determinants, therefor it is not possible to be secured in one-dimension and unidirectional way and require a holistic and comprehensive approach at the individuals, families, national and global levels. A view that gives priority to prevention rather than treatment and interventions in determinants and threats of health (which are scattered in different layers and levels of the society), and make health to be recognized as an important task, inter-sectorial, national and international affairs. If the broad definition of health (including spiritual and social wellbeing) become the belief of society then human health would be the goal of sustainable development, and taking care of health becomes a responsibility of all the social institutions. Therefore, all institutions, both public and private should make efforts in this direction.

3. Equity: Equity is the base for social values, and has an innate worthiness because it is a pre-requisite for human dignity, freedom and human rights. Inequities in health, implies avoidable and unfair differences in health status, benefit from the health services and social health determinants. The concept of justice in health should be strictly considered from two specific aspects: equity in utilization of the health services (which must be based on individual needs) and equity in health financial security (which should be based on a person’s ability to pay).

4. The right to maximum attainable level of health: Authority is responsible for promoting, maintaining and restoring health and the quality of life of all, at the highest possible level. The government is responsible for ensuring the utilization of quality health services by all of society, identification, establishment and development of methods and tools for health promotion, reducing and control of individuals’ and social risks which affect health. Their results should provide the longest possible life with health and welfare, and quality of life without disabilities for all the people.

5. Social cohesion: means solidarity and cooperation of all stakeholders (in the various political, economic, social and cultural sectors with governmental and non-governmental ownership including private, charitable and cooperative) which are working together in intertwined structures and processes with the purpose of maintaining independence and stability and creating synergy. Attaining comprehensive individuals’ and social health and equity in health is possible in the context of mutual trust and cooperation. Social cohesion, in addition to strengthening achievements of the goals, leads to maintain and enhance social capital.

The ten proposed principles for the Iran health system include:

1. Institutionalizing ethical values: respect for the Islamic – Iranian moral values, observing the rights of individuals and society including individuals freedoms within the framework of law, observance of ethical codes and professional commitments in education, research and providing health services, observing the intellectual property rights, respect of the recipients and providers of service

2. Responsiveness and accountability: Commitment to the vision of Iran 2025 and comprehensive scientific plan in 2025, foresight and planning based on considering the present and future needs, accountability for social responsibilities and the demands of receivers and providers of the services and transparency of the performance.

3. Equitable utilization: Comprehensive coverage and equitable utilization of basic health services package for all strata of the society (appropriate to their needs and culture of the society), establishment of level-based structure, referral and family doctor, sustainable financial security, special attention to the vulnerable groups and other at risk groups (rural and marginalized urban residents), equitable access to other services and health information

4. Prevention and health promotion: Interventions to prevent the occurrence of individual harms community hazards, benefitting from a desirable environment, priority of prevention to treatment, appreciation for assigning responsibility of increasing health of people to themselves and reducing the level of individual and social risks

5. People’s participation: increase in health literacy and establishment of knowledge-based societies, people’s participation in management, decision making, planning and implementation of health programs aimed at health promotion and community empowerment

6. Inter-sectorial collaboration: achieving effective, efficient and sustainable health outcomes as a result of cooperation between all sectors, realization of public responsibilities for health promotion and accountability of all organizations and institutions about the impact of their policies and actions on health, and achievement of “health in all policies”

7. Integrated stewardship: Legitimacy and supervising the proper implementation of health laws, unidirectional policy making, planning, guiding, evaluating, monitoring and allocation of health resources, using credible evidences in the policy making, integration of education, research and health services system in order to meet the real health needs

8. Benefit from innovation and desired technology: Effective utilization of the care system, monitoring and evaluation; knowledge, production and stockpiling management and application of credible indigenous evidences, use of efficient, safe and cost – effective technologies, appropriate to local cultures and responsive to the priority needs of society, in a sustainable structure and in an affordable cost for people, encouragement of creativity and converting ideas into practice in the context of the National Innovation System.

9. Improving human capital: effective management, education, training and retention of faithful, skilled, creative, motivated and with high productivity human capital which is appropriate for the present and future needs in the integrated system of health services, education and research

10. Excellence and balance: a dynamic corporate culture, based on knowledge and innovation, preparedness for meeting the changing needs and environmental changes (social, political, economic, science and technology, environment), the move towards independence and self-belief, development and justice simultaneously, development of effective communication and exchange of knowledge and technology at the international level

Discussion

Values are “the social goals or standards held or accepted by an individual, class, or Society” and Principle is:” A fundamental truth, law, doctrine, or motivating force, upon which others are based” (18).The values of Iranian health system include the general values similar to the values of health system in some other countries. These values includes: dignity of human, comprehensive health, the right to maximum attainable level of health and social cohesion.

The principles of health system are also relatively stable rules and regulations at a supreme level which define a framework for determining and consolidation the goals and a direction for achievements of the values. (18). These principles include: Institutionalizing the moral values, responsiveness and accountability, equitable access, prevention and health promotion, people participation, inter-sectoral collaboration, integrated stewardship, and integration of science and practice, benefit innovative and appropriate technology, promotion of human capital and excellence and balance. The importance of values and principles are in building consensus and like-mindedness among the executors and planners, because by considering the stakeholders’ opinions and gaining their interests, there would be more synergy in the programs and wasting the resources can be avoided. (14)

In this study, which was done by action research method, the efforts were made to consider different opinions of health system stakeholders and use the maximum participation of individuals. In primary compilation of these documents more than 300 hours/person work was done in the form of focus group discussions and consultations with the experts, and in continuation for gathering the opinion of other groups, several meetings were hold and their opinions were collected. Also in meeting with the representatives and Board of Trustees of some universities, which some representatives of people also were present, the results were studied. In task forces of the health system reform plan, which included more than 600 professors of universities and experts of health system, the participants’ opinions also were collected. In each stage, all of the comments were studied and the modifications were done, in case of being confirmed by the study team. Ultimately we reached to saturation of opinions when the new opinions were just related to editing the sentences.

Generally for compiling a set of universal values and principles, three groups should participate, experts, policy makers and people (14). In this study two groups’ opinions, experts and policy makers, was considered well but the opinion of lay people was not considered comprehensively, although the Islamic ethics and the Islamic republic constitution were considered (19).

In compiling the value set of health system reform plan, paying attention to two factors were necessary: 1- Dominant social values and philosophy of ethics in social services 2- Future trends and challenges facing the health system and for making the overall orientation for problem solving (20), which are explained below.

1- Social values and philosophy of ethics

There are three main ethical viewpoints about values in the health system: capitalism, liberalism and socialism (20). The agreement between principles and values of health system with the social values has been considered as one of the elements for the success in maximizing the health of a society (21). In general, two important references that reflect the social values in Iranian religious community, significantly, are religious books and Islamic verses and narratives and the constitution of the Islamic Republic of Iran

In Iran, as in many Islamic countries, the teachings of Islam are the basis for many of the principles, values, regulations and ethical rules in the field of medicine (22). Among the values, we can consider the dignity of human as a basis for analyzing and decisions in medical ethics. The holy Quran is explicitly, mentioned the dignity of mankind. For example, the following verse can be pointed out:

Captives chapter (Surat Al-‘Isrā’) verse 70:

“And we have certainly honored the children of Adam and carried them on the land and sea and provided for them of the good things and preferred them over much of what We have created, with [definite] preference”.

The constitution of the Iran has mentioned the human high position, the dignity of human and human rights in having access to the health services. Article 2 of the constitution, after referring to the religious principles as the foundation of Islamic republic system, emphasize the dignity and exalted value of man and his freedom coupled with responsibility before God (19).

It should be noted that the Quran and the noble Islamic teachings, recognize the human dignity for “bani adam” means the sons of Adams. This refers to all human, without considering any discrimination in the principles of dignity of human because of the secondary characteristics. This dignity is due to the huge investment for creation of men, the amazing process of evolution, reproduction and also the glory of history and civilization of mankind. Another component is the innovation, creativity and creativeness in human that all human possess it potentially, along with their inherent dignity (23).

Due to the inherent dignity, all human beings are equal, and in order to maintain and preserve their dignity, some rights are associated with them (24). In the article 29 of the constitution benefitting the social security including retirement, unemployment, old age, disability, orphan hood, abandonment, accidents and the need for health care services and medical care as insurance and so is a public right and government has become responsible for providing the above mentioned services and rights for each of the country population by using the public income and the income generated through people participation. The individuals’ right and the associated government responsibilities have been emphasized in other articles too. In the article 43 in relation to health, the need for health and medical care have been classified along with the need for housing, food, clothing, education and possibility of having family (19).

Human rights is established based on the true character of individuals and is the basic requirement for equity. But in order to harmonize between the individuals rights and the community interests, equity should be considered in its macro sense of distributive equity or legislative (against judicial justice in the concept of micro or individual justice) (24).

One of the main necessities of justice is considering the needs of all the strata of society and the health needs of all individuals, which means considering health in its holistic meaning. Although governments have the stewardship for health and welfare of societies, but this process will not be effective without will and participation of people, and one of the factors to mobilize the people forces is social cohesion, which has the concept of social capital in its heart.

Therefore the health system values has been initiated from the inherent dignity of men, which has been granted by God, and for protecting this value, some rights have been considered for him, including the right to comprehensive health. This right, in its social dimension, raises the concept of equity in health, which of its necessities are social cohesion and individual and social trust.

2- Challenges of the health system

On the other hand, adopting an ethical position is a dynamic process which its base is in realizing complexity of the health system problems and limitations of the ethical analysis (20,25). In the guidelines of the reformation plan this issue was emphasized that in order to adopt a moral stance which is appropriate to the fundamental values and also leads to optimal performance in public policy, considering both factors, public health ethics and health system challenges, is necessary and if there is any conflict between them, adjustments should be made (20). Although the primary base for determining the values and principles of health system was the sociocultural values, but in the next stage, specially while determining principles, the current and future challenges of health system and the proposed strategies in scientific evidences was reviewed so proposed principles are a framework for determining overall health system strategies in solving current and future challenges (26, 27).

These principals are emphasized in the international documents, also.

In the World Health Report 2008 entitled” Primary Care Now More Than Ever” the principle of public health care and health for all have been emphasized again. Considering reducing the health inequities which originated from the socioeconomic status of people, social participation and people mobilization, people centeredness and considering their rights, ensuring the quality services, effective stewardship, and accountability of health system, inter-sectoral collaboration in the format of health in all policies, clear vision and securing appropriate human resources; are among the principles that this report refer to them as the principles of health system (28).

In the health system principles of other counties, most of principles are related to stewardship and its sub groups specially accountability, people participation and inter-sectoral collaboration, followed by principles related to providing the services, and the emphasize is mostly related to justice in access to the health services and quality of services (18,25,29,30).

The social participation principle has been repeated under different titles in other countries plan and includes a spectrum from “hearing peoples vices” in Cambodia plan (31) to “people participation in decision making” in England (18) or like Mexico it is mostly financial participation of the people (30).

In Australia Health reformation plan, public accountability, continuity and comprehensiveness of services, justice and promotion of the quality of executive performance in efficient use of resources are considered as the main principles (32).In Japan that the insurance reform was associated with increase in costs, some changes and interventions were anticipated which were community-based and based on prevention and continuity of services; and it is expected that this program lead to improvement in the equitable access to services and responsiveness to the needs of people (33).

Conclusion

In Iran, which the values and principles of health system is based on the religious values, human dignity is the fundamental value based on the revelation; and prosperity is the ultimate goal of all programs. In this sense, health and healthy human in its perfect concept (physical, mental, social and spiritual) has centeredness; and development in any form should lead to the prosperity of healthy human, in a way that each human attain the maximum level of health in its holistic meaning. The principle of health system is also, based on this values set. On the other hand, because of integration of medical education and research into health care services in the Iran health system(3), this values set contains principles that distinguish it from other countries.

Also we need to observe evolving perspective in public health ethics originating from new mind about person and society and their relationship which is claimed more appropriate for public health challenges (34, 35).

Ethical considerations

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