Letter to the editor: What we can learn from health transformation plan

It was a pleasure to read the article entitled "Universal health coverage in Iran: Where we stand and how we can move forward" (1). We appreciate the authors’ efforts to analyze Health Transformation Plan (HTP) and its challenges toward Universal Health Coverage (UHC). Although the authors have tried to put forward the background of Iran’s health system before HTP implementation and the challenges it has faced during its progress, some major issues were not precisely expressed.

One of the most intelligent reforms in Iran has been the establishment of national Health Network System (HNS), as it is not only a unique platform for implementing and expanding primary health care but also it is a concrete foundation for upper levels of health system (2). Thus, it would be negligent not to consider further improvements based on this platform. As a matter of fact, HNS should be a starting point for all further reforms in Iran, such as establishing the family physician program. Furthermore, the efficiency of patient-centered outpatient/inpatient services and cost-effective universal health coverage should be improved and considered in the plan (3). Although the HNS requires updates to meet the dynamic needs of the increased urban population of Iran, especially for non-communicable diseases, it should not be neglected in reforms.

One of the basic error s in HTP implementation is that it starts from inpatient care instead of primary care and ignores the systematic approach of the reform. As implementation of HTP coincided with increased tariffs mainly on surgical procedures in the background of the major payment system of fee for service, it was clear from the beginning that HTP would result in augmented induced demands with greater needs for fiscal and other resources in a progressive manner. This has led to insolvency of many public hospitals and tertiary care centers which relied on public resources and could not deal with the costs and financial burden of these induced demands. In fact, after a short period of reduction in out-of-pocket payment (OOP), which was the major goal of HTP, there was an increase in OOP, both as a percentile of total health expenditure and as an absolute value (4).

Paying proper attention to the prerequisites of reforms, including organizing outpatient care, establishing and implementing a referral system, and user-friendly and convenient electronic health records, were other shortfalls of the HTP implementation.

Another neglected point was human resource readiness for HTP. It rapidly resulted in burnout of health care providers and reduced quality of care in a matter of months (5).

In the health transformation plan, little attention has been paid to a comprehensive plan (if any), in which the overall model of health care delivery in Iran should have been identified and important issues such as the role of the private sector along with other public sectors in service delivery, sustainable financing model, best payment method, and equitable distribution of resources such as hospital beds, manpower or healthcare units should have been clarified (6). Insufficient managerial skills, lack of competency, and short life management lead to less commitment to the long-term plan which is crucial for any sustainable reform (7).

There was also apparent poor coordination between the MOH as the regulator and the major provider of health services, and the Ministry of Social Welfare which is responsible for public insurance system. This lack of coordination was also seen between the deputies of MOH, especially between the deputies of health, treatment, and education, who had diverse goals and programs which were not aligned with HTP.

In conclusion, we believe that HTP aimed to reduce the inequality of utilization, increase the financial protection, and improve the quality of care. However, paying insufficient attention to the existing health system, especially HNS, improper prioritization of the intervention package and inattention to the prerequisites of such a plan, including sustainable financial resources and lack of real support from all stakeholders, were the main problems in implementing HTP. Improving managerial skills in the health system at national level should gain importance as a major precondition considering the major role of managers in all reforms.

Conflict of Interests

KBL was the minister of health and medical education of Islamic republic of Iran form 2005 to 2009. The authors declare that they have no other competing interests.

Cite this article as: Joulaei H, Fardid M, Lankarani K.B. What we can learn from health transformation plan. Med J Islam Repub Iran. 2019 (28 Sep);33:102. https://doi.org/10.34171/mjiri.33.102