Abstract
BACKGROUND:
The health reform plan (HRP) is a plan to improve Iran's health systems that began in 2014. The three main approaches of this plan include financial protection of the people, creating justice in access to health services, and improving the quality of services. It predicted that the level of health system responsiveness would increase. Achieving this goal is possible only with the correct implementation. The best people to measure the correct implementation are nurses, midwives, and physicians. Hence, this study was conducted to assess the attitude of nurses, midwives, and physicians about the implementation of the HRP.
MATERIALS AND METHODS:
This cross-sectional descriptive study was conducted in educational hospitals of Jahrom University of Medical Sciences in 2020. By convenience sampling method, 325 nurses, midwives, and physicians participated in this study. Sampling was done in all work shifts, and in all wards. A researcher-making questionnaire was used to collect data. The scoring did by the Likert scale from (completely agree = 4 to completely disagree = 1). Quantitative and qualitative face and content validity was calculated (IS: 0.84, CVI: 0.92, CVR: 0.87), and its reliability was calculated by Cronbach's alpha method (0.78). The data were analyzed by SPSS software version 16. Descriptive statistics, Mann–Whitney U-test, and Kruskal–Wallis test were used for the data analysis (P ≤ 0.05).
RESULTS:
In the study, 90.15% agreed with the implementation of the HRP. There was no significant difference between the male and female (P = 0.063). There was a significant difference between the educational degree (P = 0.006), married and the single participants’ attitude (P = 0.003), the nurses, midwives, and physicians (P = 0.001).
CONCLUSION:
HRP is more successful in the field of financial protection, so policymakers should pay more attention to justice in access to health services and improving the quality of services fields.
Keywords: Attitude, health reform plan, hospital, midwife, nurse, physician
Introduction
With the development of countries, people's expectations of medical systems increase.[1] Since the 1980s, different countries have implemented health reform plan (HRP) to improve the health system quality. In China, the HRP was implemented in 2009. But in the United States and the United Kingdom, it was done before.[2] In Iran, for improving the quality of clinical care, the HRP implemented on May 15, 2014. The three main approaches of this plan include financial protection of the people, creating justice in access to health services, and improving the quality of services. It consists of seven guidelines such as reducing of hospitalization fee for patients, supporting the presence of physicians in deprived areas and resident physicians in hospitals, improving the quality of care, improving quality of hoteling, financial support for special, and end-stage patients, increasing normal vaginal delivery, and monitoring of HRP.[3]
Patients, nurses, midwives, and physicians are the stakeholders of this plan, but most studies about HRP, important.[4] If the stakeholders were dissatisfied with the implementation of HRP, its continuation can be associated with many challenges. Executors’ dissatisfaction with a plan reduces effectiveness, reduces job motivation, and increases job stress and burnout. Eventually, patient satisfaction decreases and threatens the survival of an organization or program. Hence, it is very important to know the opinions of nurses, midwives, and physicians about the implementation of the HRP. Therefore, this study was conducted to determine the nurses, midwives, and physicians’ attitudes in regard to HRP. Patients’ opinions assessed, while nurses, midwives, and physicians feedback is equally.
Materials and Methods
Study design and setting
This cross-sectional descriptive study was conducted in three educational hospitals (Motahari and Pymanie) affiliated with Jahrom University of Medical Sciences in 2020.
Study participants and sampling
The research community contains all 700 nurses, midwives, and physicians affiliated to Jahrom University of Medical Sciences. The sample size was calculated at 384 subjects by the Cochran formula (α = 0.05, P = 0.5, d = 20%). Sampling was done by convenience sampling method in all work shifts and in all wards among nurses, midwives, and physicians. All participants had at least 2 years of work experience before and after the HRP. Fifty-nine subjects were excluded from the study due to an incomplete questionnaire. The attrition rate was 15.36%.
Data collection tool and technique
A researcher-making questionnaire was used to collect data. The first part included the sociodemographic information (age, sex, married status, ward, and job experience) and the second part consisted of the 24 questions about the attitude of nurses, midwives, and physicians in regard to the HRP. Scoring did by the Likert scale from (completely agree = 4 to completely disagree = 1) total score rank was 24–96. Quantitative and qualitative face and content validity was calculated by 11 faculty members (Impact Score: 0.84, content validity index: 0.92, content validity ratio: 0.87), and its reliability was calculated by 10 personnel using Cronbach's alpha method (0.78). The data were analyzed by SPSS software version 16 (SPSS Inc., Chicago, USA). Descriptive statistics, Mann–Whitney U test, and Kruskal–Wallis test used for the data analysis (P ≤ 0.05).
Ethical consideration
This project was approved by the Ethics Committee of the Jahrom University of Medical Sciences, Iran, (IRJUMS.REC.1394.048). The researchers gave information about the study and obtained written informed consent from all participants. They were voluntary to withdraw at any time. This study was performed according to the Helsinki Declaration. The aims of the study were explained to participants, the questionnaires were filled out during work hours. All the information remained confidential assured. The questionnaires were anonymous form.
Results
In the study, 135 nurses, 60 midwives, and 130 physicians participated. The mean (standard deviation [SD]) of age was 38.8 (8.14), 39.88% were male, and 66.25% were married. The mean (SD) of the job experience was 10.1 (4.14). Most participants, 90.15%, agreed with the implementation of the HRP. There was no significant difference between the male and female (P = .063). There was a significant difference between the educational degree (P = .006) and between the married and the single participants’ attitudes (P = .003). The Kruskal–Wallis test showed a significant difference between the nurses, midwives, and physicians (P = .001) so that the physicians had the lease agreement, while the nurses had the highest agreement [Table 1]. The ordinal regression test was performed to predict the proportion of each variables (gender, marital, degree, and job) with the HRP agreement [Table 2]. The model did not fit.
Table 1.
Personnel attitudes in regard to implementing of the health reforms plan
| Variables | n (%) | Completely disagree | Disagree | Agree | Completely agree | P |
|---|---|---|---|---|---|---|
| Gender | ||||||
| Male | 130 (39.88) | 0 | 7 (5.38) | 74 (56.92) | 49 (37.7) | 0.063* |
| Female | 195 (60.12) | 5 (2.55) | 20 (10.26) | 140 (71.79) | 30 (15.4) | |
| Marital status | ||||||
| Single | 110 (33.75) | 5 (4.54) | 27 (24.55) | 64 (58.18) | 14 (12.73) | 0.003* |
| Married | 215 (66.25) | 0 | 0 | 150 (69.77) | 65 (30.23) | |
| Educational degree | ||||||
| Associate degree | 15 (4.60) | 0 | 0 | 10 (66.66) | 5 (33.34) | 0.006** |
| Bachelor | 160 (49.08) | 5 (3.12) | 2 (1.25) | 100 (62.5) | 53 (33.13) | |
| Master | 20 (6.13) | 0 | 5 (25) | 9 (45) | 6 (30) | |
| Physicians | 130 (39.88) | 0 | 20 (15.38) | 95 (73.08) | 15 (11.54) | |
| Job | ||||||
| Physicians | 130 (39.88) | 0 | 20 (15.38) | 95 (73.08) | 15 (11.54) | 0.001** |
| Nurse | 135 (41.66) | 0 | 5 (3.70) | 78 (57.58) | 52 (38.72) | |
| Midwife | 60 (18.46) | 5 (8.33) | 2 (3.34) | 41 (68.33) | 12 (20) | |
| Total | 5 (1.54) | 27 (8.31) | 214 (65.85) | 79 (24.30) |
*Mann-Whitney U test, **Kruskal-Wallis test
Table 2.
Modeling fit information
| Model | −2 log likelihood | χ 2 | df | Signifiance |
|---|---|---|---|---|
| Intercept only | 33.513 | 33.513 | 6 | 0.089 |
| Final | 0.088 |
Discussion
According to the results of this study, 90.5% of the participants agreed with the HRP. Furthermore, it was found that the rate of agreement with the HRP is higher among married and nonphysician participants. The study of Nakhaei et al. stated that 75% of nurses were moderately satisfied with the implementation of the HRP.[5] Results of the Sajadi study showed that accountability was improved in the health system, and hospital performance indicators were enhanced.[6] The studies of Ebrahimipour and Sajadi showed that the HRP had a positive effect on the financial and functional indicators of the hospital.[6,7] Formal reports have revealed that treatment costs increased 71 times more expensive, and drugs have 107 times more expensive in the 20 past years. People paid a lot of money for their treatment every year.[8] An estimated 3.5 million people become poor for the cost of treatment in Iran every year. Perhaps, the staff did not know these details, but they heard the patients’ moans at the time of payment and discharge. The HRP solved these problems. Hence, reduce of hospitalization fees for patients, especially in the end-stage patients, improved nurses, midwives, and physicians’ attitudes about HRP. Of course, reduce in the patient's payment has led to more patients referred to hospitals. This causes physicians’ dissatisfaction.[9,10] In a study by Ghorbani-Nia, only 40% of nurses satisfied with the HRP. In a study by Shariati, it found that most nurses (83%) were not satisfied with the HRP. In a study by Nakhaei et al., only 5% of nurses were satisfied with working conditions and 2% with income.[5,11] These findings are different from our study. This difference can be due to differences in time, place, and organizational culture. There was a lot of publicity in the media about the goals of this project. This information made patients and their caregivers more aware of the time and manner of care in hospitals. As a result, it raised patients’ expectations and caused staff dissatisfaction with the implementation of the HRP.[4] Excessive hospital visits can increase medical errors, greatly reduce the quality of triage and the quality of services. The most important limitation of this study was that 15.36% of the questionnaire were incomplete and excluded from the study. Caregivers and patients’ opinions were not asked as participants in the study. This is a main weakness of the study.
Conclusion
HRP is more successful in the field of financial protection, so policymakers should pay more attention to justice in access to health services and improving the quality of services fields.
Financial support and sponsorship
The current study was financially supported by the Jahrom University of Medical Sciences. Jahrom University of Medical Sciences grants code was HSR.94/11.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
Thanks to all the staff and hospital managers who assisted us in this study.
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