Publications by authors named "Arash Rashidian"

239 Publications

Survival analysis for patients with cancer in Gaza applying for Israeli permits to exit the Gaza Strip for health care: a retrospective cohort study of patients from 2008 to 2017.

Lancet 2021 Jul;398 Suppl 1:S20

WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Background: Gaza has been under land, sea, and aerial blockade for more than 13 years, during which time Israel has continued its permit regime to control access for Palestinian patients from Gaza to health facilities in the West Bank (including East Jerusalem), Israel, and Jordan. Specific groups, such as patients with cancer, have a high need for permits owing to a lack of services in Gaza. The approval rate for patient permits to exit Gaza dropped from 94% in 2012 to 54% in 2017. We aimed to assess the effect of access restrictions due to permit denials or delays on all-cause mortality for patients with cancer from Gaza who were referred for chemotherapy, radiotherapy, or both.

Methods: This study matched 17 072 permit applications for 3816 patients referred for chemotherapy, radiotherapy, or both, from Jan 1, 2008, to Dec 31, 2017, with referral data for the same period and mortality data from Jan 1, 2008, to Jun 30, 2018. We stratified survival analysis by period of first application (2008-14, 2015-17), in light of varying access to Egypt during these times. Primary analysis compared survival of patients according to their first referral decision (approved versus denied or delayed) using Kaplan-Meier methods and Cox regression. Consent for the study was granted by the Palestinian Ministry of Health, and ethical approval was granted by the Helsinki Committee of the Palestinian Ministry of Health.

Findings: Mortality was significantly higher among patients who were initially unsuccessful in permit applications from 2015 to 2017 (141 events over 493 person-years, corresponding to a rate of 286 per 100 person-years) than among patients who were initially successful in the same period (375 events over 1923 person-years, corresponding to a rate of 195 per 100 person-years) with a hazard ratio of 1·45 (95% CI 1·19-1·78, p=0.0009) after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk between the two groups in the 2008-14 period, with a hazard ratio of 0·84 (95% CI 0·69-1·01, p=0·071).

Interpretation: Barriers to patient access to health care through denied or delayed permit applications had a significant impact on mortality for patients with cancer who applied for chemotherapy, radiotherapy, or both, in the period 2015-17. Relative ease of access through Rafah from 2008 to 2014 may have mitigated the health effects of access restrictions.

Funding: WHO received funding from the Swiss Agency for Development and Cooperation.
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http://dx.doi.org/10.1016/S0140-6736(21)01506-3DOI Listing
July 2021

Comparative survival of cancer patients requiring Israeli permits to exit the Gaza Strip for health care: A retrospective cohort study from 2008 to 2017.

PLoS One 2021 2;16(6):e0251058. Epub 2021 Jun 2.

Department of Science, Information and Dissemination, WHO Regional Office for the Eastern Mediterranean, Nasr City, Cairo, Egypt.

Background: Gaza has been under land, sea, and aerial closure for 13 years, during which time Palestinian patients from Gaza have been required to obtain Israeli-issued permits to access health facilities in the West Bank (including east Jerusalem), as well as in Israel and Jordan. Specific groups, like cancer patients, have a high need for permits due to lack of services in Gaza. The approval rate for patient permits to exit Gaza dropped from 94% in 2012 to 54% in 2017. We aimed to assess the impact of access restrictions due to permit denials/delays on all-cause mortality for cancer patients from Gaza referred for chemotherapy and/or radiotherapy.

Methods: This study matched 17,072 permit applications for 3,816 cancer patients referred for chemotherapy and/or radiotherapy from 1 January 2008 to 31 December 2017 with referrals data for the same period and mortality data from 1 January 2008 to 30 June 2018. We carried out separate analyses by period of first application (2008-14; 2015-17), in light of varying access to Egypt during these times. Primary analysis compared survival of patients according to their first referral decision (approved versus denied/delayed) using Kaplan-Meier method and Cox regression.

Findings: Mortality in patients unsuccessful in permit applications from 2015-17 was significantly higher than mortality among successful patients, with a hazard ratio of 1·45 (95% CI: 1·19-1·78, p<0.001), after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk for the two groups in the 2008-2014 period.

Interpretation: Limitations to patient access due to unsuccessful applications for permits to exit the Gaza Strip had a significant impact on mortality for cancer patients applying for chemotherapy and/or radiotherapy in the period 2015-17. The substantially higher number of annual unsuccessful permit applications from 2015, combined with severely limited alternatives to access chemotherapy and radiotherapy during these years, may be important factors to explain the difference in the impact of permits delays/denials between the two study periods.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251058PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172025PMC
June 2021

Research on health priorities: a regional agenda and its implementation in Jordan and Pakistan.

East Mediterr Health J 2021 Apr 27;27(4):319-320. Epub 2021 Apr 27.

Director, Department of Science, Information and Dissemination, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

The Eastern Mediterranean Region (EMR) is facing extraordinary social and health challenges, aggravated by epidemiologic variations, high morbidity and mortality burden (communicable, noncommunicable, injuries), consequences of emergencies (including current COVID-19 pandemic), conflicts and massive migrant population movements. Research for health is essential for generating necessary evidence, which contributes to sustainable development, economic growth and sound health policy-making. Moreover, research for health that addresses national public health priorities is essential for developing required evidence for explanations that contribute towards health improvement and can assist in best utilization of available resources towards issues that maximize the research impact on population health.
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http://dx.doi.org/10.26719/2021.27.4.319DOI Listing
April 2021

Improving health and mortality data in Eastern Mediterranean Region countries: implementation of the International Classification of Diseases, 11th Revision (ICD-11).

East Mediterr Health J 2021 Feb 25;27(2):111-112. Epub 2021 Feb 25.

Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

On 25 September 2015, the United Nations (UN) General Assembly adopted and committed to a new development agenda "Transforming our world: the 2030 Agenda for Sustainable Development", which translated into 17 Sustainable Development Goals (SDGs). Global commitment to SDGs ushered in renewed calls to improve availability and accessibility of timely and quality information to monitor the progress towards achieving the health-related SDGs globally and in the Eastern Mediterranean Region (EMR). Health-related targets - under SDG 3 and also within other goals - require careful measurement and monitoring in order to track progress and success in policy implementation. SDG targets requires accurate and timely reporting of diseases, risk factors, mortality and causes of deaths (ranging from maternal mortality to death from road traffic accidents) and health care and social determinants of health.
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http://dx.doi.org/10.26719/2021.27.2.111DOI Listing
February 2021

The experiences of merging health insurance funds in South Korea, Turkey, Thailand, and Indonesia: a cross-country comparative study.

Int J Equity Health 2021 Feb 26;20(1):66. Epub 2021 Feb 26.

Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.

Background: Fragmentation in health insurance system may lead to inequity in financial access to and utilization of health care services. One possible option to overcome this challenge is merging the existing health insurance funds together. This article aims to review and compare the experience of South Korea, Turkey, Thailand and Indonesia regarding merging their health insurance funds.

Methods: This was a cross-country comparative study. The countries of the study were selected purposefully based on the availability of data to review their experience regarding merging health insurance funds. To find the most relevant documents about the subject, different sources of information including books, scientific papers, dissertations, reports, and policy documents were studied. Research databases including PubMed, Scopus, Google Scholar, Science Direct and ProQuest were used to find relevant articles. Documents released by international organizations such as WHO and World Bank were analyzed as well. The content of documents was analyzed using a data-driven conventional content analysis approach and all details regarding the subject were extracted. The extracted information was reviewed by all authors several times and nine themes emerged.

Results: The findings show that improving equity in health financing and access to health care services among different groups of population was one of the main triggers to merge health insurance funds. Resistance by groups enjoying better benefit package and concerns of workers and employers about increasing the contribution rates were among challenges ahead of merging health insurance funds. Improving equity in the health care financing; reducing inequity in access to and utilization of health care services; boosting risk pooling; reducing administrative costs; higher chance to control total health care expenditures; and enhancing strategic purchasing were the main advantages of merging health insurance funds. The experience of these countries also emphasizes that political commitment and experiencing a reliable economic growth to enhance benefit package and support the single national insurance scheme financially after merging are required to facilitate implementation of merging health insurance funds.

Conclusions: Other contributing health reforms should be implemented simultaneously or sequentially in both supply side and demand side of the health system if merging is going to pave the way reaching universal health coverage.
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http://dx.doi.org/10.1186/s12939-021-01382-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7913450PMC
February 2021

Iran health insurance system in transition: equity concerns and steps to achieve universal health coverage.

Int J Equity Health 2021 Jan 14;20(1):37. Epub 2021 Jan 14.

Institute of Population Health Sciences, Queen Mary University of London, London, UK.

Background: Equity, efficiency, sustainability, acceptability to clients and providers, and quality are the cornerstones of universal health coverage (UHC). No country has a single way to achieve efficient UHC. In this study, we documented the Iranian health insurance reforms, focusing on how and why certain policies were introduced and implemented, and which challenges remain to keep a sustainable UHC.

Methods: This retrospective policy analysis used three sources of data: a comprehensive and chronological scoping review of literature, interviews with Iran health insurance policy actors and stakeholders, and a review of published and unpublished official documents and local media. All data were analysed using thematic content analysis.

Results: Health insurance reforms, especially health transformation plan (HTP) in 2014, helped to progress towards UHC and health equity by expanding population coverage, a benefits package, and enhancing financial protection. However, several challenges can jeopardize sustaining this progress. There is a lack of suitable mechanisms to collect contributions from those without a regular income. The compulsory health insurance coverage law is not implemented in full. A substantial gap between private and public medical tariffs leads to high out-of-pocket health expenditure. Moreover, controlling the total health care expenditures is not the main priority to make keeping UHC more sustainable.

Conclusion: To achieve UHC in Iran, the Ministry of Health and Medical Education and health insurance schemes should devise and follow the policies to control health care expenditures. Working mechanisms should be implemented to extend free health insurance coverage for those in need. More studies are needed to evaluate the impact of health insurance reforms in terms of health equity, sustainability, coverage, and access.
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http://dx.doi.org/10.1186/s12939-020-01372-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7807408PMC
January 2021

'Health for All by All' during a pandemic: 'Protect Everyone' and 'Keep the Promise' of Universal Health Coverage in the Eastern Mediterranean Region.

East Mediterr Health J 2020 Dec 9;26(12):1436-1439. Epub 2020 Dec 9.

Director of Programme Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

The Universal Health Coverage (UHC) Day has been commemorated on 12 December every year since 2017. In 2019, the theme of the day was "Keep the Promise", referring to the Political Declaration on UHC endorsed by Heads of States at the United Nations General Assembly High-Level Meeting on 23 September 2019. In 2020, the theme is "Protect Everyone", emphasizing global and individual health security in the context of the COVID-19 pandemic, attributed to SARS-CoV 2 - a virus that infected more than 4 million people in the Eastern Mediterranean Region (EMR) and left over 100 000 dead in less than 12 months (6.6% and 7.1% of the global toll, respectively). Keeping the promise of UHC, while ensuring health security, is becoming a priority agenda of policy-makers and practitioners in the EMR in order to save lives, advance health and protect livelihoods.
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http://dx.doi.org/10.26719/2020.26.12.1436DOI Listing
December 2020

Inequality in dental expenditures among Iranian households: A cross-sectional survey using the National Health Accounts.

Dent Res J (Isfahan) 2020 Jul-Aug;17(4):306-313. Epub 2020 Aug 14.

Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: Recently, inequality in dental care has become increasingly popular in both developed and developing countries as a matter of health policy. Thus, the aims of this study were examining inequality in dental care expenditures and assessing the effects of insurance coverage and other variables on these services.

Materials And Methods: In this cross-sectional and descriptive-analytical study, we used secondary data of the National Health Accounts that has been conducted in 2008 in Iran. The sample size was 17,239 households in all over the country. All analyses were performed by Stata software using Mann-Whitney test and logistic regression. < 0.05 was considered statistically significant. To determine inequality in dental services, the concentration index (CI) was used.

Results: CI for total dental expenditures was 0.315 and for orthodontics was 0.6. Findings showed that out-of-pocket expenditure for dental care was progressive and there was a significant relationship between total dental expenditure with residence areas (odds ratio [OR] =1.3; > 0.001), complementary insurance coverage (OR = 1.3; > 0.001), family size (OR = 1.46; > 0.001), and income (OR = 1.3; > 0.001).

Conclusion: Dental expenditures were progressive in Iran, and the rich have paid more share for these services. It seems that implementing insurance programs, changes in the financing of dental care, development of insurance basic benefits package, supporting programs for the poor, adopting educational policies, and promoting oral health for vulnerable people can have an effective role in decreasing inequality in using dental services.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7688036PMC
August 2020

Measuring Public Preferences for Changes in the Health Insurance Benefit Package Policies in Iran: A Survey Approach.

Iran J Public Health 2020 May;49(5):940-948

Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: This study aimed to identify the public preference in health services, the principles that Iranian people consider important, and the aspects of tradeoffs between different values in resource allocation practices.

Methods: This quantitative study was conducted to investigate public preferences on Health Insurance Benefit Package (HIBP) in 2017. A structured questionnaire was used for data collection, including the preferences of the people who live in Tehran, were above 18 year, and were covered by basic insurance for the HIBP contents and premium. The sample size was calculated 430 subjects and SPSS Statistics was used for data analyzing.

Results: 81.6% of the sample population agreed with government allocating more money to the health sector compared to other sectors and organizations and 55% were willing to pay higher premiums for expanding the HIBP coverage. The highest and lowest score regarding prioritization of budget allocation between health services was related to hospitalization services (28.6%) and rehabilitation services (1.6%), respectively. The first priority of respondents regarding health care and life cycle, was "prevention in newborns" (15.9%), the second priority was "prevention in children" (14.6%), the third priority was "prevention in adults" (9.5%), and the last priority was "short-term care in newborns" (0.9%).

Conclusion: Iranian people believe that not only the principle of health maximization but also equal opportunities to access health care and a fair allocation of resources should be considered by authorities for effective health insurance policymaking. In this case, given the scarcity of resources, setting priorities for alternative resources is inevitable.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475621PMC
May 2020

What are the potential advantages and disadvantages of merging health insurance funds? A qualitative policy analysis from Iran.

BMC Public Health 2020 Aug 31;20(1):1315. Epub 2020 Aug 31.

Information, Evidence, and Research Department, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Background: In countries with health insurance systems, the number and size of insurance funds along with the amount of risk distribution among them are a major concern. One possible solution to overcome problems resulting from fragmentation is to combine risk pools to create a single pool. This study aimed to investigate the potential advantages and disadvantages of merging health insurance funds in Iran.

Methods: In this qualitative study, a purposeful sampling with maximum variation was used to obtain representativeness and rich data. To this end, sixty-seven face-to-face interviews were conducted. Moreover, a documentary review was used as a supplementary source of data collection. Content analysis using the 'framework method' was used to analyze the data. Four trustworthiness criteria, including credibility, transferability, dependability, and confirmability, were used to assure the quality of results.

Results: The potential consequences were grouped into seven categories, including stewardship, financing, population, benefit package, structure, operational procedures, and interaction with providers. According to the interviewees, controlling total health care expenditures; improving strategic purchasing; removing duplication in population coverage; centralizing the profile of providers in a single database; controlling the volume of provided health care services; making hospitals interact with single insurance with a single set of instructions for contracting, claiming review, and reimbursement; and reducing administrative costs were among the main benefits of merging health insurance funds. The interviewees enumerated the following drawbacks as well: the social security organization's unwillingness to collect insurance premiums from private workers actively as before; increased dissatisfaction among population groups enjoying a generous basic benefits package; risk of financial fraud and corruption due to gathering all premiums in a single bank; and risk of putting more financial pressure on providers in case of delay in reimbursement with a single-payer system.

Conclusion: Merging health insurance schemes in Iran is influenced by a wide range of potential merits and drawbacks. Thus, to facilitate the process and lessen opponents' objection, policy makers should act as brokers by taking into account contextual factors and adopting tailored policies to respectively maximize and minimize the potential benefits and drawbacks of consolidation in Iran.
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http://dx.doi.org/10.1186/s12889-020-09417-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457517PMC
August 2020

Health insurance benefit package in Iran: a qualitative policy process analysis.

BMC Health Serv Res 2020 Aug 6;20(1):722. Epub 2020 Aug 6.

Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: Insufficient transparency in prioritization of health services, multiple health insurance organizations with various and not-aligned policies, plus limited resources to provide comprehensive health coverage are among the challenges to design appropriate Health Insurance Benefit Package (HIBP) in Iran. This study aims to analyze Policy Process of Health Insurance Benefit Package in Iran.

Method: Data were collected through semi-structured interviews with 25 experts, plus document analysis and observation, from February 2014 until October 2016. Using both deductive and inductive approaches, two independent researchers conducted data content analysis. We used MAXQDA.11 software for data management.

Results: We identified 10 main themes, plus 81 sub-themes related to development and implementation of HIBP. These included: lack of transparent criteria for inclusion of services within HIBP, inadequate use of scientific evidence to determine the HIBP, lack of evaluation systems, and weak decision-making process. We propose 11 solutions and 25 policy options to improve the situation.

Conclusion: The design and implementation of HIBP did not follow an evidence-based and logical algorithm in Iran. Rather, political and financial influences at the macro level determined the decisions. This is rooted in social, cultural, and economic norms in the country, whereby political and economic factors had the greatest impact on the implementation of HIBP. To define a cost-effective HIBP in Iran, it is pivotal to develop transparent and evidence-based guidelines about the processes and the stewardship of HIBP, which are in line with upstream policies and societal characteristics. In addition, the possible conflict of interests and its harms should be minimized in advance.
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http://dx.doi.org/10.1186/s12913-020-05592-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409638PMC
August 2020

Setting health care services tariffs in Iran: half a century quest for a window of opportunity.

Int J Equity Health 2020 07 6;19(1):112. Epub 2020 Jul 6.

Institute of Population Health Sciences, Queen Mary University of London, London, UK.

Background: The process of medical tariffs setting in Iran remains to be a contentious issue and is heavily criticized by many stakeholders. This paper explores the experience of setting health care services tariffs in the Iranian health care system over the last five decades.

Methods: We analyzed data collected through literature review and reviews of the official documents developed at the various levels of the Iranian health system using inductive and deductive content analysis. Twenty-two face-to-face semi-structured interviews supplemented the analysis. Data were analysed and interpreted using 'policy triangle' and 'garbage can' models.

Results: Our comprehensive review of changes in the medical tariff setting provides valuable lessons for major stakeholders. Most changes were implemented in a sporadic, inadequate, and a non-evidence-based manner. Disparities in tariffs between public and private sectors continue to exist. Lack of clarity in tariffs setting mechanisms and its process makes negotiations between various stakeholders difficult and can potentially become a source of a corrupt income. Such clarity can be achieved by using fair and technically sound tariffs. Technical aspects of tariff setting should be separated from the political negotiations over the overall payment to the medical professionals. Transparency regarding a conflict of interest and establishing punitive measures against those violating the rules could help improving trust in the doctor-patient relationship.

Conclusion: Use of evidence-informed models and methods in medical tariff setting could help to strike the right balance in the process of health care services provision to address health system objectives. A sensitive application of policy models can offer significant insights into the nature of medical tariff setting and highlight existing constraints and opportunities. This study generates lessons learned in tariffs setting, particularly for low- and middle-income countries.
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http://dx.doi.org/10.1186/s12939-020-01224-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336437PMC
July 2020

Framework for Managing the COVID-19 Infodemic: Methods and Results of an Online, Crowdsourced WHO Technical Consultation.

J Med Internet Res 2020 06 26;22(6):e19659. Epub 2020 Jun 26.

Global Infectious Hazards Preparedness, Emergency Preparedness, World Health Organization, Geneva, Switzerland.

Background: An infodemic is an overabundance of information-some accurate and some not-that occurs during an epidemic. In a similar manner to an epidemic, it spreads between humans via digital and physical information systems. It makes it hard for people to find trustworthy sources and reliable guidance when they need it.

Objective: A World Health Organization (WHO) technical consultation on responding to the infodemic related to the coronavirus disease (COVID-19) pandemic was held, entirely online, to crowdsource suggested actions for a framework for infodemic management.

Methods: A group of policy makers, public health professionals, researchers, students, and other concerned stakeholders was joined by representatives of the media, social media platforms, various private sector organizations, and civil society to suggest and discuss actions for all parts of society, and multiple related professional and scientific disciplines, methods, and technologies. A total of 594 ideas for actions were crowdsourced online during the discussions and consolidated into suggestions for an infodemic management framework.

Results: The analysis team distilled the suggestions into a set of 50 proposed actions for a framework for managing infodemics in health emergencies. The consultation revealed six policy implications to consider. First, interventions and messages must be based on science and evidence, and must reach citizens and enable them to make informed decisions on how to protect themselves and their communities in a health emergency. Second, knowledge should be translated into actionable behavior-change messages, presented in ways that are understood by and accessible to all individuals in all parts of all societies. Third, governments should reach out to key communities to ensure their concerns and information needs are understood, tailoring advice and messages to address the audiences they represent. Fourth, to strengthen the analysis and amplification of information impact, strategic partnerships should be formed across all sectors, including but not limited to the social media and technology sectors, academia, and civil society. Fifth, health authorities should ensure that these actions are informed by reliable information that helps them understand the circulating narratives and changes in the flow of information, questions, and misinformation in communities. Sixth, following experiences to date in responding to the COVID-19 infodemic and the lessons from other disease outbreaks, infodemic management approaches should be further developed to support preparedness and response, and to inform risk mitigation, and be enhanced through data science and sociobehavioral and other research.

Conclusions: The first version of this framework proposes five action areas in which WHO Member States and actors within society can apply, according to their mandate, an infodemic management approach adapted to national contexts and practices. Responses to the COVID-19 pandemic and the related infodemic require swift, regular, systematic, and coordinated action from multiple sectors of society and government. It remains crucial that we promote trusted information and fight misinformation, thereby helping save lives.
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http://dx.doi.org/10.2196/19659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332158PMC
June 2020

The Effect of Access to Primary Care Physicians on Avoidable Hospitalizations: A Time Series Study in Rural Areas of Tehran Province, Iran.

Korean J Fam Med 2020 Sep 29;41(5):282-290. Epub 2020 May 29.

Department of Family Physician Program, Iran Health Insurance Organization, Tehran, Iran.

Background: Avoidable hospitalizations (AHs) are defined as hospitalizations that could have been prevented through timely and effective services. AHs are, therefore, an indicator used to evaluate the access and effectiveness of primary health care services.

Methods: A retrospective time-series study spanning 8 years (2006-2013) was conducted to determine the relationship between AHs and gender, age, and access to primary health care physicians in rural areas in Tehran province, the capital of Iran. The total number of avoidable hospitalizations was 22,570; logistic regression was estimated for each year separately.

Results: Total hospitalizations and AHs increased during the study period, especially during the first 3 years of the study. AHs, as a percentage of total hospitalizations, did not change significantly throughout the study years. This value was 22.3% during the first year of study and varied between 17% and 19.6% from 2007 to 2013. No statistically significant relationship was seen between AH occurrence and access to a physician during the study years.

Conclusion: Increasing access to primary health care physicians cannot necessarily result in decreased AHs. Considering the factors influencing AHs while designing and implementing the family physicians program is important to achieve the expected results regarding the effectiveness of primary health care services.
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http://dx.doi.org/10.4082/kjfm.19.0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509124PMC
September 2020

Is female genital mutilation associated with eclampsia? Evidence from a nationally representative survey data.

Reprod Health 2020 May 20;17(1):68. Epub 2020 May 20.

Department of woman, child and adolescent. Division of Gynecology, Geneva University Hospitals, Geneva, Switzerland.

Background: Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia.

Methods: The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV).

Results: In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234). Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4-4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM.

Conclusion: The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.
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http://dx.doi.org/10.1186/s12978-020-00918-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238645PMC
May 2020

Estimation of a Neonatal Health Production Function for Iran: Secondary Analysis of Iran's Multiple Indicator Demographic and Health Survey 2010.

Iran J Public Health 2019 Aug;48(8):1488-1495

Center for Systems Studies, Hull University Business School (HUBS), Hull York Medical School (HYMS), University of Hull, Hull, UK.

Background: Despite constant decrease in rate of neonatal mortality, the rate is still higher than that of other under-five children. One of the first steps towards reduction of neonatal mortality is to identify its determinants using health production function. The aim of the present study was to estimate neonatal health production function for Iran.

Methods: In this cross-sectional study, Iranian Multiple Indicator Demographic and Health Survey (Ir-MIDHS) 2010 was used. Four categories of socioeconomic, mother, neonatal demographic and healthcare system factors were entered into the Binomial Logistic Regression model to estimate neonate health production function. Households' economic status was constructed using principal component analysis.

Results: History of abortion/stillbirth had the highest significant positive impact on odds of neonatal mortality (odds ratio=1.98; 95 % CI=1.55-2.75), indicating that neonates of mothers with such a history had 1.98 times higher chance of death compared to other neonates. Moreover, odds ratio of neonatal death for the poorest quintiles was 1.70 (95 % CI=1.08-2.74), indicating that by moving from the poorest quintile to the richest one, the odds of being alive for neonates increased up to 70%. However, skilled birth attendant decreased the chance of death up to 58% (odds ratio=0.58; 95 % CI=0.36-0.93).

Conclusion: Considering the most significant inputs of neonatal health production function in Iran, improvement of economic status of households, provision of appropriate care services for mothers, and improvement of delivery care provided by trained personnel, could be priorities for health policymakers to act and reduce neonatal mortality in Iran.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145914PMC
August 2019

Health research prioritization: global and regional perspectives.

East Mediterr Health J 2020 Mar 24;26(3):254-256. Epub 2020 Mar 24.

Director of Programme Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

The Eastern Mediterranean Region (EMR) confronts unprecedented health challenges, exacerbated by demographic and epidemiologic changes, triple burden of disease, increasing healthcare costs, as well as the effects of contracted emergencies, social conflicts and massive population movements. Such challenges have repercussions on health care delivery and health research systems. Research for health is essential for developing solutions that contribute to health improvements. Investment in research for health contributes to health, economic growth and equity.
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http://dx.doi.org/10.26719/2020.26.3.254DOI Listing
March 2020

Prescribing for geriatrics in Tehran; is it appropriate and rational?

Med J Islam Repub Iran 2019 19;33:143. Epub 2019 Dec 19.

Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran.

The world's population is growing older. Inappropriate and irrational use of drugs in the elderly is a considerable health concern due to consequences such as increased morbidity and adverse drug events. This study aimed to evaluate the rationality of prescribing and determining the extent of inappropriate prescribing in a sample of geriatric patients in Tehran. This cross sectional study was performed on 1512 prescriptions of patients aged ≥ 65 years from 5 pharmacies affiliated to Tehran University of Medical Sciences in 2014. Prescription of potentially inappropriate medications (PIMs) was investigated using the Beers Criteria along with WHO prescribing indices. Date were analyzed using SPSS software, and significance level was set at less than 0.05. Mean (SD) age of patients was 73.9(6.7) years. A total of 472 (31.2%) patients received at least 1 PIM. Benzodiazepines were the most frequent drug class and general practitioners (GPs) were the most frequent prescriber of PIMs. The highest and the lowest percentage of prescriptions containing brand-names were prescribed by subspecialists (62.5%) and GPs (42.2%), respectively. Antibiotics and injectable medications were prescribed for 26.8% and 28.5% of patients by GPs. Mean (SD) number of drugs per prescription was 3.57 (1.92). Prescriptions containing systemic antibiotics and PIMs had significantly higher mean number of drugs compared to those without these items (both P < 0.001). There is a need for interventions to improve the quality of prescribing for elderly patients, especially by GPs. Also, there are still some problems in rational use of drugs based on prescribing indices, especially, prescribing brand-names and injectable medications.
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http://dx.doi.org/10.34171/mjiri.33.143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137821PMC
December 2019

Correction to: Combining health insurance funds in a fragmented context: what kind of challenges should be considered?

BMC Health Serv Res 2020 03 19;20(1):231. Epub 2020 Mar 19.

Department of Health Policy and Management,Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.

In the original publication of this article [1], there are two corrections.
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http://dx.doi.org/10.1186/s12913-020-5052-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081534PMC
March 2020

Effective health information systems for delivering the Sustainable Development Goals and the universal health coverage agenda.

Authors:
Arash Rashidian

East Mediterr Health J 2019 Dec 29;25(12):849-851. Epub 2019 Dec 29.

Director of Science, Information and Dissemination, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Universal health coverage (UHC) and the health-related Sustainable Development Goals (SGDs) cannot be achieved without the appropriate measurement and monitoring mechanisms. At the global level, extensive attention is given to mechanisms that focus on measuring and reporting the status of SDG indicators, to help in shaping global priorities, and to steer political will and leverage for action at the national level.
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http://dx.doi.org/10.26719/2019.25.12.849DOI Listing
December 2019

Descriptive Study of Economic Behavior of General Practitioners in Iran: Practice Income, Hours of Work, and Patient Visits.

Int J Prev Med 2019 10;10:217. Epub 2019 Dec 10.

Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: Although there is a critical need for information on economic performance of Iranian general practitioners (GPs) in health policymaking, there is not any scientific evidence in this area. Therefore, in the present report, the characteristics of economic behaviors of Iranian GPs were described.

Methods: This was a cross-sectional study in 2015, in which the data were collected from 666 GPs. The variables including monthly gross income, hours of work, and patient visits were studied as the measures of economic behavior of GPs. Descriptive statistics, -test, and Analysis of Variance were used for analyzing the data. The statistical analysis was performed by STATA12.

Results: The annual income of the GPs understudy was 26,000 US dollar (USD) (82,680 purchasing power parity [PPP]). The ratio of this value to gross domestic product per capita and minimum wage of Iran in 2015 was 4.8 and 9.2, respectively. On average, every GP in Iran has an income of 2188.1 USD (6958.16 PPP), works 142 h, and visits an average of 494 patients/month. The results showed that the economic behavior of Iranian GPs has a significant difference in terms of gender, age, marital status, practice experience, practice location, type of practice, being a family physicians, and working in different settings ( < 0.05).

Conclusions: The Iranian GPs understudy work less than their counterparts in other (compared) countries. The studied GPs had a higher income (adjusted by hours of work and countries' per capita income) than their counterparts in other (studied) countries. Moreover, there are inequalities between GPs in terms of income, the volume of services provided and the work hours.
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http://dx.doi.org/10.4103/ijpvm.IJPVM_408_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6941379PMC
December 2019

Combining health insurance funds in a fragmented context: what kind of challenges should be considered?

BMC Health Serv Res 2020 Jan 8;20(1):26. Epub 2020 Jan 8.

Department of Health Policy and Management,Tabriz Health Services Management Research Center, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: Iran's Parliament passed a Law in 2010 to merge the existing health insurance schemes to boost risk pooling. Merging can be challenging as there are differences among health insurance schemes in various aspects. This qualitative prospective policy analysis aims to reveal key challenges and implementation barriers of the policy as introduced in Iran.

Methods: A qualitative study of key informants and documentary review was conducted. Sixty-seven semi-structured face-to-face interviews were conducted, with key informants from relevant stakeholders. Purposive and snowball sampling techniques were used for selecting the interviewees. The related policy documents were also reviewed and analyzed to supplement interviews. Data analysis was conducted through an existing health financing World Bank framework.

Results: This study demonstrated that for combining health insurance funds, operational challenges in the following areas should be taken into account: financing mechanisms, population coverage, benefits package, provider engagement, organizational structure, health service delivery and operational processes. It is also important to have adequate cogent reasons to "the justification of the consolidation process" in the given context. When moving towards combining health insurance funds, especially in countries with a purchaser-provider split, it is critical for policy makers to make sure that the health insurance system is aligned with the policies and Stewardship of the broader health care system.

Conclusions: Implementation of major reforms in a health system with fragmented insurance schemes with different target populations, prepayment structures, benefit packages and history of development is inherently difficult, especially when different stakeholders have vetoing powers over the proposed reforms. Solving the differences and operational challenges in the main areas of health insurance system generated in this study may provide a platform for the designing and implementing merging process of social health insurance schemes in Iran and other countries with similar situations.
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http://dx.doi.org/10.1186/s12913-019-4858-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6950996PMC
January 2020

Dual practice and multiple job holding among Iranian general practitioners: Rate and effective factors.

Int J Health Plann Manage 2020 May 3;35(3):799-807. Epub 2019 Dec 3.

Health Human Resources Research Center, School of Management & Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Physician's dual practice is a common phenomenon in both developing and developed countries. This study aimed to investigate the rate and factors affecting the dual practice of general practitioners (GPs) as the most important primary care providers in Iran.

Methods: This cross-sectional study was conducted on the data of 666 Iranian GPs, derived from a national survey. In this work, a researcher-made checklist was used to collect the required information. Multinomial logistic regression was used to examine the factors affecting concurrent employment in both public and private sectors and the factors affecting employment in more than one place (either public or private).

Results: About 23.51% of the GPs were only working in the public sector, and 57.84% only in the private sectors. Also, 18.65% were working in both the private and public sectors. Results also indicated that 26.17% of the GPs were working in two or more places (whether public or private). Male GPs (p < .1) as well as the GPs with higher earnings expectations (p < .01) were more likely to have dual practice. Besides, the GPs working in small towns and villages (compared with Tehran, as capital of Iran; p < .05) were less likely to have dual practice. Gender (male) and earnings expectations had a significant effect on working in more than one place (p < .01).

Conclusion: The most important and significant factor affecting GPs' dual practice in Iran was their financial expectations. Thus, appropriate policies to modify physicians' income expectations and reforms such as improving tariffs setting should be adopted in the health systems.
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http://dx.doi.org/10.1002/hpm.2961DOI Listing
May 2020

Biomedical and health research geography in the Eastern Mediterranean Region.

East Mediterr Health J 2019 Nov 4;25(10):728-743. Epub 2019 Nov 4.

Department of Science, Information and Dissemination, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Background: Measuring scientific outputs allows for objective evaluation of established health research systems and ranking countries according to scientific achievements. To our knowledge, attempts for systematic mapping health research output in the Eastern Mediterranean Region (EMR) are limited.

Aims: We aimed to conduct a detailed bibliometric analysis of EMR biomedical and health research productivity during the period 2004-2013, considering country of first author.

Methods: We applied an improved PubMed search strategy to obtain precise data on EMR research productivity, limiting articles to reviews, original research and case reports. Data were normalized to global research output, represented by total articles indexed in PubMed per year from 2004-2013, according to population size of each country. Second order polynomial trend lines were calculated and comparing 5-year periods: 2004-2008 with 2009-2013.

Results: Inspecting overall raw data, a clear increasing trend is observed. Regional share of global health related research ranged from 0.85-2.36% of total PubMed indexed publications during the study period. Five countries contributed to 80% of all published articles during study period; i.e., Islamic Republic of Iran (39%), Egypt (14%), Saudi Arabia (11%), Tunisia, and Pakistan (8% each). Overall, 2.35 articles are published per 100 000 population per year. While Kuwait maintained the highest per capita publication (followed by Tunisia, Lebanon, Qatar and Islamic Republic of Iran), Qatar, Islamic Republic of Iran and Saudi Arabia demonstrated the highest "per capita" population growth in publications. Three academic institutions accounted for over 10% of all publications that were led by an investigator from the Region. Collectively, most prolific 25 EMR institutions published 44% of all published biomedical and health research in the EMR.

Conclusions: The overall global share of EMR health research publication is smaller than its global share of population or wealth. Biomedical and health research needs greater encouragement and supporting many EMR countries and/or institutions, especially those found to be least prolific in our analysis. The increase in academic publication on health has been more prominent in a few countries only. It is anticipated that the concentration of biomedical and health research in EMR academic institutions would help in translating knowledge into public health outcomes, if more suitable conditions are provided.
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http://dx.doi.org/10.26719/emhj.19.082DOI Listing
November 2019

Healthy Cities Programme in the Eastern Mediterranean Region: concurrent progress and future prospects.

East Mediterr Health J 2019 Oct 4;25(7):445-446. Epub 2019 Oct 4.

Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Urbanization has been rapidly increasing during the past two decades and it is estimated that by 2030, two thirds of the world's population would be living in urban areas, exposing the population to a large number of environmental, social, cultural, economic and behavioural factors that impact population health and wellbeing.

In response to such challenges, the Healthy Cities concept was instigated in 1977 that, along with the Alma Ata Declaration and commitment of countries at the Thirtieth World Health Assembly in Geneva, Switzerland, would empower communities to lead socially and economically productive lives. A number of policy documents from the World Health Organization (WHO) and other bodies suggested introducing new approaches to managing cities and addressing health challenges, focusing more on health determinants and prevention than medical interventions.
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http://dx.doi.org/10.26719/2019.25.7.445DOI Listing
October 2019

Income inequality among general practitioners in Iran: a decomposition approach.

BMC Health Serv Res 2019 Sep 2;19(1):620. Epub 2019 Sep 2.

Health Human Resources Research Center, School of Management & Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: General practitioners (GPs) are among the most important resources of healthcare system and public health is considerably influenced by the function of this group. Income inequality among GPs considerably affects the motivation and performance of this group. The present study aims to examine the income inequality among Iranian GPs in order to provide the necessary evidence for health human resource policy.

Methods: In this cross-sectional study, the distribution of income and wage inequality among GPs was investigated using income quintiles. We also used the Dagum's model to analyze the inequality between different groups of GPs through the decomposition of the Gini coefficient. Moreover, a regression model was used to determine the effective factors on GPs' income.

Results: The results of this study indicated that income and wages of GPs in the highest quintile were eight times more than those of doctors at the lowest quintile. Regression estimates showed that factors such as gender, practice setting, and activity as the family physician (P < 0.001) were effective on income of GPs; and also male and self-employed GPs had significantly more wage (P < 0.001). Total Gini coefficient of GPs' income and wage were estimated at 0.403 and 0.412, respectively. Highest monthly income was found in GPs with 16-20 years practice experience ($8358) based on Purchasing Power Parity (PPP), male ($8339 PPP), and self-employed GPs ($8134 PPP) subgroup. However, the female ($5389 PPP) and single ($5438 PPP) GPs had the lowest income. Population share; income/wage share; income/wage mean; Gini coefficient; and within, between and overlap decomposed components of Gini coefficient are also reported for each GPs subgroups.

Conclusions: We found significant inequalities in income and wages among Iranian GPs. Adjustment of income based on working hours indicated that one of the most common causes of income inequality among GPs in Iran was different workloads among different groups. Since the motivation and function of physicians can be influenced by income inequality, policymakers in the health system should consider factors increasing such inequalities.
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http://dx.doi.org/10.1186/s12913-019-4473-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6721336PMC
September 2019

Inequality in geographical distribution of hospitals and hospital beds in densely populated metropolitan cities of Iran.

BMC Health Serv Res 2019 Aug 30;19(1):614. Epub 2019 Aug 30.

Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: This study aims to assess geographical distribution of hospitals and extent of inequalities in hospital beds against socioeconomic status (SES) of residents of five metropolitan cities in Iran.

Methods: A cross-sectional analysis was conducted to measure geographical inequality in hospital and hospital bed distributions of 68 districts in five metropolitan cities during 2016 using geographic information system (GIS), and Gini and Concentration indices. Correlation analysis was performed to show the relationship between the SES and inequality in hospital beds densities.

Results: The study uncovered marked inequalities in hospitals and hospital beds distributions. The Gini indices for hospital beds were greater than 0.55. The aggregated concentration indices for public and private hospital beds were 0.33 and 0.49, respectively. The GIS revealed that 216 (70.6%) hospitals were located in two highest socioeconomic status classes in the cities. Only 29 (9.5%) hospitals were located in the lowest class. The public, private, and the cumulative hospitals beds distributions in Tehran and Esfahan showed significant (p < 0.05) positive correlation with SES of the residents.

Conclusions: The high inequalities in hospital and hospital beds distributions in our study imply an overlooked but growing concern for geographical access to healthcare in rapidly urbanizing metropolitan cities in Iran. Thus, regardless of ownership, decision-makers should emphasize the disadvantaged areas in metropolitan cities when need arises for the establishment of new healthcare facilities in order to ensure fairness in healthcare. The metropolitan cities and rapid urbanization settings in other countries could learn lessons to reduce or prevent similar issues which might have hampered access to healthcare.
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http://dx.doi.org/10.1186/s12913-019-4443-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717334PMC
August 2019

Evaluation of Tuberculosis Underreporting to National Tuberculosis Program (NTBP) based on data from laboratories in Tehran and NTBP.

Med J Islam Repub Iran 2019 17;33:70. Epub 2019 Jul 17.

Department of Health Management & Economic, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

According to the Global tuberculosis (TB) Report 2014, released by World Health Organization (WHO), difference between estimated number of TB patients and the number of patients who are registered by the National Tuberculosis Programs (NTBP) is about 3 million annually in the world. In the current study, we investigated the level of under-reporting of TB cases between labs with poor collaboration background with NTBP in Tehran. In the context of TB, this is an inventory study that evaluating the level of under-reporting of TB cases. To do inventory study, first, after selecting laboratories based on poor collaboration background with NTBP and developing patient's list we matched the patient's list with the MoHME's database then, patients that were not recorded in NTBP's list were identified, and those with available telephone numbers were called. Out of 23 selected labs, 10 (5 private, 5 public (other than PHC)) had individuals with positive results. 71.6% of all samples are tested in public labs. Out of 23633 performed tests, 1396 individuals were positive. The under-reporting was, 62.5% and 39% in public and private laboratories, respectively. Public and private sector laboratories will be able to significantly reduce their failure to report if they comply with the recommended requirements and standards of the NTBP in their Processes and software for registering patient information.
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http://dx.doi.org/10.34171/mjiri.33.70DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708102PMC
July 2019
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