We observed no significant change in the CHE proportion despite policy interventions aimed at reducing such expenditures. Any solution to the problem of CHE should include interventions aimed at the determinants of CHE. It is essential to increase the depth of social insurance coverage by expanding the basic benefit package and reducing co-payments.

BackgroundCesarean section rates are increasing worldwide, and a rapid increase has been observed in Iran. Disagreement exists between clinicians about when to use cesarean section. We aimed to identify the appropriateness criteria for the use of cesarean section in Iran.MethodA consensus development study using a modified version of the RAND Appropriateness Method (RAM). We generated scenarios from valid clinical guidelines and expert opinions. A panel of experts participated in consensus development: first round via mail (12 members), second round face-to-face (9 members). We followed the RAM recommendations for the development of the scenario lists, rating scales, and statistical analyses.Results294 scenarios relevant to cesarean section were identified. 191 scenarios were considered appropriate, of which 125 scenarios were agreed upon. The panel found cesarean inappropriate for 21% of scenarios, and 'equivocal' for 14% of scenarios.ConclusionRAM is useful for identifying stakeholder views in settings with limited resources. The participants' views on appropriateness of certain indications differed with available evidence. A large number of scenarios without agreement may partly explain why it has been difficult to curb the growth in cesarean section rate.

BackgroundNo systematic review has explored the causes of and factors associated with maternal mortality in the context of Iran. This study reviewed determinants and causes of maternal mortalities during pregnancy, delivery and the puerperium using the International Classification of Diseases-Maternal Mortality (ICD-MM), introduced by the World Health Organization.MethodsA systematic electronic search of all the studies that identified causes and/or determinants of maternal deaths in any part of Iran or in the whole country were included, without any restriction of time or language of studies. To identify the studies to include in this study, a combination of hand searching and bibliographies was also conducted. These sources and citations yielded a total of 653 articles; nevertheless, only 29 articles met the inclusion criteria, hence, required data were extracted, summarized, and grouped together from these papers and are reported in the tables.ResultsAmongst the 29 studies published between 2003 and 2017 in Iran, 24 studies were cross-sectional. Overall, 4633 deaths were reviewed, and 2655 (58%) of the cases included the data on the causes of death generally. According to the ICD-MM, a total of 69.9, 20.6, and 5.2% of the mortalities were due to direct, indirect and unspecified causes respectively and 4.3% of the causes were not clear in several studies. The leading direct and indirect causes of death were identified as hemorrhage (30.7%) and hypertensive disorders (17.1%) and circulatory system diseases (8.1%) respectively. Several factors including gravidity, type of delivery, socio-economic status of mothers, locations of birth, death and maternity care venues were found in the original studies as the most important determinant of maternal mortalities in Iran.ConclusionsThis study, provided an updated summary of evidences on the causes and determinants of maternal death in Iran, which is critically important for the development of interventions and reduction of the burden of maternal mortality and morbidities.

Hospital waste management is an important process that must be dealt with diligently. The management of hazardous waste material requires specific knowledge and regulations and it must be carried out by specialists in the field. In this cross-sectional study, we assessed the main stages of hospital waste management including separation, containment, removal and disposal of waste materials in public hospitals affiliated with Tehran University of Medical Sciences (TUMS). We selected 108 units of six hospitals (three general hospitals and three subspecialty hospitals) from those hospitals supervised by TUMS using the cluster sampling method. The measurement was conducted through a questionnaire and direct observation by researchers. Association analysis was done by statistical tests; Fisher exact test and chi-squared using SPSS software. According to the results obtained by the questionnaire, most of the studied wards scored moderately in terms of quality of their performance in all stages of waste management. About one-fifth of the wards were suffering from poor management of their medical waste and only a minority of wards obtained good scores for managing their waste materials. The findings also revealed significant associations between temporary waste storage and collection and the level of education of the managers (P = 0.040, P = 0.050, respectively). In summary, the study indicated a moderate management in all processes of separation, collection, containment, removal and disposal of waste materials in hospitals with several observed problems in the process.

Background: Hospitals are highly resource-dependent settings, which spend a large proportion of healthcare financial resources. The analysis of hospital efficiency can provide insight into how scarce resources are used to create health values. This study examines the Technical Efficiency (TE) of 12 teaching hospitals affiliated with Tehran University of Medical Sciences (TUMS) between 1999 and 2011. Methods: The Stochastic Frontier Analysis (SFA) method was applied to estimate the efficiency of TUMS hospitals. A best function, referred to as output and input parameters, was calculated for the hospitals. Number of medical doctors, nurses, and other personnel, active beds, and outpatient admissions were considered as the input variables and number of inpatient admissions as an output variable. Results: The mean level of TE was 59% (ranging from 22 to 81%). During the study period the efficiency increased from 61 to 71%. Outpatient admission, other personnel and medical doctors significantly and positively affected the production (P< 0.05). Concerning the Constant Return to Scale (CRS), an optimal production scale was found, implying that the productions of the hospitals were approximately constant. Conclusion: Findings of this study show a remarkable waste of resources in the TUMS hospital during the decade considered. This warrants policy-makers and top management in TUMS to consider steps to improve the financial management of the university hospitals.

Despite a comprehensive reproductive health program there is little sex education available in Iran. In this article we present results of a study conducted to identify content area for a proposed sex education program for married Iranian women. Twenty-one married female clients (23-45 years) and 18 reproductive health providers, recruited from urban health clinics in Tehran using non-probability sampling, participated in four focus group discussions. Sexual health information needs related to reproductive tract and sexually transmitted infections, ''acceptability'' of certain sexual practices such as oral and anal intercourse, and the sexual response cycles and physiology of men and women. Women's sexual concerns related to communication, incompatibility of sexual interests and desire, and their ability to maintain a strong marriage. Two themes cut across women's responses to all questions: modesty and maintaining a strong marriage. Results contributed to the design of a sex education program that addressed the specific information needs and concerns of Iranian women.

The patient satisfaction questionnaire strives to be a valid and reliable instrument for assessing in-patient satisfaction with hospital services in Iran.

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