This study highlighted specific strengths in the technical and functional aspects of DHIS2 and also drew attention to particular challenges and concerns. These results provide a sound evidence base for decision makers and policymakers to enable them to make more accurate decisions about whether or not to use the DHIS2 in the health system of their country.

BackgroundHouseholds exposure to catastrophic health expenditure is a valuable measure to monitor financial protection in health sector payments. The present study had two aims: first, to estimate the prevalence and intensity of catastrophic health expenditures (CHE) in Iran. Second, to investigate main factors that influence the probability of CHE.MethodsCHE is defined as an occasion in which a household’s out-of-pocket (OOP) spending exceeds 40% of the total income that remains after subtraction of living expenses. This study used the data from eight national repeated cross-sectional surveys on households’ income and expenditure. The proportion of households facing CHE, as a prevalence measure, was estimated for rural and urban areas. The intensity of CHE was also calculated using overshoot and mean positive overshoot (MPO) measures. The factors affecting the CHE were also analyzed using logistic random effects regression model. We also used ArcMap 10.1 to display visually disparities across the country.ResultsAn increasing number of Iranians has been subject to catastrophic health care costs over the study period in both rural and urban areas (CHE = 2.57% in 2008 and 3.25% in 2015). In the same period, the overshoot of CHE and the mean positive overshoot ranged from 0.26% to 0.65% and from 12.26% to 20.86%, respectively. The average absolute monetary value of OOP spending per month has been low in rural areas over the years, but the prevalence of CHE has been higher than urban areas. Generally put, rural settlement, higher income, receiving inpatient and outpatient services, and existence of elderly people in the household led to increase in CHE prevalence (p < 0.05). Interestingly, provinces with more limited geographical and cultural accessibility had the lowest CHE.ConclusionsAccording to the findings, Iran’s healthcare system has failed to realize the aim of five-year national development plan regarding CHE prevalence (1% CHE prevalence according to the plan). Therefore, revision of financial health care protection policies focusing on pre-payments seems mandatory. For instance, these policies should extend the interventions that target low-income populations particularly in rural areas, provide more coverage for catastrophic medical services in basic benefit packages, and develop supplementary health insurance.

Evaluation of programs and determining its challenges to improve and implement reforms is essential in a healthcare system. A primary healthcare program was conducted since 1984 in Iran and faces various challenges after several decades of its life. The aim of this study is to evaluate Iran's primary healthcare program and determine its challenges and weaknesses. In the present systematic review study, the published articles related to Iran's primary healthcare were searched and collected from Iranian databases (SID, Magiran, Noormags and Irandoc) and international databases (Pubmed, Scopus, Web of Knowledge and Google Scholar). The Iranian grey literature was also explored. In total, from 336 papers identified, 25 papers were deemed relevant after the step-by-step review of articles and removal of non-related articles. The results of this study show that primary healthcare in Iran has different challenges and weaknesses. Most of these challenges and weaknesses relate to the structure and process of primary healthcare. The Iranian primary healthcare system has achieved many successes in community health promotion, but today, because of social, economic, political and environmental changes, it does not meet the needs of the people; therefore, this system requires structural reforms.

One of the important goals of Iran’s health transformation programme (HTP) is to improve financial protection for households against health expenditure. This study aimed to investigate the occurrence, intensity and inequality in distribution of catastrophic health expenditure (CHE) using the WHO and the World Bank (WB) methodologies with different thresholds in the years before and after HTP. We used data from seven annual national repeated cross-sectional surveys on households’ income and expenditures from 2011 to 2017. The intensity to CHE was calculated using overshoot and mean positive overshoot (MPO) indices. Finally, the inequality in distribution of exposure to CHE was calculated using the concentration index (CI), and the dominance test of concentration curves was used to inference about the significant changes in inequality of the years before and after HTP. The exposure rate to CHE in the total population and at 40% threshold of the WHO methodology changed from 1.99% in 2011 to 3.46% in 2017. Additionally, at 20% threshold of the WB methodology, it was changed from 5.14% to 8.68%. Overshoot and MPO indices increased on average based on two methodologies in urban and rural areas during seven years. The CIs for all the years show a negative value in both methodologies, indicating that CHE occurrence is higher among the poor households. In 2017, at 40% threshold of the WHO, the numerical values of the CIs were −0.15 and −0.14 in urban and rural populations, respectively. These values were −0.07 and −0.05 for the 20% threshold of WB, respectively. Results of dominance test showed no significant change in inequality for the years after than before HTP with two exceptions for total and rural populations based on the WB methodology. Generally, HTP had no considerable success in financial protection, requiring a review in actions to support pro-poor adaptation strategies.

Population health is influenced by many factors beyond the control of health system which should be addressed by other sectors through inter-sectoral collaboration (ISC). Countries have adopted diverse initiatives to operationalize ISC for health such as establishment of Councils of Health and Food Security (CHFSs) and development of provincial Health Master Plans (HMPs) in Iran. The literature, however, provides meager information on how these initiatives have been moved into the top policy agenda, how and by whom they have been formulated and what factors enable or inhibit their implementation. In addressing these knowledge gaps, we employed a qualitative case study approach, incorporating mixed methods: in-depth interviews and a textual analysis of policy documents. Iran founded the Supreme Council of Health and Food Security (SCHFS) at national level in 2006 followed by provincial and district CHFSs to ensure political commitment to ISC for health and Health in All Policies (HiAPs). In 2009, the SCHFS mandated all provincial CHFSs across the country to develop provincial HMP to operationalize the HiAP approach and Kerman was among the first provinces which responded to this call. We selected Kerman province HMP as a case study to investigate the research questions raised in this study. The study revealed two types of leverage, which played crucial role in agenda setting, policy formulation and implementation of HMP including politics (political commitment) and policy entrepreneurs. The multiple streams model was found to be informative for thinking about different stages of a policy cycle including agenda setting, policy formulation and policy implementation. It was also found to be a useful framework in analyzing HiAP initiatives as these policies do not smoothly and readily reach the policy agenda.