Fail to prepare and you can prepare to fail: the experience of financing path changes in teaching hospitals in Iran

Abstract

BackgroundIn 1995, teaching and public hospitals that are affiliated with the ministry of health and medical education (MOHME) in Iran were granted financial self-sufficiency to practice contract-based relations with insurance organizations. The so-called “hospital autonomy” policy involved giving authority to the insurance organizations to purchase health services. The policy aimed at improving hospitals’ performance, hoping to reduce government’s costs. However, the policy was never implemented as intended. This was because most participating hospitals gave up to implement autonomous financing and took other financing pathways. This paper analyses the reasons for the gap between the intended policy and its execution. The lessons learned from this analysis can inform, we envisage, the implementation of similar initiatives in other settings.MethodsWe conducted semi-structured interviews with 28 national and 13 regional health policy experts. We also gathered a comprehensive and purposeful set of related documents and analyzed their content. The qualitative data were analyzed by thematic inductive-deductive approach.ResultsWe found a number of prerequisites and requirements that were not prepared prior to the implementing hospital autonomy policy and categorized them into policy content (sources of funds for the policy), implementation context (organization of insurance organizations, medical tariffs, hospitals’ organization, feasibility of policy implementation, actors and stakeholders’ support), and implementation approach (implementation method, blanket approach to the implementation and timing of implementation). These characteristics resulted in unsuitable platform for policy implementation and eventually led to policy failure.ConclusionsAutonomy of teaching hospitals and their exclusive financing through insurance organizations did not achieve the desired goals of purchaser-provider split in Iran. Unless contextual preparations are in place, hospital autonomy will not succeed and problematic financial relations between service providers and patients in autonomous hospitals may not be ceased as a result.

Setting Health Care Services Tariffs in Iran: Half a Century Quest for a Window of Opportunity

“…However, the gap in tariffs for public and private services fluctuated and was not consistent. As noted earlier, since 1995, by approving MSIA and implementing hospital autonomy policy in Iran, tariffs were set to be revised annually and there was an attempt to align them with the inflation rate [35]. From 1995 to 2018, tariffs increased for all types of services to match the inflation rate ( Figure 3).…”

“…The line-item budgets include salaries for physicians and other staff, as well as medical equipment, based on the national salary grid. FFS payments are linked to the national medical tariffs (hereafter, the tariffs) for the health care services that each physician provides and are used as an incentive for further provision of care in public hospitals [35].…”

Setting Health Care Services Tariffs in Iran: Half a Century Quest for a Window of Opportunity

“…The line-item budgets include salaries for physicians and other staff, as well as medical equipment, based on the national salary grid. FFS payments are linked to the national medical tariffs (hereafter, the tariffs) for the health care services that each physician provides and are used as an incentive for further provision of care in public hospitals [21]. Private hospitals revenues are almost entirely based on these tariffs, paid as FFS to the hospitals by the MOHME.…”

Outsourcing in Iranian hospitals: Findings from a qualitative study

“…At the national level, all decisions about goals, policies, and resource allocations are made by the MOHME, according to the information of Ministry of Welfare and Social Security and other key stakeholders of the health system. At the provincial level, universities of medical sciences are responsible for providing health care services, monitoring the private sector activities, as well as education and research in health sciences …”

“…Special revenue funds are distributed among hospital personnel as fee for service after the costs of medicines and supplies being subtracted. The funds for construction and purchase of medical equipment are provided from separate sources after confirmation by the authorities of the universities of medical sciences …”