Demographic characteristics of participants in the study are shown in
Table 1. Demographic Characteristics of Participants in the Study
Demographic Characteristics Operational and Field Managers Healthcare Providers Clients Age (y) 27 - 53 (35.46 ± 4.33) 23 - 49 (28.16 ± 4.23) 18 - 64 (37.80 ± 7.45) Gender Male 10 17 3 Female 12 101 12 Education MD 1 11 2 MSc 9 16 8 BSc 12 91 5 Vocation field Family health and population 6 Schools and oral health 2 Prevention of disease 4 Health education and development 2 Psychological health 2 Nutritional health 1 Professional health 2 Environmental health 3 13 Midwifery 34 Health education (female) 21 Health education (male) 5 Psychology 21 Nutrition 13 General medicine 7 Dentistry 4 Student 1 Retired 1 Employee 2 Self-employment 2 House keeper 9 Duration of employment (y) 7 - 28 (18.33 ± 3.49) 1 - 23 (9.52 ± 3.76) - Total 22 118 15
Abbreviations: BSc, Bachelor of Science; MD, Medicine Doctor; MSc, Master of Science.
Qualitative data after analysis were categorized into 328 codes, 19 subcategories and 7 main categories, which are shown in Box 1.
Box 1. Iranian Health Reform Advantages in the Health Care System from the View of Managers, Health Care Providers, and Clients
Main Categories and Subcategories Improvement of general health Early diagnosis and treatment of the diseases Patients’ follow-up Promoting healthy lifestyle Prioritizing health and prevention Improvement of equity in the health system Facilitating access to health services Decreased costs of health services for population Improvement of health literacy Increased health knowledge and sensitivity Development of self-care Culturalize the referral system Providing comprehensive health services Completion and development of health service packages Care for all members of the family Providing individual-oriented health services Providing comprehensive care for the clients Providing care by the constant caregiver Increased general satisfaction Good interaction by health care providers Improvement of the physical environment of health centers Developing employment opportunities for the graduates of medical sciences Providing electronic medical records Facilitating access to health statistics Eliminating paper documents Easy access to medical records
From the viewpoint of the participants in the present study, Iranian health reform advantages in the field of health care system were improvement of general health, improvement of equity in the health system, improvement of health literacy, providing comprehensive health services, providing personalized health services, increased general satisfaction, and providing electronic health records. These categories are explained below:
3.1. Improvement of General Health
From the participants’ viewpoint, the Health Reform Plan has led to improvement of general health due to the fact that issues, such as early diagnosis and treatment of diseases, patients’ follow-up, promotion of healthy lifestyle, and prioritizing health prevention have been regarded in this plan.
3.1.1. Early Diagnosis and Treatment of Diseases
Participants stated that providing services for early diagnosis of risk factors of chronic and non-contagious diseases, especially cardiovascular diseases (lifestyle and high risk habits), and referring high risk individuals to specialists and counselors; complete and comprehensive evaluation of the target population’ history and providing in-time services for preventing and controlling non-contagious diseases; screening; risk assessment and early diagnosis of diabetes, hypertension, HIV; eye examination for teenagers; in-time treatment using diets and exercises; and mental health improvement have been helpful in preventing an increase in the number of patients and also preventing patients from reaching an uncontrollable point in their disease; its effect would become more clear in the future on the decrease in the statistics of chronic diseases, especially cardiovascular diseases.
“During this period, we have diagnosed two cases of breast cancer and one case of positive tuberculosis.”
Follow up patients’ problems until achieving the desired outcome was another result of the Health Reform Plan that health care providers and patients mentioned.
“Follow up patient until reaching the desired result and warning people about diseases and common health concerns of the society such as nutrition, physical activity, the increased rate of cardiovascular diseases and diabetes, and smoking, could be very beneficial.”
3.1.3. Promoting Healthy Lifestyle
Another outcome of the Health Reform Plan was addressing the issue of a healthy lifestyle and promoting healthy behaviors among people including a healthy diet (lowering the consumption of salt, sugar, and fat), regular physical activity, and sensitizing people to the health of consumed food, overweight, inactivity….
“Another positive point is determining the health problems of the family such as incorrect diet, which is sometimes not related to the economic condition of the family, as well as inactivity, obesity…”
3.1.4. Prioritizing Health Against Treatment
Overall, addressing the mentioned issues, especially early diagnosis and treatment of the diseases and promoting a healthy lifestyle are the signs of prioritizing prevention and health by the health system in the Health Reform Plan; the outcome would be a decreased burden of the diseases and treatments’ costs.
“Considering that economic and cultural poverty could be disposing factors for disease spread, providing free services could encourage people with lower economic status to pay attention to their health and nutritional issues.”
3.2. Improvement of Equity in the Health System
The Health Reform Plan has led to improvement of equity in the health system by facilitating access to health services and decreasing the costs of health for population, on the viewpoints of participants.
3.2.1. Facilitating Access to Health Services
Some of the outcomes of the Health Reform Plan are increased number of health centers and health care providers, decreased distance, and easy access to health services for everyone from all ages and genders in any part of the city.
“Before the Health Reform Plan, there were about 55 health centers in Qom, however, now, there are about 120 centers. It means that the number of centers has increased by 2.5 times and consequently, the access has increase by the same rate.”
3.2.2. Decreased Costs of Health Services for Population
The Health Reform Plan has decreased client’s payments by providing free health services and protected them against the costs of health services. Since the provided services are health-related and preventive, not only would it decrease the economic and financial burden of the general population, but also it is expected that in the long-term it would decrease the government’s economic burden and costs in the field of treatment. On the other hand providing free services would create an opportunity for all the groups of the society to access health services, which would be helpful in accessibility and equity in the health system.
“Free services would be provided for low-income people that would improve their health level; it would somehow help achieve health equity in the society.”
3.3. Improvement of Health Literacy
From the participants’ viewpoint, other outcomes of the Health Reform Plan were increased health knowledge and sensitivity, development of self-care and culturalizing the referral system, which have been achieved through health education. Emphasizing on face-to-face education, distributing educational pamphlets, conducting educational classes, and educating health ambassadors are some of the activities conducted by the health system to promote public education and improve the level of health knowledge among the general population.
3.3.1. Increased Health Knowledge and Sensitivity
Questions that would be asked from the clients about their lifestyle and consequently, provided personal or group health educations for the clients would increase people’s awareness and sensitivity toward health issues. On the other hand, advantaging from health follow-ups and constant education is hoped that these could lead to changes in behaviors and improvement of health among the clients.
“The Health Reform Plan has increased awareness and encouraged people to have a healthy lifestyle; it had a good effect on them. Participating in weekly classes at the center and classes for the health ambassadors has increased people’s awareness about health and care.”
3.3.2. Development of Self-Care
Participants in the present study believed that the provided educations and follow-ups by the Health Reform Plan have encouraged people to participate in their own health and developed self-care.
“People’s awareness about themselves has increased due to the comprehensive questions that they would be asked.”
3.3.3. Culturalizing the Referral System
Another mission of the health system is creating a referral system in the health system and institutionalizing it among the population and specialists. Since the health system provided its services at the first level of healthcare, it is sometimes necessary to refer the patients to the second or third levels of healthcare. Respecting this hierarchy in the health system would strengthen the referral system among the patients and the physicians. From the participants’ viewpoint, respecting the referral system would decrease the workload and financial burden at the second and third levels of healthcare.
“They referred me to the physicians that I needed. For example I had Arthritis; they referred me to a doctor.”
3.4. Providing Comprehensive Healthcare
Completing and developing health service packages and care for all the members of the family, have made it possible to provide comprehensive healthcare for all the clients; therefore, no one, due to their gender, age, or ethnicity, would be deprived from healthcare.
3.4.1. Completing and Developing of Health Service Packages
Health system planners have made their efforts to gradually place most of the health care as health packages into the health care system; this process is still continuing and these services are spreading out more and more. For example the addition health service packages such as psychological health, encountering disasters, self-care, specific groups, adolescent, middle aged and elderly care, and screening for chronic diseases, could be mentioned.
“Before the Health Reform Plan we did not have a nutritionist and psychiatrist in our center. The programs that have been added into the health services after the Health Reform Plan, such as encountering disasters and self-care did not exist before.”
3.4.2. Providing Care for All the Members of the Family
Health cares and service packages in the Health Reform Plan include a wide range of services that could cover the health of all the members of the family. Since the medical file of each family would be assigned to one caregiver and also, the health of each family member has a close relation with the health of others, it is hoped that this type of caregiving would have a positive impact on improvement the individual’s, family’s, and society’s health. This type of care would also provide a more accurate understanding and awareness for the caregiver regarding all the aspects of the family and caregiver’s closer relationship with the family so they could more effectively plan and intervene for the health of the family members. One of the strengths of the Health Reform Plan is addressing men’s health, which has been ignored in the past. Also, the services of the Health Reform Plan have been designed in a way that could cover the health of every family member from infant to the elderly.
“The person in charge of a family’s health could definitely not evaluate the mother’s health without considering the father’s condition; they could also not evaluate the child’s health without regarding the mother’s health. Well, this was a good event.”
3.5. Providing Individual-Oriented Health Services
Unlike the previous health system, which was service-oriented, the current health system is individual-oriented, meaning that it emphasizes in providing care for each client by the constant caregiver.
3.5.1. Providing Comprehensive Care for the Clients
Health services in the Health Reform Plan are emphasizing on the importance and evaluation of every aspects of health in individuals.
“Evaluating all the aspects of health in the individual like lifestyle, nutrition, and mental and psychological aspects.”
3.5.2. Providing Care by the Constant Caregiver
In the Health Reform Plan, caring for same patients would assigned to the same defined health care providers. This caregiver is responsible for providing care for their assigned clients.
“Before the Health Reform Plan, our colleagues working at the center were responsible for one program. One of them would provide care for the mothers and another for the children; however, after the Health Reform Plan, we divided the individuals between the personnel. For instance, instead of of assigning one task such as providing care for mothers to one personnel, we assigned about 2000 clients to one personnel and made them responsible for their health.”
3.6. Increased General Satisfaction
Good interaction by health care providers, improvement of the physical environment of health centers, and developing employment opportunities for the graduates of medical sciences were some of the issues that participants were satisfied with.
3.6.1. Good Interaction by Health Care Providers
Patients who participated in the present study expressed their satisfaction with the behaviors of health care providers at health care centers and mentioned that they have appropriately been greeted and spoken to, their questions have been answered, and their expectations have been fulfilled.
“The fact that they would listen to the patient, for example if you have a medical file, they would come, act appropriately, are not in a hurry, and would not send you out in a rush are all positive points. They completely listen to you and guide you. If you have a question, they would answer it. It really is good from this aspect, I approve it.”
3.6.2. Improvement of the Physical Environment of Health Centers
Some of the participants mentioned that the physical environment of the health care centers have been repaired and expressed their satisfaction with the cleanness and beauty of the health centers.
3.6.3. Developing Employment Opportunities for the Graduates of Medical Sciences
Considering the need of the health system to increase the number of care providers to achieve the goals of the Health Reform Plan and to increase the coverage of health care services, many graduates of medical sciences have been absorbed and employed.
“Creating jobs and employing a number of experts and specialists of the sub-branches of medical sciences”
3.7. Providing Electronic Medical Records
Creating electronic medical files that were performed simultaneously with implementation of the Health Reform Plan had advantages such as easy access to health statistics, eliminating paper documents, and facilitating access to medical records.
3.7.1. Facilitating Access to Health Statistics
Recording clients’ information in electronic files have provided the opportunity to easily extract health-related statistics at the time of need for determining the health condition and health issues in the society. Therefore, to achieve the statistics, it would not be necessary to count the existing information in the files and notes and fill the paper tables.
“Achieving an accurate statistic of the patients including metabolic diseases and contagious and non-contagious diseases”.
3.7.2. Eliminating Paper Documents
Eliminating paper profiles, reducing paper consumption, and not needing to provide a physical space for archiving paper profiles are some of the advantages of creating electronic medical records.
“The electronic process of the work and elimination of paper is great. Recording the services in various forms and notebooks were really time-consuming; in addition, paper files did not have the stability and would be destroyed.”
3.7.3. Easy Access to Medical Records
By electronically recording the health information of the patients, health care providers could access the necessary information as classified by category.
“The possibility of simultaneous access of all the service providers including the caregiver, the nutritionist, the psychologist, and physician to patient’s information and accurate history of diseases and examinations”