In the name of God the compassionate and the merciful

Center for Health Network Expansion & Health Promotion

In the name of God the compassionate and the merciful


Decentralization of Health System in Islamic Republic of Iran

By

Mohammadreza Rahbar

MD- [email protected]


Outlines

Definitions Evidences for the necessity of action

Indicators

Experiences and Analysis 5 Projects

Lessons should be learnt


Decentralization

Decentralization is the process of dispersing decision-making closer to the point of service or action.


Federalism and Decentralisation:

Federalism is often accompanied by decentralisation, but it is not a necessary condition for decentralisation, nor is decentralisation a sufficient condition for federalism.


Decentralisation and Development

• Decentralized governance, if properly planned and implemented, offers important opportunities for enhanced human development.


Degrees and Types of Decentralisation by Region

0%20%40%60%80%

100%120%

Sub-SaharanAfrica

East Asiaand

Pacific

SouthAsia

EasternEurope

andCentral

Asia

WesternEurope

MiddleEast andNorthern

Africa

Americas

Fiscal Political None Both


Decentralization Purposes

Decentralization is a policy pursued for a variety of purposes: Political Administrative Financial.

Many health sector reforms include decentralization as a major component.


Objectives of Decentralization

Rationale Reasons

EfficacyLocal leaders are better informed about local

problems and can make better decisions

EquityLocal leaders can better target resources to

vulnerable groups

EfficiencyLocal leaders can make more efficient decisions

because they have better information about local conditions

QualityGreater accountability may lead local leaders to

improve quality

Financial Soundness

Local leaders may be more aware of tradeoffs and fiscal constraints.

Local Choice & Priorities

In democratic localities, decentralization can allow more local choice and priority setting


Areas of decentralization and range of authorities

Range of Choice

Functions Narrow Moderate Wide

FinanceSources of revenue &Allocation of ExpendituresHospital Fees

Service OrganizationRequired Programs Hospital AutonomyInsurance Plans Payment MechanismsContracts with PrivateProviders

Human ResourcesSalariesContractsCivil Service

Access RulesTargeting

Governance RulesLocal accountabilityFacility BoardsDistrict OfficesCommunity Participation

Mapping Decision making for Decentralization


“Decentralization” of the Iranian Health System - The Challengeable Road From Relative Central plans

to Decentralism

The ChallengeTransition from a relative bureaucratic centralized to a

functional decentralized system


Network Development Center and Health Promotion Technical OfficesTechnical OfficesM I N I S T R Y O F H E A L T H

CommunityNeedsNeeds

Demands Demands

Insurance Plans

Health Facilities / Providers

Resource Providers

Epidemiologic studies

Utilization Studies

Problem priority

EffectiveInterventions Developing

Resource AllocationBased on

Quality, EfficiencyEquity, Effectiveness

AndOthers

Considerations

Feasibility Study

Integration and

Stratification

New Program Designing

Functional areas in the Health System


Necessities for Decentralization in Iran

• Local leaders are better informed about local problems and available resources and can make better decisions in Different; • Community health status, • Health related risk factors,• Utilization,• Available resources,• Opportunities and threats and• Weaknesses and strengths


راهبردهاياقتصادي اجتماعيزيست ومحيط

سيگار

غذايي عادات

جنس ؛ سن وژنتيك

دات عاخواب

ك تحر

سواد

مناسباتجنسي

شرايط زندگي

مخدر مواد

تماسهاينسلي بين

و كشاورزيتغذيه

ترافيك

كار شرايط

الكل

و فرهنگتفريحات

هاي شبكه= اجتماعي خانواده

خدماتبهداشتي

هاي حمايتاجتماعي

اجتماعي رفاه

§ تامين اجتماعي

? بيكاري

Multifactorial complex effects of Health Determinants


Mortality &

Morbidity

Development Situation

Lit

erac

y

Social structure

capacities

Une

mpl

oym

ent

rat

e

State of welfare

Nut

ritio

n

Uti

liza

tion

Age

Pyramid

Rep

rodu

ctive b

ehaviors


0

2

4

6

8

10

12

14

" Zscoreمولفهموردمطالعه

عه

طالمرد

موعهاق

ويع

وزت

توزيع نا همگن در سمت صعودي مولفه توزيع نا همگن در سمت صعودي مولفهتوزيع نرمال با پراكندگي زيا د توزيع نرمال در حول ميانگين

Different kinds of distributions of events related to the health


Some evidences from surveys

For the necessity of decentralization


Standard

Crude

Crude and standardized registered cases for Non-Intentional accidents for rural and Urban areas for 29 provinces in 2003

for 100000 population


Standard

Crude

The crude and standardized death rate for cardiovascular disease for 29 provinces- 2004 in

100,000 people


Standard

Crude

The crude and standardized death rate for Infectious disease for 29 provinces- 2004in 100,000 people


Standard

Crude

The crude and standardized death rate for cancer of stomach for 29 provinces- 2004 in 100,000 people


Standard

Crude

The crude and standardized death rate for Diabetes for 29 provinces- 2004in 100,000 people


Standard

Crude

The crude and standardized death rate for Intentional accidents for 29 provinces- 2004 in 100,000 people


The crude and standardized death rate registered for Traffic accidents for 29 provinces- 2004 in 100,000 people

Standard

Crude


مراقبت تحت كه سال شش زير دكان كو از نسبتي ( ) گفته) به دارند قرار وورن قد گيري اندازه بهداشتي

سال ( پاييز وروستا شهر تفكيك به مطالعه 1383مادر2انيس

94

91

94

82

74

79

85

77

82

70

65

91

57

84

78

66

76

74

64

77

82

86

77

74

72

79

65

69

65 65

50

60

70

80

90

100

نسمنا

ي

ارتيخلب

حارم

هاچ

هرش

وب

نصفها

ا

قم زدي

نستا

ردك

نمدا

ه

لدبي

را

ندرا

زنما

سراف

نجا

زن

ي

غربن

جااي

ربذ

آ

يكز

رم

ناستگل

الماي

يشرق

نجا

ايربذ

آ

نسا

خرا

)

شدهون

وزم

( ورش

ك

نال

گي

هشاانرمك

نرما

ك

نزوي

ق

يمد

حرا

ويوب

هلوي

هكيك

ناستر

ل

نستا

وزخ

ن

اچست

لونوب

استسي

نهرا

جزتن

هرانت

ستاا

نگامزهر

نهرا

تشهر

روستاشهر

Rural

Urban

The proportion of the children under 6 who utilized by growth monitoring services (assessments of weight and

height) according to the mother's statement in rural and urban areas in 2003- ANIS survey


يي آنها رشد كارت در رشد منحني ترسيم وضعيتاستان تفكيك به بود شده آنهامشاهده كارت كه

سال انيس 1383پاييز 2مطالعه

0

10

20

30

40

50

60

70

ل حارم

چها

لدبي

را

نسمنا

هرش

وب

زدي

سراف

نستا

ردك

نجا

زن قم

نگامزهر

نصفها

ا

يكز

رم

ندرا

زنما

نزوي

ق

الماي

يشرق

ذرآ

نسا

خرا

ورش

ك

نرما

ك

ي

غربذر

آ

هشاانكرم

نمدا

ه

نستا

رل

نال

گي

ه لوي

هكيك

نستا

گل

نهرا

نتستا

ا

نستا

وزخ

ن

هراتشهر

بون

ستاسي

منحنيرشدكاملترسيمشده قطعترسيمشده يكيدو منحنيرشدبا شدهترسيمشده تكه منحنيرشدناقصوتكه است شده حنيرشدترسيمن Completely drawnمن Relatively complete drawn Incomplete drawn Have not drawn

The situation of drawing growth monitoring chart for those who had checked for it

in 2003- ANIS survey


اي تغذيه قدي ه كوتا Z برحسب ( STUNTING )توزيعScore سن براي قد اقليم ) ( HAZ ) ؛ دو اقليم سه براي

) پورا مطالعه در اقليم بهترين و طيف انتهايبهار) ( ايران مغذيهاي ريز دروضعيت پژوهشي

كودكان , 1380 سني هه 23تا 15گروه ما

0

5

10

15

20

25

-4.25 -3.75 -3.25 -2.75 -2.25 -1.75 -1.25 -0.75 -0.25 0.25 0.75 1.25 1.75 2.25 2.75 3.25 3.75 4.25

انحرافمعيار

صد

در

استاندارد دران گيالنومازنجنوبخراسانوجنوبكرمانوسيستانوبلوچستان ان بوشهروهرمزگانوجنوبخوزست

Distribution of Stunting for 15 to 23 months children due to nutrition according to Z Score of Height for age (HAZ)

for 3 different climate regions Micronutrients Survey- Spring 2000

Read line= Standard


اي تغذيه قدي ه كوتا قد Z Score برحسب ( STUNTING )توزيع ؛سن و ) ( HAZ ) براي طيف انتهاي اقليم دو اقليم سه براي

( ) ريز دروضعيت پژوهشي پورا مطالعه ؛ اقليم بهترينبهار ( ايران كودكان , 1380مغذيهاي سني ساله6گروه

0

5

10

15

20

25

-4.25 -3.75 -3.25 -2.75 -2.25 -1.75 -1.25 -0.75 -0.25 0.25 0.75 1.25 1.75 2.25 2.75 3.25 3.75 4.25

انحرافمعيار

صد

در

استاندارد دران گيالنومازنجنوبخراسانوجنوبكرمانوسيستانوبلوچستان ان بوشهروهرمزگانوجنوبخوزست

Distribution of Stunting for 6 yrs children due to nutrition according to Z Score of Height for age (HAZ) for 3 different climate

regions Micronutrients Survey- Spring 2000

Read line= Standard


وزني كم ؛ Z Score برحسب ( UNDERWEIGHT )توزيعسن براي اقليم ) (WAZ ) وزن سه اقليم چهار براي

) پورا مطالعه در اقليم بهترين و طيف انتهايبهار) ( ايران مغذيهاي ريز دروضعيت پژوهشي

كودكان , 1380 سني هه 23تا 15گروه ما

0

5

10

15

20

25

-4.25 -3.75 -3.25 -2.75 -2.25 -1.75 -1.25 -0.75 -0.25 0.25 0.75 1.25 1.75 2.25 2.75 3.25 3.75 4.25انحرافمعيار

صددر

استاندارد جنوبخراسانوجنوبكرمانوسيستانوبلوچستان ان فارسومركزكرم ان بوشهروهرمزگانوجنوبخوزست

دران گيالنومازن

Distribution of Underweight for 15 to 23 months children due to nutrition according to Z Score of Height for age (HAZ) for 3

different climate regions Micronutrients Survey- Spring 2000

Read line= Standard


0.1

.2.3

.4.5

.6D

ensi

ty

-1 0 1 2 3 4Permanent income

Iran DHS 2000

Permanent income Province17

0.1

.2.3

.4.5

.6D

ensi

ty


Iran DHS 2000

Permanent income Province12 ايالم استان خانواردر رفاهي امكانات وبلوچستان توزيع سيستان استان خانواردر رفاهي امكانات توزيع

0.1

.2.3

.4.5

.6D

ensi

ty


Iran DHS 2000

Permanent income Province29Permanent Income City of Tehran

0.1

.2.3

.4.5

.6D

ensi

ty


Iran DHS 2000

Permanent income Province11Permanent Income Isfahan Province

Permanent Income Sistan & Baloochestan Province

Permanent Income Ilam Province


زايمان درصد براي ؛ كشور مختلف استانهاي بين واريانسپوشش ) تحت روستايي جمعيت در نديده دوره فرد توسط

مختلف ( سالهاي تفكيك به بهداشت هاي خانه

103.8

128.2

159.5175.9

212.1226.6

261.9

321.3

354.0

193.3

0

50

100

150

200

250

300

350

400

82818079787776757472سال

سان

اريو

Variation among different provinces for the percentage of deliveries have been done by non-trained attendants for the rural areas being

covered by the Health houses in different years

Year

Variation


كود مرگ ميزان براي ؛ كشور مختلف استانهاي بين واريانستا يك هاي ) 59كان خانه پوشش تحت روستايي جمعيت در ماه

مختلف ( سالهاي تفكيك به بهداشت

41.0

13.516.7

21.118.2

45.1

39.137.6

58.6

82.9

25.5

0

10

20

30

40

50

60

70

80

90

8281807978777675747372 سال

سيان

ارو

Year

Variation

Variation among different provinces for the 1- 59 months mortality for the rural areas being covered by the Health houses in different

years


سال در سال پنج زير كودكان مرگ در 1382ميزانكشور بهداشت هاي خانه پوشش تحت روستايي مناطق

55

41

37

33 32 3231 30 30 30 30 29 29 28 28 27 27 26 26

25 24 24 24 24 22 22

18

14

11

0.0

10.0

20.0

30.0

40.0

50.0

60.0

نماكر

نستا

وچبل

ون

ستاسي

نستا

لر

نستا

ردك

نگامز

هر

نسا

راخ

نستا

گل

مدحرا

ويوب

يهلو

گيكه

شاهمان

كر ورش

لکک

ي

ربغن

جابأي

ذرآ

نستا

وزخ

هرش

بو

لدبي

ار

نمدا

ه

يرق

شن

جابأي

ذرآ

سفار

يارختي

وبل

حارم

هاچ

نفها

صا

نويقز

نجا

زن

يکز

مر

نالگي

نمناس زدي

المأي

ندرا

زنما

نراهت

قم

صددر

Under 5 Mortality Rate for the rural areas being covered by the Health houses in 2001


مرگ ميزان براي ؛ كشور مختلف استانهاي بين واريانسهاي ) خانه پوشش تحت روستايي جمعيت در نوزادان

مختلف ( سالهاي تفكيك به بهداشت

13.8

12.4

10.7

12.3

11.2

15.8

9.6

5.6

9.2

6.9

11.0

0

2

4

6

8

10

12

14

16

18

8281807978777675747372 سال

سيان

ارو

Variation among different provinces for Neonatal Mortality Rate for the rural areas being covered by the Health houses in different years

Year

Variation


تا يك كودكان مرگ سال 59ميزان در 1382ماههاي خانه پوشش تحت روستايي مناطق در

كشور بهداشت

40

23

14 13 13 13 13 13 12 12 12 12 11 11 11 10 10 10 10 10 10 9 9 8 8 7 7 63

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

نرما

ك

نستا

وچبل

نوستا

سي

نسا

خرا

نستا

وزخ

ي

ربغن

جابأي

ذرآ

ورش

لکک

نستا

لر

شاهمان

كر

مداح

يربو

ويه

لوگي

كه

نستا

گل

نزگا

رمه

سفار

يرق

شن

جابأي

ذرآ

لدبي

ار

يکز

مر

نمدا

ه

يار

ختيوب

لحارم

هاچ

نستا

ردك

المأي

زدي

نمناس

هرش

بو

نفها

صا

نجا

زن

نويقز

ندرا

زنما

نالگي

نهرا

ت

قم

صددر

1- 59 months Mortality Rate for the rural areas being covered by the Health houses in 2001


y = 0.42 x + 1.01

R2 = 0.53

5

10

15

20

25

30

35

40

10 20 30 40 50 60% نسبتبيسوادي

1000

دراه

م59

تان 1

كاود

كگ

مرت

سبن

ر بها چا

كودكان مرگ نسبت خطي نسبت 59تا 1ارتباط با ماهروستايي مناطق در در 281بيسوادي كشور شهرستان

در- 1381و1380و1379سالهاي شده ثبت اطالعات اساس برومطالعه بهداشت هاي خانه حياتي DHSزيج

شميران ات

نابرابري شاخص بهترين ) ( است بتا خط زوايه ضريب

Vagstaf:2005

Linear relation between 1- 59 months Mortality to Mother's literacy rate in 281 districts between 2000- 2002 according to data on the

Vital Horoscopes in the Health Houses and DHS Surveys

The Literacy Rate

1-5

9 m

on

ths m

orta

lity rate

Inequity IndexVagstaf:2005


the distribution of percentages of 9 causes of deaths in men by age groups after correcting the garbage codes ,according to

mortality registration among 18 provinces in 2002

CANCERS

CARDIOVASCULAR.D

RESPIRATORY.D

UNINTENTIONAL.ACC

VIOLANC

SUICIDE

OTHERS

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95

سن

صددر

OTHERS

SUICIDE

VIOLANC

UNINTENTIONAL.ACC

PERNETAL .D

RESPIRATORY.D

CARDIOVASCULAR.D

CANCERS

INFECTION .D


The distribution of 9 causes of years life lost in women by separation of age groups after correcting the garbage codes in death registry program between

18 provinces in 2002

CANCERS

CARDIOVASCULAR.D

UNINTENTIONAL.ACC

SUICIDE

OTHERS

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95

age

pe

rce

nta

ge

OTHERS

SUICIDE

VIOLANC

UNINTENTIONAL.ACCPERNETAL .D

RESPIRATORY.DCARDIOVASCULAR.DCANCERS

INFECTION .D


كم تولدنوزادان وقوع بر موثر عوامل از هريك سهمدر - وزن كم نوزاد تولد شيوع تعيين مطالعه 11وزن

مهر -- كشور 1382اقليم

4.9%

1.7%

0.7%

0.5%

47.9%28.0%

21.4%

-1.2%

-1.8%

-2.3%

-3% 7% 17% 27% 37% 47%

ر نوا رفاهي خا وضعيت

وستا سكونت در شهر يا ر

در بيسوادي ما

در آن سكونت دارد اقليمي كه

يراني يا افغاني بودن ا

وقلويي د

د سن مادر در در هنگام تولدنوزا

اد جنس نوز

ري طول باردا

ولد وبت ت ن

The proportional effect of different health determinants on underweight neonates delivery-

The Survey done for prevalence of Underweight neonate deliveries in 11 different regions- Autumn 2003

Birth order

Duration of pregnancy

Sex of neonate

Mother's age

Twin birth

Iranian or Afghani

The area of living

Mother's literacy

Living in Urban or Rural area

Household income


0.2

5.5

.75

1

Cum

ula

tive p

erc

ent of death

due to s

avaneh

0 .25 .5 .75 1Cumulative percent of dead people ranked by economic status

خطر معنادار تمركزجامعه مرفه غير دربخش

Obs Prob>z (95%) CI5498 0. 0.0281 [-0.1281 -0.0072]

قبال در عمدي غير حوادث از ناشي مرگ توزيعمرگ – ثبت برنامه مشترك كار خانوار رفاه سطح

سال در برابري نا ومطالعه علت 1382برحسب

Distribution of deaths due to Non-Intentional accidents in relation to household income-

The cooperative work of death registration system and inequity survey- 2003

Meaningful concentration for the high income households


از ناشي مرگ رفاه خودكشيتوزيع سطح قبال درعلت –خانوار برحسب مرگ ثبت برنامه مشترك كار

سال در برابري نا 1382 ومطالعه

0.2

5.5

.75

1

Cum

ula

tive p

erc

ent of death

due to s

uic

ide


خطر معنادار تمركزجامعه مرفه غير دربخش

Obs Prob>z )95%( CI5498 0.002 [-0.2072 -0.0469]

Meaningful concentration for the low income households

Distribution of deaths due to suicide in relation to household income-



0.2

5.5

.75

1

Cum

ula

tive p

erc

ent of death

due to c

ancer


خطر معنادار تمركزجامعه مرفه دربخش

Obs Prob>z )95%( CI5498 0.0007 [0.037 0.137]

رفاه سطح قبال در طانها سر از ناشي مرگ توزيععلت – برحسب مرگ ثبت برنامه مشترك كار خانوار

سال در برابري نا 1382ومطالعه

Distribution of deaths due to malignancies in relation to household income-




سرپايي خدمات از مندي بهره توزيعمطالعه – خانوار رفاه سطح قبال در

اسفند مندي 1381بهره

0.2

5.5

.75

1

Cum

ula

tive p

erc

ent of seekin

g_outp

atient_

care

0 .25 .5 .75 1Cumulative percent of people ranked by economic status

N=26750 CCI = .062248 P=0.0000 CI-CCI [0.0464 0.0781]

مندي بهره معنادار تمركزجامعه مرفه دربخش


Distribution of utilization from health services in relation to household income-

Utilization survey- 2002


0.2

5.5

.75

1C

um

ula

tive p

erc

ent of choic

e


N=2413 CCI = 0.015196 P=0.0000 CI-CCI [0.0095 0.0209]

توزيع بهره مندي از حق انتخاب به مراجعه سرپايي در قبال سطح رفاه خانوار كنندگان

1381– مطالعه بهره مندي اسفند

انتخاب حق معنادار تمركزجامعه مرفه دربخش

Distribution of utilization for choosing health services provider for ambulatory care in relation to household income-




0.2

5.5

.75

1

Cum

ula

tive p

erc

ent of choic

e


به انتخاب حق از مندي بهره توزيعكنندگان سطح مراجعه قبال در بستري

اسفند – مندي بهره مطالعه خانوار رفاه1381

N=690 CCI = 0.028351 P=0.0005 CI-CCI [0.0123 0.0444]

انتخاب حق معنادار تمركزجامعه مرفه دربخش


Distribution of utilization for choosing health services provider for hospitalization in relation to household income-



خدمات دريافت براي شده انجام هزينه ميانگينهر توسط سال طول در سرپايي درماني بهداشتياز -- مندي بهره مطالعه هزينه نوع تفكيك به فرد

اسفند -- درماني بهداشتي 1381خدمات

2412 3319

65747335

1991

6635

7254

3097

3478

6607

909927426

1564

942

0

5000

10000

15000

20000

25000

30000

صي خشخصو ب تي خشدول ب صي خشدولتيوخصو ب

نوما

ت

هزينهدارو ل ووساي

هزينهاقدامات درماني

هزينهاقدامات شخيصي ت

/ هزينهويزيت / دريافتمستقيم نشيز فرا

رفتوآمد هزينه

تومان20280

تومان6680

تومان26510

Average expenses for receiving ambulatory health services in a year for a person for different type of expenditure


Drug and instruments

Curative interventions

Drug and instruments

Direct payments and user fees

Diagnostic tests

Going to the service unit and coming

backPrivate sector Governmental sector Both sectors

Exp

en

ditu

res


Providers

Service

Ambulatory care

Governmental

Private

Rates of services

34%31% 82%

3524,000 Billion

Tomans

8.4 times of visit per year

for every Iranian

0.061 times of hospitalization

for every Iranian

18% 66%69%

Hospitalization

Revenue from

health Market

ارائه در وخصوصي دولتي بخش سهم درصد نسبت مقايسهمستقيم وبطور دولتي منابع از پول دريافت وسهم خدماتبهرهمندي – مطالعه ايران سالمت بازار در مردم جيب از

اسفند -- درماني بهداشتي خدمات 1381از

The comparison of the ratio of the governmental and private sector in delivering services and revenue from governmental financing and

out of pocket payments by the people in the health marketUtilization survey- 2002


؛ ماهيانه درآمد بر باربستري يك هزينه پرداخت تاثيريا فرد شدن مقروض و دارايها فروش ؛ انداز پس

مطالعه - بيمارستان نوع تفكيك به خانوادهاسفند -- درماني بهداشتي خدمات از 1381بهرهمندي

5

55

23

3425

22

19

33

37

3026

8

15

13

16

35

12

21

12

21

6 3812 8

0%

20%

40%

60%

80%

100%

خصوصي ميناجتماعي ا ت بهداشتودرمان ه ب وابسته ) سازمانها ساير يا ساير)خيريه بيمارستاني هر

صددر

ناچيز يردرحدهيچيا تاث مصرفبيشاز 50%درآمدماهيانه ز دا آمدماهيانهومجبوربهمصرفپسان در ام مصرفتم ن بهقرضكرد ندازومجبور مامپسا مصرفتها ي روشدارا بهف قرضكردنمجبور عالوهبر

The effect of payments for one time of hospitalization on family wealth, savings, selling family resources and borrowing money for

the service payments Utilization survey- 2002

Every kind of hospitalOther (Charities and other organizations)

Ministry of healthSocial Security OrganizationPrivate

Paying more than 50% of monthly income

Paying more than all of monthly income and loan for it

Paying more which does not affect in the family

Paying more all monthly income and using the savings

Loan and selling properties for payment

Percent


نسبتي از

DALYsكهريك ه

از گروهها

كوچك يبيماري وآسيب دو درهربه جنس

خود اختصا

مي صبر ؛ دهند

پايه اطالعات

سال 1381

17

9

6

5

4

4

4

4

3

3

3

2

2

2

2

2

2

2

2

1

1

1

1

1

1

0 2 4 6 8 10 12 14 16 18

Traffic injuries

Ischemic Heart Diseases

Depressive disorders

Osteoarthritis

Diabetes mellitus

Cerebrovascular events

Falls

LBW&prematurity

Substance abuse

Other unintentional injuries

Infertility

Psychotic disorders

Rheumatoid arthritis

Asthma

Burns

Cataract

Self-inflicted intentional injuries

Epilepsy

Bipolar disorders

COPD

Leukemia

Iodine deficiency

Stomach cancer

Congenital heart diseases

Hypertention

DALYs for each

of the smaller disease

groups in 2 sexes – According to data

have been

gathered in 2002


The General Context Goals of the Health System

Health –technical efficiency of medical care in production of health Equity - (includes also efficiency considerations) Cost containment - technical efficiency of medical care in production of health

(and allocative efficiency in consumption of care) Micro-economic efficiency – technical efficiency in the production of quality care Client satisfaction, mainly through accountability

Systemic Functions --subject to devolution and decentralization: Policymaking Financing Organization and Management of Care Consumptions Provision of Care Training and medical education Research and development


Experience 1 -Current situation of PHC System

Analysis Iranian Governmental PHC Record and Legacy through a Relative Centralized system


Experience 1 -Current situation in disease prevention area ; Iranian Governmental PHC Record and Legacy

through a Relative Centralized System

Health Eradication of communicable diseases ‘Epidemiological transition’ to non-communicable diseases that

eventually led to superior health outcomes

Equity Relatively wide access to care

Efficiency In spite of low levels of spending, efficient especially when quality of

care is considered

Client satisfaction Relatively high


Comparative Decision Space: Current Ranges of Choice for Iran in Primary care

Functions Range of Choice

Narrow Moderate Wide

Sources of Revenue *

Expenditures*

Income from Fees*

Service Organization*

Required Programs & Norms *

Hospital Autonomy - -

Insurance Plans*

Payment Mechanisms*



Salaries*

Contracts*

Civil Service-

Access Rules*

Governance*

Local Government*

Facility Boards*

Health Offices*

Community Participation*

Total Decision Space:


Causes of Ineffective Government Functions in Preventive health programs

Not setting and maintaining the right priorities over time at local areas

Ineffective distribution in targeting of resources and lack of local resources

Not promoting innovation A lack of responsiveness to the new needs


Experience 2Construction Board of trustees in

universities

A relative successful experience


Comparative Decision Space




Expenditures*

Income from Fees*



Hospital Autonomy - -

Insurance Plans*

Payment Mechanisms*



Salaries*

Contracts*

Civil Service-

Access Rules*

Governance*

Local Government*

Facility Boards*

Health Offices*




Experience 3Hospital autonomy

A recommended plan but failed because of design and

implementation method





Financing*


Expenditures*

Income from Fees*



Insurance Plans

*Payment Mechanisms

*



Salaries*

Contracts*

Access Rules*

Governance*

Local Government*

Facility Boards*

Health Offices*

Community Participation

*Total Decision Space:


Causes of Ineffective Government Functions in Hospital autonomy

Not thinking about all aspects of decentralization especially in terms of; Utilization of people from different welfare status (Insurance coverage) Training Lack of allocating resource for medical education

Not think about evaluation and monitoring methodology Lack of advocacy in different areas


Consequences

Decrease equity Increase catastrophic payments Client dissatisfaction Loosing political support Making the plan insufficient


Social/Cultural Environment

Technological Environment

Futures Scenario

Development

Stakeholder Analysis

Political

Social/Cultural

Demography

Political/Regulatory

Environment

Economic Environment

Health Care

Environment

Response to External Change

Client Orientation

Innovation

Quality

Teamwork

LeadershipVision

/Mission

OrganizationalSubsystem

Resources

Competencies

Capabilities

Value-chainAnalysis

Organizational Objectives

Development

Critical Success Factor Identification

Vision Formulation

Mission Formulation

MeasurementEvaluation

Response

Objectives

Work with Steering

Team to Develop Program Strategies

Hospital Autonomy

)Unsuccessful Program(

Non consideredUncertain Considered


Experience 4Article 192

An obligatory rule in third national development law for privatization

The Pilot project was conducted in a few areas for only new expansions of health facilities






Expenditures*

Income from Fees*



Insurance Plans*

Payment Mechanisms*



Salaries*

Contracts*

Access Rules*

Governance*

Local Government*

Facility Boards*

Health Offices*




Experience 5Article 49

A new program for increasing authorities of peripheral management

areas in resource allocation


It is a new one-year designed plan according to the new tasks for resource managers based on changing the tasks of accountants

Needs conferring authorities to local managers


Lessons to be learnt Decentralization is like the story of elephant and blind men

Needs a holistic approach It is a scientific planning

Needs methodology All the stakeholders should be engaged in the planning

Bringing stakeholders together to define priorities for projects and programmes increases interest and sense of ownership, which in turn promotes sustainability.

Supporting open dialogue and participation between the local government and civil society can ensure improved self-reliance.

Not all government functions should be entirely decentralised. Decision area is the most important consideration We should consider the risks of political pressures and unilateral

considerations It shouldn't make weakening stewardship ,policy making and leadership of

the headquarter of MOH Some unpredictable events needs centralized financing Decentralization is not the goal we should avoid undesirable

decentralization without health impacts


Lessons to be learnt- Cont’d

The authorities should be transferred to the most eligible level of system

A centralized and stratified HIS is needed for monitoring and evaluation of the projects

Strategy of change in sequence of time should be clear to policymakers, program planners and local authorities

Resistance of those authorities to relinquish should be thought The plan for ‘denationalization’ should be a real one for all the

experts Technical assistance is needed for local governments More capacity development is needed at all levels of

governance.


Lessons to be learnt - Cont’d – Risks

Consider Growing regional inequalities Undermining universal access to care Not having mechanisms for system stabilization and long term reform

through innovation Growing inefficiencies due to weak mechanisms to deal with

externalities Not re-defining the roles of different levels of government and

institutions Provide financial and regulatory measures for a federal system


Priority setting according to

BOD & Burden of Risk Factors

CEA and Choosing the most

appropriate strategies

Policy making tools:

Conduct resources and

plan

Efficient Performance

Modeling Tactical DecisionsBurden of disease- Cost-effectiveness analysis-

Health performance


CustomerHealth Unit

•BURDEN OF DISEASE•COST•QUALITY•EQUITY•TIME•FLEXIBILITY• MARKET ANALYSIS

Tact

ical

Deci

sions

Policies and

strategies

resultsresults

ProcessOf Design Service Package

Poli

cym

akin

g

Design

standards for

IntegrationStratificati

onEvaluationCoverage

Tech

nic

al

Deci

sion

s

Policy making, Program planningAnd delivering services

Service Packages


Thank you for your

attention

In the name of God the compassionate and the merciful

Documents

types of decentralisation

state of decentralisation

system of governance

institutions of governance

undp decentralised governance

system of coresponsibility

decentralised countries

local levels