Iran Health System: Achieving Equitable Health

1. In the Name of God Iran Health Syttem : Ways to equitable healh Equity, Quality Efficiency Family Physician Referral System Dr Kambiz onazzam Dec - 2006

2. Islamic Republic of Iran • Area: 1648000 km2 • Population  66,000,000 • (2002) • - Rural 23000000 • - Urban 37000000 • Province: 30 • District: 280 • Village: 65000 < • Average distance Between two villages: • 25 km < • Average population • Per village:350 > • GDP:114.1 billion $(2001)

3. Iranian Health Indicators

4. Major Health Problems of IRAN : (Similar To Other Countries) • Inappropriate Structure • Health Cost Inflation • Inappropriate Quality • Non-fair Financing • Managerial Problems • Mismatch of Disease Burden & Expenditures

5. Iran Health Major Problems (1) Inappropriate Structure • Prevention / cure Dissociation • Macro – organizational Ambiguity, so conflicts of interests : • Ambiguous role of health major role players especially GOV try to do every thing, mostly delivers health services directly, policy making, supervision &… ; also, SSO goes in the same way • Highly centralized health system • Fragmentation of Health system • Macro & Micro unfair Distribution of providers • Prevention/cure • Dissociation • Integration in • Health Services • (Family physician Unit) • & Health Funds • (Virtual Fund) Fragmentation of Health system

6. Iran Health Major Problems (2) Health Cost Inflation • High utilization high technology services • High direct contact with specialists & Weak referral system • Cost escalating provider payment mechanisms • Irrational drug prescription • Health package ambiguity • New Diseases & New Technologies • High, Irrational utilization • of Expensive Technology • Drugs, Lab & Graphies • Change in PPM • to Capitation + Bonus • ( Incentives ) • CPGs on High • Cost Services • Cost escalating Provider Payment Mechanisms • ( PPM )

7. Iran Health Major Problems (3) Inappropriate Quality • Non standard Services ( No Guidelines ) • Irrational low service prices • Nonflexible hard budgeting • Irrational drug prescription • Highly centralized health system • Low outpatient visit duration • Loose control mechanisms • Decreasing responsibility & responsiveness • Nonstandard Services • ( No Guidelines ) • Using CPGs • Selective Contracting • P4P: Monitoring/Payment • Link with quality Loose Control Mechanisms

8. Iran Health Major Problems (4) Non-fair Financing • High % of catastrophic healthcare Expenditures (CHE = 3.3%) even in insured • High Out of pocket payment of people (56%) • Regressive Financing Method • Multiple Funds / Fragmentation • Low GOV Share in Health Funds High CHE 3.3 High OOP 56% • One Virtual Fund • Proportional Finance • Excise Tax (Tobacco,) Multiple Funds Regressive Financing Low GOV Share

9. Iran Health Major Problems (5) Managerial Problems • Weak Regulation • Inefficient Decision making • Mismatch of Authority & Responsibilities • Inflexible Public Rules • Less investment for evidences • Opinion based decision making • Outpatient data is not recorded (Health services & Cost Data) • Non Unique Data Definition • Private Sector Data is unavailable • Lack of Valid Data • Decentralized FPU • Integration of Services • Patient File Data • More Risk Transfer • to Providers Inefficient Decision making Mismatch of Authority & Responsibilities

10. Iran Health Major Problems (6) Mismatch of Disease Burden & Expenditures • Burden toward • Chronic Diseases and Accidents • Expenditure toward • Hospital Care & Tertiary Care • Drug, Lab & Graphies • Acute Diseases • Less on Preventive Measures • Burden on : • Chronic Diseases • and Accidents • Defining • Essential Health • Benefit Packages • & Enforcing it • Expenditure on : • Hospital & Tertiary Care • (Expensive technology) • Drug ,Lab & Graphies

12. Death rateestimation accordingto death causes and mean age - 2000 800 death per day (300000 deaths per year) 32 Peri-natal Death 102 Accident 80 Cancer 300 Cardiovascular 35.3 year 59.7 Year 68 year 0.1 Year

14. Developinga Solution • Design or plan a system to combine or integrate more of strategies / plan some options within them one have to choose one option? Possibly based on: • Potential benefits in the form of intermediate goals such as EQUITY. • Feasibility • Political or Social Acceptability

15. Major Approaches to Health Systems : • WHO Framework • HSR Cycle • Interactive Planning Method

16. Functions of the Health system Control Knobs Intermediate Goals Ultimate Goals Finance EQUITY Stewardship (oversight) Responsiveness (to non-medical expectations) Payment ACCESS Organization EFFICIENCY Creating resources (investment and training) Delivering services (Provision) Health Regulation FISCAL IMPACT Behavior Fair Financial Contribution Financing (collecting, pooling and purchasing) QUALITY Conscience

17. Developinga Solution • Design or plan a system to combine or integrate more of strategies / plan some options within them one have to choose one option? Possibly based on: • Potential benefits in the form of intermediate goals. • Feasibility • Political or Social Acceptability

18. From Root Causes to Strategies • Integration of Health Services & Funds • Change in PPM • P4P:Monitoring/Payment Link with quality • Virtual Fund • Proportional Finance • Decentralized FPU • Integration of Services • Patient File Data • Risk Transfer to Provider • Defining Essential Health Packages & Enforcing it • Inappropriate Structure • Health Cost Inflation • Inappropriate Quality • Non-fair Financing • Managerial Problems • Mismatch of Disease Burden & Expenditures

19. From Strategies to a Plan: FP Method STRUCTURE • Referral System • Selective Contracting • Monitoring with CPG • Gatekeeper GPs • Integration of Health • Services & Funds • Decentralized FPU Family Physician & Referral System Plan Information FINANCE • Patient File Data • Health Data Dictionary • Health MIS • Virtual Fund • Proportional Finance • Increase GOV % Share PAYMENT Priority Setting • Change in PPM • P4P:Monitoring/Payment Link with quality • Risk Transfer to Provider • Defining Essential Health Packages

20. HSR Project Objectives • To design and test a universal basic minimum health services package and strengthen patient referral system; • To assure stewardship and good governance in the public sector health system; • To improve health planning and management including decentralization in the health sector by delegating administrative and financial authority; and • To review the existing health financing options for introducing measures to assure fair financing, eliminating inefficiencies and bringing equity. • To build new capacities for Iranian experts to ensure participating in HSR & persistence of Reform; • To assure that HSR literature disseminated in the policymakers & stewards of the health system;

21. Important Activities • NHSRU, PHSRU (for conceptualising, formulating and implementing health sector reforms) • Flagship Course: Harvard (9),Iran-Lorestan (4) • Senior Policy Seminar (3) • Health Policy & Planning Course, Tabriz • Designing Family physician & Referral system Instruction • Piloting the instruction in Bam • Rural Insurance based on the Instruction • Fellowship • Studies • STC’s (19) • Publication (6 Books)

22. Other steps under the HSR project umbrella • Conduct the remaining flagship courses • Publishing the research proposals results • Conducting Health Sector Study • Finding the gaps in the Health system to develop proposals and new projects for the future action plan • Publishing Health Sector Study results

23. HSR Performance: New Changes • More Practical & Community Based • More scientific Based • National Confidence • More Goal Specific esp. EQUITY