3-1-Agenda Setting for Policy Development
This stage, like the Kingdon’s multiple streams model, consisted of three streams: problem, policy and politics, which are described Figure 2.
3-1-1- Politics Stream
The examination of the country's laws in the field of payment mechanisms relating to government employees proved that the major longest-standing factor in changing the payment system of Iran's public hospitals was the adoption of ‘the rule for the establishment of boards of trustees of universities and higher education and research institutions’ in 1988 as follows:
"Article 7-Duties and authorities of the board of trustees: ... D- Approval of the detailed budget of the institution; E- Approval of the accounts and annual balance sheet of the institution; F- Approval of the method of receiving specific revenues and its consumption; G- Appointing an auditor and treasurer for the institute H- Approval of financial and transaction regulations ...."
According to this law, the ministry and its affiliated institutions were given authority to receive and use exclusive revenues (the distribution of exclusive revenues of the hospital among its employees). Accordingly, in this study, ‘upstream law enforcement’ was the dominant item related to ‘politics stream’ (See Figure 2, P4P agenda setting section).
3-1-2- Problem Stream
According to knowledgeable interviewees, most of the people involved in NPS at the macro level came to the conclusion that the system should be changed.
“In the poll we did, no one stated that the previous instruction [NPS] was good, and the various strata all agreed that the instruction should be changed,” said one of the developers. (Code 22)
The problems relating to NPS caused a consensus among all stakeholders to change it. Not to mention, the nursing community, as one of the largest clinical groups in the country, also agreed with the interventions promoting this program.
“We have even stressed the need for rules in the field of nursing, in which the hourly payment should be changed into a performance-based one,” said one of the interviewees at the ministry level (Code 9).
Hence, the shortcomings of NPS were the predominant items relating to the problem stream (See Figure 2, agenda setting section).
3-1-3- Policy Stream
As a result of the above mentioned law and problem, various participants in the health system (hospitals, professional groups such as the nursing community) took several measures to address the problems and enforce the law, which can be summarized in the following three groups (See the bottom of Figure 2):
3-1-3-1- The intervention to improve NPS in some hospitals
Reviewing the operational documentation and instructions of NPS demonstrated that this program was developed in such a way that it was possible to change and upgrade in any hospital. For example, a hospital could determine the assessment criteria and the manager's satisfaction score of his staff, but the decision to do it entirely depended on the wishes of the upstream managers and the organizational characteristics of the hospital.
“We could have developed the previous NPS,” said Code 4.
The interviewees’ statements were fully confirmed by the existing administrative letters, and the letters showed that in some hospitals of the country, several changes had been made in order to eliminate some shortcomings of NPS.
3-1-3-2- Developing different kinds of mechanisms for PfP in hospitals
Reviewing documents and interviews indicated that, with the authorities resulting from the upstream laws, two of the country’s hospitals based in Tehran, namely Hasheminejad Hospital (mid-2001) (21) and IH Hospital (2008), designed and implemented two different types of PfP mechanisms in their hospitals.
“Likewise… similar programs like those implemented in the country were spontaneously carried out in IH Hospital,” said Code 25.
3-1-3-3- Approval of the New National Laws
To eliminate the shortcomings of NPS, the new laws were approved at the macro level. The nursing association, as the main beneficiary of the changes, provided the possibility of passing the two laws of nursing services tariff (2007) and manpower productivity (2009) with multiple follow-ups in the national assembly of the country. According to these rules, the method of paying salaries and benefits to nurses must be a combination of two methods: fixed and performance-based; and nurses' merit pay must be calculated based on the approved tariffs of "nursing staff’s diagnostic and treatment service packages".
“Previously, we also proposed a law in the parliament, ..., under the title of tariffing the nursing services, but not in the form of fee for service,” said Code 9.
Despite the implementation of these three important measures, the possible effects of each alone were not sufficient to overcome the problem of NPS in the whole country. Until 2010, there was no opportunity to combine their effects with each other. Therefore, the problem continued to remain unsolved.
3-1-4: The first opportunity window (Confluence Point I)
Given that the ministry was the sole custodian of the program, the major changes and interactions that led to the agenda setting of the program depended on the program-related experts within the ministry of the tenth government, particularly the deputy minister of treatment.
“The design of our performance-based payment system was started immediately after the establishment of this head office,” said Code 22.
The interviewee refers to the "Tariff & Payment system Policy making (TPP) office" in this deputy. The formation of this office brought together a group of experts interested in the topic ‘performance-based payment’ (the first policy group).
“The performance-based payment program began with the start of a new team, who served as an expert team...,” said Code 13.
As a result, the first opportunity window of beginning the development of the policy was opened by creating an internal institution and an interested policy group.
3-2- Policy Development
3-2-1- The first whirlpool and the first sub-confluence point (IA)
Howlett et al. argue that the whirlpool reflects the policymakers' efforts to validate their understanding of the problem (12). The first whirlpool for the first policy group was a more scientific examination of the shortcomings of NPS, a collection of past work related to this area in the country, and a review of global experiences for understanding PfP programs. One of the main developers of the program describes his first efforts and experiences as follows:
“We did a preliminary study and came to the conclusion that performance-based payment is very hard work. A lot of searches was carried out and things were quite different from what we thought,” said Code 17.
“They sought to see literature and what the world has done to achieve P4P models,” said another developer (Code 25).
Thus, there was the first whirlpool in the present study, and the policy group evaluated their understanding of NPS and its possible solution. In the model of Howlett et al.,(12) the end of this phase is marked by a sub-confluence (IA), which initiates the stabilization phase of policy formation and leads to the creation of other streams. Therefore, following along, we will face five streams, including three Kingdon’s streams, with a slight change in the policy stream, and two new streams (program and process streams).
3-2-2- The changes of Kingdon's three streams
The changes of kingdon's three streams at this stage are as follows:
A- politics stream: There was no change in the course of politics (implementation of the upstream law), and it was like the previous stage of the opening of the first opportunity window.
B- The problem stream (shortcomings of NPS) also remained unchanged and the stream was dominant. Therefore, the other streams were formed in line with this stream with the aim of resolving this problem.
C- Policy Stream: According to the operational documentation, this stream was out of a general mode (one of the different types of PfP programs) and was defined as a special program (performance-based program called CSDID) (See Figure 2, P4P development section).
“Mr. Doctor, the then deputy minister of treatment… said that he was not satisfied with the review process of the instruction of NPS and that he would like it to be replaced by a conditional payment instruction,” said. Code 17.
With regard to this order, a series of joint studies were conducted by the first policy group and four scientific groups from four universities of medical sciences of the country and a PfP model was designed under the title CSDID, which was defined by its developers as follows:
“I don’t want to claim that the CSDID Model, developed within the expertise of the Ministry of Health, bore 100% similar to the PfP model, but it enjoyed 80-90% of the characteristics of a PfP mechanism,” said Code 13.
3-2-3- Forming the new stream of program
After determining the solutions to the problems related to NPS, the first emerging stream was policy program (Figure 2, PfP development section). Policy program means creating plans to calibrate new policy tools and integrate them with the current situation (12), for which the first policy group carried out various activities, which were summarized in Table 2.
Table 2 : The set of activities of the first policy group for program programming
Preparing the documentation of the new Policy
• Developing the initial 200-page document with the support of four major medical universities in the country
Approval of laws that support PfP
• In the year before the implementation of the policy, several consultations were held to include two paragraphs in the country’s strategic purchasing regulations* towards designing a mechanism for quality-based payment.
Establishing the legitimacy for stakeholders and streamline the Policy
• Legislative and decision-making levels: Multiple lectures were held to familiarize the environment with the policy, at the Academy of Medical Sciences**; Management and Planning Organization***; General managers of provincial health insurance; Parliamentary Health Commission and upstream managers within the ministry.
• The new policy was primarily introduced to physician and non-physician staff as a mechanism to increase pay and create interdisciplinary justice.
• The new policy was primarily introduced to basic health insurance organizations as a mechanism to improve the quality of service delivery.
• The new policy was primarily introduced to the presidents of medical universities as a mechanism to improve quality, delegate authorities, and reduce the payment gaps for private and public hospital staff.
3-2-4- Forming the new stream of process
The second emerging stream is process stream, which is formed to explore options and reinforce valid decisions (See Figure 2, P4P development section) (12). According to operational documentation, the process stream in the agenda setting of this program meant the pilot implementation of the CSDID instruction in the country. Thus, the instruction was implemented, monitored and reviewed on a two-year trial basis in two hospitals.
In short, all these changes and developments in the five streams only led to the development of an indigenous program (CSDID) for the country, but did not lead to its implementation because it required another opportunity window to rejoin these streams.
3-2-5- The second opportunity window (Confluence Point II): joining five streams
The opportunity window for the agenda setting of the implementation of the policy was opened by the transfer of government, which led to a higher priority in the field of health among the national actions and the implementation of the Health Transformation Plan (HTP), whose pursuit apparently required a strong policy group at the ministry level.
“To me, the implementers of the policy at the Ministry really who did that had a lot of courage ... because not anyone or organization can really claim to make the dedicated revenues of a firm like a hospital based on performance,” said Code 4.
Hence, with the new government coming to power, a new policy group (the second policy group) was formed, including ministers and deputies interested in a PfP mechanism. With the start of planning for the implementation of the Health Transformation Plan, the CSDID program also had the opportunity to present itself:
“With the start of the new government and the new discussion of the Health Transformation Plan system and what we want to do in various areas, CSDID was introduced as one of the management programs of the Tariff Policy and Payment System to replace the previous program,” said Code 13.
As a result, following the transfer of government and the start of the health transformation plan, the second policy group decided to implement the proposed solution (CSDID).
3-3- Policy implementation
3-3-1- The second whirlpool and the second sub-confluence point (IIA)
According to the model of Howlett et al., once the policy is formed, the second sub-confluence of streams begins with another evaluation whirlpool. At this stage, policymakers are more likely to examine the progress of events (such as the existing policy options and stakeholders’ feedback) and determine how to move toward a final decision (12).
The second policy group examined the reports obtained from the implementation of various implemented programs towards elimination of the shortcomings of NPS. These programs included the pilot CSDID program and the three groups of actions introduced in section 3-1-3 and Figure 2.
According to Howlett et al. (2014), this potential stage is chaotic and takes place away from the public eye. After these reviews, some changes were made in five streams.
3-3-2- Changes of the existing five streams
The changes of the existing five streams at this stage were as follows:
A. Politics stream: With the transfer of power to the new government calling for reforms in the health system, the politics stream was strengthened at this stage and became the dominant stream and other streams were adjusted under its influence.
B- Problem stream: With the implementation of the health transformation plan, the primary problem stream (shortcomings of NPS) was changed. This change was reinforced by the addition of the problem of how to distribute financial resources to hospitals, which resulted from the implementation of another health transformation plan program and its need to be addressed was felt much greater.
C- Policy stream: In addition to the presence of other people in the second policy group, the presence of a person with a history of implementing a performance-based program in a hospital provided a good strength for decision-making and implementation of the final program (IR-PfP):
“One of the reasons that the CSDID program could claim to be introduced as a new program was that Mr. Dr. ..., the deputy director of treatment, ... was primarily in charge of the program,” said Code 13.
Therefore, the experiences of the pilot CSDID program and the experiences of IH Hospital were summarized, and the final program structure was finalized based on these experiences:
“The CSDID model was different from that in IH Hospital, … a work group was formed and our experiences were brought up there, thus producing a combination of experiences used in those two models, as well as various opinions which were proposed in the work group,” said Code 29.
In this quote, the interviewee refers to the series of discussions that took place in the second whirlpool and caused the final program to be a combination of the model applied in IH Hospital and CSDID model.
D- Program stream: To implement the program, a combined program was proposed in the Council of Deputies of the Ministry, in which it was proposed that the viewpoints of the eight major universities of medical sciences in the country must be taken into consideration in order for the final model to be approved.
Hence, under the influence of time and executive limitations, the final model was pushed forward for implementation with the consent of these universities. As for the manner of participation at this stage, one of the developers of the policy stated that:
“Just like you cook a food and then put it on the table and say, taste it to see if it is salty or not. In fact, they asked for our opinions about what they intended to do,” said Code 13.
E- Process stream: This stream was not created due to time and executive limitations and the final program, which was the result of combining two programs (CSDID and the model of IH Hospital), was introduced to be implemented without a pilot implementation.
“The final model was not a model that had already been implemented from scratch to completion. It was a combination of different models and opinions of a group of people. ... and these opinions were not examined in the environment ...,” said Code 13.