This study aimed to measure the TE changes and productivity variations in Iran’s health system over the 2010-2015 period. Our findings demonstrate slightly positive changes of efficiency scores in 2014 and 2015. We reviewed the changes occurred in relevant input and output indicators as well as the recent HTP. Understandably, the five indicators of DPT3, FP, TB, ART, and SAB did not change significantly during the study period. This was because the data for these indicators are not usually calculated and reported annually. Only two indicators of GGHE per capita and GGHE/THE changed over this period. Therefore, it seems that changes made in these two indicators, especially those made in the output indicator, have improved the efficiency score in 2014 and 2015, which are mostly attributable to the HTP implementation.
As the key health sector reform towards UHC in Iran18, 37, 38, HTP had five main goals: sustainable financing, financial protection against catastrophic health costs, increasing access to quality healthcare services, improving the performance of health system and better public health indicators, ultimately. Several interventions have been implementing to provide additional financial resources and increase the existing ones, control the price of drugs and medical equipment, expand health insurance coverage among all society, reduce the share of inpatient and outpatient payments, and prevent informal payments. Despite their positive impact, further interventions are still required to improve efficiency in the health system of Iran. These include reforms to improve governance structures, financial resources and service provision19, 39.
With the efficiency score of lower than average, our findings revealed Iran’s low rank among the studied countries. The efficiency model, as well as descriptive statistics of output indicators, suggest an equal to or higher than the average coverage of DPT3, TB, and SAB in Iran, compared to the studied countries over the study years. This demonstrates that Iran’s low efficiency score might be due to other factors than these indicators. Nevertheless, the status of other three output indicators is different. FP coverage has slightly increased over the study years, which is significantly lower than the average of the studied countries and dramatically lower than the maximum value. A small increase is also observed in the ART coverage indicator in Iran, which is lower than the average of the studied countries. Although Iran’s public sector share of total health expenditure was significantly lower than the average of the studied countries during 2010 to 2013, it slightly increased between 2010 and 2013. Following the implementation of HTP, it increased significantly in 2014, and decreased again in 2015. Therefore, Iran’s low efficiency score can be attributed to these last three output indicators.
In addition, part of this low efficiency score can be attributed to the changes occurred in the input indicator. The public health expenditure per capita has declined to lower than the average of the studied countries over 2010 to 201320. This indicator increased significantly in 2014, rising even above the average of the studied countries, and then declined in 2015. Nonetheless, it is still higher than the indicators calculated in 2013 and before. Since output indicators have not changed significantly, the rising trend of this indicator makes it more expensive for Iran to meet the UHC goals. In other words, Iran’s health system has failed to efficiently use the new required resources to achieve UHC.
Many international and national policies have specifically emphasized the necessity of promoting the efficiency of health systems24,25,40,41. Low efficiency scores and the waste of health resources are among the main challenges that the health systems in Iran42 and other developing countries43,44 have been facing. In this study, we selected the efficiency indicators among relevant national and international indicators45. We recommend, while maintaining the increasing trend of UHC indicators, health policymakers in Iran need to follow three below interventions to improve the status of Iran’s health efficiency:
- Interventions to expand the ART coverage: These interventions are suggested to be determined and prioritized using evidence-based practice models in order to identify and effectively cover high-risk groups through public health resources and improve effective HIV coverage.
- Targeted interventions to improve universal financial coverage against ever-spiraling health costs at the health system and public levels. At the health system level, a significant part of terrible health costs can be attributed to the wide range of services covered by public resources, as well as the use of inefficient service delivery models. In Iran, a broad range of low cost-effective services have been covered through available public resources, without following any priority setting. Considering current constraints of financial health resources in Iran, covering some of these less-prioritized services through basic health insurance seems to be economically inefficient46,47. Worse still, fee-for-service (FFS) based payment method has increased the risk of informal payments and induced demands, both of which have contributed to the increased share of direct out-of-pocket (OOP) payments, and catastrophic health costs, ultimately. Let alone, after 15 years into the implementation of family physician program and the referral system, the national health system is still behind to establish appropriate rationing of services, which adds to the burden of undesirable health costs18,22,48.
At the public level, further evidence is needed to determine the health problems that impose heavy health costs. This can in turn help design and make targeted interventions to improve coverage against expensive healthcare services. Given the significant role of private sector in Iran’s health system, particularly in hospital care, effective policies are essential for better engagement with the private sector, galvanized by empowering the community and raising public awareness about appropriate and rational use of health services.
- Sustainable interventions to allocate enough share of the government general budget to the health sector: The health sector’s share of government budget increased significantly following the implementation of HTP in 201418,42,48,49. Given the current unilateral economic sanctions against Iran and the consecutive financial limits, serious concerns exist about the amount of financial resources allocated to the health sector as well as timely allocation of such resources, if any21. Economical resiliency, for instance through some interventions to reduce Iran’s dependency on oil revenue, as proposed in the proposed budget of 2020, could enhance financial stability and strengthen the health system sector. In particular, increasing sin taxes and tolls imposed on harmful products (e.g. tobacco products and soft drinks), plus allocation of a larger share of value added tax for financing health system are helpful. Another example is increasing share of health insurance resources. Analysis conducted following the economic shocks caused by sanctions and sudden increase in the exchange rate in 2013 suggest that the most instable financial resources in the health sector include direct OOP and government funds, respectively50. Hence, these two types of resources should be transferred into insurance funds. Finally, fundamental reforms are essential to eliminate or reduce conflict of interest in health-policy making, tailor the structure of health system, and improve payment system and benefit package design, aiming to tackle the main sources of waste of healthcare resources in Iran structures39,51.