Explaining the resources wastage and its underlying factors in COVID-19 management in Iran: A qualitative study

doi:10.21203/rs.3.rs-3216484/v1

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Research Article

Explaining the resources wastage and its underlying factors in COVID-19 management in Iran: A qualitative study

https://doi.org/10.21203/rs.3.rs-3216484/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 27 Oct, 2023

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Background:

Identifying factors affecting health costs can be useful in determining the best policies for controlling and managing health costs. To this end, the present study aimed to analyze resource wastage and identify factors underlying it in COVID-19 management in the Iranian health sector.

Method:

This qualitative content analysis study was conducted in the Iranian health sector. The participants were 23 senior, middle, and operational managers in the health sector. The data were collected through semi-structured interviews with the managers. The participants were selected using purposive, quota, and snowball sampling techniques. The interviews continued until the data were saturated. The collected data were analyzed using MAXQDA software (version 10).

Results:

Following the data analysis, the factors affecting the wastage of health resources were divided into 4 categories and 9 subcategories. Vaccines, diagnostic kits, medicines, and human resources were the main factors underlying resource wastage. The identified subcategories were open and unused vials, nonuse of distributed vaccines and their expiration, excess supply and decreased demand for vaccines, expiration of diagnostic and laboratory kits and their quantitative and qualitative defects, the large number of tests, non-organization of medical staff, and the inefficiency and expiration of medicines.

Conclusion:

Given the limited health funds and the increased healthcare costs, effective preparation and planning and making reasonable decisions for unexpected events can minimize unnecessary costs and resource wastage, which requires some revisions in attitudes toward COVID-19 management in the healthcare sector.

resources wastage

health sector

covid-19

The sudden outbreak of a new coronavirus in Wuhan Province of China in December 2019 threatened the world’s population in a short period and caused an increase in the number of COVID-19 cases and deaths in most countries, leading to more than 765 million COVID-19 cases and close to 7 million deaths worldwide by May 2023 (1, 2). COVID-19 control and treatment have imposed huge costs on countries both socially and economically. On the one hand, diagnosis, screening, hospitalization, and high treatment costs and on the other hand, the cost of providing essential health items have put much economic pressure on health systems (3). Governments have made efforts to manage COVID-19, including immunizing and providing medical equipment (personal protection equipment (PPE), masks, and essential medicines). The total health cost of the response to COVID-19 is estimated to range from USD 234 to 387 billion (accounting for 0.3 to 0.5% of the GDP of the countries of the world) (4). Since the outbreak of the COVID-19 epidemic, many plans have been put into action in Iran for early diagnosis, treatment, hospitalization, and recovery of COVID-19 patients, including forming crisis management teams, formulating guidelines and protocols, and screening. One of the problems in COVID-19 management was the lack of adequate evidence and political requirements to control and prevent the spread of the disease. Thus, many plans were put in effect in parallel, and much money was imposed on the government (5). The draft of the report on the damage caused by COVID-19 on Iran’s economy (Presidential Strategic Studies Center) in December 2020 indicates much damage to the healthcare sector. The damage caused to the health sector in Iran due to the COVID-19 outbreak is estimated at 25 thousand billion Tomans in total ($961.5M) (6). According to a study conducted in Iran, the direct costs of COVID-19 for each person have been estimated at 3755 dollars, which is close to 3045 dollars in the USA. The cumulative estimate of the financial costs imposed by the COVID-19 pandemic in the United States is more than 16 trillion dollars, which is equivalent to approximately 90% of its annual GDP (7, 8). Approximately 20–40% of the total global health costs are wasted, showing inefficiency in the responsibility and monitoring of the performance of health systems. Thus, adopting efficient, cost-effective, and fair approaches for the community and individuals is necessary. This requires the implementation of healthcare delivery models with a suitable mix to meet people’s health needs (9).

General estimates show that resource wastage in the US healthcare system varies from $600 billion to more than $1.9 trillion per year, or approximately $1,800 to $5,700 per person per year. In 2018, national health expenditures in the United States reached $3.6 trillion, accounting for approximately 18% of GDP. However, this amount of US healthcare spending did little to improve population health outcomes and was mostly wasted. It is estimated that 25% of healthcare spending in the United States is wasted (10).

Cost analysis is a precursor to cost‒benefit analysis, cost-effectiveness, and planning and operational budget formulation. Cost analysis will be useful for managers at different levels to know how the funds were spent, whether these funds have been spent in line with the goals of the organization, and to what extent they have brought the organization closer or further away from its goals (11).

Previous studies have demonstrated some difficulties in determining unnecessary expenses and complex interactions between different causes in the health system. Major changes in resource wastage reduction will not occur as long as different organizations and people in the healthcare system are given clear incentives to reduce resource wastage and the necessary knowledge and tools to do this task (12).

The COVID-19 epidemic has revealed the inherent value of health and the resilience of the health sector, the importance of adequate investment in health, and the interconnectedness of health and economic processes. Countries that incorporated pandemic preparedness into their health systems were better able to cope with the pandemic and provide access to essential services and continuing care, including key public health functions without financial barriers. The absence of prior planning in an emergency can lead to the wastage of resources and unwanted loss of lives, as well as endangering public trust in medical services (13).

Qualitative research examines events and experiences in a given context with a focus on individual experiences related to that phenomenon (14). Thus, this qualitative study aims to address resource wastage and identify related factors during the COVID-19 epidemic from the perspective of medical staff. Since no study has addressed resource wastage in Iran’s health system during epidemic conditions, the findings from the present study can provide solutions and suggestions for the effective allocation of resources and preventing their wastage in the Iranian healthcare sector.

Research design

This study was conducted using a qualitative content analysis approach in 2022–2023 in the Iranian healthcare sector.

Participants and sampling

The participants in this study were 5 senior health managers (university health deputies), 7 middle managers (staff experts), and 8 executive managers (directors of healthcare centers). The managers were selected using purposive, quota, and snowball sampling techniques. The sampling process continued until the data were saturated. The inclusion criteria were having experience in COVID-19 management for at least one year since the outbreak of the epidemic and the willingness to participate in the study. The exclusion criterion was the unwillingness to continue the interview.

Instruments

The data in this study were collected through in-depth and semi-structured interviews. The data were documented by taking notes and recording and transcribing the interviews. Each interview started with a general question about the manager’s role and responsibility during the COVID-19 epidemic. More specific questions were asked based on the results of the initial interviews and the categories extracted. For example, “How do managers define resource wastage?” and “In which domains did resource wastage occur, and what are the related factors?”. All interviews were conducted with prior appointments with the participants at their workplace and in a quiet environment Written informed consent was obtained from the participants before conducting and audio recording the interviews. Each interview lasted ± 33.61 minutes on average. The interviews were conducted from November 2022 to May 2023.

Data analysis

The data collected in this study were analyzed with a conventional content analysis approach using MAXQDA software (version 2020) to extract categories and subcategories. Content analysis is an effective method to obtain valid and reliable results from textual data to create new knowledge and insights and provide facts and practical guidance for performance. Content analysis also aims to achieve a brief and exhaustive description of the phenomenon in question (15). The data were reviewed word by word by two members of the research team. Then, the members of the research team underlined the categories and subcategories related to the subject matter in question. The first and last authors had experience in health epidemic management programs, and the third author was experienced in qualitative studies. The data were collected using a semi-structured interview guide. The demographic characteristics of the participants were recorded, and the interviews were conducted using a questionnaire. Then, additional probing questions were asked based on the participants’ responses. The interviews were recorded and reviewed again. The audio file of each interview was transcribed word by word. The data were saturated when no new information or theme was discovered with additional interviews. The interviews were reviewed several times by the researcher, and their content was analyzed using the qualitative content analysis approach proposed by Graneheim and Lundman (16). Afterward, the meaning units were identified and coded. In the next step, the codes were clustered into some subcategories based on semantic similarities and differences. Moreover, the subcategories with conceptual and semantic connections were organized into more abstract categories. Finally, the main themes were extracted by merging the themes that covered a single concept (17). The data were saturated with 23 semi-structured interviews. To establish the rigor of the study, the four criteria of trustworthiness, credibility, dependability, confirmability, and transferability, proposed by Lincoln and Guba were used (18). The credibility of the findings was established through the prolonged engagement of researchers in different stages of the study, reviewing the content of each interview, reading the interview transcripts several times, presenting the transcripts to the participants, and revising them based on their feedback. Finally, the extracted codes and categories and the conceptual model were reviewed by a panel of experts and revised based on the feedback received from them. The findings were reviewed and confirmed according to the participants’ opinions. However, to further ensure the confirmability of the findings, they were reviewed by an expert experienced in qualitative methods. The dependability of the data was enhanced by recording all procedures taken to conduct the study and conducting all interviews under similar conditions. To ensure the transferability of the findings, the researchers were constantly engaged in all research procedures.

Using qualitative content analysis, this study examined the factors underlying the wastage of health resources. Interviews were conducted with 23 health deputies, managers, and experts. Most of the participants (78%) were male. The participants’ average age was ±47.8 years, their average work experience was ±21.96 years, and their average managerial experience was ±14.7 years in the health sector.

Table 1 shows other demographic data of the participants. After removing overlaps, 345 codes were extracted from 614 initial codes. Data analysis revealed four main themes (COVID-19 vaccines, diagnostic kits, medicines and medical supplies, and human resources) and 9 subthemes, as shown in Table 2.

Table 1: Demographic characteristics of the interviewees

Interview Duration (min)	Education Level	Field of study	Gender	Age	Management experience	Years of service	Interviewee
40	Ph.D	Cardiology	Female	38	6	11	P1
42	Ph.D	Biochemistry	Male	44	11	20	P2
33	Ph.D	Psychology	Male	58	33	35	P3
42	Ph.D	Health Economics	Male	43	14	18	P4
30	Professional Doctorate	General Practitioner	Female	50	12	19	P5
38	Professional Doctorate	General Practitioner	Female	43	13	18	P6
50	Professional Doctorate	General Practitioner	Male	50	10	22	P7
39	Professional Doctorate	General Practitioner	Male	43	4	15	P8
30	Professional Doctorate	General Practitioner	Male	52	21	25	P9
35	Professional Doctorate	General Practitioner	Male	61	15	28	P10
28	Professional Doctorate	General Practitioner	Male	52	20	24	P11
35	Professional Doctorate	Pharmacist	Male	58	28	25	P12
25	Professional Doctorate	Pharmacist	Male	53	25	22	P13
28	Master's Degree	Laboratory Sciences	Male	57	21	31	P14
48	Master's Degree	Laboratory Sciences	Male	42	11	20	P15
25	Master's Degree	Psychology	Female	49	12	23	P16
27	Bachelor's Degree	Laboratory Sciences	Female	52	18	30	P17
34	Bachelor's Degree	Laboratory Sciences	Male	41	7	18	P18
28	Bachelor's Degree	Public Health	Male	36	4	15	P19
27	Bachelor's Degree	Public Health	Male	53	21	29	P20
25	Bachelor's Degree	Public Health	Male	43	11	20	P21
34	Bachelor's Degree	Public Health	Male	45	8	19	P22
30	Bachelor's Degree	Pharmaceutical Affairs	Male	37	13	18	P23

Table 2: The themes, subthemes, and excerpts from the interviews

Themes	Subthemes	Excerpts from the interviews
COVID-19 vaccination	Open or unused COVID-19 vials	The high doses contained in each vaccination vial
		Unsuitable COVID-19 vaccination storage conditions
		Human error in the vaccination process
	The nonuse of COVID-19 vaccines distributed among the centers and the expiry of vaccines	Changes in the need and demand for vaccines
		People’s unwillingness to do vaccination
		Public mistrust in existing COVID-19 vaccines
	Mismanagement of distribution and redistribution of COVID-19 vaccines	Improper distribution of COVID-19 vaccines in vaccination centers
		Failure to redistribute near-expired COVID-19 vaccines
	Excess supply and decreased demand for the COVID-19 vaccines	Diverse or ineffective planning for producing COVID-19 vaccines inside the country
		Multiplicity and variety of vaccination programs and plans
COVID-19 diagnostic and laboratory kits	Expiration of COVID-19 diagnostic and laboratory kits	A reduction in the number of people referring for COVID-19 screening and diagnostic tests
		Excessive provision of COVID-19 diagnostic and laboratory kits without assessing the epidemic conditions
		Failure to redistribute near-expired COVID-19 diagnostic kits
	Quantitative and qualitative defects in COVID-19 diagnostic kits	Noncompliance of the COVID-19 kits sent from the ministry with the laboratory equipment in medical center
		Unavailability of valid COVID-19 diagnostic and laboratory kits in the market
		Occurrence of errors in COVID-19 diagnostic and laboratory tests and the need for repeating the tests
	A large number of COVID-19 tests	Conducting routine and induction COVID-19 diagnostic tests
		Conducting diagnostic tests to prepare statistics and report the COVID-19 trends
		Applying for PCR tests to confirm COVID-19
COVID-19 medicines and medical supplies	Ineffectiveness and expiration of COVID-19 medicines	Frequent changes in drug treatment protocols for COVID-19
		Indiscriminate preparation and distribution of medicines without assessing the COVID-19 condition
		Not redistributing near-expired COVID-19 drugs
Human resources	Ineffective organization and distribution of medical staff in selected COVID-19 healthcare centers	Making decisions and formulating instructions based on the function of selected COVID-19 centers
		Lack of adequate experience and skills in medical staff in selected COVID-19 treatment and vaccination centers and reference laboratories

Main theme: Resource wastage and its underlying factors in COVID-19 management

The COVID-19 epidemic is managed differently in countries depending on local and institutional conditions. The factors underlying resource wastage include ineffective planning, lack of preparation, the absence of a crisis management plan, lack of communication and coordination, and lack of coordination between different management levels. The findings from the present study showed that the factors underlying resource wastage include COVID-19 vaccination, diagnostic and laboratory kits, medicines and medical supplies, and human resources, as discussed below:

1. COVID-19 vaccination

The current strategy in addressing the COVID-19 pandemic is the optimal use of vaccines to reduce COVID-19 cases and mortality (19). An analysis of the participants’ experiences showed that factors such as open and unused vials, nonuse of distributed vaccines, excess vaccine supply, and reduced demand were the factors contributing to the wastage of vaccines.

1.1 Open or unused COVID-19 vials

Unopened vials are wasted mostly due to cold chain, supply management, and storage problems. The participants stated that the amount and number of doses in each vial and vaccine can be the main reason for the wastage of COVID-19 vaccines.

A. High doses in each COVID-19 vaccine vial

Wastage in vaccines is often due to the characteristics of the vial itself and the number of doses. According to the participants, this problem can be caused by the differences in the doses in different vials. A participant stated:

“The doses in vaccine vials put us in a lot of trouble. We were not sure whether to open the vial or not” (Participant #20).

B. Unsuitable COVID-19 vaccination storage conditions

Unsuitable storage of vaccines reduces their effectiveness or leads to their spoilage. Most of the participants stated that not keeping vaccines at the optimal temperature in the vaccination process can contribute to the wastage of vaccines. A participant stated:

“The storage temperature of the vaccines inside the vaccination cold box was the same as the ambient temperature in some cases” (Participant #22).

C. Human error in the vaccination process

Human errors can occur in the vaccination process and cause some problems. Some participants pointed out that human errors also contributed to the waste of vaccines. A participant reported:

“The vaccinator used to forget to place open and unused vials in the refrigerator and cold box and noticed the problem just the next day” (Participant #20).

1.2 Nonuse of vaccines distributed among centers and expiration of COVID-19 vaccines

The waste of COVID-19 vaccines due to expiration indicates defects in vaccine management and planning. The participants stated that the lack of referral and demand for vaccines, doubt and unwillingness of community members, and mistrust in vaccines available in the vaccination program could lead to the wastage of COVID-19 vaccines.

A. Changes in the need and demand for vaccines

The successful implementation of the COVID-19 vaccination program, in addition to the efficiency and effectiveness of the vaccines, will require public acceptance and the cooperation of all members of the community to fight this disease. Most of the participants emphasized that one of the problems with the vaccination program was the lack of referrals for vaccination. A participant stated:

“People don’t like to visit our vaccination centers as if COVID-19 is over for them” (Participant #19).

B. People’s unwillingness to undergo vaccination

Hesitation and delay in refusing vaccination is an obstacle to long-term control of the coronavirus. The participants stated that reasons such as negative publicity, allocation of vaccines to specific groups, complications, and ambiguities about the consequences and effects of the vaccines could contribute to the wastage of vaccines. A participant stated:

“Fear of vaccines and the negative publicity and beliefs of some groups such as traditional medicine professionals and clerics were also effective in reducing referrals and wastage of vaccines” (Participant #7).

C. Public mistrust in the existing COVID-19 vaccines

The participants stated that various factors may contribute to public mistrust in COVID-19 vaccines, including confusion caused by a huge bulk of information and the association between vaccination and side effects and certain diseases. One participant said:

“We politicized vaccination and even its production turned into a political issue. They produced different types of COVID-19 vaccination, and none of them were effective, and people became skeptical of the vaccines” (Participant #3).

1.3 Mismanagement of distribution and redistribution of COVID-19 vaccines

Effective management in the distribution of vaccines is important in infectious crises and requires effective planning, careful monitoring of the vaccine supply chain, equitable distribution, and increasing the capacity of health infrastructure.

A. Improper distribution of COVID-19 vaccines in vaccination centers

The participants reported that the ineffective distribution of health resources and services leads to their wastage and inefficient use of them. Most of the participants stated the ineffective distribution of vaccines, the reduction of visits to vaccination centers, and the failure to redistribute near-expired vaccines as reasons for the wastage of vaccines. A participant stated:

“Sometimes we were receiving vaccines that we had no choice but to accept. It appeared to be they were forcing us to take those vaccines regardless of the demand for vaccination” (Participant #22).

B. Failure to redistribute near-expired vaccines

A majority of the participants agreed that adopting a collaborative, redistributive, or hybrid approach to an existing vaccination program would increase vaccine access and reduce vaccination wastage. One of the participants stated:

“We told the vaccination centers in different provinces that we were going to send them some near-expired vaccines, but they replied that they had lots of unused vaccines and could send them back” (Participant #4).

1.4 Excess supply and decreased demand for vaccines

Vaccine oversupply means more production than demand. This problem may be due to overproduction or distribution problems. The participants stated that diverse or ineffective planning for producing COVID-19 vaccines and the multiplicity of vaccination programs were the reasons for the wastage of vaccines.

A. Diverse or ineffective planning for producing COVID-19 vaccines inside the country

The production of COVID-19 vaccines is a priority for countries as a preventive measure to control the spread of the disease. The participants in this study expressed concerns such as high production costs, insufficient time for clinical trials, the lack of international scientific certificates for domestic vaccines, and the lack of community participation in vaccination acceptance. One of the participants stated:

“In a scenario where the coronavirus was rampant in Iran and hundreds of people succumbed to the virus every day, priority was given to domestic vaccine production over the timely import of foreign vaccines” (Participant #4).

B. Multiplicity and variety of vaccination programs and plans

The successful fulfillment of vaccination goals requires effective and integrated planning in implementing the vaccination project. A participant stated:

“Mobile vaccination plans were carried out in certain places such as Friday prayers, holidays, gatherings, crowded markets, and offices, but people attended these places for non-vaccination reasons, which caused a large number of vaccines to be wasted” (Participant #19).

2. COVID-19 diagnostic and laboratory kits

The use of suitable laboratory equipment plays an essential role in confirming and diagnosing diseases on time. The disregard for such equipment can lead to delays in the treatment and timely diagnosis of diseases (20). From the perspective of the participants, factors such as the expiration date of the kits, the quality of equipment and their brand, and the provision of free diagnostic tests have played an important role in the wastage of the kits.

2.1 Expiration of COVID-19 diagnostic and laboratory kits

The participants in the study stated that a reduction in the number of patients referred for vacation due to the slower COVID-19 transmission rate, excessive supply of diagnostic kits without evaluating the disease trend, dependence on the past behavior of the coronavirus, and failure to redistribute additional kits were effective in the expiry of COVID-19 diagnostic and laboratory kits.

A. A reduction in the number of people referred for COVID-19 screening and diagnostic tests

The participants stated that a reason for the decrease in the number of COVID-19 tests was an increase in public awareness and health literacy. One of the participants stated:

“No one applied for COVID-19 screening and diagnostic tests and the officials asked why the number of diagnostic tests had reduced but they knew that there was a decrease in the number of COVID-19 patients across the country” (Participant #18).

B. Excessive supply of COVID-19 diagnostic and laboratory kits without evaluating the disease trend

Most of the participants emphasized that COVID-19 diagnostic and laboratory kits and other medical equipment should be supplied according to a detailed analysis of the different COVID-19 waves in the country, and decisions should not be made based on the past behavior of the coronavirus or improper preparation and distribution of laboratory kits. A participant with a surprised and angry expression stated:

“If the university was appointed as the main authority in charge of supplying COVID-19 kits from the first day, or if the requested kits were delivered to the university based on the submitted data, we would not have so many extra or near-expired kits” (Participant #14).

C. Failure to redistribute near-expired COVID-19 diagnostic kits

The participants stated that with effective planning, the authorities could monitor the received and purchased kits and redistribute the near-expired kits, thus preventing the purchase of additional kits. One of the participants said:

“The authorities bought or sent as many diagnostic kits they could. They did not think what should be done if the COVID-19 epidemic subsides one day. No one thought of redistributing them among other universities and laboratory centers to at least prevent buying and wasting additional kits” (Participant #4).

2.2 Quantitative and qualitative defects in COVID-19 diagnostic tests

Higher-quality diagnostic and laboratory kits produce more accurate and reliable results. The participants reported some problems, such as the incompatibility of kits with laboratory devices, the availability of different brands of kits in the market, and recurrent errors that could be problematic in conducting experiments.

A. Noncompliance of the COVID-19 kits sent from the ministry with the laboratory equipment in medical centers

Diagnostic and laboratory kits are very important for diagnosing diseases. A participant stated, “Diagnostic kits were of different models and the devices were more or less sensitive to some kits” (Participant #17).

B. Unavailability of valid COVID-19 diagnostic and laboratory kits

Some of the participants stated that the accuracy and reliability of diagnostic kits are very important for the correct diagnosis of suspected and confirmed COVID-19 cases, and any defective diagnosis can have serious effects on people’s health. A participant stated:

“When the PCR sample extraction kits made abroad were replaced with kits produced in the country, we had many troubles. We had strange problems with these kits and all kinds of domestic brands” (Participant #2).

C. Errors in COVID-19 diagnostic and laboratory tests and the need to repeat the tests

The participants stated that several factors may affect the test results, producing unreliable results. A participant stated:

“There are many more errors in rapid tests than PCR tests. We got into a lot of trouble” (Participant #18).

3.2. A large number of COVID-19 tests

Most of the participants confirmed a large number of COVID-19 tests due to the abundant use of diagnostic and laboratory kits. They confirmed that the unreasonable performance of PCR tests by hospitals, diagnostic tests to report the statistics of patients and monitor the course of the disease, and the confirmation of sick leave by medical staff added many costs to the health sector. A participant stated:

“Everyone expected that they would be given a PCR test. It had become a common practice for clients. Maybe their fear of the disease had prompted them to do this” (Participant #4).

A. Conducting routine and induction COVID-19 tests

Most of the participants admitted that many of the samples sent from the hospital to diagnose the disease had nothing to do with the symptoms and disease of the person who was going to be hospitalized. A participant stated, “Even if the patient was a small child and needed to be admitted to the hospital, samples were still taken from them. They truly did not have any of the symptoms of COVID-19, and there was no need for such tests” (Participant #7).

B. Conducting diagnostic tests to prepare statistics and report the COVID-19 trend

Following the instructions of the Ministry of Health, positive COVID-19 cases in the country were detected and confirmed only through PCR tests for suspected and infected patients. However, many participants believed that in severe COVID-19 peaks with a large number of positive cases, it was not necessary to carry out PCR testing on a large scale. A participant stated:

“PCR tests are administered for surveillance and monitoring purposes. However, PCR testing was of no value during COVID-19 peaks because the screening of the disease was no longer an issue as it was at the beginning of the disease” (Participant #5).

C. Applying PCR tests to confirm COVID-19

Iran’s Ministry of Health has adhered to evidence-based policymaking since the COVID-19 outbreak. However, there were many inconsistencies between different departments in implementing guidelines and recommendations. Most of the participants stated the problems of conducting medical tests for employees due to inconsistency between public and private organizations. A participant said:

“We had a client who was very angry and had a military job. He insisted that the PCR test be done for him. His organizational manager only confirmed his COVID-19 leave based on a positive PCR test. So we had to do it” (Participant #10).

3. COVID-19 medicines and medical supplies

Constant changes in treatment protocols and defects in the distribution, purchase, and storage of drugs, along with the lack of strict supervision and control, have led to the waste of a significant amount of medicines in healthcare centers (21). The majority of the participants stated that most of the medicines available in these centers remained in the warehouses due to their inefficiency or expiry.

3.1. Ineffectiveness and expiration of COVID-19 medicines

Expired medications may have less effectiveness and potency. Most of the participants confirmed that factors such as changing treatment protocols, indiscriminate preparation of medicines and medical supplies without evaluating the disease process, and not redistributing medicines played an important role in the wastage of COVID-19 medicines.

A. Frequent changes in drug treatment protocols for COVID-19

The participants stated that during the COVID-19 epidemic, prescribed drugs for COVID-19 patients were changed in Iran due to controversies among medical professionals and experts, and there are still no uniform guidelines for the introduction of effective drugs for the COVID-19 epidemic. A participant stated:

“At the onset of the COVID-19 epidemic, hydroxychloroquine was one of the drugs prescribed to patients, but later it was proven that this drug has nothing to do with the treatment of this disease” (Participant #11)

B. Excessive supply and distribution of medicines without evaluating the COVID-19 trend

The participants reported that excessive loads of COVID-19 medicine were sent to medical and healthcare centers by the Infectious Disease Management Center of the Ministry of Health or the university. One of the participants stated:

“COVID-19 medicines were sent to us by the Ministry of Health. We did not order these medicines. This trend continued even until recently and the decline of the disease” (Participant #23).

C. Failure to redistribute near-expired COVID-19 medicine

The majority of the participants stated that some of the COVID-19 drugs that were not used gradually expired, were collected, and were destroyed. The redistribution of drugs by the Ministry of Health and the university could keep these drugs in the cycle of production and reuse. A participant said:

“The officials of the Ministry of Health and the University of Medical Sciences could not make a proper decision about the remaining COVID-19 drugs. Thus, many of these drugs remained in the warehouses of healthcare centers and were wasted” (Participant #12).

4. Human resources

Controlling human resource costs is one approach that has a significant impact on the performance of organizations. Neglecting this issue can have negative consequences and affect the quality of service delivery by the organization (22). The participants stated that the lack of organization and planning for the effective distribution of medical staff in screening and diagnostic centers can play an important role in increasing costs.

4.1 Ineffective organization and planning in the distribution of medical staff

Human resource efficiency refers to the optimal use of human resources to advance organizational goals. The participants stated that the ineffective distribution of human resources in health centers, inattention to the skills and experience of medical staff, and making incorrect decisions for consistent activities of healthcare centers led to the wastage of resources for paying salaries and compensations.

A. Making decisions and formulating instructions based on the function of selected COVID-19 vaccination centers

To function effectively in dynamic environments, assessing the current situation is essential. Participants repeatedly acknowledged that decisions were typically made differently during crises due to time and documentation constraints. A participant stated:

“The number of visitors and the number of vaccinations were not proportionate to the number of medical staff working in vaccination centers. A few months earlier, the authorities should have closed some vaccination centers to avoid wasting funds and resources” (Participant #7).

B. Inadequate experience and skills of medical staff in COVID-19 vaccination centers and reference laboratories

According to some participants, factors such as inefficient selection and recruitment processes, low knowledge, competencies, and skills of medical staff, and lack of any preparation for the staff were key challenges in addressing COVID-19, leading to the waste of resources and funds. A participant stated:

“Some of the medical staff in reference laboratories and selected vaccination centers did not have any work experience and were employed in these centers immediately after starting their human resource plan, which was a mistake” (Participant #9).

This study examined the most important factors contributing to the wastage of funds during the COVID-19 epidemic in the health sector in Iran. The results showed that COVID-19 vaccines, diagnostic and laboratory kits, medicines and medical supplies, and human resources were the main factors leading to the waste of health resources. COVID-19 vaccination issues accounted for the first factor leading to the waste of resources. The participants reported that the high doses contained in each vaccination vial, the failure to use the distributed vaccines and their expiration, changes in the need and demand for vaccines, failure to redistribute near-expired COVID-19 vaccines, and diverse or ineffective planning for producing COVID-19 vaccines inside the country contributed to the wastage of health resources. Following the results of the present study, previous studies have shown that the characteristics of vaccination vials, public mistrust in existing COVID-19 vaccines, negative publicity and dissemination of false information about vaccines, the existence of vaccine-resistant groups and rumors surrounding them, expiration of vaccines, ineffective distribution and delivery of vaccines, and failure to redistribute them to vaccination centers can contribute to wasting COVID-19 vaccines (23, 24). It is estimated that more than one billion doses of the COVID-19 vaccine are wasted and thrown away, of which 8% are related to vaccines that are left unused. For example, in Georgia, out of a total of 5,334,060 doses, 408,801 thousand doses of different types of vaccines, such as AstraZeneca, Sinopharm, and Sinvac, were wasted due to public unacceptance and low demand for vaccines (25, 26). Since the onset of the COVID-19 vaccination, approximately one million doses of vaccine have been wasted in Canada, and more than 12% of these doses were wasted due to expiry (27). According to the guidelines of the World Health Organization (WHO), the maximum amount of wastage in vaccines is set between 15 and 25%, and in some vaccines (2 or 5 doses), it should not exceed 5% (28). There is a need to develop detailed and organized planning and processes to reduce waste in vaccines. Suggested strategies can include identifying the wastage rate and its root causes, efficient management of vaccine products, and strengthening the supply chain management system. To ensure the transparent and traceable distribution of vaccines, the participation of organizations and healthcare centers is necessary. Vaccination plans and programs must also be put into action through a robust management system. Innovative communication methods can be used to increase the acceptance and use of vaccines in the community. These methods should be developed based on the factors underlying vaccine hesitancy to increase public confidence in vaccines.

The findings from the study also showed that the factors related to diagnostic and laboratory kits can lead to the wastage of vaccination. Accordingly, factors such as a decline in the number of COVID-19 patients and the severity of the disease, excessive supply of diagnostic and laboratory kits without evaluating the COVID-19 trend, failure to redistribute near-expired diagnostic kits, noncompliance of kits with laboratory devices, unavailability of valid diagnostic and laboratory kits, errors in diagnostic and laboratory tests, and conducting routine and induction COVID-19 tests could contribute to the waste of COVID-19 vaccines. Providing access to valid laboratory results is always one of the goals of laboratory systems. and despite the essential role they play in the diagnosis and management of many pathologies, laboratory services are usually considered one of the cost centers of the health sector (29). Following the findings from the study regarding diagnostic tests, a study showed that diagnostic COVID-19 tests are undoubtedly useful epidemiological tools, especially for estimating the prevalence of asymptomatic COVID-19 cases. If it is truly the case that only 5% or more of the population is infected with SARS-CoV-2, performing millions of antibody tests may not help clarify the overall prevalence picture and may not be necessary (30). A study conducted by William et al. in the US health system showed that in 2019, resource wastage due to additional treatments, low-value care, and unnecessary screening and tests varied from $75 to 101 billion (31). The participants in the present study reported that at the COVID-19 peaks, all clients who had clinical symptoms of the disease insisted on unnecessary diagnostic tests as a part of providing low-value and repetitive additional medical services. If the diagnosis criteria were based on the clinical symptoms of COVID-19, the frequency of tests performed could be less than this number. Planning to improve laboratory services according to the COVID-19 trends, peaks, and genetic mutations of the virus, predicting the number of required laboratory kits and items, choosing effective and reliable equipment and kits, supply chain management (estimation, planning, distribution, and monitoring), and employing qualified medical staff can play an effective role in promoting diagnostic and laboratory services as well as reducing resource wastage related to diagnostic and laboratory kits.

The findings of the present study also revealed that changes in treatment protocols and unplanned and excessive supply of COVID-19 medicine without evaluating the trend of the disease lead to ineffectiveness of medicines and their expiration in medical centers and waste of valuable resources. Accordingly, optimal planning and management of COVID-19 medicines and medical supplies make it possible to prevent wastage and improve the efficiency of the health system. To better supply drugs and medical supplies in medical centers, paying attention to the function and safety of drugs, as well as their distribution and supply processes, is of high significance. The efficient management of the supply, storage, and distribution system of drugs is one of the most essential and effective factors in guaranteeing the quality of healthcare services. Medicines play an important role in the relationship between the patient and health services. Inefficient management of medicines, especially in the public sectors of developing countries, is an important challenge that can lead to cost savings and increase public access to medicines if resolved efficiently (32). A review of the literature shows that inadequate inventory control accounts for the loss of 4 to 9% of drugs in supply systems. More than half of drugs are improperly prescribed, distributed, or sold, especially in developing countries, where there are limited regulatory procedures for the use of drugs. Improving accurate inventory management and effective regulatory measures can prevent the waste of drugs and valuable resources (34, 33). A study conducted from 2012 to 2014 in the Federal City of Addis Ababa showed that the average rate of drug wastage during this period was 4.8%, mainly due to weak management, absence of audit procedures, transparency, and accountability in the Ethiopian pharmaceutical system. These problems can increase healthcare costs and disrupt the improvement and optimization of the pharmaceutical system (35). Following the findings from the present study, Abera Bedasa Alemu et al. (2023) showed that the wastage of medicines in Ethiopia is due to the delivery of near-expired medicines to health centers, sudden changes in treatment practices, and overstocking of medicines due to incorrect prediction of drug demands during the COVID-19 pandemic (36).

Roustit et al. examined hydroxychloroquine and its effect on COVID-19 in laboratory conditions, and the results indicated the effectiveness of the drug against SARS-CoV-2. However, as of mid-2020, clinical data have failed to confirm the effectiveness of these drugs in patients with COVID-19. On the other hand, unscientific publicity about this drug led to more than a hundred studies, endangering resources and delaying accurate tests in the treatment of COVID-19 (37). Drug waste imposes heavy costs on community health and the world economy. Innovative solutions, including the use of advanced technologies to improve the shelf life of drugs, more accurate methods for managing drugs, optimizing drug consumption, advanced information systems, and drug management for more accurate tracking of drug inventory, are recommended, which will improve drug management and reduce health and economic costs.

The data in the present study also indicated that the waste of human resources affects the management of the COVID-19 epidemic due to ineffective organization and planning in distributing medical staff, the lack of experience and sufficient skills of the medical staff, the adoption of academic and staff decisions and instructions for the activity of the centers, and the failure to update their executive instructions. Effective delivery of healthcare services is critically dependent on human resources, and concerns include the number, type, distribution, and inefficient performance of medical staff (38). Carnevale et al. showed that the success of organizations depends on the effective combination of financial, human, and logistical resources to achieve short-term and long-term goals (39). The results of the present study also showed that the organization of human resources in selected COVID-19 vaccination centers requires more detailed planning and policies to prevent the wastage of financial assets, time, and human resources.

Limitations of the study

One of the limitations of this study was the limited generalizability of its findings. However, the instructions and protocols provided by the Ministry of Health to control the COVID-19 epidemic in the health sector are almost similar and identical. Thus, the findings of this study can be generalized with caution. Another limitation of the study was the unavailability of deputies and academic administrators because of managerial changes in the new government of Iran. Moreover, given the sensitivity of the subjects and the wastage of some resources such as vaccines, some participants were hesitant to attend the interviews for political reasons.

Healthcare systems are struggling with an unprecedented crisis. The crisis caused by an infectious pandemic has revealed a very different dimension of management in the health systems of countries. The COVID-19 epidemic and other crises present us with opportunities to accelerate some of the changes we may already have or to challenge some long-held assumptions and think more creatively about new procedures. Given the limited health funds and the increased healthcare costs, effective preparation and planning and making reasonable decisions for unexpected events can minimize unnecessary costs and resource wastage, which requires some revisions in attitudes toward COVID-19 management in the healthcare sector. Cost management is based on the view that costs do not arise by themselves, but management decisions involve how to use the organization's limited resources. Accordingly, solutions such as effective planning, strengthening of health infrastructure, formulation and implementation of protocols and detailed instructions, promotion of public awareness, cooperation and coordination between institutions, review and evaluation of current costs, review and optimization of work processes, and reduction of labor costs, improvement of inventory management, accurate planning, correct recognition of needs, and use of innovative solutions to reduce costs and maintain service quality, trying to reduce costs of procurement of medicines, equipment, and consumables, and optimal use of available resources can minimize the wastage of resources. To determine what is “routine”, what is “necessary” and what is “exceptional”, it is necessary to make medical and health decisions in the paradigm of high-quality and effective care, with minimal resource waste, and to adopt the best healthcare solution and initiatives in acute and critical conditions. By taking preventive measures in potential scenarios and having effective plans, health systems can ensure the efficient allocation of resources. In addition, any unexpected event can be addressed quickly and efficiently. Such measures can contribute to minimizing costs and wasting resources, especially in times of bad economic conditions or when resources are scarce. Thus, it is essential to have a proactive approach to crisis management that is both cost-effective and efficient.

Ethics approval and consent to participate:This study was conducted based on the regulations and ethical guidelines approved by the Ethics Committee of Kerman University of Medical Sciences, with reference number IR.KMU.REC.1401.253.. They were fully informed about the research purposes, the voluntary nature of participation, and their right to withdraw at any time without any consequences. Privacy and anonymity of the participants were guaranteed throughout the study. Written informed consent was obtained from the participants before conducting and audio recording the interviews.Consent for publication: All participants in this study have provided their informed consent for the publication of the research findings in scientific journals. They have emphasized that their personal identities will be kept confidential, and any identifiable information in the article will be presented in an anonymous format. Participation in this study and the publication of its results have been voluntary and without any discrimination towards the participants. If interested in receiving a copy of the final results of this study, they may contact the corresponding author

Availability of data and materials: The datasets generated and analyzed during the current study are not publicly available due to confidentiality concerns and institutional regulations. However, reasonable requests for data access may be considered by contacting the corresponding author.Competing interests: The authors declare that they have no competing interests.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions: Each author contributed significantly to the conception, design, data collection, analysis, and interpretation of the study. Vahid Vatandoost, Mohsen Barooni, Seyed Saeed Tabatabaee, and Maryam Okhovati were involved in drafting the manuscript and revising it critically for important intellectual content. All authors have read and approved the final version of the manuscript.

Acknowledgments: This paper reported the results of a research project conducted as part of the requirements for a doctoral dissertation with the code 401000260 from the Kerman University of Medical Sciences. The authors would like to thank the vice presidents and managers and experts of the health departments of Kerman and Mashhad Universities of Medical Sciences who willingly participated in this study and shared their opinions and experiences about the factors underlying resource wastage in the management of the COVID-19 pandemic in healthcare centers.

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No competing interests reported.

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Explaining the resources wastage and its underlying factors in COVID-19 management in Iran: A qualitative study

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