Investigating the Cooperation Status Between the Health System and City Councils and Municipalities in Iran (Documents’ Analysis)

Background: The present study is aimed at investigating the cooperation status between the health system and city councils and municipalities in Iran based on rules and documents. Methods: Altheide’s document analysis model (sample selection, data collection, data organization, data analysis, and reporting) was employed in order to prepare and analyze the documents pertaining to the cooperation level between the health system and municipalities and Islamic city councils. The documents were classied at three levels including the national rules, policies, and guidelines; Ministry of Health (MOH) and city council approvals; and eventually Tehran Municipality’s measures. Results: Overall, 78 documents were analyzed including 17 documents at the level of national rules, policies and guidelines; 8 documents at the level of Ministry of Health and city council approvals; and 53 documents at the level of Municipality’s measures. Conclusion: There are adequate legal capacities for designing, planning, executing, as well as creating interaction and cooperation between health system and city councils and municipalities. Moreover, the motive behind creating a purposeful and scheduled cooperation and participation is evident among the ocials of health system and city councils and municipalities. Some mechanisms have been established for cross-sectoral cooperation between the health system and other health-related bodies on a cross-sectional basis, but these structures lack the necessary competence, appropriateness and adequacy to create the desired partnership, and especially sucient attention to existing capacities in municipalities and The city council has not. Accordingly, it is necessary to have a fundamental review on the available structures and enough attention has to be paid to the evident and hidden legal capacities in city councils, and municipalities, as well as Ministry of Health to design an appropriate structure and create competent interaction and also provide more cooperation between the two organizations.


Introduction
Population growth on the one hand and increasing demand and need to health services and healthrelated costs on the other hand have made the health issue's policy makers and international communities to conclude that health system and municipalities and Islamic city councils as two important and strategic organizations should work together and proceed along with each other with serious cooperation and interaction in line with health objectives (1,2). In the UK, this kind of cooperation is designed and executed in a purposeful manner through creation of London cooperation group (3). In Scandinavian countries, Ministry of Health has given some of its duties over municipalities and it acts as a policy maker and examines them (4).
In Iran, all health care services, from policy-making to implementation and monitoring, are all the responsibility of the Ministry of Health. All service centers, even health centers in rural areas, provide services under the supervision of medical universities. Municipalities have no duty to provide health services, and medical services in municipalities are provided only for staff working in the municipality.
Municipalities often take action in the eld of health, which is often appropriate and usually not based on the priorities of the Ministry of Health. Many actions are taken simultaneously and jointly by the municipality and the universities of medical sciences, which means parallel activities and wasted resources.
Examining the documents available in the three sections of rules and regulations, city council approvals and municipal actions shows important points. The present study is aimed at addressing the question of to what extent the cooperation between Ministry of Health and city councils, and municipalities in Iran have been included and supported in the rules, policies, and guidelines and also executive programs.

Material & Methods
Altheide's 5-stage document analysis model was implemented for investigating the status of cooperation between Ministry of Health, city councils, and municipalities in Iran (6 5). The stages included sample selection, data collection, data organization, data analysis, and reporting ( Fig. 1). The examined documents in the present study included the rules, policies, and guidelines and approvals and planning pertaining to the cooperation between Ministry of Health and city councils and municipalities which were available to the public. The documents were classi ed in three sections of rules and regulations, city council approvals and municipal actions. Among all municipalities, the actions of Tehran Municipality as the capital and metropolis were examined. These documents were searched from the national o cial websites and relevant professional organizations.

Inclusion and Exclusion Criteria
Among the obtained documents, the approvals and documents were exclusively examined which in a way contained the concept of cooperation, and participation between Ministry of Health, and city councils and municipalities. In case the rules had modi cations, only those modi cations were employed. For the documents pertaining to Tehran's municipality measures, only the measures relevant to the years 2011 to 2018 were included in the study based on the wide range of activities.

Second stage: Data Collection
The national rules, policies and guidelines were obtained by searching through the website of Islamic Parliament of Iran, Parliament Research Center, Academy of Medical Sciences, Ministry of Interior, Supreme Council of Provinces, and National Rules and Regulations System. The documents pertaining to Ministry of Health and city council were collected through referring to the websites of Ministry of Health, the portal of the Ministry's Social Affairs Department, the National Base of Health Rules and Regulations, the website of Tehran Council, the Health and Social Commissions of the City Council, as well as the comprehensive system of approvals of the council of Tehran. With regard to the documents related to the measures of Tehran's municipality, the website of the municipality and Portal of Tehran Municipality Health Department were checked. The keywords including health, hygiene, memorandum, cooperation, municipality, city council, medicine, and treatment were employed.

Third level: Data Organization
At this stage, all the obtained data and documents were classi ed in three groups of national rules, policies, and guidelines; the approvals of Ministry of Health and city council; and Tehran Municipality measures.

Fourth stage: Data Analysis
At this stage, the obtained data analysis in all three groups was done using 10 NVivo (QSR International: accessed 2 November 2016). The table of notes and data was employed for making a comparison between the documents in each group and between the three groups. The concluding remarks were combined and the research intended points were obtained.
Fifth stage: Report At this stage, the key concepts and ndings were combined and the researcher interpreted the ndings.

Results
All the relevant websites and databases were equipped with search engine and were able to search the keywords. The documents' selection was carried out at two stages. In the rst stage of the search, 26283 documents were obtained among which, 26005 were irrelevant considering the scope of the research and accordingly 2785 remained. At the second stage, among the documents of the rst and second groups (the documents related to national rules, Ministry of Health, and Tehran Municipality measures), and among the documents of the third group (Tehran Municipality measures), 3 documents due to having modi cation and 197 documents due to being referred to the years before 2011 and after 2018 were excluded, respectively. Eventually, 78 documents were analyzed which respectively included 8 and 53 documents related to Ministry of Health and Tehran council, and the measures and performance of Tehran Municipality (Fig. 2).

Discussion:
Based on 2025 vision document of the Islamic Republic of Iran, for achieving the objectives, i.e. having health, welfare, food safety, social security, equal opportunities, revenue appropriate distribution, strong family institution; being away from poverty, chaos, discrimination; and enjoying desirable environment cannot be achieved unless a cross-sectoral cooperation and participation exists between the relevant organizations and concerning the health sector, there is no way but creating purposeful and scheduled cooperation and interaction between health system and city councils and municipalities (7). In healthcare sector, in the fourth national development program, and also the general policies of health, the Supreme Leadership Authority has also referred to this important issue (8,9).
In 2017, National Health Assembly was formed on behalf of Ministry of Health with the aim of popularizing health and explaining the role of other institutions including municipality in line with promoting health (10,11). In addition, Supreme Council of Health and Food Security (SCHFS) was formed (12). National Health Assembly and Supreme Council of Health and Food Security have been formed in all provinces and cities and the members of city councils and municipalities have the membership of these two councils too.
One of the important points that was obtained through examining the documents was that in none of the available documents, a structure or position is observed for creating cooperation and interaction between city council and municipality, and health system. Moreover, in the mechanisms formed for creating a cross-sectoral interaction and cooperation between Ministry of Health and other organizations including National Health Assembly, Supreme Council of Health, and Strategic Council of Health, there has been minimum attention to the capacities and capabilities of city councils and municipalities for promoting citizens' health status.
Through reviewing the available documents related to national rules and regulations, it can be observed that according to article 29 of the Constitution, the government is obliged to provide people with healthcare services form public revenues, as well as revenues form people's participation (13). A signi cant part of municipalities' revenues is gained from public revenues and also the revenues resultant form people's participation; as a result, city councils and municipalities are obliged to present a precise program in line with promoting citizens' health and the expenditures have to be reviewed based on national health policies.
According to articles 4, 6, and 15 of municipalities law approved in 1956/01/25, municipalizes are obliged to consider the health affairs of citizens and cooperate with the institutions of Ministry of Health; therefore, adequate authority and responsibilities have been determined for municipalities in healthrelated affairs (14). Based on the statute of the Academy of Medical Sciences of the Islamic Republic of Iran (15), and the mission developed for it, the academy has the required authority and responsibility to predict, explain, and take measures in line with creating cooperation and interaction between city councils and municipalities and health system or even creating an appropriate structure with explaining the duties in a clear manner along with examining its performance (16, 17).
Although Tehran Health Strategic council has been formed with the goal of promoting health in Tehran following the conclusion of a memorandum between Ministry of Health and Tehran Municipality (18) presided over by the head of Academy of Medical Sciences and membership of senior o cials of Ministry of Health and some other relevant organizations, on behalf of city councils and municipalities, instead of the presence of the senior o cials in decision making affairs, the head of Health and Welfare Committee has joined as a member in this council (19). It seems that the importance and position of the abovementioned council is in a way that the membership and presence of the head of city council and municipalities is considered more effective in important decision makings concerning citizens' health.
In investigating the documents related to Tehran Municipality approvals, it was observed that in spite of the existence of appropriate legal grounds and wide range of capacities and also the inclination towards taking measures in health led by city council and Tehran Municipality on the one hand, and the increasing needs and lacks of the health system, there has been only 8 approvals among various approvals of city council so far since the formation of Tehran city council in 1997 on the other hand. This indicates the cooperation level of city council and municipality with the Health system which also reveals the negligence of the health system in employing the capabilities of city council or municipality in the health promoting eld. Among the above-mentioned 8 approvals, two cases regard the physical needs (20,21); one case regards equipment provision for services offering (22); two cases concern cultural measures for the health sector (23,24); one case is about the recommended measures to the superior and legislature sectors (25); and two cases regard the necessity of implementation of some activities concerning health (26, 27) by municipality and city council.
Reviewing the documents pertaining to municipality measures shows that the o cials and policy makers both in Ministry of Health, and city council and municipality, have reached the conclusion that for ful lling the objectives of a community's health and its improvement, interaction and cooperation should be created between these two important institutions which includes Ministry of Health as the major policy maker and agent of the community and city council and municipality as the policy maker and st-line executor of access to and communication with local community. These documents demonstrate that in Iran, the rst step for reaching this strategic objective (interaction and cooperation) which is understanding the necessity and feeling need has been considered and an acceptable understanding has been created by both parties, i.e. Ministry of health and city council and municipality (28,29).
Among these documents, the cooperation memorandum is available which has been concluded among Ministry of Health and municipality (2013/12/27) (30). Subsequently, in separate interviews, the o cials of Ministry of Health emphasize on the importance and necessity of employing cross-sectoral cooperation, particularly making use of the capacities and capabilities of the city council and municipality for improving the health status of citizens (31,32). The head of Academy of Medical Sciences, who is at also a member of the Health Commission of the Parliament, refers to the formation of the Strategic Council of Health on 2014/2/7 in order to make changes in the health status of citizens (29). Eventually, on 2014/2/16, the rst meeting of Tehran Strategic Council of health is formed in Academy of Medical Sciences (28) and following that, the next meetings are hold in turn aimed at compiling the statutes and strategies of council (32,33). In the same vein, city council and municipality also take measures with the aim of creating interaction and cooperation with Ministry of Health as health general directorate of Tehran Municipality has concluded a cooperation document with Tehran University of Medical Sciences on 2018/9/19 (34). These documents are indicator of understanding the need and necessity of an interaction and cooperation between these two in uential intuitions by both parties.
Some internal documents also show that despite guring out the importance of the correlation and the necessity of cross-sectoral interaction to promote citizens' health, the capacities of city council and municipality are not taken into consideration as they should be. In Strategic Council of Health, the head is Sciences, head of Iranian Health Insurance Organization, World Health Organization representative, Director General for the Medical System Organization, the head of Health and Welfare Committee of Tehran City Council, and many real members. As it is evident, among Tehran city council and municipality, just the head of Health and Welfare Committee of city council is a member of this important council in spite of the existence of a wide range of capacities (28). However, in case London corporation group is formed in London, the mayor is considered at the position of the head of group and it seems that the UK o cials have gured out the wide range of the capacities and potentials of municipalities as the frontline of dealing with the people of community seriously (4) which has not been much attended in Iran.
The documents show the wide range of activities carried out by municipalities in health-related issues which implies high budget expenditure in this regard. The serious question now is how much of the mentioned activities is based on the priorities of Ministry of Health, and basically whether the policies of Ministry of Health are communicated with this in uential and active institution in the eld of health (35). The documents are indicator of the fact that municipality possesses signi cant capacities in addition to the capabilities for taking measures based on occasions. The mentioned capacities include employing local professional workforce in the eld of health (57, 58), using international capacities to promote health (59, 60), providing preventive and screening services (61, 62), cooperating with national macro plans in the eld of health (63), taking action to promote the health of needy citizens (64,65,66), taking action to promote the health of certain groups (38,66,45), improving the level of public awareness in the eld of health (67, 68), building permanent places to provide services and improve citizens' health (69, 70), providing some determined health-related services extensively (71,72,73), empowering the status of creating conditions appropriate for students' education in the eld of community-based health, or in other words, education based on sociology of health (74), taking actions to achieve the national macro-policies which are related to community health including lifestyle changes and strengthening family foundation (75, 76,77), empowering the condition to create synergy of health service providing sectors (78), meeting the needs of local health providing service units (79,80), empowering the status to change citizens' viewpoints to prioritize health among citizens (81,82), empowering the status to create the required grounds for providing cheap services to the general public (83,84), and empowering the status to create the necessary conditions to improve the capabilities of health activists (85).
Another important issue which was evident is that in spite of understanding the necessity of cooperation with each other in this regard, the o cials of Ministry of Health, and city council and municipality still act based on their speci c duties and diagnosis which is the factor for many parallel and repetitive measures resulting in wasting resources. Most of the signi cant measures taken by municipality are also undertaken by various units of Ministry of Health simultaneously which include most occasional programs, employing the capability of charity organizations, providing services, making an attempt to promote the health-related awareness of the community, and providing services to needy groups in the form of volunteer groups (86,87).
Each organization makes use of various resources including human resources, nancial resources, etc. for the mentioned measures that at the same time, consolidating resources and taking actions according to certain predetermined policies will double the country's success in ensuring people's health. This indicates the gap of existence of a clear and determined structure for forming mutual interaction as well as cooperation between the health system and councils and municipalities. It is clear that in case this kind of mechanism is created, most of the repetitive actions and accordingly the resources waste will be removed. With the formation of Strategic Council of health, there was a hope to form an effective mechanism; however, in the available documents, no o cial and legal structure is observed with the required executive capability.

Concluaion:
There are adequate legal capacities for designing, planning, executing, and creating cooperation and interaction-speci c structure between the health system, and city council and municipalities (14,13). There is also the necessary motive behind creating purposeful and scheduled cooperation between the o cials of Ministry of Health and city councils and municipalities (18,34). There are also mechanisms for creating cross-sectoral cooperation between health system and other health-related institutions; however, in these structure, the capacities of municipalities and city councils have not been employed as they should be. As a result, either a determined structure for this important issue should be designed, or the available structures should be reviewed (28,11  Altheide's 5-stage document analysis Document Selection