In the present study, we aimed to evaluate the trend of healthcare indicators across a ten-year period and to assess the possible impacts of the UFPP intervention on the trend of indicators in Bonab County, Iran. Our findings indicated that the UFPP has resulted in changes in some process indicators such as MCU, the rates of postpartum and six-times care visits during pregnancy. However, other process indicators such as the rates of prenatal care, first-time care visit during pregnancy, and brucellosis and tuberculosis incidence rates were found to not be affected by the intervention, and were still in an aggravating trend. Also, some proximal outcomes such as the rates of delivery in high-risk groups, CS, childbirth by unskilled personnel, TFR and distal outcome indicators such as MMR were positively impacted by the UFPP. However, the trend of other outcome indicators associated to stillbirth, NMR, IMR and 1–59 months MR were found to not be positively impacted by the intervention.
After the implantation of UFPP, the rate of MCU had a remarkably decreasing trend and the rate of TFR was increasing, which may be due to implementing the new population growth policy announced by the Iranian Supreme Leader to increase population [18]. As a consequence of implementing this policy in the frame of UFPP in this period, free of charge contraceptives were not available for all women of fertility age, family planning measures were restricted, and the protocol of distributing contraceptives in health centers were improperly implemented, which may be altogether resulted in an increasing trend in the rate of delivery among high-risk groups (age groups younger than 18 and older than 35). Thus, the health of high-risk mothers and their children was endangered due to childbirth outcomes, such as increase in the rate of LBW [19]. These results are consistent with those reported in a previous study conducted in an Iranian rural population [20]. Although the trend of LBW in our study had an increasing trend after intervention, the increase in slope was not significant, due to the non-significant interaction between time and intervention.
Our findings also showed reductions in the rates of postpartum care visits and six-time care visits during pregnancy after the intervention, which was in line with those reported by Jabari et al [16]. As the number of staff (family health care providers) in the health centers increased, as recommended in the UFPP protocol, we expected an increasing trend in the rate of maternal care, but we did not find such a result. This issue is likely due to the simultaneous launching of the Electronic Health Record Plan (EHRP) with the UFPP, which could have resulted in a remarkable difference in the recorded statistics between electronic-based and paper-based registrations. Another possible reason to decline in the rate of maternal care may be the low quality of governmental health sector services [21] after implementing the EHRP, as the healthcare providers had to fill in a high number of electronic forms for a referring mother and thus did not pay enough attention to the needs of clients, and mainly referred them to the private sector based on the electronic system. As a consequence, the rate of maternal care was gradually decreased. Similarly, the limitation of inputs and lack of resources and skilled health care providers have been also reported to restrict the sustainable development of a health care system [10]. However, the issue seems to be explored with a qualitative approach in future studies with the hope to find any possible reason for the problems.
According to previous studies, better access to healthcare services can improve quality [21] and decrease maternal mortality rate [22]. Also, reduction in MMR was considered as a significant achievement of the family physician reforms in previous studies [23, 24]. In our study, however, the findings were not consistent. Although the overall MMR was declining during the whole period, the trend was found to be in an increasing manner after intervention. These contradictory results may be pertinent to social determinants of health and poor quality in health services delivery [16, 25]. As Kablinski et al. suggested, such mismatch between access to healthcare and high maternal mortality rate may be possibly due to low quality of services [26]. Therefore, further investigation on this issue, particularly through qualitative studies to explore any possible obstacles, is also recommended.
In the current study, the rate of CS was relatively upward during ten years. However, according to significant interaction between time and intervention, the trend of changes before and after the implementation of UFPP was different; the increasing trend was faster before intervention and slower after intervention, but the trend was still continued to be increasing after intervention. According to literature [16, 27–29], despite the health interventions and even some great economic and demographic changes, the rate of CS was still in an increasing trend [24]. In Iran, similarly, after implementing the special package provided by the Ministry Of Health (MOH) in 2013 to reduce unnecessary CS rate, some reduction was happened, but there is still a long way to achieve a desired rate, as noted in previous studies [30, 31]. Some measures have previously been recommended to reduce the CS rate including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, enhancing patient-centered decision making through public reporting [28] and health instructions [32, 33].
Although in several previous studies [16, 20, 34–36], a decrease in the rate of LBW was reported as an important achievement of family physician programs, we found the UFPP with no positive impact on reducing the trend of this indicator in the studied setting. In a previous study, LBW was found to be associated to family income, and the authors suggested that any improvement in reducing the rate of LBW was highly depended on the associated social determinants such as, income status, maternal education and occupation [37]. As Tu et al. reported, family socioeconomic position (SEP) was usually positively associated with birth weight [38]. Alemo et al. similarly studied the LBW prevalence and its associated factors in Ethiopia and reported that the prevalence of LBW significantly associated with the mothers’ non-employment, residing in a rural area, unintended pregnancy, non-attending antenatal care, mothers with greater than three births, birth interval less than or equal to two years and intimate partner violence during pregnancy [39].
Since a significant increase was happened in the number of physicians and family health care providers after the implementation of UFPP, we expected an improvement in the rates of prenatal mortality indicators such as, SBR, IMR, NMR, and 1-59MMR. But, the UFPP was found with no significant impact on the indicators. Many studies reported the decreasing trend of such indicators after implementing similar family physician programs [23, 24, 40, 41]. Naderi et al. studied the effects of rural FP program on child mortality indicators in rural areas of Iran and reported that after the initiation of program, in 2005, the NMR and IMR decreased in comparison to the previous years, but no significant change was observed in U5MR [6]. Chinhoyi et al. also found that FP and medical officers supply were not significantly associated with the incidence of under-5 mortality [42]. Jabari et al. similarly studied the effects of rural FP program on maternal and child mortality indicators in Iranian rural areas, and reported no significant change in the NMR [16]. All these findings suggest that some healthcare indicators, like child mortality rates, are not only depended on the provision of healthcare services but also affected by some context-originated determinants like socio-cultural, behavioral, economic and policy factors. Several previous studies have emphasized the possible role of income, health education and socio-cultural factors [43–46] in promoting healthcare indicators within different societies. According to the literature, medical care is responsible for only a small percentage of preventable mortality and evidence highlights the importance of social and particularly socioeconomic factors in shaping health [47–49]. Therefore, in order to better implement the UFPP, it is recommended to plan for a revisiting program, with a great focus on social determinants of health. To our knowledge, the present study is the first comprehensive analysis of the effects of the UFPP on health indicators. A limitation of our study was that some new health care services, including the diagnosis of non-communicable diseases (e.g. type 2 diabetes and hypertension), and healthy nutrition and mental health services were incorporated into the PHC since the initiation of the UFPP. Although trends in the associated indicators were increasing after the implementation of the plan, we could not profoundly evaluate the trend through ITSA, which was due to time-limit for intervention and lack of indicators prior to the UFPP. Previous studies on FPP in rural populations have particularly investigated the management of diabetes and hypertension and found that healthcare services with experienced healthcare workers and comprehensive guidelines can play an important role in the prevention and management of non-communicable diseases [50]. Therefore, further studies should be conducted with different approaches, either qualitative or a mixed of methods, among urban population to determine the impact of UFPP on such health indicators.
In this study, we applied the ITSA which may be considered as one of the strongest designs to evaluate the impact of UFFP on health indicators. Similar studies have not been conducted in Iran. In Taiwan, Chyi-Feng et al. reviewed the 10-year of health care reform on family practice and studied quality care indicators including structure, process and outcome, and reported that after the initiation of program, the members received more preventive care services compared to non-members [51]. While reading the findings of present study, we should keep in mind the undeniable role of economic sanctions against Iran on the UFPP implementation and funding, and the healthcare indicators as well. Sanctions, as a social determinant of health, have indirectly affected the Iranian health system [52],and directly affected the increasing trend of child mortality rate [53]. The impacts may be through making difficulties in purchasing health care, promoting people’s overall welfare, and reducing accessibility to necessities of a standard life like nutritious foods, healthcare and medicine, especially in the lives of patients, women, and children [54, 55]. With regards to the potential role of family physician programs in quality, cost-effectiveness and competency in health care [2, 4], qualitative studies should be conducted to explore deeply the efficiency and impacts of the program and to evaluate the process of the plan and identify the possibly wide range of factors associated with the implementation of the program.