M.E. conducted interviews with 15 participants from September 2023 to February 2024. We contacted 22 individuals, but seven have yet to reply. We provided details about the participants in Table 1. Some participants had both managerial and academic backgrounds. The qualitative analysis findings are based on interviewees' direct responses and the topics they raised.
Table 1
Participant’s attributes.
| Row | Type | No. of Participant | ID Code | Corporate Position (No. of Participant) |
| 1 | Policy level manager | 2 | PP | MOHME vice president(2) |
| 2 | administrative/coordinative level manager | 5 | PC | University president (2) University vice president(3) |
| 3 | operational level manager | 8 | PO | Health Network Hospital president (2) |
| AE | Related university Academic Member(6) |
Integrated, effective, and efficient care, which is one of the main objectives of regionalization, must be considered at all three levels of the health system: macro (policy), meso (administrative/coordinative level), and micro (operational) levels. Regional organizational Authorities are meso-level entities in the health system, but they cannot work independently. Only through increased coordination among these levels can the regionalization goals be realized. This study categorizes the requirements of health system regionalization at each level into three themes and 23 sub-themes (Table 2, Fig. 1).
1. Policy Level Requirements’
1.1. Socio-political context (Structural Factors)
The structural context is set up by system-driving or inhibiting factors, including economic, social, cultural, historical, political, legal, and regulatory factors. Regionalization requires the health system to have the economic capacity for implementation and sustainability, and influential political groups must support its development
"In a developed country, the people's culture may not favour political interference in the health domain, whereas, in Iran, people even demand such interference to establish health services in their local area and even consider it a reason for electing a political figure." AE1
Table 2
Requirements of Health System Regionalization
| Row | Domain/ themes | Sub-themes |
| Dimension | Process | Outcome |
| 1 | Policy level Requirements’ | Socio-political context | Spatial Development Strategies | Configuration of Regions |
| Interoperability |
| Regional Disparities |
| Governance |
| Decentralization |
| 2 | Administrative/ Coordinative Level Requirements’ | Organizational Factors | Regional Planning | Regional health Authorities |
| Capacity Factors |
| Stakeholders Partnership |
| Public Involvement |
| Regional Governance |
| Financial Arrangements |
| Regulatory Mechanisms |
| 3 | Operational Level Requirements’ | Provider and Patient Factors | Provider/ Consumer socio-cultural Marketing | Integrated Health Networks(IHNs) |
| Health Services Provision Models |
| Clinical Governance |
| Virtual Networks |
Additionally, the legal and regulatory aspects and foundations must be explicit and clear, enabling the defense of its implementation.
"Family physician programs have been the subject of extensive discussion in Iran, but the pilot project remains incomplete despite years of discussion. In other words, the laws, requirements, and legal foundations supporting this issue and underpin its structures are still lacking." AE6
Initiatives require societal acceptance, so individuals and groups with social power can influence societal behaviour and customs, preparing society for and participating in reforms without political, economic, legal, or regulatory power support.
"Cultural issues are the most serious problem. The public, health managers, and non-health managers' mindsets do not align with the logic of regionalization. People, providers, and officials believe that receiving and providing services is the right of the people, and services must be available and provided everywhere in the shortest possible time." PP2
The cultural characteristics of the target population, such as participation and cultural cohesion, are critical to the implementation of such a plan.
"Decreased social cohesion entails increased local competition for access to resources instead of seeking consensus and participation in accessing these services. This problem has led to unscientific and inefficient resource allocation among communities, sometimes without ensuring fairness."AE4
Technical and technological abilities can standardize initiatives, promoting society's acceptance. Competent experts should establish a scientific and technical roadmap for long-term regionalization programs, ensuring overall growth and systematization in national and regional development programs.
“The short duration of management teams and changes in new leaders have led to insufficient commitment to long-term programs, resulting in not designing monitoring and evaluation systems.” PP1
An essential part of regionalization is the interoperability of the factors above and crafting a shared cognitive framework among them. It is necessary to reach an inter-professional consensus on these determinants. Establish coherence in the macro-social domains and with policymakers, ensuring a shared understanding of the program and its implementation necessity.
“Policymakers must adopt a dynamic and sustainable approach to address health system issues like increasing healthcare costs and resource inadequacy. This decision will lead to the realization that reforms like regionalization are inevitable; as a result, policymakers and the public get aware of the current state of the health system and the need for change.” PP2
Furthermore, during the implementation stage, we should consider the participation of all operational levels and stakeholders. This involvement will increase acceptance of the program and reduce resistance to its implementation.
"Policymakers face the challenge of explaining and justifying decisions to the public, while community participation in decision-making processes facilitates implementing such programs. It emphasizes people's responsibility to change their behaviour and align with the program, ensuring they are adequately informed and prepared to embrace it from the start." AE3
The public should be involved in policy-making, providing community leaders with information about current situations and resources to define prioritized needs for each region. Such engagement will be much more efficient than community involvement in the implementation.
“Implementing specialized and technical programs is challenging for the public and their representatives due to their lack of knowledge (such as Health Volunteer Program experience).” PP1
1–2 Regional Disparities
As a human system, the health system must adapt to societal changes, such as population, geography, politics, community capacity, and subcultures, to ensure effective management and delivery of health services. The future health system in Iran will be influenced by constant demographic changes, including migration (from rural to urban areas and of health professionals abroad), climate change, population shifts, and population pyramid changes. Migration, which creates a social mix, can lead to declining social cohesion and participation in public programs.
"Historically, our country's nomadic, migratory nature, dependence on agriculture and livestock, and arid climate have led to communities constantly migrating and searching for resources. Climate change has worsened this situation, increasing population concentration in areas with suitable living conditions." AE5
The burden of disease, region-specific diseases, and the cost of treating and controlling them influence resource allocation. Shifting from communicable to non-communicable diseases necessitates a health system redesign to maintain an enduring relationship between the system and society. Iran’s diverse climates and epidemiological patterns necessitate attention to regional climate conditions, as sudden climate changes can disrupt communication, even with adequate infrastructure, emphasizing the importance of communication infrastructure in regionalization.
1–3 Governance
Regionalization aims to improve governance and leadership by centralizing power at the regional level, abolishing local authorities, merging functions, and delegating decision-making to independent institutions. It requires organizational solid relationships between central and local authorities. The governance structure can be evaluated by examining the power delegated in regions from the central level and the centralization of health service providers within a specific region
Thus, a robust governance structure that offers incentives makes regional organizations autonomous while fostering cooperation and competition and meets health system goals via effective administration is necessary. Therefore, government and non-government organizations should collaborate to achieve sustainable regional development.
1–4 Decentralization
Decentralization in the health system, transferring functions from central to regional structures, makes it possible to integrate healthcare providers and facilities to meet community needs. Thus, regionalization facilitates efficient cooperation and a systematic approach to regional health service provision through an organized decentralization process. In health policymaking, five core competencies, including (1) framework legislation, (2) implementation legislation, (3) financing, (4) health care delivery, and (5) regulation, may be decentralized to national, regional, and local levels in various ways, respectively.
It must delegate significant financial authority to each region, supported legally, politically, and by regulatory mechanisms to implement effective health system regionalization. The ability to finance and manage budget deficits and surpluses while the central entities act as mere supporters by granting the authority for financial exchange and budgeting among provinces and regions and giving insurance companies the authority to operate regionally is a guarantor of successful regionalization. However, the country's situation necessitates centralized budget allocation.
"The country's current budgeting system implements a system of budget return from regions and provinces, which encourages consumption rather than saving."PC1
The health system's cultural factors necessitate the centralization of legislation, regulation drafting, and executive by-laws at the program's start. Delegating authority to regions can be done later. Centralization is preferable to decentralization due to minimal regional differences and cultural influences.
Externalities’ management and health care delivery, as opposed to endemic diseases in each region, should be centralized and carried out nationally. Additionally, the national service provision model should follow a referral system approach. However, aspects such as referral levels, types of data exchanged, the distribution of physicians across different levels, etc., should be based on regional requirements and within the regional management framework. In summary, providing services with a national dimension or high costs should involve multiple regions. In contrast, the provision of services tailored to the specific needs of each region should be decentralized and regional.
Given the information system's strategic role, its regulations must be defined nationally, and other systems that exchange information with the health domain should also participate in their formulation. However, in each region, system management, as well as proper implementation, will fall under the purview of regional managers.
Centralization in administration and planning has affected the country's governing structure, not simply the health system. Since regionalization cannot separate the health domain from other systems, it is crucial to implement decentralization policies at all levels of the health system and its related systems in the nation.
"Upon further examination, we realize that this centralization has increased over time, and different governments have emphasized centralization to increase coordination."PC2
Governance-wise, the health system's control, accountability, resource allocation, and delivery might be centralized, decentralized, or both. Governments worldwide struggle to find an "optimal point" on the centralization-decentralization continuum, which may vary by context and affect political decision-making and health system structure.
1–5. Defining Regional Boundaries
The region and its boundaries outline a regionalized system. The definition of boundaries extends to other dimensions. Therefore, the regional boundaries are defined by considering the above factors for efficient coordination, resource allocation, and cooperation in forming regionalized healthcare systems. The regions are configured within the legal framework, which sets the system's organization and operation policies.
Iran's vast size may hinder the health system's ability to achieve regionalization and form an integrated health network. Therefore, it is crucial to consider the contradiction between integration and regionalization. Integration ensures service continuity at multiple levels, whereas regionalization creates new regions. It raises the question of whether to supply services nationally or regionally. These issues affect the definition of regional boundaries.
1–6. Spatial Planning
Spatial planning is a strategy for achieving financial independence in regionalized regions by considering climate, population, and capital (the region's share of GDP). It helps the region maintain its resources, ensuring self-sufficiency and independence for extended periods. It also prevents regions from relying on others for services such as health care.
"Iran's centralized resource distribution, influenced by political pressures, even poses challenges for regions producing most of the national capital and may face problems in providing their basic needs, such as drinking water, indicating improper spatial planning implementation." PP1
Spatial planning supports regionalization, which assists in the coordinated development of a region's infrastructure and resources, policy integration, and sustainable development framework. It facilitates collaboration, promotes regional balance, and provides a regional governance platform.
2. Administrative/coordinative level Requirements’
2 − 1. Organizational factors
Organizational factors include regional and/or local leadership to ensure collaboration and cooperation among different health system levels. Lack of regional leadership hinders regional governance, necessitating a detailed understanding of these contextual factors for effective regional planning and governance. Intra-sectoral cooperation within the local, regional, and national health systems is critical, as is inter-collaboration with related systems such as education, agriculture, industry, and social services. These relationships improve institutional networks, involve stakeholders, and set up governance and regulatory mechanisms that address social determinants of health.
"The long-standing mindset in the health system and others, where managers focus on their area, leads to poor intra- and inter-sectoral collaboration." AE2
The collaborative approach to health care, instead of a competitive approach, improves quality and promotes coordinated and efficient health care delivery by participating with all stakeholders. The health system regionalization creates a platform for cooperation between public and private sector entities. The various stakeholders in the health system can align their activities towards similar objectives, such as improving outcomes and optimizing resource allocation. A local board of trustees should govern the public-private partnership, balancing the public sector's interests with those of the community and all sectors.
“Numerous cases of inadequate legal frameworks hinder the full utilization of private sector capacity in healthcare delivery, as the private sector is often positioned against the public sector.” PC1
The main point is that healthcare sectors must collaborate and shift from a competitive to a cooperative mindset to achieve regionalization. Removing historical barriers to collaboration will integrate health systems' levels, ultimately improving healthcare quality and accessibility in a given region.
2–2. Health System Capacity Factors
Regional health systems' success depends on their resources, healthcare delivery facilities, and structural capacities, including environmental readiness, adaptability, and successful implementation of regional programs.
2-2-1. Primary Care Services
The regional PHC structures should focus on population health. They must be locally responsive, address local needs to achieve community development, take local and cultural sensibilities in service supply into consideration, implement multidisciplinary care at the center of planning and service delivery, integrate with other healthcare levels to ensure continuity of care and collaborate with related non-health systems to address determinants of health.
2-2-2. Hospital Capacities
The hospital's organizational structure affects healthcare delivery, outcomes, and costs, and it meets the community's different health demands. The health system has sufficient capacity for specialized and inpatient services. However, the bed index is not favorable (around .7). In this area, the primary problems in our health system are twofold: over 70% of the beds are public, necessitating a higher proportion of non-public beds, and the high number of teaching hospital beds in the public sector requires correction.
Tariff disparities impact private sector development, raising concerns about fairness in healthcare provision. However, these hospitals face unfavorable economics as physicians receive 70% of the total private sector tariff.
The regionalization process aims to achieve health for all by ensuring equity in healthcare access. Healthcare delivery in different regions depends on access to resources, especially financial resources. The issue of fair distribution of medical equipment is problematic because it hinders equity, access, and regionalization efforts.
“The distribution and availability of resources in the public health sector is almost equitable, and regulations are clear and fair. However, in the private sector, equity has not been implemented, and resources are distributed according to economic considerations rather than social needs.” PC2
2–3 Regional Governance
Restructuring the health system's decision-making structure and forming a regional social board of trustees contribute to achieving regionalization goals, fostering joint management and dialogue among technical and political members in health regions. From a hierarchical perspective, Iran's health system is regional. However, to what extent does the current structure have the ability to formulate regional health policies for the covered population, and to what extent does it implement the policies of the upstream organizations?
"Medical Universities, as regional structures, not only have the power of policy-making but are also not accountable to the upstream authorities. Even simple decisions are beyond their capacity, and the ministry resorts to lobbying to make these decisions."
The technical and political competence of the board chair (as the highest regional power) and other managers in negotiating with other institutions involved is vital to developing integrated health networks. Providing regional managers with legal, political, and social support is crucial while considering their relevant (technical and political) competencies. The regional board of trustees should select, appoint, assess, and dismiss regional managers based on technical indicators without any political pressure.
"The lack of clear indicators for the appointment and dismissal of managers is one of the problems in the health system, and political issues followed by managerial changes at the policy level influence this process." PO2
2–4 Financial Arrangements
Regionalization aims to create a more efficient, coordinated, more minor (in terms of the number of separate units), and less costly healthcare system. In analysing the financial aspects, some arrangements, such as resource redistribution, targeted budgeting for underdeveloped regions, etc., are employed to promote equity in health services’ accessibility within the region. Regional financial autonomy is achieved through resource allocation, fiscal decentralization, and budget independence in the health system, aided by factors like budget distribution formulas and financial resource management.
"The country's budget allocation process faces challenges due to insufficient information, a lack of clear indicators, and political pressures, which hinder regionalization implementation."
The development of territorial capital aims to empower less developed regions and strengthen more developed regions through the optimal use of resources in a particular territory or region. It is achieved through effective resource allocation, target-based budgets, capacity building, and infrastructure development in various regions. As a result, these arrangements lead to financial autonomy, reduce disparity effects, and improve equitable access to health services.
2–5 Regulatory Mechanisms
Regulatory mechanisms aim to achieve social goals, balance regional or local inefficiencies, improve institutional performance, minimize opportunistic behavior, and solve inherent problems hindering rationalization. Regulations establish legal frameworks for service price ceilings, investment commitments, cost calculations, and license policies, coordinating the health system at macro, meso, and micro levels during regionalization.
"The health system requires urgent legislation for regionalization implementation, as it emphasizes decentralization. The current legislation primarily focuses on centralizing, placing the ultimate responsibility for the health system's goals on the Ministry of Health. The Ministry of Health creates uniform policies across the country, even requiring reforms in Macro-level policies like development plans to implement regionalization based on global concepts."
Implementing two regulatory mechanisms is crucial: internal system regulation promoting health system coordination and regulating the covered population's use of health system services. Developing regulations tailored to each region's unique conditions and providing necessary structures for effective implementation and continuous monitoring, evaluation, and updating are also crucial.
3. Operational (Micro) Level Requirements’
3 − 1. Provider and Patient Factors
Provider socio-cultural marketing is a structural area in regionalization. It implies that all providers must be willing to accept health programs and participate in their implementation. It is a great tool for changing providers’ (especially physicians’) beliefs and thought patterns, eventually leading to the acceptance of such programs.
"The top-down implementation of healthcare programs in our country has not been successful due to dissatisfaction among health professional groups and inadequate address of their concerns." AE6
Providers may exhibit under-the-table payments or defiance in regionalization programs, accompanied by rationalization, due to potential income shrinkage. In this context, it is necessary to address "moving optimizations" and the income of physicians and service providers since the optimizations change over time in response to shifts in supply and demand behaviours, opportunity costs, expectations, technology, and other factors.
Furthermore, "Consumer socio-cultural marketing" is crucial for regionalization developers, requiring service recipients to be prepared to participate in health programs and act appropriately. Before implementing programs, it is crucial to thoroughly research and understand the community's behaviours, beliefs, customs, and traditions and prepare service users for their implementation and deployment.
There are two main approaches to health care delivery in Iran. The first group deems the right to choose in demanding and supplying essential and believes that rationalization limits individuals' choice as a fundamental human right. On the contrary, another group adhering to the "public interests first" principle asserts that individual interests are to be sacrificed for the public interest. The lack of shared understanding between these two groups persists in the health sector.
“At the moment, these two groups are adopting contradictory laws. The current factionalism between the two main factions in the health system results in the laws developing a viewpoint on a case-by-case basis at any time. “PO1
In the health system, policymaking stability is a critical concept, and it is essential to determine which approach to use for health system decisions.
3 − 2 Integrated Health Networks
Health system fragmentation is one of the main obstacles to achieving effective healthcare outcomes in many regionalized health systems resulting from decentralization. Integrated Health Networks (IHNs) are proposed to address this issue by focusing healthcare provision on primary care systems as the coordinator. In addition to primary care, other recognized entry points, such as emergency care, serve as gateways in these networks. Regional disparities, socio-economic structures, demographic, nutritional, and epidemiological changes, and the dynamic political environment in a vast and populous country like Iran significantly impact healthcare networks' performance.
The unification of medical education with healthcare delivery and the different provision services approaches at the healthcare levels—National Health Service in primary care and Social Health Insurance in specialized care—present challenges in network formation. Furthermore, primary health care delivery is restricted to health centers and houses, while general practitioner visits, primarily in private offices, are considered non-primary health care. These issues contribute significantly to the failure of health-related plans. The cooperative service delivery model allows private physicians and clinics, as well as non-public facilities like Social Security, to provide diverse healthcare services. Thus, allocating physicians to individuals will be challenging during ratification.
3–3 Virtual Service Networks
Regionalization is no longer limited to geography. Advances like telemedicine and virtual health networks will enable healthcare delivery without geographical constraints, necessitating the implementation of integrated electronic health records (IEHRs).
"The primary issue is the inability to interoperate across various healthcare levels, leading to fragmented health records and limited access to information. Sometimes, access to a patient's record at other hospitals, at the tertiary level, is not possible."AE6
In information technology, metaverse technology, including metaverse facilities, can be incorporated into healthcare programs, as seen in neighboring countries like the UAE, and can facilitate them.