Forty people participated in the study whose demographic information in detail are listed in Table 1. Challenges of non-communicable field programs according to the CIPP model were extracted including context, input, process and product for whom twelve subcategories and 37 codes were identified. Summary of categories, subcategories and a number of selected codes are provided in Table 2.
Demographic of interviews
Department / Faculty
17.5 Average year
Summary classes and subcategories based on the CIPP model
Summary of codes
Environmentally related requirements
lack of proper environmental analysis
not paying attention to disease-related indicators
absence of pilot programs
reduction of evidence-based programs
insufficient attention to group development
Prioritization and needs assessment
poor prioritization in health system
neglecting sustainable development
lack of holistic approach to diseases
inadequate needs assessment
public misconception toward diseases
lack of attention to cultural and regional dimensions
Existence financial Problems
lack of budget allocation through sustainable and independent resources
improper payment system
inadequate health per capita
ineffective cost of some programs
Existence of problems in human resources
instability of managers
inadequate distribution of manpower
Existence of problems of process and physical structure
inadequate infrastructure due to the expansion of the program
inappropriate organizational structure
lack of proper documentation in the process of developing and implementing the program
Existence of problems in the structure of technology
lack of attention to the applicability and usefulness of technology
lack of sufficient data
Problems in the structure of rules and programs
excessive changes in policies, rules and protocols
inappropriate advertising regarding the reduction of risk factors
Problems in providing services
not paying attention to providing active services in some areas
incomplete implementation of referral system
removing some basic processes in the program
improper performance of decision-making units
Existence of problems in communication and motivational system
lack of full participation of stakeholders
Existence of educational problems
lack of necessary and efficient training in the system for providing services
Existence of evaluation problems
lack of attention to the holistic evaluation system
lack of full participation in the evaluation process
failure to perform product evaluation by the expert team
inadequate development of self-assessment
inadequate feedback on evaluation
the Ministry of Health responsible for providing and evaluating services
The first dimension in the CIPP model is context. In this dimension challenges such as lack of proper environmental analysis, not paying attention to disease-related indicators, absence of pilot programs, reduction of evidence-based programs, insufficient attention to group development, poor prioritization in health system, neglecting sustainable development, lack of holistic approach to diseases, inadequate needs assessment, public misconception toward diseases, lack of attention to cultural and regional dimensions were identified [Table 2].
In this regard, lack of proper environmental analysis in the development of some programs is one of the components of non-compliance with the principles of program development. In this regard, a participant believed "... Programs are designed and developed at the ministry level and do not receive information from the environment and it is one of the weaknesses ... "(first participant) or another interviewee stated that "...The challenges are not seeing the environmental levels. Consulting environmental experts is an appropriate action that policymakers in the ministry should pay attention to this point which does not happen in practice... "(ninth participant) or another interviewee stated that "…The same is true about national campaign of measuring blood pressure, we had a good program but its main structure was problematic. If they have had consulted the staff experts before implementing the plan, they would have achieved a better result … "(nineteenth participant).
Failure to run the program as a pilot is one of the problems of the health system in non-communicable domain programs. In this regard, the participants said “…programs require zero studies to implement and their feasibility to be done which is not done correctly …” (first participant) or another interviewee stated that "… In our country, there is no belief in zero study and there is no zero study in society, and this discussion is not addressed in non-communicable programs …"(second participant).
The input problems were considered in the second dimension of the CIPP model .In this part, challenges such as lack of budget allocation through sustainable and independent resources, improper payment system, inadequate health per capita, ineffective cost of some programs, instability of managers, inadequate distribution of manpower, inadequate infrastructure due to the expansion of the program, inappropriate organizational structure, lack of proper documentation in the process of developing and implementing the program, lack of attention to the applicability and usefulness of technology, lack of sufficient data, excessive changes in policies, rules and protocols, inappropriate advertising regarding the reduction of risk factors were identified [Table 2].
That lack of budget allocation through sustainable and independent resources was identified as one of the challenges. In this regard participants said "… lack of budget in the implementation of some projects causes some goals not to be achieved ..." (Second participant or another interviewee stated that "… lack of budget and financial resources also leads to a decrease in financial motivation of employees …" (tenth participant).
improper payment system is one of the challenges of the program in the non-communicable field that the participants in this field expressed "… Some payment systems are harmful such as payment system based on employee performance (such as fee for service) leads to reduced service quality and more motivation to visit more patients and to receive the higher salary regardless of the quality of service …"(second participant)
One of the challenges of the program in the non-communicable field is the inadequate infrastructure due to the expansion of the program, which the participants stated as follows: "… proper infrastructure is not considered in the provision of services and the necessary structures in terms of considering the appropriate organizational structures and physical space are not enough to provide services …"(twentieth participant).
Inadequate advertisements to reduce risk factors is one of the problems of programs. In this regard, participants stated that “… In advertising, organizations have their own rules that have not necessarily been developed toward health promotion, especially in the field of non-communicable diseases programs. Social marketing has not been predicted for non-communicable diseases and advertising is not effective …"(Twenty-seventh participant) or another interviewee stated that “… Advertising is underused in the healthcare system. There are lifestyle modifications and effective interventions and advertising also costs a little but it is not advertised in this regard and advertisements are not effective and purposeful …"(sixth participant).
Excessive changes in policies, rules and protocols are among problems of the program development. In this issue some participants expressed "... policies change very much because most policies depend on people with the change of governments and people, many of the programs are overturned and experience serious changes ... "(Twenty-fifth participant).
In the third-dimension process problems are considered including not paying attention to providing active services in some areas, incomplete implementation of referral system, removing some basic processes in the program, improper performance of decision-making units, lack of full participation of stakeholders, reduced access, lack of necessary and efficient training in the system for providing services. In the process dimension, 3 subcategories and 7 selected codes were identified [Table 2].
Another problem of the program is the lack of attention to the provision of active services in some areas, which the participants stated “… at all levels are not active services. In the cities, services are not provided actively that sometimes is better to present active service …"(13th participant) or another interviewee stated that "… due to the provision of inactive services in cities providing laboratory services and public access is not appropriate and complete and the diagnosis is not done properly …"(ninth participant)
Another challenge of program development is the lack of attention to staff motivation and disregard for job security and timely payment. Some participants stated that "... motivation of employees providing outsourced services is reduced for reasons such as lack of job security and irregular payments ... "(second participant) or another interviewee stated that "... There are no motivating factors at the appropriate levels of care and in the field of non-communicable diseases, benefits and facilities have not been considered separately … "(ninth participant)
lack of full participation of stakeholders, including volunteers, foreign and domestic stakeholders, NGOs, the private sector is one of the problems of the program. In this regard the participants expressed "… Stakeholder participation is not appropriate which makes them not accountable for processes and results. As the Minister of Health is not accountable to the Minister of Energy and health issues are so institutionalized in the culture that only the Ministry of Health should solve the problems and other ministries are not aware of the problems ... "(Twenty-four participants), or another interviewee stated that "... The cooperation of organizations is very incomplete and low for example, the municipal organization should consider the promotion of community’s health as a priority but a lot of performance in this area is weak. External and internal participation is not suitable also, different ministries prioritize their own affairs and do not prioritize each other and it is better to prioritize organizations to be multi-sectoral … "(twenty-sixth participant) or another interviewee stated that “…. Most of the non-communicable disease agents are outside the Ministry of Health. Therefore, programs must be formulated correctly. Main risk factors should be identified and all institutions should work together to reduce and eliminate risk factors … “(Thirty -one participant) or another interviewee stated that "… The whole service chain is not seen in the programs. It is one of the dimensions of the external and internal participation chain. A challenge in programs is communication with other stakeholders to control risk factors for non-communicable diseases at the community level. This issue requires the Ministry of Health to coordinate with other organizations and ministries and institutions inside and outside …" (thirty-two Participant)
lack of necessary and efficient training in the system for providing services is one of the challenges of the program that in this regard the participants stated “… one of the challenges of the program is the lack of complete information by staff to the community. People are not fully aware and because non-communicable diseases take a long time to show their symptoms, people do not pay much attention. In the discussion of education and information, we should be much more colorful and the organizations involved in education have need more participation …” (Twenty-first participant). Inadequate information available to the community about NCDs is one of the problems that the interviewees also paid attention to "… Cooperate with domestic and foreign stakeholders in the field of education. The Ministry of Health does 20% of the work in the field of diseases and the rest of the work will be completed with the cooperation of stakeholders which is not good now and informing the community well does not happen … "(fourth participant)
In the fourth dimension of the CIPP model, product challenges were addressed such as lack of attention to the holistic evaluation system, lack of full participation in the evaluation process, failure to perform product evaluation by the expert team, inadequate development of self-assessment, inadequate feedback on evaluation, the Ministry of Health responsible for providing and evaluating services [Table 2].
One of the challenges of the program in dimension of product was the lack of attention to the holistic evaluation system that in this regard the participants stated “…There is no complete expertise to enter a program in the integration system properly, and one of the reasons is the inadequacy of not evaluating the program …" (Fortieth participant) or another interviewee stated that “… Some programs run for years, but they are not evaluated either by external appraisal or accurate appraisal or no cost-benefit review. We may spend a lot of time just working and inputs and processes are not reviewed and success is not measured … "(Twenty-eight participants) or another interviewee stated that” …in programs, the evaluation of the program is not well seen but maybe they are well designed and executed Programs but we do not pay much attention to the discussion of evaluation or if the evaluation is considered, it will be evaluated superficially ... “(thirty-fourth Participant)
One of the problems of the programs is the lack of full participation in the evaluation process that in this regard the interviewees expressed ..."there is no tool to guarantee participation in the development, implementation and evaluation of the program in particular... “(Thirteenth participant) or another interviewee stated that “… Evaluation requires preconditions such as time, expertise and cooperation, now none of these preconditions exists. For this reason, there is no complete and comprehensive evaluation "... (Fifth participant (
Failure to perform product evaluation by the expert team is another challenge of the programs. For this, interviewees stated "... NCDs programs should be evaluated by an expert team after the implementation phase to identify strengths, weaknesses and problems. There should be technical and specialized committees in the field of non-communicable planning. Standardization should be done and evaluation should be done professionally which is absent now. …"(Sixteenth participant) or another interviewee stated that” … In order to evaluate the program, expert issues must be completed and reason for existence or non-existence to become clear and all aspects of a process or activity examine and then determine whether a program should be integrated into the system or not … “
One of the problems in the evaluation dimension is the Ministry of Health being in charge of providing and evaluating services, which the interviews stated “... being in charge Ministry of Health in treatment, evaluation and doing all this by one institution is a weakness for the health system that leads to a reduction in the quality of services … " (Sixth participant) or another interviewee stated that "… one is that we work in parallel. A number of activities are performed by several duplicate ministries or units within the Ministry of Health also carry out parallel activities and the weakness of the Ministry of Health is that it is also in charge of providing services and the evaluator that this is not a very professional and appropriate work … “(Twenty-fifth participant).