1. Center for Health Network Expansion & Health Promotion In the name of God the compassionate and the merciful

2. Center for Health Network Expansion & Health Promotion Decentralization of Health System in Islamic Republic of Iran By Mohammadreza Rahbar MD- MPH mrzrahbar@yahoo.com

3. Center for Health Network Expansion & Health Promotion Outlines  Definitions  Evidences for the necessity of action  Indicators  Experiences and Analysis  5 Projects  Lessons should be learnt

4. Center for Health Network Expansion & Health Promotion Decentralization  Decentralization is the process of dispersing decision-making closer to the point of service or action.

5. Center for Health Network Expansion & Health Promotion Federalism and Decentralisation:  Federalism is often accompanied by decentralisation, but it is not a necessary condition for decentralisation, nor is decentralisation a sufficient condition for federalism.

6. Center for Health Network Expansion & Health Promotion Defining Decentralisation  "Decentralizing governance is the restructuring of authority so that there is a system of co-responsibility between institutions of governance at the central, regional and local levels according to the principle of subsidiarity, thus increasing the overall quality and effectiveness of the system of governance, while increasing the authority and capabilities of sub-national levels."UNDP  Political decentralisation  Devolution  Administrative decentralisation  Deconcentration  Delegation  Fiscal decentralisation  Divestment UN Photo Archives

7. Center for Health Network Expansion & Health Promotion Decentralisation and Development Decentralized governance, if properly planned and implemented, offers important opportunities for enhanced human development.

8. Center for Health Network Expansion & Health Promotion Degrees and Types of Decentralisation by Region

9. Center for Health Network Expansion & Health Promotion Decentralization Purposes  Decentralization is a policy pursued for a variety of purposes:  Political  Administrative  Financial.  Many health sector reforms include decentralization as a major component.

10. Center for Health Network Expansion & Health Promotion Objectives of Decentralization RationaleReasons Efficacy Local leaders are better informed about local problems and can make better decisions Equity Local leaders can better target resources to vulnerable groups Efficiency Local leaders can make more efficient decisions because they have better information about local conditions Quality Greater accountability may lead local leaders to improve quality Financial Soundness Local leaders may be more aware of tradeoffs and fiscal constraints. Local Choice & Priorities In democratic localities, decentralization can allow more local choice and priority setting

11. Center for Health Network Expansion & Health Promotion Areas of decentralization and range of authorities Range of Choice Functions NarrowModerateWide Finance Sources of revenue & Allocation of Expenditures Hospital Fees Service Organization Required Programs Hospital Autonomy Insurance Plans Payment Mechanisms Contracts with Private Providers Human Resources Salaries Contracts Civil Service Access Rules Targeting Governance Rules Local accountability Facility Boards District Offices Community Participation Mapping Decision making for Decentralization

12. Center for Health Network Expansion & Health Promotion Decentralization Objectives  Increase service delivery effectiveness through adaptation to local conditions and targeting to local needs.  Improve efficiency of resource utilization by incorporating local preferences into determination of service mix and expenditures.  Increase cost-consciousness and efficiency of service production through closer links between resource allocation and utilization.  Increase health worker motivation through local supervision and involvement of service users in oversight, performance assessment, etc.

13. Center for Health Network Expansion & Health Promotion “Decentralization” of the Iranian Health System - The Challengeable Road From Relative Central plans to Decentralism The Challenge Transition from a relative bureaucratic centralized to a functional decentralized system

14. Center for Health Network Expansion & Health Promotion Network Development Center and Health Promotion Technical Offices M I N I S T R Y O F H E A L T H ‍CommunityNeeds Demands Insurance Plans Health Facilities / Providers Resource Providers Epidemiologic studies Utilization Studies Problem priority Effective Interventions Developing Resource Allocation Based on Quality, Efficiency Equity, Effectiveness And Others Considerations Feasibility Study Integration and Stratification New Program Designing Functional areas in the Health System

15. Center for Health Network Expansion & Health Promotion Necessities for Decentralization in Iran Local leaders are better informed about local problems and available resources and can make better decisions in Different; Community health status, Health related risk factors, Utilization, Available resources, Opportunities and threats and Weaknesses and strengths

16. Center for Health Network Expansion & Health Promotion راهبردهاي اجتماعي اقتصادي ومحيط زيست سيگار عادات غذايي سن ؛ جنس وژنتيك عا دات خواب تحر ك سواد مناسبات جنسي شرايط زندگي مواد مخدر تماسهاي بين نسلي كشاورزي و تغذيه ترافيك شرايط كار الكل فرهنگ و تفريحات شبكه هاي اجتماعي = خانواده خدمات بهداشتي حمايت هاي اجتماعي رفاه اجتماعي تامين اجتماعي بيكاري Multifactorial complex effects of Health Determinants

17. Center for Health Network Expansion & Health Promotion Mortality & Morbidity Development Situation Literacy Social structure capacities Unemployment rate State of welfare Nutrition Utilization Age Pyramid Reproductive behaviors

18. Center for Health Network Expansion & Health Promotion Different kinds of distributions of events related to the health

19. Center for Health Network Expansion & Health Promotion Some evidences from surveys For the necessity of decentralization

20. Center for Health Network Expansion & Health Promotion Standard Crude Crude and standardized registered cases for Non-Intentional accidents for rural and Urban areas for 29 provinces in 2003 for 100000 population

21. Center for Health Network Expansion & Health Promotion Standard Crude The crude and standardized death rate for cardiovascular disease for 29 provinces- 2004 in 100,000 people

22. Center for Health Network Expansion & Health Promotion Standard Crude The crude and standardized death rate for Infectious disease for 29 provinces- 2004in 100,000 people

23. Center for Health Network Expansion & Health Promotion Standard Crude The crude and standardized death rate for cancer of stomach for 29 provinces- 2004 in 100,000 people

24. Center for Health Network Expansion & Health Promotion Standard Crude The crude and standardized death rate for Diabetes for 29 provinces- 2004in 100,000 people

25. Center for Health Network Expansion & Health Promotion Standard Crude The crude and standardized death rate for Intentional accidents for 29 provinces- 2004 in 100,000 people

26. Center for Health Network Expansion & Health Promotion The crude and standardized death rate registered for Traffic accidents for 29 provinces- 2004 in 100,000 people Standard Crude

27. Center for Health Network Expansion & Health Promotion نسبتي از كو دكان زير شش سال كه تحت مراقبت بهداشتي ( اندازه گيري قد وورن ) قرار دارند ( به گفته مادر ) به تفكيك شهر وروستا پاييز سال 1383 مطالعه انيس 2 Rural Urban The proportion of the children under 6 who utilized by growth monitoring services (assessments of weight and height) according to the mother's statement in rural and urban areas in 2003- ANIS survey

28. Center for Health Network Expansion & Health Promotion وضعيت ترسيم منحني رشد در كارت رشد آنها يي كه كارت آنهامشاهده شده بود به تفكيك استان پاييز سال 1383 مطالعه انيس 2 Completely drawnRelatively complete drawnIncomplete drawnHave not drawn The situation of drawing growth monitoring chart for those who had checked for it in 2003- ANIS survey

29. Center for Health Network Expansion & Health Promotion سيستن وبلوچستان حوادث ترافيكي 1235.3 سكته قلبي 537.9 مرگ بعلت بلايا و حوادث غير مترقبه وطبيعي 444.6 قتل وخشونت 388.4 ناشي از طول حاملگي ورشد جنين 382.5 قتل 287.6 سوختن با دود شعله ومواد داغ 234.8 اختلالات تنفسي وعروقي در نوزادوجنين 210.8 سكته مغزي وساير حوادث عروقي مغز 174.3 غرق شدن در آب 158.9 ساير حوادث وسوانح غير عمدي 146.6 عفونتهاي دوره جنيني ونوزاذي 144.2 اعتيادوسوءمصرف مواد 141.1 سابر عفونتهاي حاد دستگاه تنفسي 133.3 پنوموني 131.0 ساير ناهنجاريها 107.6 بيماري قلبي ريوي ( بيماري مزمن ريه وبرنش ) 105.8 ساير اسهالها 104.8 فشار خون و عوارض آن 91.9 آسم 84.7 مرگ ناشي ازتاثيرنيروهاي بيجان ومكانيكي 83.3 ناهنجاريهاي قلبي عروقي 80.0 سپتيسمي 78.1 مسموميتهاي اتفتاقي با مواد يا ذاروها 73.2 آذربايجان شرقي سكته قلبي 1063.1 حوادث ترافيكي 871.7 سكته مغزي وساير حوادث عروقي مغز 421.6 ناشي از طول حاملگي ورشد جنين 277.8 سوختن با دود شعله ومواد داغ 197.2 سرطان معده 173.9 خودكشي ( بدون توجه به روش ) 154.6 اختلالات تنفسي وعروقي در نوزادوجنين 149.2 لوسمي ها 136.0 فشار خون و عوارض آن 127.8 ديابت 108.1 پنوموني 104.2 حلق آويز 99.4 سرطان مغز مننژوسايربخشهاي اعصاب مركزي 97.6 مسموميتهاي اتفتاقي با مواد يا ذاروها 96.7 ناهنجاريهاي قلبي عروقي 94.7 آسم 82.8 ناهنجاريهاي سيستم عصبي 82.5 بيماري قلبي ريوي ( بيماري مزمن ريه وبرنش ) 78.7 سرطان مري 70.7 سرطان ريه وبرنش 67.4 سرطان روده بزرگ راست روده ومخرج 65.4 مرگ ناشي ازتاثيرنيروهاي بيجان ومكانيكي 61.9 سقوط از ارتفاع يادر همان سطح 57.4

30. Center for Health Network Expansion & Health Promotion نسبت جمعيت زير پانزده سال؛ درهردو جنس ؛درمناطق روستايي تحت پوشش خانه هاي بهداشت؛ در طول سه سال 1379 تا 1381 چابهار زاهدان خاش شاد گان سراوان ايرانشهر نيك شهر جا سك خواف تايباد سرخس تربت جام اهواز دشت آزادگان باغملك بند لنگه ميناب قشم The proportion of under 15 yrs population in both sexes in rural areas in the population which is being covered by Health houses during 2000 to 2002

31. Center for Health Network Expansion & Health Promotion نسبت جمعيت 65 سال وبالاتر؛ درهردو جنس ؛درمناطق روستايي تحت پوشش خانه هاي بهداشت؛ در طول سه سال 1379 تا 1381 دليجان فيروزكوه محلا ت نطنز تفرش آشتيان اردستان تفت ساوه گرمسار دامغان كاشان خوانسار آباده نائين اردكان قم خمين گلپايگان سمنان صدوق بافق فردوس گناباد The proportion of more than 65 yrs population in both sexes in rural areas in the population which is being covered by Health houses during 2000 to 2002

32. Center for Health Network Expansion & Health Promotion ميزان خام مواليد ؛درمناطق روستايي تحت پوشش خانه هاي بهداشت؛ در طول سه سال 1379 تا 1381 زاهدان خاش ايرانشهر سراوان چابهار قشم خوا ف نيكشهر جاسك دشت آزادگان اهواز شادگان سرخس تربت جام فريمان تايباد ماكو سيه چشمه خوي سلماس اشنويه پيرانشهر باغملك لردگان ماهشهر كنگان لنگه ميناب The ratio of Crude Birth Rate in rural areas in the population which is being covered by Health houses during 2000 to 2002

33. Center for Health Network Expansion & Health Promotion نسبت مرگ كودكان 1 تا 59 ماه به مواليد ؛ درهردو جنس ؛درمناطق روستايي تحت پوشش خانه هاي بهداشت؛ در طول سه سال 1379 تا 1381 جاسك چابها ر نيك شهر ايرانشهر بجنورد اسفراين خاش كهنوج املش و ماسا ل 1- 15 months mortality rate to births in both sexes in rural areas in the population which is being covered by Health houses during 2000 to 2002

34. Center for Health Network Expansion & Health Promotion ميزان مرگ 15 تا 50 سال ؛ درهردو جنس ؛درمناطق روستايي تحت پوشش خانه هاي بهداشت؛ در طول سه سال 1379 تا 1381 زاهدان ايرانشهر راور ايوا ن نيك شهر جاسك گناوه ديلم كوهدشت پاوه 1- 50 yrs mortality rate in both sexes in rural areas in the population which is being covered by Health houses during 2000 to 2002

35. Center for Health Network Expansion & Health Promotion توزيع كوتا ه قدي تغذيه اي (STUNTING ) برحسب Z Score ؛ قد براي سن ( HAZ ) براي سه اقليم ( دو اقليم انتهاي طيف و بهترين اقليم ) در مطالعه پورا ( پژوهشي دروضعيت ريز مغذيهاي ايران ) بهار 1380 گروه سني, كودكان 15 تا 23 ما هه Distribution of Stunting for 15 to 23 months children due to nutrition according to Z Score of Height for age (HAZ) for 3 different climate regions Micronutrients Survey- Spring 2000 Read line= Standard

36. Center for Health Network Expansion & Health Promotion توزيع كوتا ه قدي تغذيه اي (STUNTING ) برحسب Z Score ؛ قد براي سن ( HAZ ) براي سه اقليم ( دو اقليم انتهاي طيف و بهترين اقليم ) ؛ مطالعه پورا ( پژوهشي دروضعيت ريز مغذيهاي ايران ) بهار 1380 گروه سني, كودكان 6 ساله Distribution of Stunting for 6 yrs children due to nutrition according to Z Score of Height for age (HAZ) for 3 different climate regions Micronutrients Survey- Spring 2000 Read line= Standard

37. Center for Health Network Expansion & Health Promotion توزيع كم وزني (UNDERWEIGHT ) برحسب Z Score ؛ وزن براي سن ( WAZ ) براي چهار اقليم ( سه اقليم انتهاي طيف و بهترين اقليم ) در مطالعه پورا ( پژوهشي دروضعيت ريز مغذيهاي ايران ) بهار 1380 گروه سني, كودكان 15 تا 23 ما هه Distribution of Underweight for 15 to 23 months children due to nutrition according to Z Score of Height for age (HAZ) for 3 different climate regions Micronutrients Survey- Spring 2000 Read line= Standard

38. Center for Health Network Expansion & Health Promotion توزيع امكانات رفاهي خانواردر استان ايلام توزيع امكانات رفاهي خانواردر استان سيستان وبلوچستان Permanent Income City of TehranPermanent Income Isfahan Province Permanent Income Sistan & Baloochestan Province Permanent Income Ilam Province

39. Center for Health Network Expansion & Health Promotion واريانس بين استانهاي مختلف كشور ؛ براي درصد زايمان توسط فرد دوره نديده در ( جمعيت روستايي تحت پوشش خانه هاي بهداشت ) به تفكيك سالهاي مختلف Variation among different provinces for the percentage of deliveries have been done by non-trained attendants for the rural areas being covered by the Health houses in different years Year Variation

40. Center for Health Network Expansion & Health Promotion واريانس بين استانهاي مختلف كشور ؛ براي ميزان مرگ كود كان يك تا 59 ماه در ( جمعيت روستايي تحت پوشش خانه هاي بهداشت ) به تفكيك سالهاي مختلف Year Variation Variation among different provinces for the 1- 59 months mortality for the rural areas being covered by the Health houses in different years

41. Center for Health Network Expansion & Health Promotion ميزان مرگ كودكان زير پنج سال در سال 1382 در مناطق روستايي تحت پوشش خانه هاي بهداشت كشور Under 5 Mortality Rate for the rural areas being covered by the Health houses in 2001

42. Center for Health Network Expansion & Health Promotion واريانس بين استانهاي مختلف كشور ؛ براي ميزان مرگ نوزادان در ( جمعيت روستايي تحت پوشش خانه هاي بهداشت ) به تفكيك سالهاي مختلف Variation among different provinces for Neonatal Mortality Rate for the rural areas being covered by the Health houses in different years Year Variation

43. Center for Health Network Expansion & Health Promotion ميزان مرگ كودكان يك تا 59 ماه در سال 1382 در مناطق روستايي تحت پوشش خانه هاي بهداشت كشور 1- 59 months Mortality Rate for the rural areas being covered by the Health houses in 2001

44. Center for Health Network Expansion & Health Promotion چا بها ر ارتباط خطي نسبت مرگ كودكان 1 تا 59 ماه با نسبت بيسوادي در مناطق روستايي 281 شهرستان كشور در سالهاي 1379 و 1380 و 1381 - بر اساس اطلاعات ثبت شده در زيج حياتي خانه هاي بهداشت ومطالعه DHS شميرانات بهترين شاخص نابرابري ضريب زوايه خط( بتا) است Vagstaf:2005 Linear relation between 1- 59 months Mortality to Mother's literacy rate in 281 districts between 2000- 2002 according to data on the Vital Horoscopes in the Health Houses and DHS Surveys The Literacy Rate 1-59 months mortality rate Inequity Index Vagstaf:2005

45. Center for Health Network Expansion & Health Promotion ارتباط خطي نسبت مرگ كودكان 1 تا 59 ماه با ميزان مرگ 15 تا 50 سال در مناطق روستايي 281 شهرستان كشور در سالهاي 1379 و 1380 و 1381 - بر اساس اطلاعات ثبت شده در زيج حياتي خانه هاي بهداشت بهترين شاخص نابرابري ضريب زوايه خط( بتا) است Vagstaf:2005 Inequity index Vagstaf:2005 Linear relation between 1- 59 months Mortality to 15 -50 years mortality rate rate in 281 districts between 2000- 2002 according to data on the Vital Horoscopes in the Health Houses 1-59 months mortality rate 15 -50 yrs mortality rate

46. Center for Health Network Expansion & Health Promotion The comparison of death causes between Tehran 1971 and other 18 provinces in 2001

47. Center for Health Network Expansion & Health Promotion the distribution of percentages of 9 causes of deaths in men by age groups after correcting the garbage codes,according to mortality registration among 18 provinces in 2002

48. Center for Health Network Expansion & Health Promotion The distribution of 9 causes of years life lost in women by separation of age groups after correcting the garbage codes in death registry program between 18 provinces in 2002

49. Center for Health Network Expansion & Health Promotion سهم هريك از عوامل موثر بر وقوع تولدنوزادان كم وزن - مطالعه تعيين شيوع تولد نوزاد كم وزن در 11 اقليم كشور -- مهر 1382 The proportional effect of different health determinants on underweight neonates delivery- The Survey done for prevalence of Underweight neonate deliveries in 11 different regions- Autumn 2003 Birth order Duration of pregnancy Sex of neonate Mother's age Twin birth Iranian or Afghani The area of living Mother's literacy Living in Urban or Rural area Household income

50. Center for Health Network Expansion & Health Promotion تمركز معنادار خطر دربخش غير مرفه جامعه Obs Prob>z (95%) CI 5498 0. 0.0281 [-0.1281 -0.0072] توزيع مرگ ناشي از حوادث غير عمدي در قبال سطح رفاه خانوار – كار مشترك برنامه ثبت مرگ برحسب علت ومطالعه نا برابري در سال 1382 Distribution of deaths due to Non-Intentional accidents in relation to household income- The cooperative work of death registration system and inequity survey- 2003 Meaningful concentration for the high income households

51. Center for Health Network Expansion & Health Promotion توزيع مرگ ناشي از خودكشي در قبال سطح رفاه خانوار – كار مشترك برنامه ثبت مرگ برحسب علت ومطالعه نا برابري در سال 1382 تمركز معنادار خطر دربخش غير مرفه جامعه Obs Prob>z (95%) CI 5498 0.002 [-0.2072 -0.0469] Meaningful concentration for the low income households Distribution of deaths due to suicide in relation to household income- The cooperative work of death registration system and inequity survey- 2003

52. Center for Health Network Expansion & Health Promotion تمركز معنادار خطر دربخش مرفه جامعه Obs Prob>z (95%) CI 5498 0.0007 [0.037 0.137] توزيع مرگ ناشي از سر طانها در قبال سطح رفاه خانوار – كار مشترك برنامه ثبت مرگ برحسب علت ومطالعه نا برابري در سال 1382 Distribution of deaths due to malignancies in relation to household income- The cooperative work of death registration system and inequity survey- 2003 Meaningful concentration for the high income households

53. Center for Health Network Expansion & Health Promotion توزيع بهره مندي از خدمات سرپايي در قبال سطح رفاه خانوار – مطالعه بهره مندي اسفند 1381 N=26750 CCI =.062248 P=0.0000 CI-CCI [0.0464 0.0781] تمركز معنادار بهره مندي دربخش مرفه جامعه Meaningful concentration for the high income households Distribution of utilization from health services in relation to household income- Utilization survey- 2002

54. Center for Health Network Expansion & Health Promotion N=2413 CCI = 0.015196 P=0.0000 CI-CCI [0.0095 0.0209] توزيع بهره مندي از حق انتخاب به مراجعه كنندگان سرپايي در قبال سطح رفاه خانوار – مطالعه بهره مندي اسفند 1381 تمركز معنادار حق انتخاب دربخش مرفه جامعه Distribution of utilization for choosing health services provider for ambulatory care in relation to household income- Utilization survey- 2002 Meaningful concentration for the high income households

55. Center for Health Network Expansion & Health Promotion توزيع بهره مندي از حق انتخاب به مراجعه كنندگان بستري در قبال سطح رفاه خانوار – مطالعه بهره مندي اسفند 1381 N=690 CCI = 0.028351 P=0.0005 CI-CCI [0.0123 0.0444] تمركز معنادار حق انتخاب دربخش مرفه جامعه Meaningful concentration for the high income households Distribution of utilization for choosing health services provider for hospitalization in relation to household income- Utilization survey- 2002

56. Center for Health Network Expansion & Health Promotion ميانگين هزينه انجام شده براي دريافت خدمات بهداشتي درماني سرپايي در طول سال توسط هر فرد به تفكيك نوع هزينه -- مطالعه بهره مندي از خدمات بهداشتي درماني -- اسفند 1381 20280 تومان 6680 تومان 26510 تومان Average expenses for receiving ambulatory health services in a year for a person for different type of expenditure Utilization survey- 2002 Drug and instruments Curative interventions Drug and instruments Direct payments and user fees Diagnostic tests Going to the service unit and coming back Private sectorGovernmental sector Both sectors Expenditures

57. Center for Health Network Expansion & Health Promotion Providers Service Ambulatory care Governmental Private Rates of services 34% 31% 82% 3524,000 Billion Tomans 8.4 times of visit per year for every Iranian 0.061 times of hospitalization for every Iranian 18%66%69% Hospitalization Revenue from health Market مقايسه نسبت درصد سهم بخش دولتي وخصوصي در ارائه خدمات وسهم دريافت پول از منابع دولتي وبطور مستقيم از جيب مردم در بازار سلامت ايران – مطالعه بهرهمندي از خدمات بهداشتي درماني -- اسفند 1381 The comparison of the ratio of the governmental and private sector in delivering services and revenue from governmental financing and out of pocket payments by the people in the health market Utilization survey- 2002

58. Center for Health Network Expansion & Health Promotion تاثير پرداخت هزينه يك باربستري بر درآمد ماهيانه ؛ پس انداز ؛ فروش دارايها و مقروض شدن فرد يا خانواده به تفكيك نوع بيمارستان - مطالعه بهرهمندي از خدمات بهداشتي درماني -- اسفند 1381 The effect of payments for one time of hospitalization on family wealth, savings, selling family resources and borrowing money for the service payments Utilization survey- 2002 Every kind of hospital Other (Charities and other organizations) Ministry of healthSocial Security Organization Private Paying more than 50% of monthly income Paying more than all of monthly income and loan for it Paying more which does not affect in the family Paying more all monthly income and using the savings Loan and selling properties for payment Percent

59. Center for Health Network Expansion & Health Promotion نسبتي از DALYs كه هريك از گروههاي كوچك بيماري وآسيب درهر دو جنس به خود اختصاص مي دهند ؛ بر پايه اطلاعات سال 1381 DALYs for each of the smaller disease groups in 2 sexes – Accordin g to data have been gathered in 2002

60. Center for Health Network Expansion & Health Promotion The General Context  Goals of the Health System  Health –technical efficiency of medical care in production of health  Equity - (includes also efficiency considerations)  Cost containment - technical efficiency of medical care in production of health (and allocative efficiency in consumption of care)  Micro-economic efficiency – technical efficiency in the production of quality care  Client satisfaction, mainly through accountability  Systemic Functions --subject to devolution and decentralization:  Policymaking  Financing  Organization and Management of Care Consumptions  Provision of Care  Training and medical education  Research and development

61. Center for Health Network Expansion & Health Promotion Experience 1 -Current situation of PHC System Analysis Iranian Governmental PHC Record and Legacy through a Relative Centralized system

62. Center for Health Network Expansion & Health Promotion Experience 1 -Current situation in disease prevention area ; Iranian Governmental PHC Record and Legacy through a Relative Centralized System  Health  Eradication of communicable diseases  ‘Epidemiological transition’ to non-communicable diseases that eventually led to superior health outcomes  Equity  Relatively wide access to care  Efficiency  In spite of low levels of spending, efficient especially when quality of care is considered  Client satisfaction  Relatively high

63. Center for Health Network Expansion & Health Promotion Comparative Decision Space: Current Ranges of Choice for Iran in Primary care Functions Range of Choice NarrowModerateWide Sources of Revenue * Expenditures * Income from Fees * Service Organization * Required Programs & Norms * Hospital Autonomy -- Insurance Plans * Payment Mechanisms * Functions Range of Choice NarrowModerateWide Salaries * Contracts * Civil Service - Access Rules * Governance * Local Government * Facility Boards * Health Offices * Community Participation * Total Decision Space:

64. Center for Health Network Expansion & Health Promotion Causes of Ineffective Government Functions in Preventive health programs  Not setting and maintaining the right priorities over time at local areas  Ineffective distribution in targeting of resources and lack of local resources  Not promoting innovation  A lack of responsiveness to the new needs

65. Center for Health Network Expansion & Health Promotion Experience 2 Construction Board of trustees in universities A relative successful experience

66. Center for Health Network Expansion & Health Promotion Comparative Decision Space Functions Range of Choice NarrowModerateWide Sources of Revenue * Expenditures * Income from Fees * Service Organization * Required Programs & Norms * Hospital Autonomy -- Insurance Plans * Payment Mechanisms * Functions Range of Choice NarrowModerateWide Salaries * Contracts * Civil Service - Access Rules * Governance * Local Government * Facility Boards * Health Offices * Community Participation * Total Decision Space:

67. Center for Health Network Expansion & Health Promotion Experience 3 Hospital autonomy A recommended plan but failed because of design and implementation method

68. Center for Health Network Expansion & Health Promotion Comparative Decision Space Functions Range of Choice NarrowModerateWide Financing * Sources of Revenue * Expenditures * Income from Fees * Service Organization * Required Programs & Norms * Insurance Plans * Payment Mechanisms * Functions Range of Choice NarrowModerateWide Salaries * Contracts * Access Rules * Governance * Local Government * Facility Boards * Health Offices * Community Participation * Total Decision Space:

69. Center for Health Network Expansion & Health Promotion Causes of Ineffective Government Functions in Hospital autonomy  Not thinking about all aspects of decentralization especially in terms of;  Utilization of people from different welfare status (Insurance coverage)  Training  Lack of allocating resource for medical education  Not think about evaluation and monitoring methodology  Lack of advocacy in different areas

70. Center for Health Network Expansion & Health Promotion Consequences  Decrease equity  Increase catastrophic payments  Client dissatisfaction  Loosing political support  Making the plan insufficient

71. Center for Health Network Expansion & Health Promotion Social/Cultural Environment Technological Environment Futures Scenario Development Stakeholder Analysis Political Social/ Cultural Demography Political/ Regulatory Environment Economic Environment Health Care Environment Response to External Change Client Orientation Innovation Quality Teamwork Leadership Vision /Mission Organizational Subsystem Resources Competencies Capabilities Value-chain Analysis Organizational Objectives Development Critical Success Factor Identification Vision Formulation Mission Formulation Measurement Evaluation Response Objectives Work with Steering Team to Develop Program Strategies Hospital Autonomy (Unsuccessful Program) Non consideredUncertainConsidered

72. Center for Health Network Expansion & Health Promotion Experience 4 Article 192 An obligatory rule in third national development law for privatization The Pilot project was conducted in a few areas for only new expansions of health facilities

73. Center for Health Network Expansion & Health Promotion Comparative Decision Space Functions Range of Choice NarrowModerateWide Sources of Revenue * Expenditures * Income from Fees * Service Organization * Required Programs & Norms * Insurance Plans * Payment Mechanisms * Functions Range of Choice NarrowModerateWide Salaries * Contracts * Access Rules * Governance * Local Government * Facility Boards * Health Offices * Community Participation * Total Decision Space:

74. Center for Health Network Expansion & Health Promotion Experience 5 Article 49 A new program for increasing authorities of peripheral management areas in resource allocation

75. Center for Health Network Expansion & Health Promotion  It is a new one-year designed plan according to the new tasks for resource managers based on changing the tasks of accountants  Needs conferring authorities to local managers

76. Center for Health Network Expansion & Health Promotion Lessons to be learnt  Decentralization is like the story of elephant and blind men  Needs a holistic approach  It is a scientific planning  Needs methodology  All the stakeholders should be engaged in the planning  Bringing stakeholders together to define priorities for projects and programmes increases interest and sense of ownership, which in turn promotes sustainability.  Supporting open dialogue and participation between the local government and civil society can ensure improved self-reliance.  Not all government functions should be entirely decentralised.  Decision area is the most important consideration  We should consider the risks of political pressures and unilateral considerations  It shouldn't make weakening stewardship,policy making and leadership of the headquarter of MOH  Some unpredictable events needs centralized financing  Decentralization is not the goal we should avoid undesirable decentralization without health impacts

77. Center for Health Network Expansion & Health Promotion Lessons to be learnt- Cont’d  The authorities should be transferred to the most eligible level of system  A centralized and stratified HIS is needed for monitoring and evaluation of the projects  Strategy of change in sequence of time should be clear to policymakers, program planners and local authorities  Resistance of those authorities to relinquish should be thought  The plan for ‘denationalization’ should be a real one for all the experts  Technical assistance is needed for local governments  More capacity development is needed at all levels of governance.

78. Center for Health Network Expansion & Health Promotion Lessons to be learnt - Cont’d – Risks Consider  Growing regional inequalities  Undermining universal access to care  Not having mechanisms for system stabilization and long term reform through innovation  Growing inefficiencies due to weak mechanisms to deal with externalities  Not re-defining the roles of different levels of government and institutions  Provide financial and regulatory measures for a federal system

79. Center for Health Network Expansion & Health Promotion Priority setting according to BOD & Burden of Risk Factors CEA and Choosing the most appropriate strategies Policy making tools: Conduct resources and plan Efficient Performance Modeling Tactical Decisions Burden of disease- Cost-effectiveness analysis- Health performance

80. Center for Health Network Expansion & Health Promotion Customer   Health Unit BURDEN OF DISEASE COST QUALITY EQUITY TIME FLEXIBILITY MARKET ANALYSIS Tactical Decisions Policies and strategies results Process Of Design Service Package Policymaking Design standards for Integration Stratification Evaluation Coverage Technical Decisions Policy making, Program planning And delivering services Service Packages

81. Center for Health Network Expansion & Health Promotion Thank you for your attention