Academic journal article Bulletin of the World Health Organization

The Impact of Rural Health System Reform on Hospitalization Rates in the Islamic Republic of Iran: An Interrupted Time Series

Academic journal article Bulletin of the World Health Organization

The Impact of Rural Health System Reform on Hospitalization Rates in the Islamic Republic of Iran: An Interrupted Time Series

Article excerpt


According to the World Health Organization (WHO), the purpose behind universal health coverage (UHC) is to ensure for all people, whether rich or poor, access to effective health services that meet most of their needs without being exposed to the risk of financial hadrship. (1,2) In most low- and middle-income countries, these conditions are not met and the effective health services that are available are not accessible to the entire population. (1,3)

An important prerequisite for UHC is the adequate provision of health services, which depends on factors such as the availability of physicians and hospital beds to meet demand. By adequate service provision we mean the existence of a sufficient number of services of acceptable quality distributed in a manner that allows the population's health-care needs to be fulfilled. People who lack health insurance coverage or another form of financial protection find it very difficult to access health services, especially inpatient care, (4-6) or delay in doing so. This is commonly referred to as the "uninsured access gap". (7-11) When not enough services are covered under a protection plan or when the financial protection for those services that are "covered" is insufficient, households can be deprived of essential health care or face catastrophic costs. (12) Delayed care can also lead to hospitalizations that could have been avoided with timely treatment. (2,9,13)

Poor access to health care and underutilization of healthcare services are problems that may be remedied by expanding primary care and social protection schemes through measures such as social insurance or publicly-funded health care. (1,3) However, social protection schemes have a mixed effect on hospital utilization--in theory at least. (14) By increasing the use of effective outpatient primary care services, improvements in social protection could reduce hospitalizations that are potentially avoidable--i.e. "primary-care-sensitive" hospitalizations--in what is known as an "efficiency effect". At the same time, people with better social protection are more likely to be hospitalized when they need to be. This would lead to an increase in "referral-sensitive" hospitalizations in what is termed the "access effect". (14,15) The efficiency and access effects of social protection materialize only if health service provision is adequate.

Health-care financing and delivery in rural parts of the Islamic Republic of Iran

Since the mid-1980s, the Islamic Republic of Iran has enjoyed an extensive network of publicly funded primary health-care (PHC) services in rural areas. (16) The network has relied primarily on community health workers (behvarz) as first-line service providers. The behvarz are selected from the locality where they live, receive training for two years and provide basic services at a "health house". A health house is a part of the district PHC network. It is staffed by one or two behvarz who serve a population of about 1500 on average. A health house offers primary services to mothers and children, including vaccinations, prenatal and postnatal care, growth monitoring, family planning, management of common infectious and chronic conditions, and environmental health services. PHC physicians are based in rural health centres and manage the patients referred to them by the behvarz. The PHC network is well organized and is credited with the improvements in health outcomes that have been observed since the 1980s in rural areas. (3,17,18)

Secondary care services for the Islamic Republic of Iran's rural population have been less easily accessible. Unlike PHC, which is almost entirely financed by the central government, outpatient care is not free and is delivered mostly by private sector professionals in urban areas. Such care includes, for example, visits to non-PHC physicians, specialist visits, laboratory and radiology services and medicines dispensed at private pharmacies. …

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