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A COMPARATIVE STUDY OF HEALTH PLANNING AND PRIMARY HEALTH CARE IN SELECTED COUNTRIES AND IRAN
REZA BESHARATI
Assistant Professor, Department of Nursing, Islamic Azad University, Kashmar branch, Kashmar, Iran Abstract
Introduction: One of the primary issues of the global health system is always optimal planning. It is essential to identify planning mechanisms for use by policymakers and health trustees. Comparative research and learning from other nations' experiences will be highly beneficial in the meantime. The purpose of this study was to compare the primary healthcare and health planning systems in Iran to those in other chosen nations.
Method: In 2023, a cross-sectional methodology was used to conduct this practical research. The characteristics of operational planning in internal Iranian organizations, such as the Ministry of Health and Medical Education, the Social Security Organization, and the Health and Medical Organization of the Oil Industry, as well as in a few foreign nations, such as Turkey, Russia, France, and Sweden, have been studied in this research. The methodologies and requirements of operational planning in the health and treatment sector in certain nations and internal organizations of Iran are covered by this study, which uses comparative tables and flashcards as data gathering tools. Care providers, health planning providers, planning systems, program components, how to set goals and objectives, how to choose activities, and monitoring and evaluation systems for health programs are some of the elements that were investigated.
Findings: In countries like Sweden and France, municipalities play a major role in providing services, and governments act as a supervisor. It was also noted in the field of service provider units that some countries have multiple organizations providing parallel services. The research results revealed that the custodians and units of providing health care in selected countries and Iranian organizations are different from one another. At the macro level, all the nations under study are governed by the government; but, at lesser levels, planning and execution are the responsibility of regional organizations, and the planning system is frequently decentralized and semi-centralized. There were several components to the health programs in each of the examined foreign nations and Iranian organizations. Each country had a different approach for identifying the objectives, but they all gave priority to this program's component when making plans. Additionally, there were common activities in all of the studied countries that helped achieve the program's objectives, but there were differences in how these activities were determined in the operational plans of the organizations and the countries under study. One of the elements of all the programs researched in Iranian organizations and abroad was monitoring and assessment.
Discussion and conclusion: It is thought that Iran has an edge over other nations due to its extensive network of medical facilities and the ability to plan and provide healthcare through comprehensive urban and rural health service centers, which can reduce planning parallelism. Given that centralized, semi-centralized, and decentralized planning all have benefits and drawbacks, it is recommended that each approach be used in accordance with the facilities already in place and local conditions rather than complicating things across the board.
Keywords: Comparative study, health planning, primary health care, health system
INTRODUCTION
One can wait and respond to events as they happen, consider the future and make plans for various scenarios, forecast the future by analyzing present events, or even create the future. This speech serves as the conceptual cornerstone for future planning and design (1). Planning is now a very serious, routine, and objective process for allocating resources based on documented information, whereas in
the past it was viewed as a form of foresight based on mental comprehension of the current situation and experiences gained from previous activities.
Planning, which is making decisions for the future in order to make it feasible to attain desired goals, is the cornerstone of management. Planning enables the transformation of the objective into an operational plan and the prediction of how they will be executed. Planning involves selecting the goal and developing organizational policies. A program is a collection of ongoing, connected actions that a health organization does to go somewhere (2). The ultimate goals of health and treatment planning are to enhance "health" and improve the "quality of life" of society's members. They are also included in the framework of general ideas and planning principles. Like any planning in other industries, healthcare planning can benefit from operational, tactical, and strategic planning techniques and methods. These techniques and methods include scatter grid, critical path, Gantt charts, and others
(1). In the health and treatment sector, planning refers to taking part in the best distribution of limited resources in order to get advantageous, equitable, safe, and timely health care services. These services may be given at the level of an institution, such as a health center, clinic, hospital, or university of medical sciences, or they may be given to individuals living in villages, cities, provinces, cities, and countries, or they may take the form of regional, trans-regional, or international health cooperation (3). Examining documents pertaining to the planning and implementation of health programs in Iran reveals that the main issues with planning in this area include inappropriate program goals, a lack of commitment and interest in planning, a lack of proper evaluation, and the absence of a suitable system for gathering statistics and information. Ineffective coordination, a lack of training and a scarcity of labor, poor formations and management and unanticipated changes, an imbalance between budget and credit, and a lack of adequate facilities are further implementation challenges
(2). In a study, Mossadegh Rad et al. came to the following conclusions about the planning of health managers: poor management and leadership, ineffective planning, unsuitable organizational culture, disregard for organizational learning, and poor management of staff, resources, and work processes (4). The findings of Nafari and Behrouzi conducted at a government hospital demonstrated that planning should pay more attention to human resource strategies since they all had a positive impact on organizational performance (5). In a different study conducted in medical science universities, Doshmen Ziari and his colleagues came to the conclusion that a number of factors, the most significant of which are human factors, such as education and job qualification requirements, and technical factors, such as modifications to the accounting system and management information system, can affect the establishment of the financial planning system (6). Health and treatment managers must be able to identify, implement, document, and assess all types of planning categories, describe organizational resources, and move in the direction of planning in order to address the aforementioned issues. A manager who is unwilling to forecast or unable to predict would hamper the efficiency and effectiveness of the business and have devastating effects on her professional growth (1). This is because of changes in technology, payment structures, and resource availability. Comparative research with other nations in this area can help to review, identify, and complete the aspects of planning and empowering managers, and its components can be included in the nation's mandatory health programs, given the significance of health planning and the existence of shortcomings and problems in the current programs of Iran's health and treatment system. In order to compare health planning and primary care in a few chosen nations as well as Iran, this research was carried out.
METHOD:
In 2023, a cross-sectional methodology was used to conduct this practical research. Operational planning components in the healthcare systems of a few nations, including Iran, are the subject of investigation. All pertinent papers have been examined in order to determine the present state of affairs in Iran. Official records from the World Health Organization and the World Bank, as well as associated websites, books, and articles were researched in order to assess the state of the chosen nations. The research's steps were as follows:
Step 1: Identifying the chosen nations and internal organizations via a review study.
Step 2: performing a library research (qualitative study) on selected components in Iran and a few
other countries and gathering data on planning aspects. Step 3: Creating a comparison matrix and making conclusions.
In this study, the operational planning characteristics in selected domestic organizations in Iran, such as the Ministry of Health and Medical Education, the Social Security Organization, and the Oil Industry Health Organization, as well as in a few foreign nations, such as Turkey, Russia, France, and Sweden, have been examined. Having primary healthcare units and employing government funding (apart from the Social Security Organization) was the requirement for include foreign nations and Iranian organizations in the research. The research's scope comprises operational planning methodologies and specifications in the health and treatment sectors of chosen nations and internal Iranian organizations. Comparative tables and flash cards were used to collect data for this study's data analysis. Care providers, health planning providers, planning systems, program components, how to set goals and objectives, how to choose activities, and monitoring and evaluation systems for health programs are some of the elements that were investigated. The World Health Organization, the ministries responsible for maternal and child health services, doctoral dissertations, the Internet, and collecting and scanning for articles in scientific databases are all used to gather data during the comparative study stage. Additionally, the instructions for the chosen nations are taken directly from the website of the appropriate nation's Ministry of Health.
RESULTS:
In some nations, such as Sweden and France, municipalities play the primary role in service provision, while governments serve as supervisors. In the realm of service providers, it was also noted that some nations have multiple organizations providing parallel services (Table 1). The research results revealed that the custodians and units of providing health care in selected countries and Iranian organizations are different from one another.
Table 1. Trustees and units providing primary health care in selected countries and Iranian
organizations
Name of country (organization) Health service provider Units providing health services
Sweden Municipalities Nursing homes and midwives - health service centers
Turkey Ministry of Health (Government) Health centers for mothers and children - health centers - health posts - free medical centers for the disabled
Russia Ministry of Health (Government) Uchastok health centers and hospitals - midwifery stations - health complexes - a number of ministries that provide parallel services, Municipalities
France Ministry of Health -Municipalities Health centers - private doctors and dentists' offices
Iran Ministry of Health Comprehensive urban and rural health service centers - health centers - mobile teams - health houses
Social Security Organization Social security clinics provide a limited number of services.
Oil Industry Health Organization Family health and treatment centers - industrial medicine and health centers - medical centers
In all the organizations under study, Table No. 2 demonstrates that policy-making is the responsibility of the government at the macro level, and that regional organizations are tasked with planning and implementing policies at lower levels. As seen in Table 2, the planning system is frequently decentralized and semi-centralized.
Table 2. Trustees and health planning systems and providing primary health care in selected
countries and Iranian organizations
Name of country (organization) Planning manager Planning system
Sweden Municipalities - central government Decentralized
Turkey Ministry of Health (Government) - State Planning Organization Semi-centralized
Russia Ministry of Health (government) -regional governments - insurance funds Centralized and semi-centralized
France Ministry of Health - Municipalities Decentralized
Iran Ministry of Health Ministry of Health - universities and faculties of medical sciences Semi-centralized
Social Security Organization Vice President of Planning and Policy -Vice President of Treatment Semi-centralized
Oil Industry Health Organization Oil Industry Health Organization Centralized
According to Table 3, the health programs in each of the examined foreign nations and Iranian organizations included unique components.
Table 3. Components of health programs and providing primary health care in selected countries and
Iranian organizations
Name of country (organization) Program components
Sweden Subject, project number, program title, start time, end time, activities, implementation person, start and end time of the activity, monitoring time, considerations
Turkey Title, implementation cost, overall goal, indicators confirming the realization of the overall goal and program goals, approving authority, authorities reviewing and approving indicators, result, indicators confirming the realization of the result, approving authorities, activities, tools and equipment
Russia Program title, approval date, project start and end date, total cost, implementation area, general project goals, goals and results, and program evaluation indicators.
France Title, purpose, description of the program, requirements and conditions necessary for implementation, start and end time, required costs, implementation method in detail, expected activities and indicators for monitoring and evaluation.
Iran Ministry of Health Title, cost of the program, percentage of goal realization, type of program, method of implementation, priority, goals, related goals, executive, activities, costs, distribution of costs, indexing, laws, factors affecting the non-implementation or reduction of the quality and quantity of the program
Social Security Organization The name of the field, the long-term goal of the organization and the field, strategies, tier, activity, start and end time of the activity, executor, measure of activity, considerations and requirements for program
Name of country (organization) Program components
implementation, required credit.
Oil Industry Health Organization Program title, program implementation prerequisites, program implementation solutions, progress percentage, Gantt table
The study's findings revealed that, despite the fact that each country may have a distinct system for choosing locations, they all prioritized this aspect of the program above all others. Additionally, the program's objectives were jointly pursued in each of the studied nations, but how these activities were determined in each nation's and organization's operational plans varied (Table 4).
Table 4. How to determine the objectives and activities of health programs and providing primary health care in selected countries and Iranian organizations
Name of country (organization) How to determine goals and activities
Sweden Turkey Determina tion of goals by local health committees based on government policies and community problems
Determina tion of activities by local health committees and receiving opinions from primary health care centers
Russia Determina tion of goals by the state planning organization and health centers based on national goals and environmental analysis
Determina tion of activities by the main planning team and subgroups of the planning team
Name of country (organization) Sweden Determina tion of goals by regional health departments
Determina tion of activities by regional health departments
Turkey Determina tion of goals District Health Council in cooperation with institutions and representatives of governmental and regional organizations
Determina tion of activities District Health Council in cooperation with institutions and representatives of governmental and regional organizations
Iran Determination of goals Determina tion of goals by the minister _ office and departments
Determina tion of activities by a team consisting of process owners in offices and departments
Determination of goals Determina tion of goals Based on the objectives of the strategic plan - the opinions of provincial experts
Name of country (organization) How to determine goals and activities
Determina tion of activities Expert opinions of implementing units
Determination of goals Determina tion of goals Based on environmental analysis and opinions of provincial experts
Determina tion of activities by the planning team
Monitoring and assessment are among the programmatic elements shared by all Iranian organizations and the foreign nations under consideration, as shown in Table 5 (Table 5).
Table 5. How to determine the monitoring and evaluation system of health programs and providing primary health care in selected countries and Iranian organizations
Name of country (organization) Program monitoring and evaluation systems
Sweden At the national level of the National Association of Health and Social Welfare, at the regional level of municipalities and state organizations
Turkey At the national level, the Ministry of Health's departments and general managers oversee the programs, while local and regional units are in charge of doing the same at the local and regional levels.
Russia by senepid networks and regional governments and departments
France At the national level by the National Health Monitoring Institute and at the regional level by the District Health Council
Iran Ministry of Health The offices and departments of the Ministry are monitored on a monthly basis and the programs are evaluated at the end of the program.
Social Security Organization by the vice president of treatment every 4 months
Oil Industry Health Organization Through the self-audit of the units - deputy health and treatment of the oil industry
DISCUSSION
The findings of the research on trustees and service delivery units demonstrated that municipalities play a major role in delivering primary health care in Sweden and France, with the government serving as the supervisor. However, the government plays a major role in providing services and overseeing them in Russia, Turkey, and Iranian organizations, despite the fact that many other organizations, such as the Social Security Organization and the Oil Industry Health Organization, also offer parallel services in a variety of fields. The Ministry of Defense, the Railways, health care facilities and hospitals, among other departments and ministries, all offer services concurrently and collaboratively in Russia. In Iran, the Ministry of Health is primarily in charge of delivering healthcare through networks for both prevention and treatment, with some assistance from other organizations. According to a qualitative study, the lack of collaboration across parallel institutions is mostly caused by interpersonal, organizational, and structural impediments (7). The study by Rashidian et al. shown that monitoring affects the provision of services (8). According to the World Health Organization, Iran and other developing nations do not have the best health status in their healthcare systems, and it is crucial to give this issue greater attention. Accordingly, the primary issues in the area of governance
included failing to consider all relevant factors and stakeholders when formulating policies, focusing only on the creation of laws and regulations, and ignoring the implementation and oversight of policies
(9). Abdi et al. characterized the issues with Iranian administration as having imbalanced policies and regulations, reckless interference, poor overall supervision, a lack of thinking and caring management, and inconsistency within and across departments in their research. Despite outlining the issues with trusteeship, it is still clear that Iran's primary trustee institution is unique compared to other nations
(10). The results demonstrate that the tutelary structure and caretaker organization are successful at many levels of policymaking and inter- and extra-sector collaboration (9).
At the macro level of policymaking in each of the chosen nations under consideration, the government is in charge, while regional organizations and municipalities are tasked with planning and carrying out implementation at smaller levels. The Ministry of Health and Medicine in Iran is in charge of formulating national policies. The Ministry of Health and Medical Organization is in charge of planning and carrying out implementation at the primary level of health care, while universities of medical sciences, the Ministry of Welfare, the Vice President of Treatment of the Social Security Organization, and the Ministry of Petroleum are also involved. The planning process has been decentralized in Sweden and France, semi-centralized in Turkey, and both centralized and decentralized in Russia. Planning has been semi-concentrated in the Iranian Ministry of Health and the Social Security Organization, and centralized in the Health Organization of the Oil Industry.
According to studies, both centralized and decentralized planning have benefits and drawbacks. We may list the following benefits of centralized planning systems: swift decision-making, cheaper costs, rapid availability of human resources, and equitable allocation of financial resources. Its drawbacks include the planners' lack of experience with the program implementation environment and local facilities, their disregard for the program executives' perspectives, and the unequal allocation of resources. On the other hand, the benefits of decentralized planning may be listed, including program executive planning and consideration of environmental factors, as well as its drawbacks, including decision-making that is too sluggish, the necessity for a supervisory structure, and higher costs (11). Abimbola et al. came to the conclusion that institutional, socioeconomic, and geographic background variables have a significant impact on the degree of decentralization in health systems. Additionally, in order to maximize the benefits and reduce the drawbacks of decentralized governance, policymakers and implementers should take note of them (12). Smith et al. demonstrated in a study conducted in Canada during the Corona epidemic that centralized planning and improved public health system integration had positive effects on disease prevention and enabled the decentralization of appropriate local responses within the framework of provincial leadership (13). Evidence from low-and middle-income nations around the globe reveals that decentralized health governance can provide various results depending on the location. Planning must thoroughly understand and comprehend the scope of the decentralization issue, the diversity of sociopolitical systems, and the intricate interactions of the many health system components. Decentralization as a corrective measure for the health sector has to look at procedures based on medical facilities, local customs, and provider traits (14).
The findings of the current study demonstrated that the program elements in the chosen nations varied from one another and from Iranian organizations. However, there are many things that they have in common, among them the program title, implementation cost, general goal, goals, and results, evaluation indicators, rules, implementation manager, monitoring, and start and end dates of the program. The availability of financial and human resources is effective on planning, as evidenced by study findings in the area of operational planning model design for the hospitals of the Iranian Ministry of Health (15). In his study, Besharati also came to the conclusion that a proper planning team organization may enhance operational planning efficiency in hospitals (16).
In support of these findings, it was demonstrated in a different study that providing the operational planning prerequisites with regard to the legal and statistical factors will facilitate the implementation of healthcare programs, which will ultimately improve performance and services (17). Furthermore, the performance indicators of the first level of Iran's healthcare networks can be improved by using the operational planning model, which comprises analysis of the current situation, determination of
operational goals and objectives, procedures, and methods, budget adjustment, monitoring, and program modification (18). According to the results of another study conducted at Mashhad University of Medical Sciences, "planning financial and human resources" has an impact on the caliber of medical and educational services (19). The findings of these studies highlight the need for practical and comprehensive components in health initiatives. In certain nations and Iranian organizations, setting goals and objectives as well as how to choose the appropriate actions to attain them was an essential component of the planning process for health care. Local committees decide where to go in Sweden, state planning organizations and health centers decide in Turkey, regional departments decide in Russia, and the district health council decides in France, all of which are similar to how planning is done in Iranian organizations by local offices and experts.
The research's findings in the area of program monitoring revealed a fundamental similarity between Iranian organizations and those in the chosen nations, where regional reviews are carried out by local authorities and final evaluations are conducted at the national level. Besharti and colleagues' findings are supported by the fact that they believe one of the issues with planning in health and treatment facilities is the improper management of objectives and the neglect of the organization's operational planning rules and guidelines (20). It has been underlined to create and complete monthly and yearly forms for performance monitoring in order to fulfill the aims and objectives of the plan in another research in the area of designing operational plans to implement the strategic plan in organizations (21). In order to enhance the plan and its execution, it is important to pay attention to the "plan-do-check-action" cycle, which Sorra and colleagues found to be a continuous cycle (22). Demari highlights the scheduling of planning operations throughout the year and the time period of the five-year plans to meet the goals in a study on the restructuring of the operational planning system at the Ministry of Health (23).
CONCLUSION:
The current research's findings indicate that all of the characteristics of health planning that are examined, such as those responsible for providing care, units of providing care, those responsible for health planning, planning system, components of programs, how to formulate goals and objectives, determining activities, and monitoring and evaluation system, are crucial and crucial in particular countries, including Iranian organizations. The effectiveness of the overall Iranian healthcare system may benefit from paying attention to them. However, based on the results of this comparative study, it is possible to maximize the use of current infrastructures and expand them by removing and fixing some structural and operational barriers. Iran's health planning system lacked the required cohesion, and several governmental and non-governmental groups were operating independently of one another while offering rival services. There was no service continuity due to issues with policymaking and cross-sectoral cooperation. While Iran has a large network of medical facilities, the ability to plan and deliver healthcare through comprehensive urban and rural health service centers is thought to give it an edge over competing nations and reduce parallelism in this area. Given that centralized, semi-centralized, and decentralized planning all have benefits and drawbacks, it is recommended that each approach be used in accordance with the facilities already in place and local conditions rather than complicating things across the board.
This may have the essential impact on defining program objectives, program components, how to choose activities, and finally program evaluation.
It is proposed that more studies be carried out with a greater number of nations that are leaders in health planning due to one of the drawbacks of this research, which is the small number of selected countries.
Ethical considerations:
The rights of the authors and sources are protected by providing the complete names of the studies that were utilized, and the author or authors whose information or works were directly used are properly cited in the publishing and presentation of the materials.
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