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In the name of God the compassionate and the merciful

In the name of God the compassionate and the merciful. Decentralization of Health System in Islamic Republic of Iran. By Mohammadreza Rahbar MD- MPH mrzrahbar@yahoo.com. Outlines. Definitions Evidences for the necessity of action Indicators Experiences and Analysis 5 Projects

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In the name of God the compassionate and the merciful

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

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

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

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

  5. 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. Center for Health Network Expansion & Health Promotion

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

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

  8. 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. Center for Health Network Expansion & Health Promotion

  9. Objectives of Decentralization Center for Health Network Expansion & Health Promotion

  10. Areas of decentralization and range of authorities Mapping Decision making for Decentralization Center for Health Network Expansion & Health Promotion

  11. “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 Center for Health Network Expansion & Health Promotion

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

  13. 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 Center for Health Network Expansion & Health Promotion

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

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

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

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

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

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

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

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

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

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

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

  25. 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 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 Rural Urban Center for Health Network Expansion & Health Promotion

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

  27. 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 2000Read line= Standard 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 1380گروه سني ,كودكان 15تا 23 ما هه Center for Health Network Expansion & Health Promotion

  28. 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 2000Read line= Standard 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 1380گروه سني ,كودكان 6ساله Center for Health Network Expansion & Health Promotion

  29. 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 2000Read line= Standard 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 1380گروه سني ,كودكان 15تا 23 ما هه Center for Health Network Expansion & Health Promotion

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

  31. 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 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 Year Center for Health Network Expansion & Health Promotion

  32. Variation among different provinces for the 1- 59 months mortality for the rural areas being covered by the Health houses in different years 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 Variation Year Center for Health Network Expansion & Health Promotion

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

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

  35. 1- 59 months Mortality Rate for the rural areas being covered by the Health houses in 2001 ميزان مرگ كودكان يك تا 59 ماه در سال 1382 در مناطق روستايي تحت پوشش خانه هاي بهداشت كشور Center for Health Network Expansion & Health Promotion

  36. 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 ارتباط خطي نسبت مرگ كودكان 1تا 59 ماه با نسبت بيسوادي در مناطق روستايي 281 شهرستان كشور در سالهاي 1379و1380و1381- بر اساس اطلاعات ثبت شده در زيج حياتي خانه هاي بهداشت ومطالعه DHS بهترين شاخص نابرابري ضريب زوايه خط( بتا) است Vagstaf:2005 Inequity Index Vagstaf:2005 چا بها ر 1-59 months mortality rate شميرانات The Literacy Rate Center for Health Network Expansion & Health Promotion

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

  38. 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 Center for Health Network Expansion & Health Promotion

  39. 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 orderDuration of pregnancySex of neonateMother's ageTwin birthIranian or AfghaniThe area of livingMother's literacyLiving in Urban or Rural areaHousehold income Center for Health Network Expansion & Health Promotion

  40. Distribution of deaths due to Non-Intentional accidents in relation to household income-The cooperative work of death registration system and inequity survey- 2003 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 Obs Prob>z (95%) CI 5498 0. 0.0281 [-0.1281 -0.0072] Meaningful concentration for the high income households تمركز معنادار خطر دربخش غير مرفه جامعه Center for Health Network Expansion & Health Promotion

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

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

  43. Distribution of utilization from health services in relation to household income-Utilization survey- 2002 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] Meaningful concentration for the high income households تمركز معنادار بهره مندي دربخش مرفه جامعه Center for Health Network Expansion & Health Promotion

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

  45. Distribution of utilization for choosing health services provider for hospitalization in relation to household income-Utilization survey- 2002 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] Meaningful concentration for the high income households تمركز معنادار حق انتخاب دربخش مرفه جامعه Center for Health Network Expansion & Health Promotion

  46. Average expenses for receiving ambulatory health services in a year for a person for different type of expenditureUtilization survey- 2002 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 26510تومان Drug and instruments Drug and instruments 20280تومان Curative interventions Expenditures Diagnostic tests 6680تومان Direct payments and user fees Going to the service unit and coming back Private sector Governmental sector Both sectors Center for Health Network Expansion & Health Promotion

  47. 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 marketUtilization survey- 2002 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 Service Revenue from health Market Ambulatory care Hospitalization Providers 31% 82% 34% Governmental 69% 18% 66% Private 8.4 times of visit per year for every Iranian 3524,000 Billion Tomans 0.061 times of hospitalization for every Iranian Rates of services Center for Health Network Expansion & Health Promotion

  48. 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 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 Paying more which does not affect in the family Paying more than 50% of monthly income Paying more all monthly income and using the savings Paying more than all of monthly income and loan for it Loan and selling properties for payment Percent Social Security Organization Ministry of health Other (Charities and other organizations) Private Every kind of hospital Center for Health Network Expansion & Health Promotion

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

  50. 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 Center for Health Network Expansion & Health Promotion

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