Research Center for Modeling in Health, Kerman University of Medical Sciences, Jahad Blvd, Kerman, Iran.
Health Policy Plan. 2013 Aug;28(5):480-94. doi: 10.1093/heapol/czs082. Epub 2012 Sep 22.
The question of how priority setting processes work remains topical, contentious and political in every health system across the globe. It is particularly acute in the context of developing countries because of the mismatch between needs and resources, which is often compounded by an underdeveloped capacity for decision making and weak institutional infrastructures. Yet there is limited research into how the process of setting and implementing health priorities works in developing countries. This study aims to address this gap by examining how a national priority setting programme works in the centralized health system of Iran and what factors influence its implementation at the meso and micro levels. We used a qualitative case study approach, incorporating mixed methods: in-depth interviews at three levels and a textual analysis of policy documents. The data analysis showed that the process of priority setting is non-systematic, there is little transparency as to how specific priorities are decided, and the decisions made are separated from their implementation. This is due to the highly centralized system, whereby health priorities are set at the macro level without involving meso or micro local levels or any representative of the public. Furthermore, the two main benefit packages are decided by different bodies (Ministry of Health and Medical Education and Ministry of Welfare and Social Security) and there is no co-ordination between them. The process is also heavily influenced by political pressure exerted by various groups, mostly medical professionals who attempt to control priority setting in accordance with their interests. Finally, there are many weaknesses in the implementation of priorities, resulting in a growing gap between rural and urban areas in terms of access to health services.
在全球范围内，每个卫生系统的优先事项设定过程如何运作的问题仍然是热门、有争议和政治性的。在发展中国家，由于需求与资源不匹配，这一问题尤为突出，而决策能力和薄弱的机构基础设施往往使情况更加复杂。然而，对于发展中国家如何制定和实施卫生优先事项的过程，研究还很有限。本研究旨在通过考察伊朗集中式卫生系统中的国家优先事项设定计划如何运作以及哪些因素在中观和微观层面影响其实施，来填补这一空白。我们采用了定性案例研究方法，结合了混合方法：在三个层面进行深入访谈，并对政策文件进行文本分析。数据分析表明，优先事项设定的过程是非系统性的，对于如何决定具体的优先事项几乎没有透明度，而且所做的决策与其实施是分开的。这是由于高度集中的系统，即卫生优先事项是在宏观层面设定的，而不涉及中观或微观层面或公众的任何代表。此外，两个主要的福利套餐是由不同的机构（卫生部和医学教育部以及福利和社会保障部）决定的，它们之间没有协调。该过程还受到来自各个团体的政治压力的严重影响，这些团体大多是试图根据自身利益控制优先事项设定的医疗专业人员。最后，优先事项的实施存在许多弱点，导致农村和城市地区在获得卫生服务方面的差距越来越大。
