Takian Amirhossein, Rashidian Arash, Doshmangir Leila
Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, National Academy of Medical Sciences, Tehran, Iran, College of Health and Life Sciences, Brunel University London, Uxbridge, UK,
Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Health Policy Plan. 2015 Dec;30(10):1261-71. doi: 10.1093/heapol/czu135. Epub 2015 Jan 18.
The Iranian health system, under the banner of family physician (FP) programme, has undergone substantial reforms to change utilization of health services, improve quality of care and enhance affordability. The national implementation of FP initiated in 2005 in parallel with rural health insurance (RHI) in rural areas and cities of <20 000 populations in Iran. The implementation of FP was the first national attempt to split the purchaser and provider of the primary health-care services in Iran. Using an adapted institutional approach, this article aims to explore the process of purchaser-provider split (PPS) during the implementation of FP and RHI reforms, and its consequences for the health system in Iran.
We conducted 71 face-to-face interviews and three focus group discussions at national, provincial and local levels with policy makers, managers, researchers, health-care practitioners and representatives of the public. Interviews and focus groups were digitally recorded and transcribed verbatim. Data collection was supplemented by the review of relevant documents at all three levels. We analysed the data using an inductive-deductive framework analysis approach.
Views towards PPS and its consequences on the implementation of FP were diverse. Some participants identified the PPS as an essential reform for undertaking the parallel implementation of FP and RHI. Others wondered whether the split has been beneficial as expected and asked for more scrutiny.
The implementation of FP and RHI in Iran demonstrated the mixed effects of PPS on health system performance. Our research revealed that PPS did not succeed in changing the status quo, became a reason for fighting, misunderstanding, lack of co-operation and failure of the fragile partnership between the purchaser and provider. We advocate careful contextual preparation prior to large-scale application of PPS during nationwide implementation of FP in Iran as well as other settings.
伊朗卫生系统在家庭医生（FP）计划的旗帜下进行了重大改革，以改变卫生服务的利用情况、提高医疗质量并增强可承受性。2005年，伊朗在农村地区以及人口少于2万的城市推行农村健康保险（RHI）的同时，开始在全国范围内实施家庭医生计划。实施家庭医生计划是伊朗首次在国家层面尝试将初级卫生保健服务的购买方和提供方分开。本文采用一种经过调整的制度方法，旨在探讨在实施家庭医生计划和农村健康保险改革过程中购买方与提供方分离（PPS）的过程及其对伊朗卫生系统的影响。
我们在国家、省和地方层面与政策制定者、管理人员、研究人员、医疗从业者和公众代表进行了71次面对面访谈和3次焦点小组讨论。访谈和焦点小组讨论进行了数字录音并逐字转录。通过查阅所有三个层面的相关文件对数据收集进行补充。我们使用归纳 - 演绎框架分析方法对数据进行分析。
对于购买方与提供方分离及其对家庭医生计划实施的影响，各方观点不一。一些参与者认为购买方与提供方分离是同时实施家庭医生计划和农村健康保险的一项重要改革。另一些人则质疑这种分离是否如预期那样有益，并要求进行更严格的审查。
伊朗实施家庭医生计划和农村健康保险表明，购买方与提供方分离对卫生系统绩效产生了混合影响。我们的研究表明，购买方与提供方分离未能成功改变现状，反而成为了冲突、误解、缺乏合作以及购买方与提供方之间脆弱伙伴关系破裂的原因。我们主张在伊朗全国实施家庭医生计划以及其他地区大规模应用购买方与提供方分离之前，要进行谨慎的背景准备。
