Reform In Iran Research Articles

Integrating Mental Health Services into the Primary Health Care System: The Need for Reform in Iran.

Objective: The main objective of this study was to review aspects of the current situation and structure of the integrated mental health care services for planning a reform. Aspects of the newly designed infrastructure, along with specification of duties of the various human resources, and its relation with Iran’s Comprehensive Mental and Social Health Services (the SERAJ Program), will also be presentedMethod: This is a study on service design and three methods of literature review, deep interview with stakeholders, and focused group discussions. In the literature review, national and international official documents, including official reports of the World Health Organization (WHO) and consultant field visits, were reviewed. Deep semi-structured interviews with 9 stakeholders were performed and results were gathered and categorized into 3 main questions were analyzed using the responsibility and effectiveness matrix method. The Final results were discussed with experts, during which the main five-domain questions were asked and the experts’ opinions were observed.Results: In this study, the main gaps of the public mental health care (PHC) services in Iran were identified, which included reduction of risk factors for mental disorders, training the general population, early recognition and treatment of patients with mental disorders, educating patients and their families, and rehabilitation services. The new model was then proposed to fill these gaps focusing on increasing access, continuity of care, coordination in service delivery, and comprehensiveness of care. A mental health worker was placed besides general healthcare workers and general practitioners (GPs). Services were prioritized and the master flowchart for mental health service delivery was designed.Conclusion: A reform was indeed necessary in the integrated mental health services in Iran, but regarding the infrastructure needed for this reform, including human and financial resources, support of the senior authorities of the Ministry of Health (MOH) is necessary for the continuity and enhancement of services. In this model, attention has been given to the principles of integrating mental health services into primary health care. Current experience shows that the primary health care system has been facing many executive challenges, and mental health services are not exclusion to this issue. Monitoring and evaluation of this model of service and efforts for maintaining sustainable financial resources is recommended to make a reform in this system and to stabilize it.

Teachers’ incentive for grammar instruction in Iran's reformed EFL context

AbstractAn educational reform in Iran required teachers to employ communicative pedagogies while teaching English at secondary schools in order to develop students’ communicative ability. This study seeks to understand three Iranian English language teachers’ incentives for supporting their strongly established grammar instruction practices as they trialed aspects of task‐supported language teaching. Interviews and observations were used to gather data from these teachers in a junior secondary school. The results revealed that despite the teachers’ practical attempts to implement reform changes, their strong beliefs in the importance of accuracy, enhanced by their students’ low English proficiency and parental expectation, continued to guide lessons with an initial explicit grammar teaching. The results support the post‐method pedagogical idealism, emphasising that communicative goals should embrace class context particularities.

Three Decades of Healthcare System Reform in Iran from the Perspective of Universal Health Coverage: A Macro-Qualitative Study.

Background: The healthcare system in Iran has undergone several reforms to achieve the objectives of universal health coverage (UHC). Some reforms have delivered positive benefits, however, still many challenges remain. Hence, the current study assessed the progress and outcomes of these reforms over the past three decades. Methods: The present nationwide macro-qualitative study was conducted in Iran during 2016-2017. Data were collected through 32 in-depth interviews with 30 high-ranking policymakers and healthcare providers at the national and provincial levels to identify their experiences and perceptions of the reforms. The data were analyzed using the constant comparative analysis method. Results: Analysis of the interview data resulted in two main themes, six categories, and 18 sub-categories. The extracted themes were adverse situational context and the chaotic healthcare system. The results showed that the Iranian healthcare system reforms could be characterized as incoherent and passive, and that these were the main reasons for not achieving the objectives of UHC reforms. It was revealed that the implemented reforms lacked a comprehensive approach and at times were counterproductive. Moreover, the situational context adversely hindered the successful implementation of the reforms.Conclusion: Despite many efforts to improve the Iranian healthcare system through reforms, the situational context and organizational factors have prevented achieving the main objectives. Iran’s health policymakers should consider a phased implementation of small-scale reforms based on a comprehensive master plan that takes social, political, and economic factors into account. This approach would minimize potential risks and encourages the cooperation of the main stakeholders.

Medical Graduates’ Viewpoints on the First Big UME Reform in Iran

Background: Shahid Beheshti General Medical Degree Curriculum (2004) is the first big reform program in Iran with more than 10 major educational interventions. Objectives: We aimed to evaluate the graduates’ viewpoints about the program. Methods: This study is a descriptive cross-sectional graduate survey in 2018, in which 194 medical graduates from 2011 to 2014 participated with a response rate of 51.3%. The authors prepared a questionnaire with a four-point Likert scale based on the stakeholders’ viewpoints. The questionnaire contained 121 questions in seven domains: Job status, undertaking social responsibility, self-improvement, competency, effects of interventions, adequacy of educational facilities, the impact of faculty members, and reform book effectiveness. In data analysis, the authors combined the positive ratings of "I agree" and "I strongly agree" and negative ratings of "I disagree" and "I strongly disagree.” Results: More than 88% of the respondents were specialists, medical residents, or were preparing for the medical residency entrance exam. More than 94% of the graduates evaluated themselves as competent in clinical skills, health promotion, and self-improvement, but 48.9% were competent in health advocacy, 43.3% in rehabilitation, 38.6% in the knowledge of diseases, and 29.4% in cognitive skills. The organ system approach (99%) and the approach to the presentation (87.1%) were the most favorable aspects of the program; but, communication skills education (60.8%), problem-solving sessions (64.3%), and professionalism education (66%) were the weak aspects. Bedside clinical teaching (83%) was more effective than outpatient education (79.4%) and didactic education (74.2%). Among the participants, 64.4% assessed the educational facilities as desirable, and 78.4% of them, the educational hours. Besides, 77.8% of the respondents agreed with the positive effect of clinical faculty members, and 45.9% agreed with the basic faculty members. Moreover, a difference was observed between the effects of student textbooks (80.4%) and study guides (60.3%) on enhancing students' learning. Conclusions: Overall, the program has shown effectiveness in many areas; however, it has a few weaknesses that should be considered in curriculum revision.

Analysis of vegetable oil demand and its price reform in Iran: using rural and urban household level data

In a group of food types, vegetable oils are the second-largest source of energy in the human diet and their consumption is very important from a health and economic viewpoint. Consumer behavior evaluation can help a lot in adopting the right policies; so, the framework of the Almost Ideal Demand System model for food expenditures was used to examine rural and urban vegetable oil consumer behavior in Iran using household survey data conducted by the Iranian Statistical Institute for the 2018 year. For this purpose, income, price and cross-price elasticities under ten aggregated food groups i.e., Cereal, Meat, Dairy, Butter and Animal Oil, Vegetable Oil, Fruits and Nuts, Vegetables and Legumes, Sugary, Spices and, Dinks were estimated for vegetable oil using the Seemingly Unrelated Regression. The obtained results showed that vegetable oil concerning the positive income elasticities is a necessity goods both rural (0.872) and urban (0.889) consumers. Own-price elasticities revealed that the demand for vegetable oil is less responsive to the increase in the price in urban areas (-0.280) than the rural area (-1.073). Moreover, Butter and Animal Oils food groups are highly substitutable with vegetable oil for rural consumers. Since the absolute value of cross-price elasticities are often less than an entity, consumers of vegetable oil will not have a noticeable change in demand as prices change for other food groups. Due to vegetable oil price reform, per capita compensation payments for a typical rural person would be greater than the urban person. The results suggest that policymakers should adopt different policies about rural and urban consumers of vegetable oil.

Spatial-geographical analysis of urbanization in Iran

The development of urbanization and urbanism in Iran has created a wide socioeconomic gap in urban areas. Rapid population growth along with the lack of socioeconomic growth programs and urban development strategies have deteriorated unemployment, inflation, housing price, traffic congestion, and marginalization in cities, particularly in metropolises of Iran. This paper, using a descriptive-analytic research method and a meta-analysis technique, addresses the urbanization and urbanism changes in Iran. Using GIS technique and CV formula, the spatial distribution of urbanization and its rapid growth in Iran are depicted. The research data was derived from a systematic review of documents and techniques over 40 years. The results of the study demonstrated that Iranian cities have undergone an unsustainable growth trend and urbanization has overtaken urbanism. Over the past 4 decades, cities have been struggling with rapid growth and development. In this regard, development-oriented governments can play a significant role in tackling growth and urbanization problems. These problems are especially evident in the socio-economic, urban planning and urban ecology. The rapid growth of urbanization (74% in 2016) has resulted in the emergence of metropolitan areas in an unstable process. Also, in metropolitan areas of Iran, environmental and ecological threats, rural–urban migration and marginalization have posed serious national–regional and local challenges. The structural–functional reforms in Iran, along with skeletal–spatial and socio-economic changes in cities, have given rise to a new social class (low-income people), which is characterized with non-formal businesses and informal settlements in the outskirts of cities, especially metropolitan areas. This has prompted unsustainability in main indicators of urban development such as security, building density, environmental threats, and centralization, among other things. This analysis is based on indicators such as density and centralization, informal settlement, and urban security.

Using Compensating Variation to Measure the Costs of Taxing Cigarette in Iran

Background: The impact of pricing strategies on different socioeconomic groups is not uniform. There is urgency in addressing of characteristics of household demand to make a policy choice in line with development goals. Objectives: This study was done to assess the effect of welfare loss from counterfactual tax-induced cigarette price increases on representative smokers by different expenditure quintiles in Iran. Methods: This analytical study was conducted using pooling cross-sections and compensating variation (CV) to evaluate the costs of taxing cigarettes. The data source used in our study was the Household Income and Expenditure survey (HIES) from 2001 - 2017. We did an almost ideal demand system (AIDS) analysis to estimate elasticities for cigarette demand and compute welfare losses from simulated cigarette price increases by socioeconomic groups. We used STATA version 15.1 (StataCorp, College Station, TX, USA), and Microsoft Excel 2016 to undertake the relevant analyses and estimates. Results: The highest loss was suffered by households of the poorest quintile, who should afford 1.41%, 2.47 %, and 3.20% more budget in the long-run, respectively, as the result of three simulated price increases to stay at the same well-being as before. Conclusions: Concerning direct welfare loss from the cigarette taxation reform in Iran, and focusing on low-income groups, such a policy can be considered as regressive. However, this regressivity can be reduced by informing strategies to redirect sin tax revenues that benefit the poor.

Impacts of Health Reform Plan in Iran on Health Payments Distributions and Catastrophic Expenditure

Health reform in Iran began in 2014, aimed at improving financing pattern of health services. We assessed the reform by changes in variables representing distribution of health payments and catastrophic expenditures. Using data from households' income-expenditure survey, this study computed the financial variables, representing poverty line and households at poor state, household's catastrophic health expenditure, fairness in financial contribution (FFC) index, and household's impoverishment state, in the years 2010-2016, in urban and rural areas. The variables were computed by special software designed for this study, based on C-Sharp(C#) programming language, with yearly data on more than 38000 households, each with 1072 information sources. The food share-based poverty line after sharp rise in 2010-2013, in 2014-2016 raised slowly, and the average percent of households facing catastrophic health expenditure, after sharp rise in 2011-2013, left at 3.25 in 2014-2015 and raised to 3.45 in 2016. The average FFC index remained at 0.839 to 0.837 in 2013-2016. However, interestingly, the average percent of households impoverished after out-of-pocket payments improved from 1.36 to 0.912 in 2013-2016. In three years of health reform, the major impact of reform was considerable improvements in the rate of the impoverished after out-of-pocket payments. The reform had limited impacts on the rates of households facing catastrophic health expenditure, and on FFC indexes, for the rural and urban residents.

The New Public Management: Administrative Reform in Iran

New Public Management (NPM) has become one of the dominant paradigms for public management across the world. This paper proceeds by defining NPM and giving an insight on the context within which it emerged. The paper goes on to explore essential characteristics of NPM. Thereafter, it recommends administrative reforms that need to be adopted to strengthen public administration (PA) in Iran as a case study and the challenges in implementing them. It concludes with a summary of key issues and suggestions posed in the discussion.

Achievements and Challenges in Implementing Urban Family Physician Program in Iran: Viewpoint of Managers and Executives

Background: Urban family physician program is one of the relatively large reforms in Iran's health care system implemented in Fars and Mazandaran provinces since 2012. Nearly five years after implementation of the program, this study aimed to identify the achievements and challenges of this program from the viewpoints of managers and administrators. Methods: This cross-sectional study was conducted in winter of 2016. The research population included administrators and experts monitoring the urban family physician program and representatives of the family physicians and health care providers selected using the census method. The data collection tool was a two-part researcher-made questionnaire containing 15 questions with confirmed validity. To collect data, 29 panels of experts were held and the collected information was analyzed by SPSS 23 using independent t-tests and ANOVA. Results: Among the total of 647 participants in 2 provinces, 1540 achievement cases, 2387 challenge cases, and 1641 strategies were found. The average numbers of achievements, challenges, and strategies stated by each person were 2.38 ± 2.0, 3.70 ± 2.7, and 2.54 ± 2.0, respectively. The most frequent achievements, challenges, and strategies were increased disease detection and care (430), untimely payment to physicians (198), and providing sustainable resources for timely payments (119). The means of achievements, challenges, and strategies had significant relationship with some of the individual and social variables (p < 0.05). Conclusion: This study showed that increasing the rate of detection was the most important achievement and lack of timely payment was the biggest challenge of the program, which should be considered by policy makers.

The impact of health reform in Iran on catastrophic health expenditures: Equity and policy implications.

In 2014, the Islamic Republic of Iran launched the Health Transformation Plan (HTP), with the goal of achieving universal health coverage (UHC) through improved financial protection and access to high-quality health services among Iranian households. We aimed to investigate the impact of the HTP on the level and pattern of out-of-pocket (OOP) payments for health care. Using data from two rounds (2013 and 2016) of the Iranian Statistics Centre's Household Expenditure and Income Survey (HEIS), collected before and after implementation of the HTP, we estimate changes in the level and drivers of OOP payments, and the prevalence, intensity, and distribution of catastrophic health expenditures (CHEs) among Iranian households. Our results indicate that per capita OOP payments on health remained stable during the observed period, with the largest proportion of OOP payments spent on medicines. Using thresholds of 10% and 25% of total consumption, there was a slight increase in the prevalence of CHE. The prevalence of CHE increased from 3.76% to 3.82% at threshold of 25% of total consumption. Using 40% capacity to pay threshold, prevalence diminished modestly from 2.5% to 2.37% and the intensity decreased from 13.16% to 12.32%. At all thresholds, CHE were more concentrated among wealthier households. These results suggest that while financial protection of the poor in Iran has improved due to the HTP, more work is needed to achieve UHC in Iran. For the next phase of health reforms, more emphasis should be placed on shifting away from OOP co-payments for health financing to progressive prepayment mechanisms to facilitate better sharing of financial risks across population groups.

Urban Unsustainability Engineering in Metropolises of Iran

This paper addresses the ecological changes and urban unsustainability in metropolises of Iran based on three important indicators: administrative—political centralization, worn-out tissues and urban security. Urban unsustainability engineering is a process in urban planning and urbanization that has not been administrated and managed based on Iranian regional architecture and urban planning. The research data were gathered from a statistical analysis of documents and techniques in a systematic review (1956–2016). The results of the study demonstrated that metropolises of Iran had undergone an unsustainable growth trend. The government seeks to improve indicators of urban sustainable engineering and centralization of the metropolis. Over the past 60 years, cities have been facing rapid growth and development in Iran so that development-oriented governments can play a significant role in tackling growth and urban problems. These problems are especially evident in the socioeconomic and unsustainability of urban ecology. The rapid growth of urbanism and urbanization (74% in 2016) has culminated in the emergence of metropolitan areas in an unstable process. Also in metropolitan areas of Iran, environmental and ecological threats, rural–urban migration and marginalization have posed a serious national-regional challenge. The structural–functional reforms in Iran have been accompanied with skeletal-spatial and socioeconomic changes in cities, giving rise to a new social class called the low-income characterized with non-formal businesses and informal settlements in the outskirts of metropolitan areas.

Analysis of the Health Sector Evolution Plan from the perspective of equity in healthcare financing: a multiple streams model

Purpose Health Sector Evolution Plan (HSEP) is known as the biggest and most comprehensive reform in Iran’s health system. One of the goals of HSEP is to reduce inequity in the healthcare financing. The purpose of this paper is to demonstrate HSEP agenda setting from the perspective of equity in healthcare financing (EHCF) using the multiple streams model. Design/methodology/approach This qualitative study was conducted by 26 documents review and analysis, and 30 semi-structured interview with Iranian key informants in the field of HSEP that were selected based on purposeful and snowball sampling method. Data were collected using a researcher-made checklist based on the goals. All audio-taped interviews were transcribed and analyzed thematically. Data management and analysis were performed using the framework analysis in MAXQDA software. Findings The framework analysis identified 12 complementary sub-themes totally. Problem stream included four sub-themes (high share of Out Of Pocket, high index of catastrophic health expenditures, low EHCF index, and inappropriate economic state and sanctions). Focus on EHCF in general policies of the Iran World Health Organization’s report in 2000, the Targeted Subsidies Law and emphasis on equalizing healthcare financing in the Fourth and Fifth Development Plan were considered as policy stream sub-themes. Finally, political stream showed four sub-themes including strong support from the Minister of Health for HSEP, mass media, the pressure of WHO and people’s request to reduce health costs. Research limitations/implications The limitations of the present study included paying attention to one package (evolution in the treatment sector) of three health packages to assess EHCF, as well as the lack of similar national and international evidence in implementation framework. Practical implications The results of this study can be used to analyze other health sector reforms around the word and can help the formulation and implementation of most practical reforms, especially in field of health system financing. Social implications This study gives a holistic view about health system policy setting that can be used for understanding policy-making streams to population. Originality/value This is the first study that has examined HSEP (the biggest health sector reform in Iran) from the perspective of agenda setting. In addition, using the popular and well-known Kingdon’s model to explain HSEP agenda setting is one of the strengths of this study. Furthermore, taking advantage of a wide range of related views by including highly informed people increased the strength of the results of the study. In addition, the short interval between the interview and reviewing the results on reforms reduced the recall bias of the participants in the study.

Health Complex Model as the Start of a New Primary Healthcare Reform in Iran: Part B: The Intervention Protocol

For overcoming the existing problems and finding a pathway for realization of universal health care, health complexes were implemented in the form of a pilot project in Tabriz suburban area. Tabriz Health Complex Project was designed in 2013 in the provincial health center of East Azerbaijan. In terms of execution schedule, this intervention had 4 phases including 1) study phase, 2) planning phase, 3) pilot phase, and 4) implementation phase. Each health complex covers a population of 40,000 to 120,000 in a defined geographic area and consists of a Comprehensive Health Center (CHC) including health centers and a management center, which usually located in CHC. The important features of this project are as follows: people-centered primary health care, special attention to health promotion and prevention and establishment of a referral system within the region (organic connection between the first and second levels). An accountable and responsive health care system has been established to deliver integrated care services to people in a defined catchment area against identified per capita payment, under district health centre policies and regulations. Each health team consisted of a general practitioner and a family health nurse who covered around 4000 people to deliver prevention, promotion, and treatment services especially in and NCDs field. Health complex as a model of public-private participation and practical solution to address many of the problems in the primary care system of the country. The project can organize the PHC system and family medicine program.

Does rural health system reform aimed at improving access to primary health care affect hospitalization rates? An interrupted time series analysis of national policy reforms in Iran.

To evaluate the effects of rural health insurance and family physician reforms on hospitalization rates in Iran. An interrupted time series analysis of national monthly hospitalization rates in Iran (2003-2014), starting from two years before the intervention. Segmented regression analysis was used to assess the effects of the reforms on hospitalization rates. The analyses showed that hospitalization rates increased one year after the initiation of the reforms: 1.55 (95% CI: 1.24-1.86) additional hospitalizations per 1000 rural inhabitants per month ('immediate effect'). This increase was followed by a further gradual increase of 0.034 per 1000 inhabitants per month (95% CI: 0.02-0.04). The gradual monthly increase continued for two years after the reforms. The higher hospitalization rates were maintained in the following years. We observed a significant increase in hospitalization rates at a national level in rural areas that continued for over 10 years after the policy implementation. Primary health care reforms are often proposed for their efficiency outcomes (i.e. reduction in costs and use of hospitals) as well as their impact on improving health outcomes. We demonstrated that in populations with unmet needs, such reforms are likely to substantially increase hospitalization rates. This is an important consideration for successful design and implementation of interventions aimed at achieving universal health coverage in low- and middle-income countries.

Socioeconomic inequities in health services' utilization following the Health Transformation Plan initiative in Iran.

Health equity has become a progressively popular research topic in recent years. Therefore, this study was made to identify the contributions made by socioeconomic determinants in order to quantify their roles to healthcare utilization inequity and to show their status especially after the recent reform in Iran, i.e. Health Transformation Plan, which one of its main goals is providing access to healthcare for all people. This study is a cross-sectional study conducted on a national level in Iran in 2015. For the sampling frame, three-stage cluster sampling was used. A total of 22 470 households from the whole country were surveyed by questionnaires through face-to-face interviews. A total of 78 378 subjects responded to the survey, 18 984 subjects (24.2%) reported the need to outpatient healthcare services in the 2 weeks preceding the interview and 12 944 (68.2%) of them had utilized the outpatient services. In addition, 5928 participants (7.6% of total population) reported the need to inpatient healthcare in the 15-month interval prior to the interview. Of these, 5405 subjects (91.2%) had received the inpatient cares. Several factors such as age group, education, marital status and status of household economy play significant roles in seeking inpatient cares. In addition, age group and household economic status have significant impacts on the utilization of outpatient services. While there are several variables that have different effects in determining the need for both outpatient and inpatient services, most of them are not any more significant than what are on the receiving end of these services.

The impact of rural health insurance and the family physician program on hospitalizations, a beforeafter study at the county level conducted in Tehran province, Iran.

Background: The health insurance and family physician reform in Iran were implemented in 2005. This study was conducted to assess the effect of these reforms on avoidable hospitalizations among the rural population of Eslam-shahr County, Iran. Methods: We conducted a before-after study in Eslam-shahr County’s single existing hospital. This county is a part of the Tehran Province of Iran. The demographic characteristics and diagnostic codes of the rural population that were hospitalized during the 2 years leading to, and after the reforms were extracted from the hospital’s electronic information system. A list of 61 three-character and 131 four-character AHs codes were developed based on the literature review. We estimated a logistic regression model which included gender and age as independent variables to assess changes in the probability of avoidable hospitalizations following reform implementation. Analyses were carried out using STATA version 13. Results: We recorded 817 rural hospitalizations before and 967 hospitalizations after reform implementation, suggesting that hospitalization growth after the reforms was almost 18.4%. The logistic regression results show that the probability of avoidable hospitalizations after the interventions had decreased compared to before the interventions were put into place (OR: 0.46; 95% CI: 0.24-0.88). Also, the probability of AHs among the 60< year-old age group was considerably higher compared to other age groups. No statistical relationship was found between avoidable hospitalizations and gender. Conclusion: The reforms may have had a mixed effect on hospitalization. They may result in increased hospitalizations due to responding to the unmet needs of the population, and simultaneously they may lead to a decrease in avoidable hospitalizations and eliminate the costs imposed by them upon the health system.

The British, the Tudeh party and the 1947 World Federation of Trade Unions’ visit: battle for labour reform in Iran

ABSTRACTAfter the British-Soviet occupation of Iran during the Second World War, Iran became the key battleground for the international labour movement. The plight of the workers had become an important political issue with the Iranian government in conflict with the socialist Tudeh party for leadership over the trade unions. The Labour government in Britain was also deeply interested in the matter but regarded the Tudeh as too dangerous and too aligned with the Soviet Union to be supported. Within this climate, the World Federation of Trade Unions (WFTU) made an official visit to Iran. With its international delegates, they represented different views over the Tudeh, which caused much conflict during the visit. This article sheds crucial light on this important visit and reveals how international the Labour questions were in Iran and how the WFTU visit brought the various tensions to light. This research will also show how the timing of the visit may have impacted on the removal of the Iranian strong-man Ahmad Qavam by the end of 1947. This work is of particular significance as it looks at the previously understudied role and interest of the British government on the Iranian labour.

The effect of Iran's health transformation plan on utilization of specialized outpatient visit services: An interrupted time series.

Background: Health Transformation Plan (HTP) has been one of the biggest reforms in Iran's health system over the past 3 decades. The plan has been implemented since May 2014 and includes several packages that can affect the utilization of health care services. We aimed to assess the effect of implementation of HTP on utilization of specialist outpatient visit rate in clinics affiliated to university hospitals. Methods: We chose Kurdistan province to collect monthly specialist outpatient visit data for 50 months because this province was not a patient referral hub. An interrupted time series (ITS) analysis and segmented regression analysis were used to evaluate the effects of HTP on specialist outpatient visit rates. Statistical analyses were conducted using STATA version 13. Results: A significant increase was observed in the specialist outpatient visit rate (12.1 outpatient visit per 1000 population) in the first month after the implementation of HTP (p= 0.000, 95% CI= 6.36-17.83). Also, after the implementation of HTP, a significant increase was observed in the monthly trend of specialist outpatient visit rate equivalent to about 0.53 every month per 1000 population compared to the monthly trend in specialist outpatient visit rate before the intervention (p= 0.033, 95% CI= 0.04-1.01). Conclusion: HTP has significantly increased the specialist outpatient visit rate in clinics affiliated to university hospitals in Kurdistan province. Thus, it is necessary to perform some comprehensive studies on all public, private, and semi-private sectors in different parts of the country to provide a better and more comprehensive picture of the effects of HTP on utilization of specialist outpatient visit services.

Health care reform in Iran: Implications for nurses' moral distress, patient rights, satisfaction and turnover intention.

The aim of the present study was to assess the implications of Iran's recent health care reforms on nurses' experience of moral distress, their perceptions of the respect for patient rights and the relationship of these variables to job and income dissatisfaction and turnover intention. Health systems around the world are reforming themselves to adapt to meeting the future needs of increasing patient care to an ever-growing population. This was a cross-sectional correlational study. The participants were 276 nurses at six large private and public hospitals in Tehran, Iran. Negative correlations were reported between turnover intention and respecting patient rights (r=-0.560, p<0.001), satisfaction with job (r=-0.710, p<0.001) and satisfaction with income (r=-0.226, p<0.001). The correlation between moral distress intensity (r=0.626, p<0.001) and frequency (r=0.701, p<0.001) was positive with turnover intention. Moral distress was significantly correlated to poor respect for patient rights, poor job satisfaction and income satisfaction and was a major predictor of turnover intention. Health system reform must take into account the concomitant increasing workload and its negative impact in order to ensure that reform does not lead to unintentional detrimental outcomes of increased moral distress, decreased satisfaction and increased turnover rates among nursing personnel.