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Parnian E, Aboutorabi A, Sheikhy-Chaman M, Sakhidel Hovasin A, Soltani Z. The People’s Right To Choose their Healthcare Services: View Point of Health Managers. EBHPME. 2021; 5 (1) :52-62
URL: http://jebhpme.ssu.ac.ir/article-1-314-en.html
Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Background: People, as the main recipients of healthcare services, consider themselves entitled to the right to choose in the health system. This study aimed to investigate people’s right to choose and freedom about healthcare services from healthcare managers’ perspective.
Methods: This qualitative study was conducted in 2020. Data were collected through semi-structured interviews with 15 healthcare managers. Then, the snowball sampling method continued until data saturation level was achieved. All interviews were recorded, analyzed, and the main themes were extracted. MAXQDA10 was used for data analysis using content analysis method.
Results: The people’s rights to choose their healthcare services were categorized into five main themes: people’s awareness of their right to choose, freedom of choice regarding receiving or not receiving services, government guidelines and policies, choice of hygienic services and medical services in a special way, and barriers to free access to services.
Conclusion: Recently, more attention is paid to social values in health systems than in the past, and people have more freedom and choices. On the other hand, to strengthen social justice foundations, there is a need for comprehensive policies and planning in various aspects.
 
Key words: Right to choose, Freedom, Health system, Qualitative study
Introduction
 
Health is considered one of the basic rights of every society members, and the government is obliged to provide it equally for all. On the other hand, having healthy human beings is at the center of all social, economic, political, and cultural development in any human society and, therefore, is of utmost importance in developing infrastructure of different sectors (1). In each country, the healthcare system has been considered the main trustee of health, including different health organizations (2). In some countries, these organizations are only public, but in others, the private sector also operates within a specific framework (3). The common point of all health systems in the world is that the people are the main recipients of healthcare services and recipients of these services consider having the right to choose one of their basic rights. Besides, this right to choose is considered a social value (4). Advances in technology and health technologies, development of communication and information methods, increased health literacy. Improved quality of healthcare services has raised expectations of service recipients from health systems. Any failure to provide them with desirable services will result in dissatisfaction and protest (5) Therefore, policy-makers and the health system managers have concluded that paying attention to the social criteria and values of healthcare recipients is one of the fundamentals for the proper management of this system and should be given special attention, to meet the needs of the population (6,7) fully.
The social values of the health sector can be divided into two axes: process (transparency, accountability) and content (cost-effectiveness, freedom of choice, and justice) (6). It should also be noted that some of these criteria and social values are specific to a particular culture, but some are universal and important in all social systems (8). According to the previous researches, paying attention to social values in healthcare processes leads to public trust and legitimizes the decisions made by health policy-makers and planners (9,10).
The level of attention to these values ​​ varies in different health systems. For instance, Britain, Germany, and Australia are in a good position, Thailand and Latin America are in a relatively good position, and South Korea and China are in an unsuitable position (9). Also, in a qualitative study in accordance with the structure of the health system of Iran, it was found that according to health experts’ perspective, freedom to choose healthcare services is divided into three categories: freedom of choice for treatment services, freedom of choice for preventive and hygienic services and freedom of choice for choosing the insurance organization (5). Another study found that paying attention to the patient’s right to choose is essential for improving healthcare services quality (11). Chavehpour et al. (12), in their cross-sectional research, uncovered marked inequalities in hospitals and hospital bed distributions in the Iranian health system as one of the challenges of freedom access to healthcare services. Equitable distribution of human resources was also recognized as another factor influencing access and freedom of choice in the health system (13).
Having the right to choose is one of the examples of social justice and considering the progress of societies in all fields, especially in the field of health. Also, people expect to have a more prominent role and practical freedom in their health-related decisions than in the past, and disregarding to this right may cause them dissatisfaction when receiving services and even influence their subsequent referrals, which is contrary with the objectives of any health system. Therefore, it is necessary to conduct studies in this regard to provide a basis for evidence-based policy-making by creating valid evidence. The present qualitative research was conducted in 2020 to examine the people’s right to choose healthcare services from healthcare managers’ perspective.
Materials and Methods
Data collection
This study has been conducted using a qualitative approach in the first six months of 2020 to investigate people’s freedom of choice regarding healthcare services. It is important to note that the right to choose does not imply choosing the type of healthcare services provided by the recipient, which is up to the service provider to determine. Also, in all parts of the current study, the word “people” refers to the recipients of health care services, and “freedom” means having the right to choose.
Fifteen healthcare managers from the city of Kerman, with at least five years of managerial experience, were included by the snowball sampling technique, as one of the purposive sampling methods, and the sampling has been extended until the data were saturated. This sampling method was chosen to include participants who have a proper understanding of the concept of equity in health due to their relevant education or research background. Participants were ensured that they could leave the interview table at any time, even though they remain anonymous during the research time. The guiding questions for the semi-structured interviews were determined based on the relevant studies and finally approved by the research team. In the first step, four in-depth interviews were organized to better understand the subject and identify more important topics for semi-structured interviews. After doing the necessary coordination, all interviews were conducted face to face at the participants’ workplace, and they lasted for 30 to 45 minutes, with an average of 40 minutes. The questions were asked in a manner that would carefully explore the interviewees’ perspectives. Interviews were continued until data saturation (no new findings emerged), and saturation was reached with 15 interviews. The researcher wrote the recorded information verbatim on paper after each interview and as early as possible. It was done after listening to the recordings several times. Moreover, note-taking was done by the researcher while recording the interview. In the findings section, the letter “P” with the number means the quoted interviewee.
Data analysis
MAXQDA10 was used for data analysis using content analysis method. Before starting the data transfer and adjustment process, the researcher became familiar with its scope and diversity and gained an overview of what was collected. The researcher performed all interview stages, including listening to the recorded audio and reading the transcripts. Also, all recorded interviews and discussions were reviewed again, and the possible questions were identified. To achieve the data’s validity and accuracy, the following criteria were assessed: credibility, dependability, and conformability. To ensure credibility, the main extracted themes were checked with participants in the study, and they expressed their perspectives on the extracted concepts; moreover, they answer the questions and issues raised by the research team at various stages of the study. The conformability was ensured by maintaining documentation throughout the research process. Furthermore, the data was assessed to ensure that the findings accurately represent the participants’ information. The researcher also sought the perspective of another study team about the results to ensure conformability.
Finally, the study process was provided to two researchers who had experience with qualitative research, and after reviewing this process, the research results were confirmed, and the study results were completed and classified into five main themes.
At all stages of the study, from data collection to the end of the analysis and reporting the findings, issues of informed consent, anonymity, the confidentiality of information, and the right to withdraw from the study at any time were observed to meet ethical considerations in this study. Besides, participants were entered completely voluntarily and consciously, and their specifications and information remained completely confidential. The authors declare that they have complied with the principles of the Helsinki Declaration.
Results
The characteristics of the participants are summarized in Table 1.
 “Location of Table 1
The findings of the current study were categorized into five main themes and presented in Table 2. It should be noted that the right to choose in this study does not mean the choice of healthcare services by the recipient of the service, and making this decision is left to the service provider.
 “Location of Table 2
People’s awareness of their choice
The first theme identified in this study was related to people’s awareness of their right to choose in the health system. Few interviewees believed that people were fully aware that, according to the constitution, health was their primary right and that the government had a duty to ensure it. “If a woman goes to a rural or urban primary health center to have her child vaccinated and the center does not have a vaccine, she will try to go to a higher center; a city primary health center or even a medical university and ask the authorities about the reason for the health staff’s negligence. It means that people have the right to choose and are aware” (P.12).
On the other hand, most of the interviewees
had different opinions about this subject. “Unfortunately, people do not have information about their right to choose. The level of awareness and health literacy of the people should be raised, and organizations such as governmental broadcasting networks and the ministry of education, which are in more contact with the public and have a wide means for communication, should act properly with the help and cooperation of the Ministry of Health” (P.14).
Freedom of choice regarding receiving or not receiving services
The second identified theme was related to the scope of people’s right to choose. In other words, of the total number of healthcare services provided by the Iranian health system, how much is the freedom of service recipients to receive or not to receive these services. In this regard, the interviewees believed that people have the full right to use healthcare services, and there is no obligation to receive them. “People who use healthcare have 100% free choice and have free will. For example, a woman who comes for her child vaccination wants a specialist health worker to do it, and the staffs also generally leave the individuals free to choose” (P.2). “In the current healthcare system of the country, the client has the ultimate right to choose. For example, the recipients of healthcare services choose the method of contraception without any obligation, and there is no obligation on the part of the staff” (P.7). “Fortunately, in the health system of Iran and based on responsibilities that the government is obliged to fulfill, which is to provide the health needs of individuals in the society, various services like primary healthcare services, treatment (medical services) and rehabilitation services are provided, but there is no obligation for people to receive services. Sometimes face to face follow-ups or follow-ups via telephone are done by rural primary health centers, which are considered an act of compassion on behalf of the service provider, and it is not mandatory” (P.15).
Government guidelines and policies
The third identified theme was classified as government guidelines and policies affecting people’s right to choose. This theme elaborates on whether there is a law or regulation by the government that affects the right of people to choose regarding receiving healthcare services or not. A group of interviewees believed that there was no law in this regard and stated that the government had adopted no policy. “Government guidelines and policies in our country are generally superficial, and in reality, we are witnessing the implementation of different processes. In the health sector, there are no instructions from high officials to change the people’s right to choose” (P.9). “It is the government’s responsibility to ensure the people’s health and to make every effort in this regard, but no instructions have been communicated to the healthcare centers that affect the people’s right to choose, and whoever wants, can use the available healthcare services” (P .14).
Another group of interviewees stated that the only government policy that affects the service recipients’ right to choose is insurance coverage. “In our country, there are several insurance funds, and each of them covers a group of the population according to their mission. So, the recipients of services have to go to centers that have a contract with their insurance system, and this limits their freedom of choice” (P.8).
Choice of hygienic services and medical services in a special way
The fourth theme identified includes the people’s right to choose in two separate areas of hygienic services (hygienic system) and medical services (medical system). Some interviewees stated that people have a choice in all areas of hygienic services and medical services. “The people of our country are intelligent people, for most of them, in both hygienic system and medical system, the manner that services are provided, and the type of service provider is very important, which shows that people have a complete choice” (P.13).
Some interviewees saw this option only in primary healthcare. “In the primary health system, the recipient of the service has more choice, but in the medical system, due to various barriers, including the region (urban, rural) and city of residence, health insurance, and even the amount of household income, this right of choice is diminished” (P.11).
Another group of interviewees believed that people generally receive primary healthcare services from the health centers near their address, but for medical and treatment services are free to choose from a variety of available centers and have more options. “The quality of provided services in the country’s hygienic system does not differ much in practice, but in cases when more specialized services are needed, people need a good specialist doctor to continue their treatment process. At this stage, they can freely choose their therapist according to individual preferences and priorities” (P.5).
Barriers to free access to services
The last theme identified includes barriers to free receipt of services in Iran’s health system. Many interviewees believed that some of the obstacles in this area are beyond the health system’s control. “If we also believe that healthcare recipients should be free to receive the services they need, there are some limitations that are beyond our control and are mainly due to lack of different resources” (P.4). “In a rural health center and even in an urban hospital, there are minimal staff and specialties, so the patient is unable to choose” (P.10). “In dental centers, when there is only one dentist, the recipient of the service cannot choose. The same is true of midwifery and vaccination services. So, the lack of human resources significantly reduces people’s options and their right to choose” (P.6). “The services provided in healthcare centers should be very diverse, but unfortunately in practice, when a recipient is going to visit a general practitioner or a specialist, he usually faces a lack of human resources, and even in some cities there’s a lack of specialists, which limit your freedom to choose between them or to have any right to choose“ (P.9). Region (rural, urban) and city of residence are also mentioned as restricting people’s right to choose. “The city of Kerman has about 30 health centers and, of course, certain areas have been defined, specified, and planned for the coverage of services for recipients. In other words, there are certain areas where people living in that area are compulsorily covered by the healthcare center where they are located and have no other choice“ (P.1). The interviewees also believed that “despite the limited resources of the health system,
which inevitably affect the freedom to receive healthcare services, with proper managerial and economic policies and proper use of available resources, barriers to free access to services can be partially removed. However, it needs a strong will of the government and officials to achieve this
” (P.8).
 

 
Table 1. The characteristic of the participants
Expertise Frequency Gender
Male Female
Health economics 3 2 1
Healthcare management 4 3 1
Health policy 3 3 -
Epidemiology 2 1 1
Medicine (MD) 3 1 2
Total 15 10 5
Table 2. The right of the people to choose in the Iranian health system
Main Themes No.
People’s awareness of the right to choose 1
Freedom of choice regarding receiving or not receiving services 2
Government guidelines and policies 3
Choice of hygienic services and medical services in a special way 4
Barriers to free access to services 5
 

Discussion
In the health systems, freedom of choice has always been controversial, as some see it as beneficial for recipients, and some people believed it as a disadvantage. In societies with a democratic government system, people have more choices in various matters, and the consideration of this social value by different sections of society is of particular importance. For example, European countries, the United States, and Australia are in this category. In contrast, Asian and African countries with more conservative governments offer people fewer choices (6). According to the results of the current qualitative study conducted in the first six months of 2020 to investigate people’s right to choose healthcare services from healthcare managers’ perspective, participants had different views about each area that will be discussed here.
In the first main theme of the study, a small number of interviewees believed that people are fully aware of their right to choose and consider ensuring society’s health as the government’s duty. In contrast, most experts stated that people have low awareness and health literacy. Thus, inter-organizational measures need to be taken. Numerous studies have been conducted to investigate the health literacy of different demographic groups of the population. The research titled “Assessment of health literacy studies in Iran: a systematic review” conducted by Robatsarpooshi et al. (14) found that health literacy in different groups in Iran is not desirable. Therefore, coherent planning and efficient health policy should be considered. Moradi et al. (15), in their descriptive-analytical research titled “The Study of Health Literacy of Patients Referring to Specialist Physicians’ Offices in Kermanshah City” demonstrated that the patients and their relatives had a decent level of health literacy. The priority sources for obtaining health related information were the Internet, television and radio programs, and consultation with doctors and medical staff. Also, health literacy was different in terms of sex, education, age, and occupation. Mahmoodi et al. (16), in their paper titled “A Systematic Review and Meta-analysis of Health Literacy in the Iranian Population: Findings and Implications,” showed that it seems necessary to provide education for communities with inadequate and low levels of health literacy. Overall, Health literacy is an important component of public health and needs to be upgraded by policy-making, and its realization can be an essential step towards raising the awareness of the people about their right to choose in the health system.
In the second main theme of the study, the interviewees agreed that various services had been provided in the country’s health system, but there is no obligation to receive them. In all health systems worldwide, the government provides some services with its available resources, and recipients of services are completely free to use or refuse those (17). In both cases, the government is not deprived of health stewardship, and the government must take care of and be concerned about its people’s health. It seems that comprehensive and evidence-based policy-making can encourage people to use healthcare services, especially the consumption of hygienic services. According to health economics studies, more people use inexpensive hygienic goods and improve health indicators in that community, reducing the need to use costly medical goods (18).
In the third main theme of the study, health insurance was introduced as the only government policy affecting people’s right to choose, where recipients of services are forced to go to healthcare centers that have a contract with their health insurance with some freedom barriers. This study’s findings are in accordance with the study’s findings conducted by Rashidian et al. (5). Achieving universal coverage and equitable access to healthcare services in different parts of the country, reducing the financial risks of using healthcare services, and improving the quality of healthcare services are the main reasons for creating and forming health insurances (19). In Iran, several major insurance organizations (insurers) have covered many people with their services. The existence of multiple insurance funds can increase the quality and variety of provided services by creating competition to attract more customers. In other words, defining a framework in which people were free to choose an insurance plan among different insurance funds based on each insurer’s conditions and characteristics is equal to giving people the right to choose. In the qualitative study conducted by Rashidian et al. (5), one of the dimensions of freedom in the health system was choosing an insurer. The integration of health insurance funds in the Iranian health system is one issue that affects the freedom to choose the insurer. According to studies, the dispersion of insurance funds may lead to a lack of risk pooling and resource collection, eliminating the possibility of insurance organizations’ strategic purchase and reducing their bargaining power (20,21).
In the fourth main theme of the study and the right to choose hygienic and medical services separately, the interviewees’ opinions varied completely. Some interviewees stated that people have full choice in all areas of hygienic and medical services, some believed that this right is only related to primary healthcare services, and the last group stated that the right to choose is only related to medical services. The results of a study showed that the people have an acceptable amount of freedom to choose a healthcare organization, and this freedom varies depending on the type of hospital ownership so that patients have more freedom when dealing with the private sector and in public hospitals due to limited resources and large numbers of patients this freedom is limited (5). In South Korea, people have more freedom in the private sector than in the public sector (22). In Australia, people have relative freedom to choose a healthcare provider, but they can increase their right to choose health technologies by paying extra money (23). In Germany (24), the United Kingdom (25), and China (26), people do not have much choice in choosing a therapist (healthcare provider) and are subject to the law. In general, considering the nature of hygienic services and planning for universal healthcare services coverage, barriers to receiving services from defined centers in a given geographical area can be justified. It is better to guide the recipients in different healthcare services categories by fully implementing the referral system. The right to choose in the medical sector is mostly related to economic variables; people who afford freely among different healthcare centers and even travel to other cities and countries to receive better and high-quality services, which contrasts with justice theories. Justice (equity) is one of the most important social criteria and values ​​in the health system that all health policy-makers consider, but it seems impossible to establish it even in developed countries (27,28) fully. In the Iranian health system, measures (actions) have always been taken to achieve relative justice, especially to protect the weak and vulnerable sections of society, and there is a need for more planning to increase justice and giving people the freedom of choice.
The fifth and final main theme of the study was the barriers to free access to services in the health system. According to the results, a group of interviewees believed that some of the barriers in this area are beyond the health system’s control, and its root is the lack of material and human resources. Also, the region (rural, urban) and the city of residence were introduced to restrict the people’s right to choose. Finally, interviewees stated that people could be given more freedom of choice by appropriate managerial and economic policies and proper use and allocation of available resources. Balancing the supply and demand of human resources in the health sector (human resources management) along with the fair distribution of material and economic resources is one of the major challenges of all health systems around the world (29,30), and there is a positive relationship (correlation) between the equitable distribution of facilities and society’s level of health status (31). The study of Mossadegh Rad et al. (32) showed that the unfair distribution of health resources will lead to the referral of patients to other cities, which will impose more costs on patients and the health system, and will also reduce patients satisfaction. The distribution of physicians in Japanese hospitals is undesirable; in China, the disproportionate distribution of human resources is more prevalent in rural areas (33), and specialized human resources show little inclination to operate in small towns and rural areas (34). In general, in the country’s health system, with the help of the right policies, the allocation and distribution of resources should be done legally, especially in deprived areas, so that the recipients of services can have more freedom of choice.
Qualitative studies allow for in-depth analysis of fac­tors influencing outcomes and provide a basis for de­veloping conceptual frameworks for different assessments. Neverthe­less, this type of study does not compensate for the necessity of quantitative assessment of contributing factors. Statistical modeling and analysis allow for quantitative identification of the causal relationship among contributing factors, ranking influencing factors, and determining policy priorities. In this study, the snowball sampling method was used to find the participants, resulting in missing some experts. Difficult access to interviewees was another limitation of the present study. Finally, only the main themes were identified and extracted (nothing was done about the sub-themes) to answer the research question. Hence, it is better to generalize the results of the current study more carefully. Despite these limitations, in this study, various aspects of people’s right to choose in the Iranian health system were investigated and discussed. For future research, doing more specialized studies from other health system employees’ perspectives and finding the hidden aspects hidden from the present study results are suggested. The findings derived from different researches can be applied and implemented by policy-makers in large-scale policies to make better decisions based on scientific and valid evidence (evidence-based policy-making) (35).
Conclusion
Generally, with the measures taken, more attention is paid to social values in health systems, and people have more freedom and choices than in the past. However, to strengthen the foundations of social justice, there is a need for comprehensive policies and planning in different aspects to improve community health indicators and ensure that recipients of healthcare services are satisfied with receiving these services.
Acknowledgments
The authors sincerely would like to thank all of Kerman city’s healthcare managers who helped improve the study’s quality through constructive criticism and professional viewpoints. The authors are especially thankful to Mr. Mojtaba Hasoumi, Ph.D. Student of Health Economics, Iran University of Medical Sciences.
Conflict of interests
The authors declared no conflict of interests.
Authors’ contributions
Aboutorabi A and Parnian E designed research; Sheikhy-Chaman M conducted research; Soltani Z analyzed data; and Parnian E and Sakhidel Hovasin A wrote the manuscript. Sheikhy-Chaman M had primary responsibility for final content. All authors read and approved the final manuscript.
Funding
There was no funding for this study.
 
Type of Study: Original article | Subject: Health Policy
Received: 2020/09/26 | Accepted: 2021/03/10 | Published: 2021/03/10

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