Evidence Based Health Policy,

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Background: Today, peace and stability of health diplomacy in the Eastern Mediterranean region is faced with many challenges. In spite of extensive ignorance on health consequences in other fields and priorities of foreign policy, but foreign policy can be applied to improve health particularly in international health negotiations.
Methods: To conduct this non-systematic review, articles relevant with the topic were selected from published texts and credible databases for investigation. Databases included Medline, web of science, Google scholar, Springer, PubMed, and all news websites.
Results: Since issues of health are getting more political, having political view and mastering negotiation techniques is necessary. One of these conditions is multilateral negotiations, in which non-governmental organizations, advocacy groups, foundations, research centers, and private sectors get together to affect the present representatives of the member countries’ decision making about health topics and also to be part of the negotiation process.On the other hand, the international commitments of the Millennium Development goals, has put the health issue in a special position in international discussions. Further, epidemic growth of emerging diseases (such as AIDS, hepatitis, and influenza), immigration, and the sanctions have their impacts on the health sector, especially medicines and equipment, its serious impact on public health is also considered as an undeniable threat.
Conclusion: In order to have effective application, health policy principles should be coordinated with other forms of diplomacy and also be placed at the top of all key stakeholders’ affairs including the Ministry of Health and other organizations effective on the health. Thus, to achieve the Millennium Development Goals and to escape from the problems based on the objectives of Vision 2025; this approach will solve many problems.

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Background: Osteoarthritis is the most common joint disease in humans, which is the greatest cause of physical disability among the elderly in developed countries. Homeopathy is a specific therapy that treats patients based on precise stimulation of the immune and vital systems by certain homeopathy medications. Given the widespread use of this technology, in this article, we compared homeopathy Health Technology with non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis.
Methods: In this study, Health Technology Assessment (HTA) was employed to compare homeopathy treatment with non-steroidal anti-inflammatory drugs (NSAIDs), by reviewing clinical trials. The study population included patients with knee osteoarthritis; the intervention group included homeopathy, and the control group comprised routine medical treatment (NSAID) and outcomes measured included efficacy, safety, and cost effectiveness. The most important electronic medical databases were searched for relevant articles published from 2000 to 2016, including The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL); Center for Reviews and Dissemination, University of York (CRD; NHS EED), Trip; PubMed; EMBASE and Google Scholar.
Results: Effectiveness was measured by indicators of pain and motor function. Total changes in VAS index revealed about 34 units decrease in the intervention group, while there was 12 units reduction in the control group. Reducing the consequences of pain and knee function problems were 10 points more in the intervention group in comparison to the control group. Safety outcomes were measured via skin reactions (and sensitivity) which were lower in the intervention group. In terms of cost-effectiveness, the results revealed that for each unit of pain relief, more cost was spent in homeopathy method.
Conclusion: Given that the overall costs of both treatments were low, even with the higher effectiveness and safety of homeopathy treatment, compared with NSAIDs, homeopathy is preferable.

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Background: The clinic in a hospital is usually the first place to which patients are referred. A long queue, which results in dissatisfaction among patients, is economically costly for managers; medical institutions can, therefore, determine the level of required resources for optimum investment through management tools like queue theory and waiting time caused by it. The current study was conducted to evaluate waiting time at various clinics of Amir Alam Hospital in Tehran.
Methods: The analytical study was conducted in the period from April to August in 2015 on 150 patients who were referred to five clinics of Amir Alam Hospital. The samples were selected through stratified random proportion to sample size and data was collected in a designed frame through SPSS₂₁ and descriptive tests of mean, standard deviation and regression analysis.
Results: The longest waiting time for patients was related to the surgery clinic at 61.05 minutes. Also, the longest time to provide service was related to the surgery unit at 26.84 minutes. Results obtained from univariate logistic regression test indicated that all evaluated variables—including time to receive service, capacity of providing service, order of queues and number of doctors—exert a significant effect on waiting time of patients in the hospital (P-value < 0.05).
Conclusion: Increasing capacities, keeping adequate number of doctors, reforms, removal of unnecessary works and using scientific tools to manage queues can be effective in reducing waiting time for patients. Owing to its importance for patient satisfaction, it is necessary for managers to think of ways to shorten queues in hospitals

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Background: Paving the way for having equitable access to medical intervention programs is the most important action that a health system can take in realizing social justice. This study aims at examining proper distribution of specialist physicians as an strategy towards realizing justice and equity in access to and use of health services as well as providing recommendations for policy-makers. 
Methods: This is a review-narrative and bibliographic research that used databases consisting of Magiran, Irandoc, Iranmedex, SID, PubMed, Scopus, EMBASE, Direct Science with the key words including Specialists, Health, Equity,  Accessibility, Health system and Human resources. The data were collected from 1990 to 2015.
Results: There are evidences of regions in the world that still are lacking sufficient number of physician workforce and are not only faced with challenges of recruiting, but also with retention of specialist physicians. In fact, migration of human workforce from deprived regions to more organized and prosperous parts has been a factor influencing workforce shortage in these regions; thereby it adds further problem of recruitment and retention of specialist workforce.
Conclusions: Human workforce distribution (Specialist or non-specialists) has direct effects on realizing equity and justice in health system; it also influences economy of a given country indirectly. On the other hand, compensation is one of the important incentives that drives workforce behavior and makes them more inclined towards working in deprived regions. Taking the above mentioned ideas, it is recommended for the health system to use more economic incentives and insure proper distribution that fits individuals' needs. Using various tax policies in deprived, wealthy, and generally different geographical regions is one of the most important incentives available to leverage this purpose.

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Background: The Cancer Institute of Iran, located in Tehran (Iran’s capital city), is a national specialized center for cancer. Cancer patients from all over the country refer to it. This study compared the out-of-pocket  (OOP)  expenditures of patients from Tehran and patients from other parts of Iran who were hospitalized in this center.
Methods: This cross-sectional study included all patients over 18 years of age with head and neck or digestive system cancer who were actively undergoing primary treatment in the Cancer Institute of Iran located in Tehran (the capital city). Data was collected through a structured interview with the patients themselves and/or their companions and then analyzed using SPSS₁₆ software.
Results: Direct medical costs of patients from Tehran were much higher than those of patients from other provinces. In contrast, the average direct non-medical costs including transportation, accommodation, food, etc. of patients from other provinces were significantly higher than those of patients from Tehran, and 53% of patients borrowed money for their treatments.
Conclusion: It seems necessary to develop new supportive policies to alleviate financial costs for cancer patients and help them manage their cancers effectively. Patients from the provinces faced additional costs for travel, food, and accommodations which complicated their access to special services. Establishing and improving specialized cancer centers in other cities can reduce the burden of out-of-pocket expenditures for patients from remote areas.
 

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Background: One approach to improve efficiency in health care is to identify patients with high risks of readmission so that resources should be distributed in a way they would benefit targeted care. A model named LACE (length of stay, acuity of admission, Charlson comorbidity index (CCI(, and number of emergency department visits in preceding 6 months) has been proposed to predict patient readmission which is widely used due to its simplicity to rank factors’ risks. The aim of this study is to determine if LACE Index could be used to predict Iranian hospital readmission.
Methods: This was a prospective cohort study in which the prediction of readmission for patients admitted to the cardiac intensive care of Shahid Beheshti Hospital of Qom during April to June 2012 within one month after the discharge was evaluated based on 4 items of LACE index. Following-up readmission states by making calls within a month after discharge. Purposive sampling was used to select the sample, patients having four most prevalent chronic heart diseases in the CCU of the hospital were selected and at last sample size was 109 patients. We used logistic regression, the phi and Spearman correlation coefficient to analyze data using SPSS₁₈. the significance level was considered as 5% in all tests. 
Results: Among the items of LACE model, 48.6% of patients stayed at the hospital for 4 to 6 days. Only 11 patients (10.09%) referred to the hospital after a month. None of the components of the LACE index could enter the stepwise logistic regression model.
Conclusions: Considering that LACE model with its four items is a weak in predicting readmission, in order to improve the model in predicting the readmission of cardiac patients, it is recommended that individual variables and factors associated with the service providers be added to it.

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The revision of health benefits package is considered a potential policy for making reforms in the healthcare system. However, limited studies have been carried out on the concept of revising health benefits packages and finding applicable levers to effective revision and also determining the characteristics of a desirable model. This paper investigates the concept and the levers in revising the health benefits package and also suggests the characteristics of desirable model.

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Background: Evidence Based Medicine can be define as the process of systematically finding, critically appraising, and using recently published researches as a basis for making decisions regarding individual patients.One of the most prevalent MRI procedures is Brian MRI. This study aimed to identifying and developing appropriate indications for prescriptions of Brain MRI in Iran.
Methods: This is a consensus based study using one of the practical methods, RAND Appropriateness Method. The study sample were among experts in the treatment and diagnostic field of brain disorders. The experts consisted of nine specialists: Four neurosurgeons and five neurologists, all of whom were faculty members and worked in educational hospitals. The list of indications and scenarios sent to 9 experts for scoring. They scored the scenarios according to RAM instruction.
Results: A total of 104 indications and scenarios were extracted. After that, Finally80scenarios fall in the category of appropriate scenarios, 20 in uncertain and4 in the category of inappropriate scenarios.
Conclusion: Currently a huge number of medical imaging prescriptions may be unnecessary in Iran and there is need for developing clinical practice guidelines. The findings of this study can be used for developing national guidelines, conducting research to assess whether the criteria are followed in practice and whether their application can curb the growing rate of unnecessary care in all countries. In Iran, a limited amount of resources are allocated to the health sector

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Background: High hospital costs on one hand, and limited resources and facilities on the other hand, have led hospital managers to reduce costs and increase efficiency. Performance measurement is one of methods for assessing efficiency of hospital .in terms of resource utilization. Therefore, the present study was conducted with the aim of evaluating the efficiency of hospitals affiliated with Bushehr University of Medical Sciences before and after the implementation of the Health development Plan.
Methods: This study is descriptive-analytic. The research population of this study was all hospitals affiliated with Bushehr University of Medical Sciences whose performance was evaluated in two years of 2013 and 2014. To measure the efficiency of these hospitals, data frontier analysis was used. The criteria of the total number of employees, the total number of physicians, the number of nurses and active beds were studied as input variables, and the percentages of cesarean section in total deliveries, number of surgeries, average residence. The data were collected in collaboration with the University's Center of Statistics as well as referring to the hospitals and analyzed using DEA software.
Results: The mean technical efficiency, managerial and scale of performance before the implementation of health system development plan were reported 0.934 ± 0.116, 1.00 ± 0.0 and 0.934 ± 0.116, respectively. Furthermore, six out of the eight hospitals studied were technically and scale-oriented efficient, and all eight hospitals were efficient regarding management. Only two hospitals had a surplus and two hospitals were inadequate. The mean efficiency after the implementation of the development plan was 0.9504 ± 0.131, 0.977 ± 0.059 and 0.966 ± 0.088, respectively. Conclusion: According to the findings of this study, the health system development plan has had a positive effect on the efficiency of hospitals, Although the efficiency of hospitals is desirable, it is essential that managers and policymakers of the health sector take measures to improve the efficacy and increase the use of resources.

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Background: In recent years, the tendency of women to have C-section has increased, without enough knowledge about it and its side-effects. Vaginal birth promotion program is one of programs included in the health care reform plan which is an important step in promoting the awareness of vaginal birth. The aim of this study is to investigate the impact of the health care reform plan on C-section rates in one of educational hospitals in Tehran University of Medical Science.
Methods: The present study was descriptive-analytic which was conducted in longitudinal and retrospective manner. Data were collected from 8510 deliveries through the patients' medical records in the span of three consecutive years, one year before implementing the health care reform plan and two years after its implementation. Calculations were done via Excel and SPSS ₂₀ soft wares.
Results: From the total of 2309 deliveries in 2013, (before implementing the plan), 69 percent of them had C-section and 31 percent had vaginal delivery. In the first year of the plan, from a total of 2989 deliveries, 70.8 percent had C-section and 29.2 percent had vaginal delivery and in the second year, from a total of 3212 deliveries, 71.3 percent had C-section and 28.6percent had vaginal delivery. The rate of avoidable C-sections in 2013, was 21.6 %, in 2014, 14.8 % and in 2014, 15 % .The execution of health care reform plan led to a 6.7 % decline rate in avoidable C-sections such as elective caesarians.(p = 0.001). Among the reasons for non-avoidable caesarians are, repeated caesarian, failure in delivery, and preeclampsia, respectively.
Conclusion: Although this hospital did not succeed in reducing the rate of C-section, considering the causes for C-section, it could reduce avoidable caesarians like elective deliveries. Given that this hospital has a large number of critically ill patients referred from other centers for C-section, it has a high rate of C-section. Two important factors contributing to the execution of this program are, making the delivery room's space pleasant according to the birth center standards, and increasing human resources and professional and friendly obstetricians. Therefore, in order to promote vaginal birth a comprehensive planning is needed.

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Background: In today competitive world, human work force has always been a concern for organizations, especially healthcare providers, and organizations are always looking for improving their employees' job performance. Among various factors affecting job performance are two factors of organization and personality traits of the workforce. Therefore, the aim of this study was to investigate the relationship between five personality traits of nurses and the organization knowledge of their job performance.
 Methods: This is an analytical study conducted in a cross sectional way in 2016. Sixty one nurses working in a traumatic hospital proportional to different wards were selected and entered the research. The instruments for collecting data were three organizational knowledge questionnaires (35 items), five personality traits (60 items), and job performance (15 items). Data were analyzed using SPSS20 and descriptive statistics and artificial neural networks.
 Results: Among demographic characteristics, variables of marital status (% 16.7) and gender (% 1.5), among aspects of organizational knowledge, two dimensions of rewards (% 64.6) and leadership (% 4.3) and among aspects of Five-personality traits, accountability (% 100) and flexibility (% 11.3) had the highest and lowest importance coefficient respectively.
Conclusion: rewarding and accountability can improve nurses' job performance.
Therefore, hospital managers can help to improve their nursing performance by using appropriate rewarding mechanisms, reinforcing staff accountability and employing responsible personnel.

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Background: The mothers' role in health of family members is very important, and her death has uncompensable losses for the family and society. With regard to the importance of maternal mortal ratio in development indicators of the United Nations (UN) this study is conducted to investigate the impact of socioeconomic factors on maternal mortality ratio
Methods: In the current study the role of socioeconomic factors on maternal mortal ratio was investigated by panel regression. Data include number of maternal mortality, total fertility, number of hospital beds, number of midwifes, number of physicians and urbanization in the period between 2008 and 2012. Since the dependent variable was in count form, Poisson estimator, Hausman test, and Breusch-pagan test were used.
Results: Based on the findings, household’s income and fertility rate had direct and inverse association with maternal mortality, respectively. Investigating the association between midwifes and maternal mortality showed that increasing the number of midwifes decrease it, but no significant association was found between the number of physicians and maternal mortality. Number of hospital beds also showed a direct association (significant at 10%).
Conclusion: All of the variables to somehow are related with the level of development. In developed regions, per capita income, access to health resource and urbanization is higher and there is more equity in distribution of health resources. It could be concluded from the findings that by increasing the level of development, maternal mortality would decrease.

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Background: Equity is one of the most important issues in the distribution of resources and access to health services. Although it is very challenging to address health equity issues, it deeply affects policy making, resource allocation, and generally the legal principles of government and society. This study aimed to determine the inequality of distribution of general practitioner in Tehran province.
Methods: This was an applied study that by ecological descriptive method investigated the relationship between the distribution of general practitioners and the mortality rate of children in the cities of Tehran province in 2012-2015. The data collection tool was a researcher-made form including the name of the city, the number of general practitioners, the mortality rate for children under five years old, and the population of each city. The STATA software with the DASP₂₁ version 2.1 was used to draw the Lorenz curve. The SPSS₁₉ software and Pearson correlation coefficient (P-value < 0.05) were utilized for analyzing data.
Results: Based on the results the Gini coefficient for general practitioners was not significantly changed and was in a relatively equitable position, the Gini coefficient varied from 0.269 to 0.299. The results of the study did not show a significant relationship between the distribution of general practitioners and the mortality rate of children, although, with an increase in the ratio of general practitioners, the mortality rate of children decreased (P-value ≤ 0.05).
Conclusion: The results of the study indicate that the distribution of general practitioners was relatively inequitable. Therefore, it is essential for the Ministry of Health to establish the balance in the distribution of the human resources

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Background: Several explicit approaches are used to make decision on health services coverage and to develop the basic health package. In this study, first the approaches used to prioritize health services were introduced, and then the limitations of each method were reported.
Methods: We critically reviewed market literature regarding explicit priority setting approaches. The current literature focusing on explicit priority setting approaches in health care system was reviewed.
Results: Eight explicit approaches for prioritizing health care were identified: CEA, CEA / BOD, PBMA, HTA, MCDA, A4R, the Value Assessment Framework, and combinational approaches such as MCDA-A4R and PBMA-A4R. Developing the value framework for making a decision, not just informing a decision was needed to be investigated.
Conclusion: This study addressed the explicit health services prioritization methods. The results showed that a value framework approach as one of the innovative approaches that has become increasingly widespread in recent years can help to achieve goals of the health system.

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Background: In inflationary conditions, financing is one of the most important and challenging issues in different sectors of economy, including health. Health financing means the way money is collected, accumulated and spent for health care services. The process undergoes a change in inflationary conditions.
Methods: This is a qualitative research. The data were collected through a survey of documentation related to health system expenditures in Iran.. The search strategy in this study was based on the PRISMA protocol. In the preliminary search, 147 official documents and reports were obtained. After removing inconsistent and repetitive cases, 47 documents were examined. These documents were classified into 11 categories and the position analysis was based on this.

Results: Findings show that inflation has had a very negative impact on Iran's financing system; specifically inflation has seriously threatened country's health insurance industry. The study of trend of return loss index in Commercial Insurance in The field of treatment revealed its unfavorable status in the study years. However, the demand for these insurance packages has also been increasing.

Conclusion: The rising trend of inflation in the field of treatment in the study duration, along with increased focus of quality services in private sector, in contrast to the public sector, have led to the transfer of treatment costs from public to private sector. This has increased the share of payment from the pocket of patients. This process has increased the influence of this sector in determining tariffs. The lack of authority of insurance companies to monitor and evaluate the performance of these centers is considered as an important factor in transfer of health finances from state and social insurance to private sector and commercial insurance. It should be noted that during the period under study in health market of Iran, the inflation rate and the amount of direct payments have been interacting, and each has intensified another.

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Background: Severe and complex environmental changes that have occurred from technology, makes need for change of knowledge, attitude and behavior, and as a whole empowering and Personal Mastery. The aim of this study is to present components of personal mastery model for Learning Healthcare Organizations.
Methods: this is a comparative and cross-sectional study. After theoretical and organizational studies about personal mastery, comparative tables are drawn and designed Model. Delphi technique is used. Members of the Delphi technique gained consensus after two stages.
Results: Personal Mastery titled as “Individual Excellence” in this study and certified with 3 components, including “Personal Excellence” with 5 variables, “Mental Excellence” with 4 variables, and “Professional Excellence” with 4 variables. Variables of general knowledge and moral growth (mean = 4.61) in personal excellence, moral growth (mean = 4.75) in mental excellence and expert skill (mean = 4.65) in professional excellence gained the highest grade from other variables.
Conclusion: If managers provoke employees to gain personal excellence, mental excellence, and professional excellence, individuals and organizations would function more efficiently. Persons should change themselves through increase their knowledge, skill and moral growth and upgrade their view points, vision and system approach, as well as organizations should support employees and provide necessary resources.

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Background: Evaluation is a key process to improve the organization. The maintenance and improvement of the health is the priority of the people of each country these days. Ensuring the provision of appropriate services requires the evaluation of the health system performance. European Foundation for Quality Management (EFQM) model is a self-assessment model and allocates more for health and care organizations and almost evaluates an organization in all structural and functional aspects. This study was conducted with to the aim of evaluating the performance of a public hospital in Tabriz according to the model of Europe Foundation for Quality Management.
Methods: This study was a cross - sectional study in 2015 in a public hospital in Tabriz. Data collection tools had been standard questionnaire of Europe Foundation Model for Quality Management. Data was gathered through standard and prestigious questionnaire of Europe Foundation Model for Quality Management which consisted of 90 questions, same in the field of nine criteria. After visiting the hospital by experts, meeting was hold among them and proceeded to consult and complete the questionnaire. The data was reported by descriptive tests and software of EXCELL was used for data analysis.
Results: The mean score of performance evaluation in terms of leadership was 73.6 points out of 100 points, in terms of policy and strategy, 46.8 points out of 80, in terms of human resources 54.1 out of 90 points, in terms of strategies and policy 41.9 points out of total 90 points, in terms of processes 59.8 points out of 140 points, 66 points out of 200 in terms of customer results, in terms of human resources results 23.76 points out of a total of 90 points, 40.2 points out of a total of 60 points, in terms of society results and in terms of key performance the result was 71.35 points out of 150 points . The average total score of 477 points out of 1000 points was performance evaluation. The results of the report are 47.75%. Finally, the results showed that the hospital had relatively appropriate status.
Conclusion: The findings showed the need for more attention to human resources and customer results. Enhancing employee's satisfaction factors to increase their satisfaction and efficiency, identifying foreign customers, categorizing and measuring different needs of patients in order to response and upgrade the system of addressing the complaints through the reform the processes are those cases that are proposed to improve the organization and increase compliance with organizational excellence model .

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Background: The significance of rabies is due to high mortality rate, economic damage caused by livestock loss, and high costs of treatment. Considering the economic problems in developing countries as well as the lack of resources and facilities, economic assessments will be very useful in obtaining the necessary financial information. Therefore, the present study aims to estimate the cost of prevention and control of rabies in Ahar, East Azarbaijan, during 2010-2011 and 2011-2012.
Methods: This is a descriptive, cross-sectional study conducted in Ahar, East Azarbaijan. This study was carried out using available documents (Vaccine registries, Human Resources Department records, Staff daily wages) and data collection (Ministry of Health and Medical Education, Taxi Administration, Municipality Office and the Veterinary Network) to estimate the cost of prevention and control of rabies during 2010-2011 and 2011-2012. The societal perspective was taken into account to estimate costs. Data was entered into SPSS version 20 and the total cost was calculated. Also, the Mann-Whitney U test was used for data analysis.
Results: The total financial burden of preventing and controlling rabies in Ahar during 2010-2011 and 2011-2012 was about 803 and 850 million rials respectively. The loss of the patient's income (240 and 260 million rials during 2010-2011 and 2011-2012), cost of rabies vaccine (approximately 231 and 237 million rials during 2010-2011 and 2011-2012), and staff costs (approximately 118 and 247 million rials during 2010-2011 and 2011-2012) had the largest share of the cost, while cost of tetanus vaccine (1.3 and 1.2 million rials during 2010-2011 and 2011-2012) had the smallest share.
Conclusion: The present study showed that the prevention and control of rabies put a significant financial burden on the government through direct medical expenses, rabies control program for dogs, and care of the disease. It put a burden on the people, as well, through the loss of productivity and income, and transportation costs.