Download - Priority setting and implementation in a centralized health system: a case study of Kerman province in Iran

Priority setting and implementation in acentralized health system: a case study ofKerman province in IranAkram Khayatzadeh-Mahani,1,2,3* Marianna Fotaki4 and Gillian Harvey4

1Research Center for Modeling in Health, Kerman University of Medical Sciences, Kerman, Iran, 2Research Center for Health ServicesManagement, Kerman University of Medical Sciences, Kerman, Iran, 3School of Management and Medical Informatics, Kerman Universityof Medical Sciences, Kerman, Iran and 4Manchester Business School, The University of Manchester, UK

*Corresponding author. Research Center for Modeling in Health, Kerman University of Medical Sciences, Jahad Blvd, Kerman 7619813159,Iran. E-mail: [email protected]. Tel: þ98-913-397-3153

Accepted 6 June 2012

The question of how priority setting processes work remains topical, contentious

and political in every health system across the globe. It is particularly acute in

the context of developing countries because of the mismatch between needs and

resources, which is often compounded by an underdeveloped capacity for

decision making and weak institutional infrastructures. Yet there is limited

research into how the process of setting and implementing health priorities

works in developing countries. This study aims to address this gap by examining

how a national priority setting programme works in the centralized health

system of Iran and what factors influence its implementation at the meso and

micro levels. We used a qualitative case study approach, incorporating mixed

methods: in-depth interviews at three levels and a textual analysis of policy

documents.

The data analysis showed that the process of priority setting is non-systematic,

there is little transparency as to how specific priorities are decided, and the

decisions made are separated from their implementation. This is due to the

highly centralized system, whereby health priorities are set at the macro level

without involving meso or micro local levels or any representative of the public.

Furthermore, the two main benefit packages are decided by different bodies

(Ministry of Health and Medical Education and Ministry of Welfare and Social

Security) and there is no co-ordination between them. The process is also

heavily influenced by political pressure exerted by various groups, mostly

medical professionals who attempt to control priority setting in accordance with

their interests. Finally, there are many weaknesses in the implementation of

priorities, resulting in a growing gap between rural and urban areas in terms of

access to health services.

Keywords Health care priority setting, benefit package, implementation, Iran

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine

� The Author 2012; all rights reserved.

Health Policy and Planning 2012;1–15

doi:10.1093/heapol/czs082

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KEY MESSAGES

� The processes of setting and implementing health priorities should be integrated to enhance their feasibility of service

provision.

� The decision making team on health priorities should include representation from a range of stakeholders, in particular

policy implementers and the public.

� The health priority setting decision-making process should be based on transparent criteria, in order to provide a rationale

behind the decisions made to providers and the public alike.

� Health policy makers should always be aware of the political environment they work in, since decision making on health

priorities is as much a political as it is a technical process.

IntroductionAll health systems across the world need to prioritize health

services. Among the key reasons are the scarcity of resources,

with the demand for services outstripping the available

resources (Bate et al. 2007), and concerns about equity in the

distribution of and access to services (Hoedemaekers and

Dekkers 2003). Health care priority setting is of particular

importance in developing countries, where a mismatch between

needs and resources is often compounded by an underdevel-

oped capacity for decision making, and weak institutional

infrastructures (Baltussen et al. 2006). Priority setting in

developing countries is perceived to be difficult and full of

uncertainties, due to the lack of reliable evidence, analytical

methods for identifying priority options and coherent processes

for decision making (Kapiriri et al. 2003). This gives rise to a

proliferation of approaches to priority setting and has provoked

an ongoing debate about the best way to conduct this process.

The most recent debate is how to make the process more

explicit (transparent), based on defendable evidence, rather

than an implicit, informal process supported by heuristics or

intuition (Mitton and Donaldson 2004; Rosen 2006). Needs

assessment and health economics evaluation methods therefore

constitute the main technical approaches to setting health

priorities (Donaldson and Mooney 1991).

While there is a wealth of literature describing priority setting

processes at the macro (national) level in many health systems,

this mostly focuses on developed countries (for example, Ham

1997; Busse 1999; Calltorp 1999; Rissanen and Hakkinen 1999;

Stepan and Sommersguter-Reichmann 1999; Pedersen et al.

2005; Sabik and Lie 2008). Most of the studies on priority

setting focus on evaluating the fairness of the process using the

Accountability for Reasonableness (also known as A4R) frame-

work (Daniels and Sabin 2002). Most importantly, while there

is a growing body of knowledge on the decision makers’

perspectives on the priority setting process (e.g. Gibson et al.

2004; Mitton and Prout 2004), we have only a very limited

understanding from the implementers’ perspectives (Kinnunen

et al. 1998; Mshana et al. 2007). Because of the limited research

on health priority setting in developing nations (Hrabac et al.

2000; Gonzalez-Pier et al. 2006; Kapiriri et al. 2007), there is a

distinct lack of evidence about how priorities are decided and

implemented at all levels of the system.

This research aims to address these gaps by examining how a

macro-level priority setting programme works in a centralized

health care system, and what factors influence its

implementation at the meso and micro levels, using Iran as a

case study. The national-level decision making bodies in the

Iranian health system, such as the Ministry of Health

and Medical Education (MOHME) and the Ministry of

Welfare and Social Security (MOWSS), are not new, but there

is a paucity of information available about the priority setting

processes they use and the factors governing their decisions. In

other words, the rationale behind health priority decisions

has not been made explicit or publicly discussed. Moreover,

despite the introduction of new technical priority setting tools

into the Iranian health system, such as Burden of Disease

(BOD), it is unclear how those tools are understood and applied

in practice. Alongside the lack of detailed information about the

process of priority setting, there is an equal knowledge gap in

terms of how priorities are implemented at a service delivery

level. In addressing these knowledge gaps, the research

presented in this paper sought to answer two specific research

questions:

(1) How does a macro-level health care priority setting process

work in practice in the centralized health system of Iran?

(2) What factors influence the process of priority setting and

implementation in this system?

Qualitative methodologies were chosen as the most suitable

means for our investigation, because of the type of research

questions addressed (what and how health priorities are set

and put in practice), the novelty of the research topic in this

specific context and the complexity of the phenomenon under

investigation (Creswell 2009). The study is one of the rare

empirical examples exploring the perceptions of policy makers

at the macro level, key decision makers at the meso (provincial/

regional) level, and health authorities at the micro (local/

district) level of the health system with regards to the national

priority setting process and its implementation.

By providing empirical evidence in an area that has not been

previously investigated, research makes a contribution to

knowledge, through three distinct ways. First, it identifies

factors influencing the process of setting and implementing

priorities in a specific context, namely the centralized health

system of Iran. Second, it evaluates how the system of priority

setting works at various levels by examining the views of both

policy makers and policy implementers. Third, it explores the

priority setting programme from two perspectives, namely, the

process (how benefit packages underpinning priority setting are

developed at the macro level of a health system), and the

2 HEALTH POLICY AND PLANNING

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outcomes (how the benefit packages are implemented at the

meso and micro levels of a health system).

In the remainder of the paper we describe the context and

methods before presenting the findings of the study. We then

discuss these and a put forward a number of policy implications

resulting from the study.

Context

Iran has a population of nearly 75 million, with 72% living in

urban areas and 28% in rural parts (Statistical Centre of Iran

2010). The country is administratively divided into 30 provinces

(Ostans); each province, in turn, is split into a number of

districts (Shahrestans or sub-province), and each district includes

a number of urban centres (cities/towns) and villages. Up to

95% of the rural population has access to the primary health

care (PHC) services (Aghajanian et al. 2007). As far as

secondary and tertiary care are concerned, the broad population

coverage by various health insurance schemes in Iran has

improved access to health services for over 92% of the

population (Russell 2005; World Bank 2007).

In the period following the 1979 Islamic revolution, the

Iranian government focused on PHC development, especially in

rural areas. This has led to success in improving several health

indicators such as decreased child and maternal mortality rates,

and increased life expectancy at birth (Mehryar 2004).

However, according to the World Health Organization (WHO),

Iran was ranked 93rd among 191 countries in terms of the

population’s health status, and 112th with respect to the fair

financial contribution index (FFCI) (WHO 2000). The poor

performance of the Iranian health system measured by the

FFCI index is due to many households lacking any type of

health insurance or financial protection against the costs of

illness. Accordingly, there is a high rate of out-of-pocket (OOP)

payment among Iranian households as revealed by the World

Bank report (2007). Almost 50% of health expenditures in Iran

are OOP (Ibrahimipour et al. 2011). Another challenge facing

the Iranian health system is the change in the burden of

disease pattern towards non-communicable diseases and acci-

dents, which is similar to many other health systems world-

wide. A recent study of the BOD in Iran revealed a high

percentage of cardiovascular disorders, cancers, mental health

disorders, traffic accidents and injuries (Naghavi 2006). All of

these challenges suggest that the issue of how priorities are set

and implemented in the Iranian health system is an important

and timely issue to study.

The organization and structure of the Iranianhealth system

Planning and policy making are decided at the central level in

Iran, and are then devolved via the meso level to the micro

levels for implementation. The implementation of centrally

developed plans is supervised by the macro level. For many

years and until recently there was no official centre for policy

making. The only body for planning and decision making was

the Management and Planning Organization (MPO) based at

the macro level under direct supervision of the president.

However, in 2007, a centre called the ‘Health Policy Unit’ was

launched within the MOHME to devise policies and provide the

evidence underpinning these policies, supported by the

establishment of a dedicated research centre (Khayatzadeh-

Mahani 2010).

There are many providers and purchasers, including the

public sector, the private sector, non-government organizations

(NGOs) and various health insurance organizations, which play

a role in the provision and financing of health care, but the

health system is managed primarily by the government. The

structure of the public health system of Iran spans through

three levels, as presented in Figure 1: macro (national), meso

(provincial or regional) and micro (local or district).

Macro level

The MOHME and the MOWSS1 are the main organizations at

the national level responsible for providing and financing

health services in Iran. The respective ministers are accountable

to both the parliament and the government (that is the cabinet

or president, see Figure 1), but are also members of the cabinet

and are proposed and appointed by the president, subject to

approval by the parliament (Schieber and Klingen 1999; WHO

2004). The MOHME is the ultimate decision maker on matters

concerning the Iranian health system. It is responsible for the

provision of health care services, medical education, supervision

and regulation, as well as policy making, production and

distribution of pharmaceuticals, and research and development.

It also regulates the provision of private health services and

the health services provided by the NGOs. The PHC benefit

package is developed and financed by the MOHME at the

macro level.

The MOWSS, on the other hand, develops and finances the

Medical Services benefit package via health insurance organ-

izations. The MOWSS comprises four major health insurance

organizations, all of which are controlled by the government:

(1) the Social Security Organization (SSO) for formal sector

employees and the self-employed and their dependants; (2) the

Medical Services Insurance Organization (MSIO) for govern-

ment employees, rural households, the self-employed and

others, such as students; (3) the Armed Forces Medical

Services Organization, for members of the military and their

dependants; and (4) the Imam Khomeini Relief Committee,

which covers the poor. These four organizations come under the

jurisdiction of the High Council for Health Insurance (HCHI),

made up of ministers from seven ministries and headed by the

Minister of Health. HCHI is responsible for inclusion or

exclusion of services, and sets the fee schedule for providers’

payments. All health insurance schemes use the same fee

schedule. Some major banks (e.g. Melli Bank) and companies

(e.g. Oil Company) also have specific benefit packages for their

own employees. Private insurance is supplementary to these

public programmes.

The Medical Services benefit package provides a comprehen-

sive set of curative services, including hospitalization, diagnostic

tests and pharmaceuticals, for which the public has to co-pay.

People who have health insurance coverage can visit any

specialist directly and use the secondary and tertiary level of

health services without going through the referral system. All

curative services are potentially included in this package. A few

services are excluded, which are cosmetic surgeries, transplants

(e.g. heart, liver, and fingers), infertility services, joint replace-

ments, non-accidental injuries (e.g. knife stabbing or problems

HEALTH CARE PRIORITY SETTING AND IMPLEMENTATION 3

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related to drug abuse) and cochlear implants. All dental care

procedures, except for tooth fillings, are included in the

package. Preventive services such as immunization and screen-

ing tests are provided by the PHC package which is offered for

free, but the public has to co-pay for services included in

Medical Services benefit package (Khayatzadeh-Mahani 2010).

Meso level (provincial medical universities)

At the meso (provincial/regional) level, medical universities are

responsible for medical education, including all medical fields

(e.g. medicine, pharmacy, dentistry, midwifery, nursing, com-

munity and occupational health and others), and the provision

of health services in their respective provinces. The provincial

medical universities are representatives of the MOHME at the

meso level and are the highest level of authority in the

province. They are linked to the lower, micro, levels and

supervise them.

Micro level (district level)

Health service delivery in Iran is based on a waterfall system

that builds on a well-established Primary Health Care Network

at a micro level (especially in rural areas), with the provincial

medical university overseeing the provision of health care in the

entire province. This network is administered at the micro level

by the District Health Network (DHN), one per district, which is

accountable to the provincial medical university. The DHN is

responsible for the planning, programming and monitoring of

health services at the micro level. It is also the sole body tasked

with the implementation of various centrally-determined

Figure 1 Structure and organization of the Iranian health system (Khayatzadeh-Mahani 2010).Notes: HH¼Health Houses; HP¼Health Posts; RHC¼Rural Health Centres; UHC¼Urban Health Centres.


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packages of health services, mainly the PHC package and the

Medical Services benefit package.

Each DHN is composed of three main parts: the district

health centre (DHC), the district hospital and a Behvarz training

centre. Each DHC, in turn, comprises different health facilities

identified as (1) Health Houses whose responsibility is to

implement the PHC programmes (with a Behvarz, who is a

community health worker, delivering the PHC benefit package

for rural residents), (2) Health Posts (similar to Health Houses,

providing the PHC benefit package for urban residents), and

(3) Urban and Rural Health Centres (UHC and RHC). All these

facilities work under the supervision of a DHN Director who is

the representative of the provincial medical university chancel-

lor at the micro level (Shadpour 2000).

MethodsData collection

This study adopted a qualitative research stance and a case

study methodology in order to gain a depth of understanding

about the priority setting programme in the context of the

Iranian centralized health system (Ritchie and Lewis 2005).

Two main approaches to data collection were employed:

(1) face-to-face in-depth interviews conducted at three levels

of the health system: macro, meso and micro; and (2) docu-

mentary analysis of key policy texts. The interviews constituted

the main data source, supported by a review of relevant

documentation. Thematic analysis of the data was carried out

to identify emerging categories and sub-categories, as described

in more detail below.

Sampling methods

Qualitative inquiries typically focus on small samples chosen

purposefully to get an in-depth understanding of the phenom-

enon under study (Patton 2002). Kerman province was selected

as the most accessible case for the principal researcher to

conduct the fieldwork (Hartley 2004), in order to explore the

implementation of nationally set health priorities. In conduct-

ing the case study, we were guided by a constructivist

methodology, hence were less concerned about the generaliz-

ability of the results and focused on providing a rich and

detailed description of the case under study (Stake 1995). The

selected province, however, shows similar demographic and

health indicators to that of the country (see Table 1), and as

such it is broadly representative of Iran.

In order to select the interviewees at the macro level, we

applied snowball sampling. We drew up an initial short-list of

potential participants using the organizational chart of the

MOHME and three previously conducted pilot interviews.

Snowball sampling was then followed in order to identify all

participants involved in the process of priority setting. At the

meso level, purposive methods were used. The focus at the

meso level was on provincial health authorities who were in

charge of transferring the centrally set health priorities from the

macro level to the micro levels. At the micro level, in order to

employ maximum variation as a sampling strategy, and to

represent diverse cases to describe the implementation process

(Creswell 2009), all ten District Health Networks affiliated to

the Kerman Medical University were included because of their

distinct socio-economic and cultural characteristics. In each

district, two main health authorities were then selected: the

District Health Centre Director responsible for implementing

the PHC benefit package, and the District Hospital Director in

charge of implementing the Medical Services benefit package.

Table 2 shows the location and number of interviewees from

macro to micro level.

All interviews took place in the interviewees’ work place as

agreed in advance. Permission to record the interview was sought

in all cases. All interviews were fully transcribed in Farsi, but were

analysed by the principal researcher in English. Ethical guidelines

were adhered to throughout the research. These included

obtaining official approval for the research (from the MOHME

and key decision makers at Kerman Medical University),

providing the research participants with a consent form and

information letter, and ensuring them of anonymity.

Notes were also taken at all of the interviews. The principal

researcher analysed the following documents: (1) the Third

Five-Year Development Plan of Iran (2000/2001–2004/2005);

(2) the Fourth Five-Year Development Plan (2005/2006–2009/

2010); (3) articles related to health in the Iranian Constitution

(e.g. Article 29); (4) the Iranian Budget Law (e.g. the Year

2007–08); (5) the Iranian National Health Insurance Act;

(6) BEHBAR and Family Medicine policies; and (7) documents

showing the results of important studies done by the MOHME,

such as the BOD study, the National Health Account study, and

the Demographic and Health Survey study. The data gathered

from these documents included extracts captured in such a way

as to record and preserve the original context (Patton 2002).

Data analysis

We used a qualitative thematic framework analysis, which is a

matrix-based analytical method (Ritchie et al. 2003; Bryman

2008), to analyse the interview data and excerpts from docu-

ments (Patton 2002). The data analysis took an a priori

thematic approach (Bryman 2008) in line with the analytical

framework method (Ritchie and Spencer 1994). An initial

thematic conceptual framework (see Figure 2), based on the

research questions, was developed at a very early stage of the

analysis (Ritchie et al. 2003).

Table 1 Comparing selected demographic and health indicatorsbetween Kerman province and Iran as a whole in the year 2000

Indicator Kermana Irana,b

Population under 5 years (%) 8.9 8.0b

Population under 15 years (%) 35.3 28.7b

Population above 65 years (%) 5.3 5.5a

Access to improved drinking-water sources (%) 89 93a

Birth rate (births per 1000 population) 18.3 14.3b

Total fertility rate (average number ofchildren per woman)

2.4 2a

Adult literacy rate (%) 79.9 82.4a

Sources: aMOHME (2000), Population and health in the Islamic Republic of

Iran: Demographic and Health Survey.bWorld Health Statistics 2008 (WHO 2008).


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We followed an adapted version of Ritchie and Spencer’s

(1994) thematic framework approach which entailed six steps

to analyse the data, including: (1) familiarization, (2) develop-

ing a thematic framework, (3) indexing and charting, (4) sum-

marizing and synthesizing, (5) mapping and interpretation, and

finally (6) conceptualization. The analysis of data started at the

macro level, followed by the meso level and finally the micro

level. In keeping with the qualitative methodology, the research

was judged against trustworthiness criteria (see Table 3),

namely, credibility, transferability, dependability and confirm-

ability (Lincoln and Guba 1985).

Limitations

The study is not without limitations, particularly in relation

to: (1) issues of generalizability, (2) social desirability bias, and

(3) constant turnover of policy makers. The choice of a single

case study raises a question of generalizability of the

findings (Gerring 2004). However, the theoretical paradigm

(constructionism) justifies the selection of a single case to

elucidate and provide a rich and detailed description, through

which the aim is to enhance the transferability of the findings

to other settings (Guba and Lincoln 1989; Bryman 2008).

Another possible limitation of this research is that partici-

pants might have been influenced by a social desirability bias,

meaning that they may have described what they thought the

researcher wanted to hear, rather than the actual events. There

is also a possibility that at least some of the respondents

provided politically correct responses, regarding their roles,

responsibilities and the actual performance of the system. To

address these problems we applied a triangulation of the data

collection methods (to include interviews and the analysis of

the documents). A final concern is that the policy and decision

makers were constantly changing and there was a constant

state of flux at all levels of the health system during this

project. In order to minimize this limitation, we have also

conducted some interviews with former policy makers who had

previously been in charge of national policy making.

ResultsThe results of the research are organized into two main sections

based on the research questions, namely, (1) the process of

macro-level health care priority setting and (2) factors affecting

the process and its implementation at meso and micro levels.

Macro-level health care priority setting process

Priority setting is enforced in Iranian law, including the

Five-Year Development Plans and the Budget Law, as illustrated

in the Fourth Five-Year Development Plan (see Box 1).

Table 2 Location and number of interviewees at macro, meso and micro levels

Organization (body) Location No.

Macro level Ministry of Health &Medical Education

Deputy for Health 11

Health Policy Unit 2

Deputy for Logistic and Management Development 1

Deputy for Parliamentary and Coordination Affairs 2

Former Policy Makers 3

Health insuranceorganizations

Medical Services Insurance Organization (MSIO) 1

Social Security Organization (SSO) 1

Armed Forces Medical Service Organization 1

Imam Khomeini Foundation 1

MPO Health Department 2

Meso level Kerman MedicalUniversity

Chancellor of the University 1

Deputy for Health 4

Deputy for Logistic 1

Deputy for Food and Drug 1

Deputy for Treatment 3

Micro level District Health Networks Director of District Health Centre 10

Director of District Hospital 10

Total 55

National healthcare

priority setting process

Implementation process

Factors affecting priority setting & implementation

Practice of priority setting

Priority setting

methods

Role of meso & micro

levels

Figure 2 Thematic conceptual framework


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The analysis of interview data from all levels confirmed that

the Iranian health system practises a centralized process in

terms of health care priority setting. In exploring the current

process of health care priority setting in practice, macro-level

respondents were able to describe these processes, including the

methods and procedures used to set priorities. Although

decisions on health priorities are taken at the macro level, the

meso- and micro-level participants delineated their important

roles in this process, as is explained in more detail below.

Different packages of health services

One of the emerging findings of this research was the

distinction, made by the macro-level participants, between

various health services (for example, public health care,

curative and diagnostic services, health technologies, and

drugs) and the various bodies responsible for setting priorities

and financing them, although the services may be still delivered

by the MOHME. As can be seen from the following table there

are four packages of health services available to the Iranian

population, which are financed by various bodies (see Table 4).

The main point made by almost all participants at the three

levels (macro, meso and micro) was a lack of co-ordination

between the different bodies in charge of setting and providing

various packages of health services. This was believed to have led

to a discontinuity of care in the public sector, which is worsened

by the lack of an effective referral system and gate keeping. The

recommendation offered was to integrate the separate packages

into a single, all-embracing package covering all sorts of services

including primary, secondary and tertiary care.

Ma11:2 ‘‘There are various decision making bodies which are

not linked together and each makes decisions in isolation. For

instance, the Ministry of Health and Medical Education sets policies

in isolation from the Ministry of Welfare and Social Security

and vice versa. So, it is no surprise to see that many poor rural

people, seeking medical treatments, are left unattended in towns

since policy making for preventive care is separated from curative

care.’’

Ma4: ‘‘. . . I remember that we at the Ministry of Health and

Medical Education were in long discussions with the health

insurance organizations in order to convince them to cover breast

cancer screening service. Our efforts, however, were unsuccessful.

Their argument was that this is a preventive service and should be

included into the PHC benefit package. This clearly shows that the

approach of health insurance organizations in this country is

treatment-oriented.’’

Another interesting set of findings concerned the structure of

current benefit packages. Almost all participants believed that

the two main benefit packages available to the Iranian

Box 1 Excerpts from Iran’s Fourth Five-Year Development Plan (Government of Iran 2004)

Article 91

The following measures shall be taken in order to increase effectiveness of the health service delivery system in the country

and to enhance and develop the universal health insurance system: A) All the commercial and non-commercial insurance

companies are permitted to render the basic and supplementary health services solely by observing the laws and regulations

of the High Council for Health Insurance; B) The High Council for Health Insurance shall initiate the required means of

establishing the family-physician-based health insurance and referral system; C) In order to expand equity in utilization of

health services, the basic rural health insurance services shall be defined and executed equal to their urban counterparts.

Article 96

Government is bound to increase gradually the population health insurance coverage and financial supports which are the

concerns of the Article twenty nine (29) of the Constitution of the Islamic Republic of Iran. The resources for this purpose

are the general revenues and the income derived from public participation, through insurance, protective and supportive

activities. In doing so, the following measures should be taken into account: A) To increase the social insurance coverage,

with due consideration of the rural inhabitants, tribal population and urban employees who have not been covered so far; B)

Complete population coverage (one hundred percent) by the public insurance for the basic medical services; C) To provide

special insurance for women who are head of households and for unprotected individuals, given priority to orphans.

Table 3 Strategies adopted to ensure trustworthiness

Criteria Strategy

Credibility Six main strategies were adopted to increase the credibility of this research including: (1) prolonged engagement, (2) fact-findingvisits, (3) peer debriefing, (4) triangulation, (5) member checks and (6) referential adequacy.

Transferability (1) Thick descriptions and (2) purposive sampling were the principal methods employed to enhance the transferability of thestudy findings.

Dependability Three tactics, namely (1) detailed documentation, (2) data checks and (3) an external auditor, were adopted to increase thedependability of the research.

Confirmability An external auditor, a final year PhD student, whose research was on the health system of a developing country, was used inorder to enhance the confirmability of the research. He reviewed the whole project and looked for relationships between theresearch questions and the findings, and consistency throughout the entire work.


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population (the PHC benefit package and the Medical Services

benefit package) are very wide, with a plethora of services and

interventions included. This was deemed to be the result of a

‘no exclusion’ policy. According to this policy, no formal and

explicit exclusion is allowed, although as the data illustrate,

exclusion happens informally, mostly in the form of rationing

of services. There was also a widely held belief that policy

makers were trying to avoid the possibility of public unrest

caused by the exclusion of services from the benefit packages,

and they reacted typically by rationing the excluded services

(for example, by offering it only in certain health facilities

or by certain health professionals) or even by lifting the ban

completely.

Macro-level participants made a distinction between priority

setting and rationing. It was acknowledged that rationing is

necessary alongside priority setting. However, rationing also

appears to occur instead of exclusion, apparently to avoid

problems caused by the explicit elimination of services, as the

following comments illustrate.

Ma23: ‘‘In the year 2002, the high council for health insurance

decided to include 13 items of drugs into the Medical Services

benefit package. In the meantime, it was decided to exclude

vitamins with the rationale that vitamins are not essential drugs

and are not usually included in the benefit packages of other

countries. The decision on exclusion led to an unrest in the country.

Thereafter, it was decided to place a limit by which vitamins could

only be offered in some specific hospitals.’’

Ma7: ‘‘I remember that the Beta HCG test was one of the services

covered by the health insurance organizations which could be

prescribed by all medical doctors including GPs. Recently, however,

only specialist physicians can prescribe it in order to reduce the

amount of prescriptions.’’

Another finding with respect to the exclusion of services was

that although there is no formal process of exclusion in

developing the current benefit packages, exclusion does happen

informally. For example, if a medical procedure or a drug is not

used or prescribed for a certain period of time, it can become

informally excluded.

Ma16: ‘‘Nowadays nobody uses Amoxicillin as physicians prescribe

Sephexin instead. So Amoxicillin will be gradually taken out of the

benefit package.’’

A further issue of concern, expressed mostly by micro-level

interviewees, was the vagueness of services and interventions

covered by the benefit packages, which was believed to lead to

personal interpretation and a degree of discretion at the micro

level as well as manipulation of priorities at the macro level.

Mi17: ‘‘. . . A few years ago the Ministry of Health allocated us

little funds to implement some interventions towards elderly care.

Unfortunately, they did not tell us what exactly to do. We were

confused at first what to do with this little money, but finally

decided to develop some brochures and flyers about elderly healthy

eating and distribute them across the city.’’

Mi4: ‘‘. . . The benefit package, for instance, indicates that it covers

X-surgery. But it does not specify in detail which procedures are

exactly covered. This leaves room for insurance organizations to

avoid reimbursing hospitals for some procedures used during a

surgery and this is a very common phenomenon in this country.’’

The centralized process was also criticized by micro-level

participants for setting priorities which were not feasible.

Participants at meso and micro levels revealed a further concern

about the centralized priority setting process at the macro level,

which does not provide them with a rationale behind the

inclusion of health services and interventions. Another issue of

concern expressed by micro-level participants was a lack of

transparency in the process of centralized priority setting.

Mi19: ‘‘A couple of years ago the family medicine policy was

enforced and we had to implement it across the rural parts. Some

GPs were assigned for our rural health facilities as gate keepers. At

the same time, the health ministry sent us several circulars and

booklets containing the clinical guidelines that the GP has to follow

as well as the duties of the family medicine team, including the

GP, and the list of medicines that the GP was allowed to prescribe.

We faced resistance from the GPs in, accepting the nationally

developed clinical guidelines and the list of medicines. I believe they

had a valid point to ask why we should perform the guidelines and

prescribe certain medicines that we don’t know who has decided

them and how and why.’’

Priority setting methods

The analysis of the data highlighted several technical and

non-technical methods, which are currently applied in setting

priorities in the Iranian health system. The two main

non-technical methods described were bargaining and the

historically-based approach. Bargaining was referred to by the

majority of respondents as the most common informal proced-

ure. The historically-based approach, on the other hand, was

considered the dominant perspective in allocating resources.

More recently there was a shift to implementing economic

evaluation methods. Two commonly applied technical methods

Table 4 Type of packages and bodies responsible for priority setting and funding in Iran

Type of package Responsibility for priority setting and funding

Primary Health Care (PHC) benefit package Ministry of Health & Medical Education (MOHME)

Medical Services benefit package (secondary/hospital care) Ministry of Welfare & Social Security

The Supplementary Package (mostly providing health technologies, new medicalprocedures and drugs)

MOHME and the private health sector

Special Diseases Package (expensive medical treatments subsidized by the government) MOHME


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were BOD methodology and expert panels. The former is

employed to set priorities among different diseases, while the

latter is the most commonly used approach in setting priorities

among health services and interventions to be included into the

benefit packages. The results of the BOD study are not

reportedly employed in setting priorities for the Medical

Services benefit package; there does, however, seem to be

some (non-systematic) application of BOD data in the PHC

benefit package. However, there was a view expressed that

burden of risk factors should be measured instead of burden of

disease, with the directing of scarce resources towards high

burdened risk factors. This means that many diseases and

health problems that share the same risk factors could be

tackled simultaneously.

The data also revealed that expert panels, which decide on

priorities of the benefit packages based on a host of technical

and non-technical criteria such as systematic review (if any),

cost, international priorities (such as pandemics) and bargain-

ing, comprise, predominantly, of medical professionals acting as

policy makers in this instance. It also emerged that although

the principle of equity is an implicit influential criterion in

setting priorities in the main benefit packages, in practice (i.e.

during the implementation of priorities) the principle of

personal choice plays a greater role. In the Medical Services

benefit package, the most influential criterion on the deter-

mination of priorities was deemed to be cost (i.e. budget

impact). The analysis of documents and interview data revealed

that urban residents exercise a great deal of choice in Iran

compared with their rural counterparts whose choice has been

limited by state policies. Family Medicine and the BEHBAR

(rural health insurance for all rural residents) are the two state

policies, which have limited rural households access to second-

ary and tertiary care through a referral system, although they

aimed to improve rural access to basic health services.

Role of meso and micro levels in the macro-levelpriority setting process

The data analysis revealed that the meso level (the provincial

medical universities) report regularly on health indicators of

their provinces to the MOHME, which is supposed to set

priorities at the national level based on that evidence.

Nevertheless, there is also a degree of discretion allowed at

the meso level. The establishment of the Board of Trustees at

each provincial medical university, for example, has granted the

meso levels some managerial and financial responsibilities as

the following excerpt from the Fourth Five-Year Development

Plan (Article 49) shows:

‘Each provincial medical university should establish a Board

of Trustees and there should be a direct transfer of global

budgets from the government (MPO) to medical univer-

sities, which the Board of Trustees could then use their

discretion to allocate resources as needed’.

However, analysis of the interviews suggests a degree of

dissatisfaction with the level of discretion afforded to the meso

level, as policy implementers in the region are still required to

obtain authorization from the MOHME for many decisions. For

instance, in relation to the issue of resources, especially human

resources, it was highlighted that the meso level is not allowed

to hire personnel without the permission of the macro level.

Moving to the micro level, participants believed that the

health information produced at this level forms the basis for

macro-level priority setting. There was a general feeling among

respondents that they played a vital role in priority setting, with

a prevailing view that macro-level priorities are based on the

local data.

Mi10: ‘‘The Ministry of Health and Kerman Medical University

ask for health information and health indicators frequently and I

am sure they use those data in policy making. For instance, we

send them health information on all types of mortalities such as

maternal and child mortality as well as disease prevalence and

incidence rates. Definitely in the BOD study, our information is

used.’’

Factors affecting the setting and implementationof national health priorities

A host of factors influencing the process of setting and

implementing priorities were identified. Overall, three main

factors related to priority setting were: (1) the nature of decision

making, (2) political pressure and (3) policy makers’ behaviour,

as is discussed below. Regarding the implementation of

priorities, the most influential factors were: (1) the status and

the clout of health professionals implementing priorities,

(2) the private sector and (3) rural–urban disparities.

Factors influencing the process of setting priorities

The reactive nature of the decision making process was seen to

be the main factor impacting on the way health priorities were

set. It was suggested that reactive decision making (in response

to emergencies and not planned in advance), along with the

non-sustainability in decision making, lack of transparency and

non-systematic decision making have all contributed to weak

outcomes of the health priority setting process.

Ma8: ‘‘. . . Decision making for priority setting in Iran looks like a

crisis management. It responds to the daily problems which occur

and makes temporary decisions to sort them out.’’

Mi18: ‘‘. . . We don’t really know why they [policy makers] have

changed the procedures for child growth monitoring. They keep adding

paperwork for which we can’t see the point to fill them up.’’

Political pressure emerged as another key factor influencing

the process of setting health priorities. It was deemed to be

induced by different means, such as changes in the cabinet and

parliament, as can be seen in the following statement.

Ma21: ‘‘Change of some cabinet members such as president, health

minister, finance minister, or environment minister affects the

health system greatly. For instance, change of the finance minister

might affect GNP allocated to the health sector, which directly

affects priority setting because if more resources are allocated to the

health system, we can include more services into the publicly

funded benefit packages.’’

Other influences could also be discerned, such as the impact of

national and international trends, the policies of international


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organizations, group pressure applied by pharmaceutical com-

panies and companies importing new health technologies and

drugs, the medical profession, and the media.

Regarding the policy makers’ behaviour, factors identified

were personal interests, ethical viewpoints (e.g. libertarian or

egalitarian) and perceptions about priority setting (whether

they perceive it to be an important issue and what their specific

views are about it), as is reflected in the following statement.

Ma19: ‘‘. . . Many years ago, I was in the office of one of policy

makers and I could hear what he speaks on the phone. He was

basically saying that it is not important for me whether a medicine

is expensive or not, or if it is produced in Iran or abroad. What

matters for me is that this medicine should be available for patients

who need it. He actually had a very liberal point of view. I can

provide you with many examples like this.’’

Factors influencing the implementation of priorities

The three most influential factors affecting the implementation

of priorities related to the policy implementers’ political ‘clout’,

the power of the private sector, and rural–urban disparities.

While policy makers appeared to have the most influence on

the process of setting national priorities, policy implementers

including health personnel (responsible for implementing

the PHC benefit package) and physicians (who implement the

Medical Services benefit package) at the micro-level were the

most influential groups in putting those priorities into practice.

The study revealed an asymmetry in the amount of discretion

exercised by these two groups of policy implementers when

translating priorities into practice. Whilst health personnel

responsible for the PHC benefit package appeared to lack any

type of freedom, physicians enjoyed a high degree of discretion

when implementing the Medical Services benefit package. This

lack of autonomy for PHC personnel is typically compounded

by workload pressures, poor in-service training, lax supervision,

staff and resource shortages. The result is often a relatively low

standard of service delivery at the local level.

Me3: ‘‘. . . Every day you ask a Behvarz, with a high school

education, to perform a new service or intervention and you do not

tell her what to exclude. So, she excludes services on her own

decision. Even though she does not exclude any services, she

performs the service with a low quality.’’

Mi13: ‘‘. . . A few years ago, the ministry people decided to add the

blood pressure and diabetes screening intervention into the PHC

package. So, our Behvarzs had to perform this service for the whole

population over 35. Almost at the same time, another service was

added namely the national newborn screening programme for

congenital hypothyroidism, to be performed by Behvarz for all

newborns in 3–5 days of birth. Apart from these, there is a lot of

paperwork that a Behvarz has to do. We keep asking the same

Behvarz to do all these tasks with the same salary. Many times I

feel very uncomfortable to let them know of a newly added service

when I can’t add a new staff or can’t spare resources.’’

The private sector also appeared to wield considerable influ-

ence over the way national health priorities were put into

practice. In Iran, the public has a choice to seek all types of

health services (primary, secondary and tertiary) from either the

public or the private sector, based on, predominantly, their

ability and willingness to pay. This, however, is mainly induced

by the physicians practising in the private sector who encourage

utilization of services, mostly covered by the Supplementary

Package, including new medicines, new medical procedures, and

expensive diagnostic services such as Magnetic Resonance

Imaging (MRI) and Computed Tomography (CT)-scans.

Reasons for this behaviour that were put forward included a

lack of proper control by the public sector, a lack of support from

the government, the low rate of tariffs and easy access to high

medical technologies. There is a considerable difference in terms

of health service tariffs (service charge) between the private and

the public sectors, with the latter much lower than the former. It

was argued that, over the last few years, this gap has led to

under-staffing in the public sector, affecting the quality of

services, because the majority of physicians and health staff

prefer to work in the private sector where they can earn more.

The data analysis also revealed significant rural and urban

disparities in access to and utilization of health services, which is

partly linked to the activities of the private sector. The role of the

private health sector appeared to exacerbate the rural–urban

disparity as far as the implementation of national health

priorities is concerned. The private sector, which predominantly

operates in urban areas of Iran, increases the gap between rural

and urban regions in terms of access to and utilization of all types

of services (i.e. primary, secondary and tertiary) with the state

policies (i.e. Family Medicine and BEHBAR) intensifying this

divergence. It is interesting to note how perceived rural–urban

differences affect the implementation of benefit packages in

different regions: the provision of the PHC benefit package

services is the centre of attention in rural areas, while the Medical

Services benefit package is provided mainly in urban areas.

Me7: ‘‘. . . In the rural areas, a Behvarz performs actively all PHC

services for the whole population in her/his geographical area. For

instance, if a pregnant woman does not attend the health house to

receive the prenatal care, Behvarz visits that lady in her house. In

the urban areas, however, the PHC services are offered passively,

meaning that if the pregnant women do not refer themselves,

nobody will trace them. Apart from that, in towns pregnant

women do not usually seek services from health posts and urban

health centres. They prefer to receive the same care from the

gynaecologist because there is no limitation to visit a specialist in

this country. So, even for the very basic services, which a midwife

can perform more effectively, people visit a specialist physician.’’

DiscussionThe aim of the study was to investigate how a national priority

setting programme works in the centralized health system of

Iran and what factors influence its implementation at the meso

and micro levels. From the analysis of the findings, five key

themes emerge (as shown in Figure 3):

(1) The process of setting priorities is non-systematic, leading

to many shortfalls in developing the benefit packages;

(2) Health priorities are set at the macro level, by expert

panels, using a host of methods (e.g. cost, bargaining,

international priorities), without involving the local level

or any representatives of the public;


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(3) The process is heavily influenced by political pressure

exerted by various interest groups;

(4) The centrally set priorities (i.e. benefit packages) are

communicated to the local levels via the meso level,

whose role is unclear in the process; and

(5) There is a clear difference between the implementation of

benefit packages in rural and urban areas, with the former

more focused on the PHC package (providing primary

healthcare services), while the Medical Services benefit

package (providing secondary and tertiary care services) is

central in the latter.

Below we discuss each of these five themes in more detail.

Lack of systematic priority setting

The data analysis showed that the process of priority setting is

non-systematic, there is little transparency as to how specific

priorities are decided, and the decisions made are separated

from their implementation. In other words, decisions on

priorities are being taken without considering the realities of

policy implementation. We argue that this is the most

problematic area in terms of health priority setting in Iran,

resulting from the highly centralized system, whereby health

priorities are set at a macro level without involving the meso or

micro levels or any representatives of the public. As a result, the

current benefit packages bear the shortfalls of (1) being very

wide, (2) lacking clarity, (3) being unrealistic and (4) having

no clear rationale underpinning them. Taken together, these

weaknesses in the process contradict the logic and the objective

of priority setting.

The current benefit packages are very comprehensive, mostly

due to the policy of no formal exclusion, which has caused

many difficulties with implementation, mostly because of a lack

of resources available to cover such a wide range of services. In

reality, however, the exclusion of health services in Iran

happens informally in two ways: rationing and informal

(or natural) exclusion. Explicit exclusion of services is

recognized to be unpopular (Ham 1997; Greb et al. 2005) and

because of this an often-used alternative is to base service

provision on consumer choice and ability to pay at the micro

level. This implicit exclusion is claimed to be common in other

Figure 3 Health care priority setting and implementation in the Iranian health system


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health systems, for example, the US, which has a strong private

insurance system, while most European policy makers are

against it for equity reasons (Greb et al. 2005). However, this is

not to say that exclusion does not occur by other implicit

means. For example, in the UK National Health Services (NHS),

exclusion is seen to occur at the point of access to health

services, with general practitioners (GPs) acting as gate-

keepers, for instance, by controlling access to secondary care

specialists (Coast 1996; Owen-Smith et al. 2010).

Another possible reason for including a plethora of services in

the Medical Services benefit package, provided by health insur-

ance organizations (i.e. the MOWSS), could be the payment

system by which hospitals are reimbursed (diagnosis-related

groups or DRGs). According to the DRG system, a fixed price is

paid for each episode of care. It is believed that one way for

providers to maintain their income under the DRG payment

system is to increase the number and range of services (Allen

2009).

Lack of clarity is another pitfall of the current benefit

packages available in Iran, which leads to either manipulation

of services at the macro level or individual interpretations of

priorities by the implementers at the micro level. Leese et al.

(2001), measuring the success of primary care organizations in

the British health system, found a similar situation, which they

attributed to the central decision making (Leese et al. 2001).

The benefit packages are also unrealistic and end up expres-

sing aspirational rather than actual policy, as is the case in

many other countries where there is an unwillingness to

exclude services explicitly for political reasons (Fotaki 2009).

Policy implementers in this research raised a general complaint

over the non-feasibility of many of the health interventions

(mostly those covered by the PHC package). This suggests that

the realities of implementation have not been taken into

account when the interventions were developed. It could also

be the result of decision making often carried out in a rush

without comprehensive advanced planning, which is a common

shortfall of decision making in Iran.

Lastly, the health care priority setting process in Iran does not

provide any rationale behind the prioritized services. This could

be one explanation for the shift of physicians towards the

private sector, and away from providing the services covered in

the benefit packages: the physicians may not be convinced

about why certain services (e.g. medicines) are included in (and

rarely excluded from) the benefit packages.

The two main benefit packages (the PHC benefit package and

the Medical Services benefit package) are decided by two

different bodies (MOHME and MOWSS, respectively) and there

is no co-ordination between the two, which has led to discon-

tinuity of care. We hypothesize that this might be due to the

autocratic government’s lack of willingness to make difficult

political decisions concerning the structure and governance of

the system and managing public expectations extending beyond

the declaration of intent as seen in other comparable cases

(Fotaki 2006; Fotaki 2009; O’Donnell 2010).

Priority setting methods

The historically-based and bargaining methods that are cur-

rently applied in setting health priorities in Iran, which are also

the most commonly used approaches in all health systems

worldwide (Coast and Donovan 1996), are unlikely to maximize

health benefits within a given budget (Mitton and Donaldson

2004). In contrast, the BOD study, which is the main technical

health priority setting tool in Iran, and which uses local health

information (e.g. mortality and morbidity) (Murray and Lopez

1996), is believed to be a good method of setting priorities

among diseases. The missing loop in the Iranian health system

is the application of this evidence in developing the benefit

packages (i.e. setting priorities among health services and

interventions). One reason for the lack of uptake of the study

results could be that the BOD study conducted in Iran does not

prioritize among health interventions or risk factors. Moreover,

after establishing this study as a means of prioritizing among

the diseases, no follow-up studies were conducted to estimate

the cost-effectiveness of health interventions or their afford-

ability (Doherty 2010). In any case, our findings indicate that

the results of such studies are not utilized when deciding on

benefit packages, in turn suggesting a need to improve the

skills of policy makers in interpreting and applying sound

evidence.

Political pressure

Another key finding concerns the issue of political pressure

shaping the whole process. No matter how well the process is

managed by the application of sound technical methods,

political pressure (that is, the pressure imposed by various

interest groups) is crucial in determining what type of health

services, diseases or groups of people receive priority (Baltussen

and Niessen 2006; Dionne et al. 2008). In the Iranian health

system, power is predominantly in the hands of medical

professionals and pharmaceutical companies (Ibrahimipour

et al. 2011). Decisions on the inclusion (and rarely exclusion)

of services and interventions in the benefit packages are made

by expert panels, which are dominated by clinicians without

involving micro levels or any representatives of the public. The

current panel composition works against the main purpose of

holding expert panels, which is to assemble multidisciplinary

groups of experts to decide on priorities based on the evidence

available (Schmidt 2009). Mitton and Donaldson (2004) argue

that the composition should involve a mix of clinical personnel,

managers and lay participants. As such, the current situation is

far behind the classical pluralism concept proposed by Held

(2003) in which diverse and competing interest groups form

the basis for a democratic equilibrium. In such a governance

arrangement the distribution of power tends to be evened out.

However, in developing countries, a very small number of

groups exercise the majority of the power (Kimenyi and Mbaka

1993). Most policies are decided by small, elite groups within

the government or even outside it. This is more evident in a

centralized government, such as that of Iran, in which the

political power and the decision making process are dominated

by selected groups rather than broad representation.

Implementation at the meso and micro levels

The centrally set priorities (i.e. benefit packages) in the Iranian

health system are communicated to the micro levels via the

meso level, whose role is somewhat unclear in the process. It

could be seen to play a brokerage role between the top and

bottom levels of the health system but the key actors at the


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meso level lack any type of independent constituency or

political legitimacy. However, moving towards the micro level

and the point of service delivery, there is more diversity in

terms of the discretion allowed, although the extent of this

discretion varies with the status of those delivering the services.

Here, physicians, who primarily perform the Medical Services

benefit package, claim autonomy in the way they use their

clinical judgement in the allocation of resources to patients.

Physicians, particularly specialists, are mainly based in urban

areas. This explains why the Medical Services benefit package is

utilized and demanded more in the urban areas of Iran. This

may also explain the paradox whereby clinicians largely make

the decisions at a macro level, yet their colleagues in the field

do not necessarily follow the priorities set. Physicians can not

only influence the priority setting process, but they can also

jeopardize its implementation by shifting towards the private

sector when it suits them, and away from providing the services

covered in the benefit packages. In urban areas of Iran, it is

very common to see medical specialists (mostly the well-known

ones) refuse to contract with the health insurance organiza-

tions; meaning that they still offer services provided by the

Medical Services benefit package, but the public has to pay

the entire cost out-of-pocket as if the service is received from

the private sector. These physicians (mostly practising in the

private sector) also urge the public towards utilization of

services covered by the Supplementary Package, which are

mostly new medical technologies and new expensive medical

procedures and interventions. On the other hand, the health

staff (including GPs in rural areas) who implement the PHC

benefit package services, have a less secure professional status

and are accordingly given only limited control over the use of

their resources.

Rural–urban disparities

Unsurprisingly, the study revealed many weaknesses in the

implementation of priorities. Perhaps the most significant of

these is the growing gap between rural and urban areas in

terms of implementing benefit packages. One of the reasons for

this disparity could be the imperfect operation of the PHC

network, which has not been well extended to the urban areas.

There is, however, a strong private health sector, operating

predominantly in the urban areas, which intensifies this gap.

The PHC network, which is poorly established in the urban

areas, creates differences between rural and urban areas in

terms of health services provision and utilization. The urban

segment of the PHC network has remained underdeveloped,

mostly because of its poor referral system and gate keeping,

which does not facilitate the interface between various levels of

the PHC network (primary, secondary, tertiary; rural, district,

centre of province) and different levels of the health system

(micro, meso, macro). As a result, there is poor integration and

continuity of care and a real challenge in terms of controlling

unnecessary access to secondary and tertiary care.

An aspect of the rural–urban disparity in terms of benefit

package implementation could also be attributed to the strong

private health sector, which is poorly controlled by the govern-

ment. This leads to a high utilization of services and drugs not

covered by the Medical Services benefit package, especially

expensive diagnostic services, new health technologies and new

medical procedures. This is mainly because the private sector in

Iran is not involved in the provision of PHC services, but only

secondary and tertiary services. As a result, in urban areas,

there is a higher utilization of curative and diagnostic services

rather than the PHC services, which are used more in the rural

communities (Hosseinpoor et al. 2007).

ConclusionsThis research set out to examine how a macro-level priority

setting programme works in the centralized health system of

Iran, and what factors influence its implementation at the meso

and micro levels. The findings provide policy makers with a

number of practical recommendations to improve the process of

setting and implementing health priorities. Firstly, the process

of setting and implementing priorities should be integrated to

enhance the feasibility of provision of services. Secondly, the

decision making team should include representation from a

range of stakeholders, in particular policy implementers and the

public. Thirdly, the decision making process should be based on

transparent criteria, in order to provide a rationale behind the

decisions made to providers and the public alike. Fourthly,

decision makers should always be aware of the political

environment they work in, since decision making on health

priorities is as much a political as it is a technical process.

FundingThis work was supported financially by the Iranian Ministry of

Health and Medical Education.

Conflict of interestNone declared.

Endnotes1 In June 2011, the Iranian legislators passed a bill to merge the

MOWSS with two ministries of Labour and Social Affairs as wellas Cooperatives into the new Ministry of Cooperatives, Labour andSocial Security. Throughout this paper we use MOWSS as at thetime of the study it was the responsible national organization incharge of priority setting.

2 The abbreviations Ma, Me and Mi stand for macro, meso and micro,respectively; this code for the interviewees is used in order tomaintain the anonymity of the participants.

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