Article Text
PDF
Abstract
From the WHO’s perspective, trained and motivated healthcare workers can promote community access to essential health services in deprived areas; this could also help achieve the millennium development goals. The concentration of healthcare workers in the capital has caused a lack of them in deprived areas and made delivering services difficult in almost all rural and underdeveloped areas. So, one of the main concerns of all health systems is planning to attract and keep physicians in underprivileged areas.
The number of retained physicians has tripled.
24/7 coverage of specialised medical services in the hospital has been provided.
People’s access to health care has improved.
Dispatching of patients to other cities’ hospitals for essential medical services has been minimised by providing it locally.
Illegal payments have been eliminated.
This practice study aims to present Iran’s Universal Health Coverage approach to addressing the lack of access to physicians in deprived areas through the ‘supporting physician retention in deprived areas’ programme and demonstrate its outcomes from 2014 to 2016. This national programme is designed to improve people’s access to high-quality health services and reduce out-of-pocket payments at hospitals in underdeveloped areas.
The number of retained physicians has tripled.
24/7 coverage of specialised medical services in the hospital has been provided.
People’s access to health care has improved.
Dispatching of patients to other cities’ hospitals for essential medical services has been minimised by providing it locally.
Illegal payments have been eliminated.
The programme began by ranking all the cities in the country based on socioeconomic indicators. Then, 302 regions in 30 provinces of Iran were selected and classified into four groups. Finally, each group’s incentive package was defined, consisting of a combination of fixed and performance-oriented payments. This programme has obtained the following achievements in the deprived areas:
The number of retained physicians has tripled.
24/7 coverage of specialised medical services in the hospital has been provided.
People’s access to health care has improved.
Dispatching of patients to other cities’ hospitals for essential medical services has been minimised by providing it locally.
Illegal payments have been eliminated.
- Health policy
- Health systems
- Public Health
- Health economics
- Health insurance
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
Summery box
One of the barriers to accessing healthcare is the unwillingness of physicians to work in deprived areas, resulting in a shortage of healthcare providers in these regions. This problem has significantly impacted key health indicators such as life expectancy at birth, maternal mortality, and under-five mortality rates, and it remains a critical issue within healthcare systems.
This study describes Iran's experience designing a program for physician retention in deprived areas. The program has proven effective in incentivizing physicians to stay and enhance healthcare services in these areas by implementing pay-for-performance and proportionate payment based on the level of deprivation in the region.
This study demonstrated that having full-time physicians in the public sector is directly linked to the improved delivery of health services to people, particularly in socioeconomically deprived areas. Furthermore, regular and motivating payment to physicians plays a significant role in retaining them in these areas.
Introduction
Universal health coverage (UHC) is a sustainable development goal aimed at improving global health convergence. It promotes social justice and guarantees everyone can access necessary healthcare services without financial hardships 1–3. The three critical components of healthcare coverage are population coverage, healthcare benefits and financial protection costs. Simultaneously achieving all three dimensions is challenging for all countries due to financial constraints.4–6 According to the WHO, having skilled and motivated healthcare workers (HCWs) can improve access to vital health services in underserved areas and contribute to achieving the millennium development goals.7 8 Accessibility to physicians is crucial in preventing minor health issues from becoming severe and long-term illnesses.9 However, underserved areas suffer from a shortage of HCWs, making providing diagnostic and therapeutic services challenging. Ensuring physicians remain in these areas is a global top priority for healthcare systems.
This practice study aims to introduce Iran’s experience in solving the problem of shortage of physicians in deprived areas through the ‘supporting physician retention in deprived areas’ programme. The national strategy aims to achieve UHC by improving access to healthcare services and reducing out-of-pocket payments in underdeveloped regions. Before the implementation of this programme, access to doctors in underserved areas was limited, both physically and financially. Patients in these areas had two choices for medical services: either go to a private doctor’s office and pay a much higher fee than the public sector or travel to larger cities, incurring travel expenses and missing work, in order to receive services at the government tariff. This programme offered access to a doctor in a government hospital in underprivileged areas at a government-approved tariff, reducing patients’ out-of-pocket payments. The plan incentivises ‘full-time physicians’ in the public sector (The public sector comprises government hospitals and medical centres that offer services at government-approved rates) to attract and retain them in deprived areas. The share of out-of-pocket payments from health expenses decreased from 47.97% before the programme in 2013 to 32.46% after implementation in 2017.10
HCWs, the cornerstone of UHC
According to WHO, human resources are the backbone of the system and the most essential component and strategic source of any healthcare system.7–9 Better management of HCWs is needed to improve coverage, benefits and quality of care.11
The physician-to-population ratio is used to assess healthcare professional availability, and the worldwide average is 14 physicians per 10 000 people. The USA has a higher ratio of 24.2, while Brazil has a ratio of 17.6, with uneven distribution between urban and rural areas.12 Many countries face physician shortages, particularly in deprived areas.13
Several countries have implemented programmes and financial incentives to attract and retain physicians in deprived areas. Examples include the ‘Health Territory Treaty’ in France and ‘More Physicians’ in Brazil.14 15 However, some believe that a long-term solution that invests in public infrastructure and human resources is needed.
Studies have shown that financial incentives encourage physicians to practice in these areas.16 17 Factors influencing physician retention include social facilities and job satisfaction. Health system interventions to address retention typically fall into four categories: regulations, financial incentives, individual-professional support and educational interventions.17–20
The most important interventions recommended in these studies to retain physicians in deprived areas include establishing a comprehensive and sustainable strategy to meet the requirements of physicians, improving the inappropriate geographical distribution of physicians, developing financial incentive systems to retain physicians, designing managed policies for the migration of HCWs and creating guidelines and regulations for physician retention.17 21 22
Studies have shown that physicians who provide services in rural areas will likely leave there after 2 years.23
Incentive packages are designed to encourage physicians to provide medical services in underserved areas, reducing the need for patients to travel to urban centres.24 It is essential to consider the context while designing these packages.25 Although hiring physicians has been emphasised as a critical motivator for retention,26–28 financial incentives have been proven to be more effective in motivating physicians to work in deprived areas.29–31
Iran’s solution to the shortage of physicians in deprived areas
A study conducted in Iranian public hospitals revealed an uneven distribution of specialist physicians across provinces despite increasing graduates in medical specialties. Before the health system reform 2014, physicians were concentrated in big cities. Studies showed a relationship between deprivation of an area, dissatisfaction with salary and lack of retention among physicians.32 33
In June 2014, under the umbrella of health system reform, medical universities implemented the supporting physician retention programme nationwide to address the above-mentioned challenges. This programme classified cities (with active hospitals) by socioeconomic, geographical and health factors. Each city was scored based on the following criteria:
Coefficient of the region’s deprivation.
Different types of weather and their degree of unpleasantness.
Being located in borderline or non-borderline cities.
City’s population.
Region coefficient to attract physicians: This score pertains to the qualitative factors of the region’s socioeconomic and cultural conditions and amenities, which contribute to attracting physicians.
After scoring each item in a specific city, the total score for each city was tallied. These scores categorised the deprived cities into Groups A–D. The area’s deprivation level decreases as we move from Group A–D (figure 1).
The graph illustrates the percentage share of each group in the cities included in the programme. The country’s 302 disadvantaged cities are divided into four groups; the government gives the most financial support to the least privileged group; therefore, the incentive package becomes less prosperous in Groups A–D.
This programme has assessed and ranked cities in all provinces of Iran, excluding Qom province, which has no deprived areas. It has included 329 hospitals in 302 areas, encompassing various locations across Iran’s geography, from small towns to larger cities. For example, the programme covers most of the cities in the southern provinces with scorching weather (such as Aghajari, Hendijan and Bashagard), an eastern province of Sistan and Baluchistan bordering Afghanistan and Pakistan (such as Zahak, Khash and Saravan), the hard-to-reach areas of the west located along the Zagros Mountains range and the cold areas of the northwest (such as Varzaghan and Kaleibar).
Thus, suitable incentive packages for each group are designed to comprise two types of support.
Fixed payment
A fixed amount is paid to physicians in cities with small populations. Physicians are offered fixed payments in these regions as a financial incentive. They receive this fixed fee every 24 hours for their presence and practice. This payment option is exclusive to Groups A and B. The deprivation level in Group A is higher than in Group B, so the amount offered is also higher.
Performance-oriented payment
A variable coefficient to increase the physicians’ income depending on their performance. For this purpose, physicians are compensated based on their efficiency and performance. The more services they provide, the more payment they receive. Performance payment is applied and decreased from Groups A to D. It is crucial to enhance the quality of service delivery and minimise patient referrals to large and significant cities for procedures that can be carried out in their hometown. These factors are important in determining performance-based compensation. However, this payment increase does not include certain services like ‘caesarean’ which health policymakers aim to decrease promotion.
The combination of the above-mentioned payments, developed in each incentive package, is generally tailored to the conditions and characteristics of service delivery in that area and potentially provides extra job motivation.
A national assessment of health system reforms (The national assessment of health system reforms was carried out by the highly regarded National Institute of Health Researches of Iran. As a specialised external evaluator in the field of health systems, this institute was assigned by the Ministry of Health to assess the health system reforms. In this evaluation, a qualitative study conducted through interviews with retained physicians revealed that an increasing number of physicians are willing to work in deprived areas if they receive incentives.) found that an increasing number of physicians are willing to work in deprived areas if they receive the above-mentioned incentives. In 3 months, the percentage of physicians willing to work in these areas rose by 17%, that is, from 42% to 59%. This study, along with another study,34 has confirmed the effectiveness of this programme in encouraging doctors to work in underprivileged areas and improving service quality and patient access to healthcare.
Lesson learnt
Implementing the incentive package for physician retention in deprived areas of Iran has had a significant and positive impact. The national programme, wholly funded and supported by the government, has been implemented in deprived areas. The data collected from 329 hospitals included in the programme showed positive and effective outcomes. As depicted in figures 2 and 3 and table 1, the programme has increased the number of physicians, retention coverage index and provision of health services, such as outpatient visits and surgical operations, in these areas. In Iran’s healthcare system, 10 geographic regions have been designated, each with its own management authority. To calculate the retention coverage index in each region, the total number of doctors is divided by the population of that region, and it is expressed as per every 10 000 people.
The graph above compares the number of physicians retained in disadvantaged areas before (2013) and after (2014–2016) the implementation of the ‘supporting physician retention in deprived areas’ programme in Iran.
The time trend above compares the retention coverage index in deprived areas before (2013) and after (2014–2016) the implementation of the ‘Supporting Physician Retention in Deprived Areas’ programme in Iran.
Comparison of the growth of health service provision before and after the implementation of the programme in deprived areas
The program’s impact on health status and financial protection is illustrated in figure 4.35 36 It is evident that mortality rates have decreased37 38 and life expectancy has increased39 following the program’s implementation. In other words, access to good health has increased equitably across all populations. According to the World Bank Report, the risk of falling into poverty due to high medical expenses has significantly reduced, highlighting the program’s impact on financial protection. Additionally, the UHC index score (UHC Service Coverage Index or UHC Index Scope combines 14 tracer indicators of service coverage into a single summary measure. It is a coverage index for essential health services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases, and service capacity and access. It is presented on a scale of 0–100), an important indicator for measuring progress towards UHC, which increased from 54 to 75, according to the WHO.40
The chart illustrates how programme outcomes affect the health system’s impact (such as UHC index score, under-5 mortality,38 maternal mortality ratio,37 life expectancy at birth39 and risk of catastrophic and impoverishing expenditure for surgical care.35 36 It demonstrates how enhancing service delivery in underserved areas increases access to high-quality healthcare services for all and improves total life expectancy at birth. This is the goal that UHC aims to achieve. UHC, Universal Health Coverage.
Best practices and lessons learnt from 9 years of programme implementation can be classified into two headings. It is noteworthy to add that reflecting on these lessons, recognising our strengths and weaknesses, and making the positive changes we have made could inspire and assist other countries in creating effective UHC policies and making healthcare accessible for all.
1. Essential points in determining the indices and coefficients measuring the level of deprivation.
Indices measuring deprivation should be determined by considering both geographic and health-related factors in all cities nationwide, ensuring a thorough understanding of the situation.
The Human Development Index (HDI measures a country's average achievements in three essential aspects of human development: health, education and income) and Social Determinants of Health (SDH are the conditions in which people are born, grow, live, work and age) equip indices of deprivation to analyse broader dimensions, considering economic, social, geographical and health factors. For instance, areas with a higher density of low-income populations, absolute poverty and low literacy levels have more significant healthcare needs. Health and demographic indicators such as life expectancy, maternal mortality ratio, under-5 mortality and at-risk population are crucial factors in determining deprivation coefficients and dispatching physicians to deprived areas.
Indices of deprivation should be selected from factors for which information is available in all country regions.
Incentive coefficients should be determined to motivate physicians to work in deprived areas rather than in privileged regions, ensuring a fair distribution of healthcare resources. This justifies the fact that every region, regardless of its socioeconomic status, has access to quality healthcare.
2. Critical particulars for implementing the programme:
Decentralised management, which involves delegating decision-making authority to lower levels, could improve the accuracy and effectiveness of monitoring and lead to faster resolution of environmental issues. This is particularly important in healthcare resource distribution, as it allows for more localised and specific solutions to be implemented based on each region’s unique needs.
An external organisation is required to assess the quality of services provided by physicians. This evaluation will ensure accountability, transparency and continuous improvement in healthcare delivery.
Centralised management of financial incentives and the distribution of specialists are necessary to ensure fair payment.
Deploying electronic systems like HIS and Timex is recommended to ensure the accuracy of physician functional reports.
In addition to financial incentives, it is more effective to use non-financial incentives such as transportation facilities, the possibility of couples living together, the option of continuing education after a period of working in deprived areas and facilitating clinical activity in non-deprived areas after completing the period of working in disadvantaged areas.
Facilitating admission to medical school with the requirement of serving in underprivileged regions should be defined; physicians should be prohibited from practicing outside their designated area for a minimum of 10 years.
Supportive programmes for disadvantaged areas should be integrated at the national level. These programmes aim to address the specific healthcare needs of underprivileged regions and improve health outcomes.
In summary, if we were to implement this programme in Iran again, we would take the following five steps to improve it after reviewing our experiences and lessons learnt:
Determining a small subgroup of cities within Group A that are highly deprived and require further incentives for physician activity.
Determining a limited number of key performance indexes, including the mortality rate of pregnant mothers and providing financial and managerial authority to universities for implementing the programme, considering the evaluation results of these KPIs.
Determining mandatory guidelines that universities do not have the authority to modify or deviate from.
Establishing a management dashboard by the Ministry of Health to monitor doctors’ and universities’ performance and link that to financial payments.
Drafting a law prohibiting the application of opinions by other authorities, including the parliament, in implementing the programme.
Conclusion
A critical challenge in delivering equitable healthcare services is the preference of physicians to work in big and developed cities, leaving underprivileged areas with a shortage of medical professionals. Iran has planned a programme to address this issue. In this programme, cities are categorised into four groups based on indices of deprivation. Each group has its customised incentive package that considers its specific conditions and level of deprivation. The programme has resulted in a noteworthy rise in physicians per population and improved access to hospital services in deprived areas. Implementing this programme has increased UHC by increasing the number of doctors in deprived areas and reducing people’s out-of-pocket payments. The continued effectiveness of this programme relies on timely payments to physicians and the government’s financial support.
Limitation
The data for referring patients to other cities’ hospitals was inaccessible, preventing authors from analysing the rate and reasons for referrals.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors wish to express their appreciation to everyone who supported this study. They are especially grateful for the valuable comments from the reviewer, whose expertise and insights improved the manuscript.
References
Footnotes
Handling editor Helen J Surana
Contributors LP and FF designed the research; AO and SM conducted the study; LP gathered and analysed data; LP wrote the manuscript supporting with SM. All of the authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.