Table 5 The thematic framework explaining the themes, sub-themes and issues that represented the influential factors that influenced the development and implementation of hospital autonomy policy in Iran
Theme | Subthemes | Issues |
|---|---|---|
Policy content | Sources of funds for the policy | -Capitation payment as employer contribution to government |
- Financial contribution of insured people | ||
- Government financial support | ||
- out of pocket health expenditure | ||
Implementation context | Organization of insurance organizations | - An inexperienced insurance organization (MSIO) |
- Inadequate insurance fund | ||
- Inadequate health insurance coverage (population covered and depth of coverage) | ||
- delayed hospitals’ reimbursement | ||
Medical tariffs | -Technical aspects of setting medical tariffs | |
- Delays in adjusting tariffs by general inflation | ||
- Stewardship and policy making in setting tariffs | ||
Organization of hospitals | - costs and revenues information system | |
- teaching nature of target hospitals | ||
- imbalances in different aspects of autonomy (relative autonomy in generating revenues while no autonomy in staff management) | ||
- asymmetry of information between hospitals and insurance organizations | ||
- hospitals administration requirements | ||
Implementation feasibility | -lack of pilot study | |
- no formal assessment of research evidence on autonomy implementation | ||
- no feasibility assessment | ||
Actors and stakeholders support | -lack of cooperation and coordination among various stakeholders | |
- inadequate/ignorance of legal framework | ||
- cultural issues in hospitals | ||
- the interpretation of the policy | ||
Implementation Approach | Implementation method | - top- down approach |
- expanding hospital autonomy before establishing its financing source (i.e., an effective universal health insurance organization) | ||
Blanket approach (‘one size fits all’ approach) | -Hospital Catchment Areas | |
- Hospitals’ patients’ turnover | ||
-resources distribution among hospitals | ||
Timing of implementation | - difficult economic conditions (high national inflation rate) | |
- hasty implementation | ||
- hospitals’ internal strategy for the implementation | ||
- optimistic time frames for policy success (expecting too much too soon) |