Table 2 Definitions of the ADEPT criteria used to code data from the collected documents

Accessibility

 1. The policy is accessible (hard copy and online)

Evaluated during the data collection stage—online availability was enough to satisfy this requirement

Policy Background

 1. The scientific grounds of the policy are established

The policy includes a discussion of health financing. The share of out-of-pocket payments (OOP, both formal and informal) in Total Health Expenditure (THE) and Measuring incidence and intensity of catastrophic payments are made explicit

 2. The goals are drawn from a conclusive review of the literature

The policy shows evidence that the literature was reviewed, and this literature review was used in the decision-making process

 3. The source of the health policy is explicit (Authority, data analysis, deduction)

The policy references a reputable source such as the World Health Report 2000 and draws on scientific studies such as the national health account, OOP index, and other health indices. Also, important documents, including the constitution and general healthcare policies, have predicted such a policy

 4. policy encompasses some set of feasible alternatives

The policy describes potential alternative solutions to those that are intended to be implemented. For example, CHE reduction by increasing enrolment in government health insurance; compulsory membership, increasing financial stability through stable government subsidies, and increasing the government share of spending on health are stated in policy documents

Goals

 1. The goals are explicitly stated

The policy clearly states the overarching aims the policy program seeks to achieve; reduction of the OOP proportion of THE to 30%, and the reduction of households’ exposure to CHE to 1%

 2. The goals are concrete enough to be evaluated later

Quantitative targets or benchmarks are built into the goal, as well as a time frame within which it is to be achieved

 3. The goal is clear in its intent and in the mechanism with which to achieve the desired goal

Each goal is not accompanied by specific strategies or action items that can help achieve this goal once implemented

 4. The action centers on improving the health of the population

Each goal in the policy is relevant, either directly or indirectly, to improving health outcomes. For example, the policy links the goal of WHO to ensure that the cost of care does not put people at risk of financial catastrophe

 5. The policy is supported by evidence of external consistency in logically drawing a health outcome from the goals and policy outcome

The policy doesn't describe the influence of policies from other countries or Inter-Governmental Organizations' documentation on decision-making

 6. The policy is supported by internal validity in logically drawing a health outcome from the goals and policy outcome

The policy doesn't link the scientific evidence to the goals and strategies being proposed

Resources

 1. The cost of condition to the community has been mentioned

In the implementation regulations of Article 90 of the 4th Development Plan, it has been specifically mentioned that the information related to the health expenditure index should be prepared by the Iranian Statistics Center and the Ministry of Health and Medical Education (MoHME) and included in the annual budgets

 2. Estimated financial resources for the implementation of the policy are given

Despite the emphasis of the program and the approval of the law, none of the documents related to the policy, a specific source for financing the implementation of the policy has not been identified. Annual budgets are not provided in this field either

 3. Allocated financial resources for the implementation of the policy are clear

The policy doesn't estimate the amount of money available for implementing the policy, and the sources of this money (the government, NGOs and IGO donors, etc.)

 4. There are rewards/sanctions for spending the allocated resources on appropriate programs

The policy doesn't describe either financial rewards for implementing the policy or financial sanctions for not implementing the policy

 5. Human resources are addressed

A description of the equitable distribution of human resources needed for implementation isn't provided. Also, there isn't an assessment of the resources based on WHO recommendations

 6. Organizational capacity is addressed

The policy describes the infrastructure in place for implementation; for example, the MoHME responsible for carrying out policy implementation is described

Monitoring and Evaluation

 1. The policy indicates monitoring and evaluation mechanisms

The policy doesn't clearly describe the method by which monitoring and evaluation of the policy is to proceed

 2. The policy nominates a committee or independent body to perform the evaluation

The policy mentions a Statistical Center of Iran responsible for monitoring and evaluation, by providing statistics and information necessary to analyze health cost indicators and transfer them to annual budgets. In this context, it is mentioned in the executive regulations of Article 90 of the fourth plan

 3. The outcome measures are identified for each of the explicit and implicit objectives

For each goal, there is a description of the indicators that are used to measure the progress toward this goal

 4. The data, for evaluation, are collected before, during and after the introduction of the new policy

The policy doesn't report the baseline quantitative (or qualitative) data for each goal

 5. Follow-up takes place after a sufficient period to allow the effects of the policy change to become evident

The policy doesn't describe the time periods within which evaluations of the policy implementation are to be conducted

 6. Other factors that could have produced the change (other than policy) are identified

The policy doesn't consider social, economic, cultural, and other factors that could increase CHE rates that may fall outside the specific strategies that are implemented

 7. Criteria for evaluation are adequate and clear

The policy doesn't describe the method for collecting and evaluating data to obtain specific outcome measures

Public Opportunities

 1. Multiple stakeholders are involved

The policy names multiple individuals, groups, or organizations that have a role in decision-making or policy implementation, such as insurance organizations, MoHME, NGOs, and services providers,…

 2. Primary concerns of stakeholders are recognized and acknowledged to obtain longer term support

The policy doesn't identify the primary concern of each stakeholder and doesn't take it into account in decision-making

Political Opportunities

 1. The political climate has either worsened or improved

The policy doesn't describe the political factors that may have influenced decision-making and how they have changed over time

 2. Cooperation between public and private organizations has either worsened or improved

The policy doesn't describe the nature and extent of the cooperation between the public and private sectors of health care

 3. The lobby for the action has either worsened or improve

Lobbying groups, their mandates, and the effect they have on decision-making aren't described

Obligations

 1. The obligations of the various implementers are specified—who must do what?

Each goal or strategy has a specific actor (individual or organization), but the responsibility for implementing the strategy is not specified

 2. Scientific results are compelling for action

The policy doesn't express a clear obligation to act based on scientific results laid out in the document. Failure to implement the policy clearly indicates a lack of professional obligation to the policy. Due to the complexity of the issue and its intersectoral nature, organizations are not independent in the implementation of this policy and its strategies, and these interactions have sometimes created role interference