The experience of implementing the board of trustees’ policy in teaching hospitals in Iran: an example of health system decentralization

Abstract

Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy 
\nof teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in 
\neach hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor 
\npolicy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as 
\nenhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were 
\nnever realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of 
\ntrustees’ policy did not achieve its perceived objectives.
\nMethods:We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 
\nand 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive 
\nand snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed 
\nverbatim and analyzed thematically, following a mixed inductive-deductive approach. 
\nResults: Three main themes emerged from the analysis. The implementation approach (including the processes, views 
\nabout the policy and the links between the policy components), using research evidence about the policy (local and 
\nglobal), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity 
\nand actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization 
\npolicies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration 
\nof the above factors in policy implementation into account. 
\nConclusion:The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals 
\nin Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not 
\nprepared appropriately and key stakeholders, particularly the government, did not support the decentralization of 
\nIran’s health system.