Health System Governance: A Qualitative Study with Grounded Theory Approach in Iran

Trustworthiness

Ethics and values

Ethics and values is one of the main themes of this study, which consists of two subthemes: justice and philanthropy and public interest. According to the interviewees, justice is one of the issues of governance in the health system that is the most important one and so needs more attention.

One of the interviewees, referring to justice, considers it as "the highest value" and states:

" I want to take justice as the highest value in governance, to pay attention to the deprived people... to see or not to see attention to justice in governance, it has a detailed story." (P16)

Another interviewee who has a similar opinion and considers justice as the most important issue states:

"Although how to manage resources and understand the needs of the people is important, but justice is more important." (P6)

Another sub-theme mentioned by the interviewees is the issue of philanthropy and public interest. It seems that securing the public interest can be one of the main goals of governance in any sector. One of the interviewees believes that for good governance, the first goal of any ruler should be to gain the public interest:

"For proper governance, as the first step the government must consider the pursuit of the public interest as its goal." (P24)

Another interviewee emphasizes that policy-making and governance at the macro level should be in the public interest:

"At the macro level and in policy-making and governance, interventions must be considered that ultimately serve the public interest and are in the public interest." (P6)

balance of power

Another theme in this study is the balance of power. The balance of power consists of three sub-themes: recognizing actors, acting and regulating actors' relationships. Recognizing the actors indicates that for good governance, it is necessary for each ruler to have a good knowledge of the actors so that be familiar with the characteristics and interests of each actor in order to distribute power properly.

Distributing role between actors properly and regulating them to achieve the desired health system requires a good understanding of the health system's actors and their characteristics. One of the interviewees points out the need to recognize the large number of actors in the governance perspective:

"In the governance perspective, I must first understand that there are many actors in governance. I must understand and accept this." (P12)

Another interviewee, referring to the emergence of new actors in health, emphasizes the identification of actors and their characteristics:

" Health rules and regulations are not set by one person and there are different and new actors. A dynamic approach is needed to identify the roles of actors and their characteristics." (P16)

Another interviewee emphasizes the issue of the characteristics of actors and the distribution of roles based on their characteristics:

" If you know the characteristics of the private and the public sector, it will be clear what role each of them should play in the governance process." (P6)

Another important subtheme is the subject of "acting". Balancing the relation of the actors so that the best results can be achieved. One of the important issues in governance which mentioned in the interviews is considering the appropriateness of the context. The interviewees believed that this implies being an "active actor" and that it requires changing the ruler's view and identifying the requirements of the context and governing according to that:

"... If the government wants to be effective actors, in the first step must change their view about the actors, and become an active actor." (P3)

Today, the existence of multiple actors is one of the characteristics of governance. From the interviewees' point of view, the government have to consider the role of each actor:

" The pharmaceutical system has their own governance, Hospitals have their own governance. Insurance companies have their own governance too. I have to know this governance package. I can only play a very limited role in the process of these types of governance." (P12)

Another interviewee, referring to this issue, emphasized the role of the government in strengthening leadership:

"The tools of intra-sectoral governance must be strengthened, and inter-sectoral leadership must be strengthened, that is, a certain ministry or organization must not be allowed to create disorder and anarchy! " (P14)

Another point that has been mentioned in the interviews is the role of regulation and regulating the relations between the actors, which refers to the acting and managing the actors:

" Stewardship entered in our policy literature from the fourth, fifth and sixth Economic, Social, and Cultural Development Plans... this means that the main regulator is the Ministry of Health. This is our understanding of the concept of stewardship." (P13)

Another important subtheme is the regulation of actor relationships. The purpose of this subtheme is also to help the acting. At one level, acting and determining the rules of the game between actors requires determining the relationships between them. Of course, it should be noted that this subtheme has a very close mean to regulation. This issue was raised in one of the interviewees' statement, which he considers to be related to the concepts raised in stewardship and governance:

"The first philosophy of governance is to best regulate the relationship between society and different groups in society." (P1)

The statements of another interviewee confirm the position of governance in regulating relationships. He believes that the characteristics of the health market are such that there is a greater need to regulate relationships between actors:

"In other sectors, such market failures are usually less.... but in the health system, because this relationship is not regulated for the various reasons I mentioned, is where the governance shows its place and importance. It is here that if there is no strong, accurate and effective governance, this system completely loses its function and cannot achieve its goals. "(P9)

However, another interviewee believes that the ruler should be an active actor and to this should know how to manage relationships:

"An active actor is someone who first knows the context well, knows other actors and their power well, and in this space has a plan for managing relationships and leading behaviors." (P3)

Monitoring

This theme is related the concept of the future on the one hand and to the concept of observation on the other. This theme consists of three subthemes including monitoring and evaluation, foresight and roadmap.

The monitoring subtheme includes concepts related to the collection of the reliable data and its analysis to assist policy makers in decision making. The concept of monitoring is a well-known but very broad concept in the governance literature.

"In the upstream documents, the stewardship of health has been assigned to the Ministry of Health, and consequently all its sub-measures, including policy-making and monitoring the implementation of policies and programs, developed by the authorities under the health system, are the responsibility of the health system trustee." (P7)

For good monitoring, in addition to good law, complete and appropriate data is needed. In addition to the above, another interviewer considers cross-sectorial coordination as a prerequisite for good monitoring:

" Passing the law alone is not enough. Monitoring the implementation of the law is the next step. The Ministry of Health can have good monitoring by access to good data. In addition, without good teamwork and cross-sectorial coordination, good monitoring is impossible. "(P14)

In addition, the independence of regulatory bodies is an important issue that has been mentioned:

" If there is no monitoring mechanism, the governance of the health system will be difficult. In fact, the monitoring bodies must be independent." (P17)

Another issue in governance is the relationship of monitoring with the legislation and the implementation, whether a good legislator is a good executor, or whether a good legislator or governer should be a good observer:

" At first, good governor must be a good legislator. The second; governor must improve implementation. The third, governor must improve monitoring. Monitoring completes this cycle. The governor should not be involved in the implementation at all, but should provide good monitoring conditions." (P10)

Another considerable point is the relation between monitoring and evaluation with the required infrastructure:

" In practice, in addition to analysis and the use of expert opinions, monitoring requires strong information technology infrastructure that collects the up-to-date information and leads to the most accurate answers with the lowest costs." (P17)

Another subtheme of this theme is foresight. The Foresight has emerged as a new and important issue in recent decades. The foresight is especially mentioned in connection with the Health Reform Plan:

"What has been observed in recent years was the lack of foresight on the subject of the Health Reform Plan... considerable resources have been injected into the health system, but t But a few years later, the program ran into financing problems because there was no foresight." (P21)

The last subtheme is having roadmap. One interviewee points to the need for a roadmap in both the health system and the health sector:

" All the elements of health, whether in the health sector or in the health system, there must be a set with specific goals. A clear roadmap, in a way, defines the boundaries of health so that they can plan, monitor and evaluate, and take care of everything." (P22)

One of the interviewees refers to foresight and relates it to the roadmap:

"The world is changing rapidly ... We must plan for the desired future in line with the infrastructure, needs and economic situation in order to have a roadmap to achieve that goal." (P20)

It noted that the lack of a roadmap has led to disruptions in Economic, Social, and Cultural Development Plans:

"We need a roadmap of what we want to do in the next years in different areas. There is now a serious break in the development of health services..." The fact that we do not have a roadmap does not mean that there is no roadmap at all; but the necessary comprehensiveness, coordination and foresight of the maps is questionable and we must think about this." (P25)

Corruption control

Some subjects that were frequently mentioned in the interviews were related to the corruption control. Areas of corruption, the most important of which are conflicts of interest, are mentioned, which include various dimensions of conflicts of interest and aspects of corruption. In this section, the areas of corruption, the most important of which is the conflict of interests, have been frequently mentioned, which include the various dimensions of the conflict of interests and corruption. Another important issue is the transparency, which is one of the important tools in corruption control. These two issues (conflict of interest management and transparency) are the two main subthemes in the corruption control.

Interviewees believed that conflict of interest is a major cause of corruption, which should be managed. In the present study, aspects, dimensions and areas of conflict of interest were mentioned as factors causing corruption and a large number of interviewees considered the issue of conflict of interest management as an effective factor in corruption control and health system governance.

"When you want to make a change, there are many obstacles and many people oppose ... and some of these people have clear conflicts of interest." (P9)

On the other hand, despite the fact that Economic, Social, and Cultural Development Plans have been developed in the country, most of them have not been implemented in the field of health. One of the interviewees, considers the conflict of interest as the main cause of policy failure:

" We passed laws in Economic, Social, and Cultural Development Plans, but few of them have been implemented. There are several main reasons, and until they are resolved, the problem will not be solved. I want to say do not look for anything else as long as there is conflict of interest!" (P29)

Another interviewee introduces the conflict of interest as the obstacle to adopt effective laws:

"In codification of law, we must consider the fact that, the law should improve people health. But implementation could be affected by a personal conflict of interest." (P26)

Elsewhere, managing conflicts of interest in the health system is mentioned as one of the effective factors in reforming the health system:

"One of the serious principles through which the world has been able to reform the governance of its health system is to take notice to the issue of Public interest, which is the opposite of conflict of interest. We must look for a model that minimizes conflicts of interest in the health system." (P17)

Another important subtheme in the fight against corruption is transparency. Free information flow, performance transparency and data transparency are examples of transparency that are effective tools in fighting against corruption in health system governance. One interviewee cited transparency as a key factor in the fight against corruption in governance:

" Corruption is a serious problem in the governance of many organizations. Transparency has been a major factor in reducing corruption worldwide." (P17)

In another interview, transparency is introduced as a new tool for governance, and it also indicates that a new look at governance is not possible with traditional tools:

"In the new view of governance, the government must address its main tasks, such as setting the stage, legislating, etc. But the problem is that these tools alone no longer work... for this new perspective new tools must be used. Such as transparency that can facilitate governance."(P3)

Another interviewee sees information as a resource that should be distributed fairly, and believes that fairness in the distribution of information can lead to transparency that will help better governance:

" Information is also a resource that must be distributed fairly. All of this must be considered as a resource, from hard resources to soft resources. Like transparency, which may be defined in the field of information justice." (P4)

Another issue that has been made is the importance of transparency in policy making. In one example, the effect of information transparency on implementation of policies is noted:

"The fact that road traffic accidents are very prominent in the society at the moment started with the fact that the Ministry of Health certified the deaths and realized that the main cause of death in the country is road traffic accidents. So Ministry of Health announced it clearly and regularly. This drew the attention of executives and policymakers to this issue."(P6)

Policy-making capacity

This theme enumerates the factors that have a positive effect on creating the appropriate capacity for policy-making in health sector and thus facilitate the governance process in the health system.

The first subtheme is infrastructure. IT infrastructure provides the context for policy implementation. One of the participants considers the IT infrastructure necessary for governance:

"If we want to have good governance we need a good IT infrastructure. Without this we can't." (P9)

Another interviewee divides infrastructure into two categories: soft infrastructure and hard infrastructure, and believes that we need more attention in the field of soft infrastructure:

" I think the main problem of our governance is in the area of soft infrastructure. We have invested a lot in the area of hard infrastructure. Maybe we have gone beyond per capita and GDP in these areas. But whether the output is not enough to invest in hard software is due to weaknesses in soft infrastructure."(P7)

Coordination is next subtheme. Coordination seeks the organic connection between the actions of actors in order to accompany them all in achieving the goals of the system. One of the interviewees considers governance as a kind of coordination function:

"The concept of governance is more about coordination than just policymaking." (P30)

One interviewee, referring to the three major actors include service receiver, provider, and purchaser, believes that coordination between these actors within the health system is a difficult task that is part of governance:

"There are a series of service recipients in the health system, a series of service providers, and usually a series of buyers, there is an interaction between them ... it is necessary to have mechanism that coordinate these and define their connections. This is the part of governance. "(P9)

Elsewhere, with reference to the social determinants of health and the emphasis on the high contribution of other sectors in the realization of health, inter-sectorial coordination is of particular importance:

"There is a discussion of politics and economics, and each of these is in itself a very broad area ... 75% of health is determined by these factors; well, to achieve them, it must involve other sectors which has its own difficulties and complexities."(P7)

Another important subtheme is accountability. Respondents cited accountability as a key condition for professional governance and believed that poor accountability would lead to the loss of public trust.

One of the interviewees considers accepting the consequences of decision-making as one of the components of governance and believes that managers should be accountable while having responsibility and authority:

"Managers stay for a while, and then they go... If they are questioned later, they will say others did not let us work. I did the right thing. My decision was right; others did not let it work properly. This means escaping accountability." (P30)

Another interviewee believes that governance means accountability and responsibility:

"In the health system, the function of governance is like an umbrella over all other functions and in a way it means something, part of which is meant in accountability and responsibility". (P33)

Last subtheme in this theme is participation. Its importance can be interpreted and expressed from various dimensions. One of the interviewees describes participation as an essential thing and as a point of interaction with the community:

" Participation is the point of connection with society, the point of interaction with today's society, and can realize the efficiency of the health system." (P7)

Elsewhere, the move towards participation is seen as a new thing in governance, and it is understood that the new approach to governance is a participatory approach:

"We used to think that someone in the health system should have the last word, but now perspective is to participation in governance." (P1)

Support and mobilization of the community to solve problems can also be achieved through the participation process:

" The government must be able to find the right points of intervention... to do so through Intra-sectorial policy making or through seeking support, to be able to mobilize the resources of society to address that dilemma." (P6)

The dominance of health culture and multilateral interaction and networking with other sectors is also an issue that will be achieved with the participation of non-governmental sectors in the process of health governance:

" If the culture of health prevails, it is possible to better promote multi-faceted interaction and networking with other sectors, and multilateral and bilateral interaction in the pillars of governance or civil society. The second step is that we should be able to maximize the participation of non-governmental sectors in the health governance process."(P7)

People's interest in participating in the health system is also another important issue that has been mentioned:

" People like to be influential in the health system and be the source of effect... so, for that we need to define a participatory mechanism." (P4)

In this study, by analyzing the views of 36 major policy makers of the Iran's health system, finally 5 main themes and 14 sub-themes including: ethics and values (equity and equality, philanthropy and public interest), balance of power (recognizing actors, acting, regulating actors' relationships), monitoring (monitoring and evaluation, foresight, roadmap), corruption control (conflict of interest, transparency) and policy-making capacity (infrastructure, coordination, accountability, participation), were extracted and reported.

One of the most important issues extracted from the participants' perspectives was ethics and values. This issue has always been considered by researchers and policy makers in many models and definitions that have been proposed in the field of stewardship/governance in the health system. In one of the oldest definitions and concepts of health system, this issue has been considered clearly and with special emphasis [29]. Also, another old concept, emphasizes the issue of ethics, values and social welfare and benefit in the governance of the health system [30]. One of the key factors in this regard is the ethical approaches of policy makers and in general the socio-political system of countries. So that the moral approaches and beliefs of any society are the key determinants of the general orientations and approaches of each system and the health system is no exception to this rule [31, 32].

However, ethics and value, especially the key and sensitive issue of justice in the health system, are not an issue that is not considered in societies, and health policymakers and administrators do not care about it [33, 34]. This issue is very important in countries such as Iran, which has a special culture and social conditions and there are many different values and traditions in society, due to the Islamic values [35]. But the important thing to note is the existence of a practical guide and adherence to it in health system governance. In other words, to avoid problems and personal tastes in this area, policy makers and relevant officials should follow a single framework and guideline to make decisions.

Another topic that was extracted from the participants' point of view was the balance of power, which refers more to the identification and management of key actors in the issue of the stewardship and management of the health system. Perhaps less can be found that is as dependent on different sectors and individuals as the health of society and people. Therefore, how to manage these people and different groups is one of the major challenges in the governance of the health system in countries. The WHO emphasizes that the design and implementation of policies and programs without the participation and proper management of all stakeholders and key actors will not have significant results. Therefore, it is necessary to learn the strategies and proper management for involving the main actors and use them in the governance of the health system [36].

An important point for policymakers and planners to address is the conflict of interest, which also addressed by participants in the subject of corruption control. Indeed, it is natural that the existence of different actors with different interests and benefits will cause conflicts of interest. In other words, the most key issue in the discussion of actor management is the management of conflict of interest [37]. To this end, the WHO has proposed two key strategies, Advocacy and Conflict Negotiation, and provided guidance on these issues [38]. In other literature, also the necessary guidelines have been provided in this regard, which can be used policy makers and health officials, as required [39, 40]. This issue is even more important in Iran and other LMIC countries due to the weakness of the stewardship and legislation, as well as the presence of a wide range of actors. Thus, in such countries, more attention should be paid to this issue.

Monitoring, which covers the three key issues of monitoring and evaluation, foresight and roadmap, was another concept that was extracted from the experts' perspective. In one of the latest definitions of governance in the health system, special emphasis is placed on the issue of monitoring and evaluation and roadmap [41]. Another study consider the three key dimensions of health system governance to be the design, implementation and monitoring of laws, assurance about responsibilities and roles are played by different sectors, and the strategic organization and orientation of the health system, which all three topics are somehow consistent with the concepts extracted in the present study [42]. Another study which examined the issue of stewardship in the Ministries of Health of the European region of the World Health Organization, also placed special emphasis on the issue of vision and roadmap [43]. In another study who used a Delphi study to design the governance model of the Iranian health system in six dimensions, special attention has been paid to the issue of monitoring [44]. Also, in the policies of the Supreme Leader in the field of health, special emphasis and attention has been paid to the issue of monitoring and evaluation [45]. It seems that the issue of monitoring is one of the most important components of governance in the health system. However, there seems to be a lot of controversy about how to effectively implement these concepts in practice, and there are many differences between different countries. Also, in this field there are many weaknesses in LMICs [46]. Given that there are many different models and methods for evaluating /monitoring the health system, it seems that the main problem is how to implement the existing concepts and policies in this field. For example, unlike many leading countries in this field, in many LMICs, including Iran, the issue of separation of service provider from evaluator has not yet been seriously considered and this has created many problems for the health system, especially in the field of governance.

Another issue that emerged from the participants' perspectives was the issue of corruption control, which included the conflict of interest and transparency subthemes. The results of various studies have shown that corruption in the health sector has many destructive effects and endangers the lives of many people [47-49]. Therefore, the governance in the health system must deal with this issue seriously. In this regards, there are several important issues that policy makers and health care providers need to address. First, they must prioritize prevention programs and policies over identifying and tackling corruption. The next is the use of existing capacities and potentials in other sectors especially close cooperation with judicial institutions. Also, since identifying and dealing with non-corruption cases will have worse consequences, transparent and objective interventions and tools should be used to detect and deal with corruption. Also, since identifying and dealing with non-corruption cases will have worse consequences, transparent and objective interventions and measures should be used to detect and deal with corruption. Finally, another important issue in this regard is prioritization. If the prioritization is not addressed, the health system may focus on minor corruptions, while serious and dangerous corruptions are forgotten. In this study, another important issue in the field of corruption was the transparency. There are many available studies and experiences that show that one of the main ways to fight corruption is transparency [50-52]. In another study which examined the concept and role of stewardship and its functions in the health system through a scoping review, the indicators of stewardship assessment in the health system are presented, one of the most important of which is the transparency [53]. Therefore, the officials of the health system can seriously address the issue of corruption using effective and efficient governance, considering conflict of interest and transparency and many strategies and experiences that exist in this field.

Another main theme extracted in this study is policy-making capacity, which includes four sub-themes: infrastructure (hardware and software infrastructure for effective and efficient policy-making), coordination (with other agencies and departments), accountability (for performance and results) and partnership (with other sectors and identities). The subject of capacity building for policy-making has been considered by policymakers and managers of health systems for many years, and many efforts have been made in this field. For example, a framework presented three skills and capacities including analytical, operational and political at three levels of individual, organizational and system in the form of a 9-house matrix [54]. In another study which tried to design a model of stewardship in the health system through literature review, the researchers introduced 7 general tasks for stewardship, one of the key of which is the capacity building, which leads to the creation of a suitable structure for proper and effective stewardship [55]. The PAHO regional model, which is presented in the field of health system governance/stewardship and includes 11 Essential Public Health Functions (EPHF), also pays special attention to capacity building for effective policy making [56]. In this study, although the participants pointed out the key issues in capacity building, however, it seems that the examples and cases of capacity building for effective policy-making and governance in the health system are much broader than those mentioned in this study. One of the most important of them can be financial resources that have been mentioned in various scientific literatures [57, 58]. Therefore, conducting further studies in this field to more accurate and comprehensive identification of capacity building dimensions and methods and measures required in this field, seems necessary.

However, based on the results of literature review and experiences of researchers, this study is the first study of its kind that from the perspective of experts and policy makers of the health system has examined the issue of health system governance and provide comprehensive and practical information for readers and decision makers, however, there were several limitations in conducting this study, one of the most important of which was the difficulty of accessing some experts and major policymakers despite extensive follow-up. The main reason for this was the busy schedule of these people.

CONCLUSION

The governance of the health system in Iran faces many challenges and problems. While literature review and experiences of researchers shows that the concept and nature of this issue has not been sufficiently explored and especially from the perspective of policy makers and senior health officials, it also seems that there is no consensus and a common language on this issue at different levels and among policy makers. Therefore, the results of present study, in addition to creating a consensus and providing a clear and comprehensive view of the concept and dimensions of governance in the health system, can be used by policy makers and senior managers of the health system in order to exercise appropriate and effective governance in the health system.

ACKNOWLEDGMENTS: This article was a part of the PhD dissertation approved and supported by the School of Health Management and Information Sciences, Iran University of Medical Sciences, with the code of IUMS/SHMIS_97-4-37-13351.

CONFLICT OF INTEREST: None

FINANCIAL SUPPORT: This study was supported by Iran University of Medical Sciences.

ETHICS STATEMENT: In order to observe ethical issues in this study, informed consent was obtained from the participants, and also individuals had the right to cancel and leave the study at any time. In addition, the objectives of the study were first explained to the participants. For the present study, ethical approval was obtained from the Research Ethics Committee located at Iran University of Medical Sciences (cod: IR.IUMS.REC.1397.595).