Research Article - Journal of Public Health Policy and Planning (2021) Volume 5, Issue 10

Universal health coverage index in the poorest region of Iran, Sistan and Baluchestan: 2012-2018.

Azar Abolpur¹, Fatemeh Setoodehzadeh^2*, Mehdi Zanganeh Baygi³, Alireza Ansari-Moghaddam¹, Mohammad Khammarnia³

¹Department of Public Health, School of Health, Zahedan University of Medical Sciences, Zahedan, Iran

²Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

³Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

Corresponding Author:

Fatemeh Setoodehzadeh
Health Promotion Research Center
Zahedan University of Medical Sciences
Zahedan, Iran
Tel: +989177364693
Email: f.setoodehzadeh@zaums.ac.ir

Accepted date: October 18, 2021

Citation: Fatemeh S. Universal health coverage index in the poorest region of Iran (), Sistan and Baluchestan: 2012-2018. J Public Health Policy Plann 2021; 5(10):89-93.

Abstract

Introduction: Universal health coverage means that all people have access to basic and quality health interventions, including promotion, prevention, treatment and rehabilitation at costs that people can afford. Such coverage is the third goal of the Sustainable Development Goals. Given the importance of the issue and the influential characteristics of Sistan-Baluchestan province on this index, we decided to conduct the first study to achieve a universal health coverage index in this province.

Materials and Methods: The present quantitative study was conducted in 2019 in Sistan and Baluchestan province as a retrospective cohort. In this study, secondary health data were used during a seven-year trend from 2012 to 2018. Data were collected through an information form and analyzed using dispersion center indices, frequency distribution tables, t-test and ANOVA in SPSS 16 software.

Results: The mean general health coverage in Sistan and Baluchestan province was 13%, ranging from 17.1% in Khash city to 6.3% in Sarbaz city. Also, this coverage was significantly different in the cities of the province (P <0.05). In this study, the highest coverage index pertained to vaccination (99.71%) and the lowest coverage pertained to essential drugs (0.006%). Also, the mean percentage of general health coverage before and after the transformation plan and also between 2012 and 2018 showed a statistically significant difference (p <0.002).

Discussion and Conclusion: The results of the present study showed that access to universal health coverage is affected by many factors such as material, physical and human resources, infrastructure, economic, climatic, geographical and cultural conditions of the society. This coverage in Sistan and Baluchestan province was much lower than the national average, which indicates the unfair and inadequate distribution of financial, human and physical resources in this province.

Keywords

Evaluation, Universal health coverage, Service coverage

Introduction

In order to ensure health, which is one of the most important rights of individuals in society, healthcare systems provide services at different levels [1-3]. Therefore, since a healthy society achieves growth, prosperity and economic development, universal health coverage (UHC) is one of the important ways to achieve better health for any healthcare system [4-6]. UHC is a term used by the World Health Organization (WHO) to describe its proposed strategy for "health for all". UHC recognizes health as a fundamental human right, and is committed to ensuring the highest possible level of health for all. The WHO, in its 1978 Health for All Policy, emphasizes the highest level of access to health services for all. Furthermore, the 2008 report of the WHO emphasized the principle of universal coverage and achieving social indicators of health [7,8]. Thus, world leaders adopted the Sustainable Development Goals in September 2015 with 17 general objectives and 169 sub objectives, the third of which is called adequate health and well-being or achieving UHC [9-13].

UHC is the access of all people to basic and quality health interventions, including promotion, prevention, treatment and rehabilitation at a cost that people can afford. In other words, "it is the only concept of power that has been able to provide public health" and has three basic dimensions of population coverage, service coverage and financial protection [3,11,14-19]. Also, to calculate this coverage, the WHO has considered 16 indicators in 4 categories: 1- Reproductive, maternal, newborn and child health, 2- Infectious diseases, 3- Non-communicable diseases, and 4- Capacity and access to services. [3,11,14].

In 2012, the United Nations introduced a move, accepted as a political aspiration of all developed and developing countries, towards UHC with the goal of financially accessible and farreaching access to these services [10,13,20]. The level of service coverage varies from 22 to 86 in different countries, with the highest in East Asia, North America and Europe, and the lowest in sub-Saharan Africa and South Asia. Iran, with a score of 65, is ranked 89th in the world (11). UHC in Iran is one of the ultimate goals of the healthcare system and also one of the general health policy clauses announced by the Supreme Leader in 2014. This important necessity has also been emphasized in the Fourth, Fifth and Sixth Development Plans, as well as in Article 29 of the Constitution of the Islamic Republic of Iran. some of the reforms implemented in Iran to achieve UHC are as follows: The expansion of healthcare networks in the 1980s, rural insurance and family physician program since 2005, urban family physician program in 2012 and finally Health Transformation Program 4 (HTP), inspired by the experience of Turkey and Thailand in 2014, was designed and approved in four phases [19,21-26].

Considering that UHC is one of the general goals of the Sustainable Development Plan, and that it was declared the slogan of the WHO for two consecutive years of 2018 and 2019, achieving this goal has been very important for all countries including Iran.

Sistan and Baluchestan province has unique features: vastness; high marginalization ratio; lack of facilities in many rural areas such as drinking water piping, gas supply in many parts of the province, proper communication, paved roads, proper and adequate educational facilities; low socio-economic status; high population growth; high unemployment rate; bordering Afghanistan and Pakistan and illegal migration; lack of health facilities; lack of specialized human resources in the field of health and treatment, and distance from the center of the country. Since these features are among the important and effective factors in achieving the goals of UHC, we decided to select this province and conduct the first study to assess the status of public health coverage indicators.

Materials and Methods

The present study aimed to assess UHC index in Sistan and Baluchestan province, compare it among different cities and compare it before and after the transformation plan. This research is a retrospective cohort applied study conducted quantitatively in 2019.

Sistan and Baluchestan province is located in the southeast of Iran, occupying about 11.5% of the country's area. It has 19 cities as well as three universities of medical sciences: Zahedan, Iranshahr and Zabol. As of 2019, 28 hospitals with 3658 active beds and 1439 centers provided primary health care including comprehensive health service centers, health bases, health houses, maternity facilities and border healthcare bases.

After coordination and necessary correspondence with Zahedan, Iranshahr and Zabol universities of medical sciences, the researcher went to the relevant universities. Since secondary data were used by census, the data related to 16 WHO indicators required for calculating UHC were obtained through an information checklist from the studied cities (Iranshahr, Chabahar, Khash, Sarbaz, Zabol, Zahedan, Saravan and Nikshahr) during 2012-2018. Indicators with inadequate or incomplete data were excluded. These data were obtained from all comprehensive healthcare centers of the studied cities from the SIB national health archives system and statistics related to the years before the establishment of the SIB system.

The information checklist used for data collection contained relevant questions that indicated the status of 16 indicators in the cities under study. Indicators include: 1- Reproductive maternal, newborn and child health(family planning, pre- and postnatal care, complete vaccination of children and health measures to prevent pneumonia) 2- Infectious diseases (treatment of tuberculosis, antiviral treatment of HIV, proper hygiene and malaria prevention measures) 3- Non-communicable diseases (prevention and treatment of hypertension, prevention and treatment of diabetes, cervical cancer screening and nonsmoking) 4- Capacity and availability of services (access to hospital services, the ratio of health workers to the defined standard, access to essential medicines and health security (according to the main health regulations). Since our research covered 7 years, only cities that remained unchanged during this period and after the implementation of the transformation plan, i.e. according to the new divisions of the country were included for comparison.

Data were collected and entered into SPSS-16 software for statistical analysis. Dispersion center indices were used to describe quantitative data, frequency distribution table (absolute and relative) was used to describe qualitative data, and t-test and ANOVA were used to compare data. Also, each indicator was calculated using standard formulas defined by the Ministry of Health and WHO [9,27-29].

How to calculate indicators for reproductive, maternal, newborn and child health

Percentage of prenatal care coverage: (Mothers who received care ≥4 times during pregnancy / Total number of pregnant mothers × 100)

Complete childhood vaccination index: (number of children who have received three doses of Tdap or pentavalan vaccines in one year / total number of children under one year in that area × 100).

Percentage of family planning coverage: (number of women using modern methods of contraception / all married women aged 15 to 49 × 100).

Pneumonia Prevention Coverage Index: (Number of people receiving pneumonia prevention care / population at risk × 100).

How to calculate the indicators of infectious diseases

HIV treatment coverage: (treatment of HIV-infected people at a specific place and time/ the number of people diagnosed at the same place and time × 100).

Coverage of malaria prevention measures: (measures taken at the time and place / the number of households at risk in that area at the same time × 100).

Success rate for completing TB treatment: (The number of cases of TB who completed treatment /total number of TB cases × 100).

Access to minimum basic health services: (Number of households with sanitary toilets/all household’s × 100 and number of households with safe drinking water/all household’s × 100).

How to calculate non-communicable disease indicators

Percentage of patients with known hypertension or controlled hypertension: (number of patients with controlled hypertension / total number of patients with hypertension × 100).

Percentage of diabetes prevention and treatment: (Number of people with diabetes being treated or controlled / Number of people 30 and older in an area × 100)

Percentage of people who do not smoke: (Number of people who did not smoke in the last three months / Total number of people surveyed × 100)

Percentage of Pap smears performed to screen for cervical cancer: (Number of people screened / married women aged 30- 65 × 100)

How to calculate service capacity and availability indicators

Access to essential medicines: (number of pharmacies / population × 100).

Access to hospital services: These indicators are received from the Vice Chancellor for Treatment of the university.

(Number of hospital beds / mid-year population × 100).

Density of healthcare workers: (Physician ratio: number of physicians per 1000 people, surgeon ratio: number of surgeons per 100,000 and psychiatrist ratio: number of psychiatrists per 100,000)

Health security: (according to international regulations)

UHC was calculated as follows

A: (Pneumonia care coverage × Vaccination coverage × Pregnancy care coverage Family planning coverage) 1/4

B: (TB treatment coverage × AIDS treatment coverage × Malaria prevention measures coverage Minimum health care coverage) 1/4

C: (Blood pressure treatment coverage × Blood sugar treatment coverage × Cervical cancer screening × Non-smoking coverage) 1/4

D: (percentage of hospital bed density × ratio of hospital staff × coverage of access to essential medicines) 1/4

Universal Health Coverage = (A × B × C × D) ¼

Results

According to your Table 1, the percentage of UHC in Sistan and Baluchestan province is 13%, with the highest rate in Khash (17.1%) and the lowest in Sarbaz (6.3%). Furthermore, the highest index pertained to vaccination coverage in Iranshahr (103%) and Khash (101%), non-smoking coverage in Khash (99.09%) and Nikshahr (96.95%) and the lowest coverage pertained to essential medicines in Sarbaz city (0.0024%) and Nikshahr (0.0031%), and staff coverage in Sarbaz city (0.64%) and Saravan (0.71%).

Table 7.  Comparison of the percentage of UHC by studied universities.

Discussion

The present study was conducted to achieve UHC in Sistan and Baluchestan province, compare it in the cities, and before and after the Health Transformation Plan. The results of this study showed (Table 1) UHC in Sistan and Baluchestan province is 13%, which varies from 17.1% in Khash city to 6.3% in Sarbaz city. The results also showed that there is a significant difference in the mean percentage of UHC in different cities of Sistan and Baluchestan province (P <0.05). A study by Arhogan et al. calculating UHC in 183 countries in 2017 showed that UHC ranged from 22 to 83 (mean= 65). Arhogan et al. reported UHC as 65 in Iran. According to the available results, UHC in Sistan and Baluchestan province is lower than the national average [11].

Based on the results, most deficiencies were observed in treatment indicators such as low active bed index, low essential drugs index and low ratio of doctor, surgeon and psychiatrist (Table 2), which seriously affect UHC. Low manpower index and other indicators in this province can be attributed to its unique features such as deprivation, geographical dispersion, hot and dry climate, being far from the central cities of the country, difficulty traveling to this province, lack of recreational places, and its location at the borderline.

Cities were ranked based on their UHC obtained in this study in respective order as follows: Khash (17.1%), Saravan (9.3%), Zabol (8 33%), Iranshahr (7.8%), Chabahar (7.6%), Zahedan (7.3%), Nikshahr (7.2%), and Sarbaz (6.32% (Table 4). Mohammad Reza Shahraki et al., on the contrary, ranked the cities in Sistan and Baluchestan in 2018 as follows: Zabol, Zahedan and Ghasreghand topped the list while Sib Suran and Fanuj ranked the lowest [27]. Yazdani reported Sistan and Baluchestan province with the lowest rank in terms of access to health indicators in Iran [28].

The results also showed that the highest percentage pertained to vaccination (99.71 ± 0.46%) and the lowest to essential drugs (0.0005 ± 0.0061%) (Table 2). In his study of the world, Arhogan stated that the highest coverage pertains to vaccination (96%) and pregnancy care (87%) while the lowest pertains to physician-to-population ratio (1.6%) and diabetes treatment (5.6%). These results are largely consistent with our research [11].

Regarding reproductive, maternal, newborn and child health indicators, the highest percentage of family planning coverage was observed in Zahedan (53.9%), the highest percentage of pneumonia prevention measures in Khash city (99.8%), the highest vaccination coverage in Iranshahr (103%) and the highest coverage of pregnancy care in Zabol (82.18%), which was reported above 50% in most cities. Arhogan study in 2017 on 183 countries showed that the percentage of family planning coverage varied from 38% to 83%, which is reported 76% in Iran. Arhogan reported that the mean coverage of pneumonia prevention measures was 76% in the world, and 76% in Iran, which makes Iran one of the countries with high coverage for this index, but these results were not consistent with our research. Arhogan et al. also reported vaccination coverage 96% in the world and 98% in Iran, and pregnancy care coverage in all countries above 50% and on average 87%, and 94% in Iran, which is consistent with the present study [11]. Prenatal care coverage was obtained less in our study in less developed cities. This low coverage in Zahedan can be attributed to the existence of private midwifery offices and clinics providing midwifery services and lower identification of pregnant women. Due to the importance of pregnancy care coverage as an important and effective indicator on reducing mortality in pregnant women, it is recommended to conduct more extensive studies on this indicator in the province.

Regarding the indicators of infectious diseases, the mean coverage of tuberculosis treatment was reported 88.28%, with its highest amount in Khash (99.8%). Also, mean coverage of HIV treatment was obtained 47.2%, which was less than 50% in most cities, with the highest amount in Zabol (99.85%). The mean coverage of malaria prevention measures in this study was 18.36% and less than 50% in all studied cities. Also, mean public health coverage, taken from two indicators of access to safe drinking water and sanitary toilets, was 88% with the highest amount of 92.37% in Saravan city. Maliheh Metanat et al. reported the highest incidence and prevalence of tuberculosis in Zabol and Zahedan in 2011 in southeastern Iran [29]. Arhogan reported tuberculosis treatment coverage as high with a mean of 64% in the world and 64% in Iran [30-35].

Conclusion

Access to UHC is affected by many factors such as adequate healthcare equipment, human resources, infrastructure, economy, climate, geography, and culture. This coverage in Sistan and Baluchestan province was estimated to be much lower than the national average, which indicates the unfair and inadequate distribution of financial resources, human resources, health facilities, as well as deprivation and unique features of this province. Therefore, it is recommended that policymakers pay more attention to the distribution of resources, especially the treatment sector, coverage of essential drugs, as well as deprivation elimination in Sistan and Baluchestan province. Quantitative studies have been performed on some indicators such as uterine cancer screening, pneumonia, maternal care coverage, and IHR rules. UHC should also be a research priority in other universities of Iran.

Funding

This project was approved and funded by Zahedan University of Medical Sciences.

Acknowledgments

The present study is taken from a dissertation with the code of ethics UMS.REC.1398.420IR: ZA conducted this research with the help of professors and experts of Zahedan Health Services Management Department, especially Dr. Zanganeh and other experts from the Deputy for Health in Zahedan, Zabol and Iranshahr universities of medical sciences. I hereby appreciate all those involved for their material and spiritual support.

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