Threats and Opportunities of the Health Reform Plan from the Nurses’ Perspective in Ilam

BACKGROUND : The Health Reform Plan is one of the greatest state services in Iran. However, this plan has its own weaknesses and strengths. This study was conducted with the purpose of determining strengths and weaknesses of the Health Reform Plan from nurses' perspective. METHODS: This is a cross-sectional study in which 100 nurses who work in clinical education centers on Ilam participated. The data collection tool was a questionnaire which consisted of 12 items regarding the strengths of the Health Reform Plan and 18 items about the plan's weaknesses on a six-option Lickert scale. Data analysis was carried out using SPSS V. 19 and applying descriptive and inferential statistics. RESULTS: The mean score for weaknesses was 79.94 and the mean score for strengths was 52.49. There was a significant statistical relationship between the variable of age and the strengths (P=0.015). CONCLUSION: If we manage to increase strengths and reduce weakness of the Health Reform Movement, we can be hopeful that this great plan will be administered more efficiently at a national level. It is suggested that future studies be conducted about individuals' perspectives in other occupations in the field of medical sciences working in different medical communities and hospitals in Iran and the results be compared.


Introduction
Provision of national healthcare in Iran as a developing country, is an ultimate goal of the healthcare system, one of the most important principles in Iranian constitution and a clause in the healthcare policies issued by the Supreme Leader.In the Iranian Development Plans including the Fourth and the Fifth Five-year Development Plans, the necessity of providing healthcare at national level has been emphasized.Principle 29 of the Iranian Constitution states that all Iranian citizens have the right to be provided with healthcare services and medical care (Carrin et al., 2008;Savedoff, 2012).Due to problems in the healthcare system in recent years regarding unfair distribution of equipment, specialists and budget and because of the ever-widening gap between more developed and less developed regions, huge diagnosis and treatment costs at private clinical centers, inadequacy or even lack of access to most diagnosis and treatment facilities in public clinics and clients' dissatisfaction with the quality and quantity of the services provided at healthcare and clinical centers which followed a national healthcare system, forced the top administrators to reform the existing healthcare system so that people can achieve their legal rights.Therefore, in the National Visions Document, the prospects of providing satisfactory healthcare for Iranian citizens in accordance with the up-to-date universal standards were outlined (Pinelopi et al., 2012;Aldaqal et al., 2012).Part of these prospects turned into a first-stage Health Reform Plan in May 2014 which consisted of eight service-provision categories (reducing the amount of money that hospitalized patients have to pay, encouraging doctors to stay in underserved areas, presence of resident doctors in state hospitals with more than 64 beds, improving hoteling quality in state hospitals, improving examination services in state hospitals, promoting natural childbirth, providing financial support for patients who suffer from refractory or incurable diseases as well as the needy patients, establishing air emergency service (Boerma et al., 2014;Carrin et al.,2008).Some developing countries such as China, Turkey, Thailand, South Korea, Mexico and Brazil have tried to make large-scale reforms with the aim of protecting and improving every individual's health in their societies.Most of these countries have provided their people with a comprehensive package which consists of services in the areas of prevention, improvement, therapy and empowerment (National Institute of Health Research, 2015).
Every country has a specific procedure for the implementation of this health reform plan that affects on its successful implementation.Health system of Iran is based and noted on the principles and values.In some countries, such as Unites state, Egypt and Brazil, there are restrictions that reduce the possibility of changes in various fields (Esmailzadeh et al., 2013).Health reform plan is a program that needs time and should be evaluated periodically and regularly over time to identify and overcome their weaknesses and boost its strengths.For example, checking the effects of influential external environment takes a 15-year schedule.Although many factors contribute and have influence on this plan such as political system of a country, budget, and population growth; some techniques have been devised by the Ministry of Health to examine the challenges and opportunities of this plan, in this regards (Rostamigooran et al., 2013).
Although the aims of such plans in improving a society's health are very important and the administration of plans can lead to people's satisfaction and that of some actors in the field of public health provision, to continue the exercise of these plans, we are faced with serious challenges.The purpose of this study is to determine the strengths and weaknesses of such plans from nurses' perspectives.

Method
This is a descriptive cross-sectional study carried out in a period of time between September 2015 and October 2015.Nurses who worked in educational hospitals in the city of Ilam make up the population of the study.Census was applied as the sampling method.Thus, all nurses who worked in educational hospitals in Ilam were invited to participate in the study and eventually 100 nurses who were willing to take part were selected as the sample.
Since, the numbers of nurses in the hospital were 160 and some of them were not reachable/available, 100 persons were chosen for investigation.

Data Collection Tools
The demographic information about nurses such as age, gender, level of education, work history, working section in the hospital and the mean number of work shifts in a week was collected through questionnaires.A reliable and valid two-part questionnaire (8) was used to measure strengths and weaknesses of the Health Reform Plan.The first part consisted of 12 items about the strengths of or opportunities created by the Health Reform Plan on a six-option Lickert scale (very high to very low).The range of scores for this part of the questionnaire varied between 12 and 72 and it was divided into four sub-ranges: 12-27 (weak), 28-42 (below average), 43-57 (above average) and 58-72 (good).The second part consisted of 18 items about the weaknesses or the threats brought about by the Health Reform Plan on a six-alternative Lickert scale.The score range was 18-108 for this part and consisted of four sub-sections: 18-40 (weak), 41-63 (below average), 64-85 (above average) and 86-108 (good).In order to re-examine the validity of the questionnaire, content validation method was applied.The questionnaire was given to 10 experts in the field of nursing and their comments were taken into consideration while classifying groups and scoring.The validity was thus confirmed.The reliability of the questionnaire was also verified through a pilot study in which 10 nurses participated, using test-post-test method.Cronbach's Alpha coefficient was 0.84.
After getting the approval of the Committee of Research Ethics, the informed consent of the participants was acquired.Then, the researcher went to the clinical centers, distributed the questionnaires among the participants and collected them after they had been filled out.Data collection was carried out from September 2015 until October 2015.Data analysis was conducted using SPSS V. 19.Descriptive statistics (frequency, mean, standard deviation) and inferential statistics (independent t-test and one-way ANNOVA) were used to determine the relationship of strengths and weaknesses with demographic features.P<0.05 was considered as the level of significance.

Results
According to the results of the study, 61 participants (61%) were male and 39 (39%) were female.88 subjects (88%) were married and 12 (12%) were single.24 individuals were younger than 25 (24%), 49 were in the age range of 25-35 (49%), 22 were between 35 and 45 (22%) and 5 nurses were older than 45.Table 1 shows weakness scores and table 2 illustrates strength scores related to the Health Reform Plan.In table 1, the relationship of the weakness and the strength scores with demographic variables (age, gender, marital status) is presented and this shows that there is a significant statistical relationship between the plan's weaknesses and age variable (P=0.015).So, by increase in age the mean scores would be higher.However, there is not a significant relationship between the strengths of the plan and the demographic variables.Table 2 shows the correlation of the Health Reform Plan's domains with demographic variables of age, gender and marital status.Table 3 illustrates the maximum, the minimum and the mean scores for the weaknesses and strengths of the Health Reform Plan.Finally, table 4 shows the responses given to all the items on the questionnaire and Table 5 shows the Strengths and weaknesses questionnaire.   .The two-way ANOVA between the variables of age and gender and that of the strengths for the Health Reform Plan.In the group of married participants, the ones older than 45, got the highest score and the ones younger than 25 obtained the lowest.In the group of unmarried participants, the obtained score gets higher by increase in age Figure 2C.The two-way ANOVA between the variables of gender and marital status and that of the strengths for the Health Reform Plan.In the group of married participants, the female subjects' score was higher than that of the male ones.In the group of single nurses, male participants' score was higher than the females Figure 3C.The two-way ANOVA between the variables of age and marital status and that of the weaknesses of the Health Reform Plan.Female participants' score was higher than that of male ones for both married and unmarried subjects

Discussion
The Health Reform Plan is one of the greatest services provided by the government in Iran.However, it has some strengths and weaknesses.According to the results of this study, the mean score for weaknesses was 79.94 and the mean score for strengths was 52.49.Besides that based on the classification of the plan's strengths into four categories, the highest score (46% of the total score) was given to the above average category (a score between 43 and 57).The weaknesses were also placed in four categories and the highest rate of scores (52% of the total score) was given to the above average category (a score between 64 and 85).In a study carried out by Nematbaksh et al. (2015), the mean score for strengths was 40.5 out of 60 and the mean score for weaknesses was 80 out of 90.These rates fall into the category of above average scores and are consistent with the results of our study.
According to the results, the age range of 25-35 has acquired the highest score in the strengths and weaknesses and the age group of the participants younger than 25 got the lowest score.The mean score given to the weaknesses of the plan by female participants was lower than the mean score given by male participants.However, regarding the strengths of the plan, the mean score given by male participants was higher than that given by female ones.Finally, the mean scores for weaknesses and strengths given by married participants were higher than the scores given by unmarried ones.According to the results, there is a significant statistical relationship between age and strengths but there are not any significant relationships among other dimensions.
Study conducted by Khayeri et al. (2015) franchise reduction plan for hospitalized patients is important dimension.
In addition the highest mean score belongs to referral chain as the most favorable dimension and the lowest mean belongs to two dimensions of training and informing personnel and informing patients as the most unfavorable dimension.
Studies show that not only satisfaction for all sectors of society with the health system in Iran has increased as long as this plan is conducted (Hashemi et al., 2015), but also other elements of health systems such as the areas of health and medical education are affected (Akhondzade, 2014).
In other countries based on their goals of reform plan many results obtained.for example in Australia, Suitably-trained nurses, physician assistants or nurse practitioners undertaking greater responsibility for initial diagnosis and triage in hospitals; enrolled nurses taking on some of the tasks currently done by registered nurses (AHCRA, 2016); The mortality rate improve and the country save approximately $570 billion a year in the United States (Hsiao, 2011); and a majority supports significant state involvement in health care financing, ranging from providing safety net for the poor, through co-subsidising or regulating the social insurance system, to providing state-financed universal free care in Bulgaria (Balabanova & McKee, 2004).
According to the survey carried out in this study, the Health Reform Plan can potentially have positive effects but the essential condition for these effects to take place is to minimize the factors that influence the efficient exercise of this plan as weaknesses or threats.If the potential strengths or opportunities of this plan such as creation of electronic health files are not operationalized in a serious manner, not only medical research but also medical education plans would severely suffer from negative consequences (Nematbakhsh, 2015).
According to the results, the strong point of health reform plant is necessity of establishing electronic files and national system of events' registration for future.The weakest point of this plant is the chance to access the big data of observation (change from the model of inductive to reasoning) and repeatable experience (medical evidence based).According to the results, the most weakness of health reform plan is decrease in the quality of research data due to increase in the cost of treatment and lack of research funds for this plan that totally agrees with that of literature (Nematbakh, 2015).

Conclusion
Health system reform should be based on problems and challenges.Knowledge-based opportunities and threats can be helpful in resolving the technical problems.the most weakness of health reform plan was decrease in the quality of research data due to increase in the cost of treatment and lack of research funds for this plan, while the strong point of health reform plant was necessity of establishing electronic files and national system of events' registration for future.It is suggested that health officials at least spend a budget for management studies and better implementation of this reform plan.
If we can increase the strengths and decrease the weaknesses of the Health Reform Plan, we can hope that this enormous plan will be administered more effectively nationwide and better services would be provided for clients quantitatively and qualitatively.

Limitations of the Study
Since this piece of research is one of the first studies conducted in Iran about the strengths and weaknesses of the Health Reform Plan, we could not compare the results of this study with those of others.Statistically, the relationship between demographic variables and the strengths or weaknesses of the plan could not be compared to other studies.Subcategories of the demographic variables were not compared to any other studies either.Therefore, conducting similar studies about other medical occupations in different communities and different hospitals in the country can lead to valuable results which would contribute to the improvement of the Health Reform Plan.

Ethical Approval
No ethical approval was necessary for this study/project because it did not involve access to or collection of private, sensitive or health data.

Figure
Figure 1A.classification of the scores based on the strengths of the Health Reform Plan into four categories: 1% of the participants' scores were placed in the category of weak scores (12-27), 21% were in the below-average class (28-42), 46% were in the above-average category (43-57) and 32% were in the good (58-72) range

Figure 2A .
Figure 2A.The two-way ANOVA between the variables of age and gender and that of the strengths in the Health Reform Plan.For male participants, increase in age (from 25 to 45 and above) would lead to increase in the mean scores and for female participants in the age range of 25-35 the highest score and for the age range of 35-45 the lowest score were obtained

Figure 3A .
Figure 3A.The two-way ANOVA between the variables of age and gender and that of the weaknesses for the Health Reform Plan where the age group of 25-35 had the highest score and the age group of 35-45 had the lowest.25-35 year old female participants had the highest and 35-45 year old ones had the lowest scores

Table 1 .
Statistical relationship of demographic variables with weaknesses (threats) and strengths (opportunities)

Table 2 .
Correlation between the Health Reform Plan domains and the demographic variables

Table 3 .
Mean scores for the two domains of weaknesses (threats) and strengths (opportunities) related to the Health Reform Plan

Table 4 .
Comparison between the scores in the two domains of weaknesses (threats) and strengths (opportunities) of the Health Reform Plan in accordance with the demographic subcategories

Table 5 .
Strengths and weaknesses questionnaire