|Year : 2013 | Volume
| Issue : 2 | Page : 109-114
Estimation of standard and quality of health indices for provinces by totally fuzzy analysis 1
Arashk Masaeli1, Hossein Sadeghi1, Ali Ghanbari1, Mohammad Reza Vaez Mahdavi2, Marzieh Javadi3
1 Department of Economics, Tarbiat Modares University , Tehran, Iran
2 Department of Physiology, Shahed University, Tehran, Iran
3 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||4-Mar-2014|
Health Management and Economics Research Center, Isfahan Univesity of Medical Sciences, Isfahan
Source of Support: Health Management and Economic Researches Centre. Medical University of Isfahan Iran, Conflict of Interest: None
Introduction: With the expansion of new indexes in the area of health, calculation of these indexes has been welcomed by the intellectuals of this area. The present study determines the standard and quality of health in the provinces of Iran. Materials and Methods: The present analytical descriptive survey has used fuzzy logic to calculate the indexes of standard and quality of health, which is very similar to the relative and ambiguous concept of the standard and quality of health. The targeted community is also the provinces and the year of survey is 2007. Results: The calculations show that Chaharmahal and Bakhtiari, Tehran and Semnan have the highest ranks in terms of the standard of health and Chahrmahal and Bakhtiari, Yazd and Mazandaran have the highest ranks in terms of the quality of health; however, Northern Khorasan, Gilan and Sistan and Baluchestan are the critical provinces in terms of the standard of health and Kurdistan, Tehran and Sistan and Baluchestan are the critical ones in terms of the quality of health. Conclusions: The findings of Pearson's correlation coefficient show that there is a meaningful relationship between the indexes of human development and standard of health at the level of 0.005 as well as between the indexes of standard and quality of health at the level of ten percent; whereas no relationship exists between income per capita and the quality and standard of health which seems that in provinces level it is logical.
Keywords: Fuzzy logic, standard of health index, quality of health index
|How to cite this article:|
Masaeli A, Sadeghi H, Ghanbari A, Mahdavi MV, Javadi M. Estimation of standard and quality of health indices for provinces by totally fuzzy analysis 1. Int J Health Syst Disaster Manage 2013;1:109-14
|How to cite this URL:|
Masaeli A, Sadeghi H, Ghanbari A, Mahdavi MV, Javadi M. Estimation of standard and quality of health indices for provinces by totally fuzzy analysis 1. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2022 Jan 25];1:109-14. Available from: https://www.ijhsdm.org/text.asp?2013/1/2/109/128126
1This paper is the result of a plan called "Evaluation of standard and quality of health indices in provinces of Iran using totally fuzzy logic" in the center of Management Research and Health Economics of the University of Esfahan Medical Sciences" also is a part of Arashk Masaeli PhD thesis entitled by: Health composite indices, financial protection, health equity and welfare effect of catastrophic cost in Iranian provinces with fuzzy approach.
| Introduction|| |
Index is a component or variable evaluating a certain subject, its sensitivity and its comparison between various places and with reference to what purposes and aims are and how the situations are predicted in the future, and the situations may be evaluated. Indexes determine the characteristics and components in any system and they are divided into two parts: Qualitative and quantitative. There are many indexes to evaluate health, however, it is a difficult task to combine them because they do not have the same unit and there are multiple indexes. 
Now a days, the category of welfare and development is one of the biggest concerns of programmers and policy makers in any country. Welfare means achieving high satisfaction from living for any individual. Achieving other purposes does not make utility for a person without having health, so nobody is consent from his/her life without health; therefore, health may be considered as one of the fundamental principles of people's welfare. With regard to this issue, standard of living represents a certain situation of the country, region or province which has a very close relationship with economic issues and stable economic development in the national and regional level. To understand better the standard of living concept, it may use social-economic indexes. One of the sub-indexes of standard of living is standard of health. Standard of health is a combined, multidimensional and vague index determining the level of achievement to the sources and outputs of health sector with regard to the existing standards in this sector. The aim of measurement of the index is the determination of ability to achieve the principles and standards of health sector.
Quality of life can be considered as the introverted social-economic level of society acquired with regard to the extroverted factors such as social institutions, environment, produced distributive technologies, social relations and formation of capital chains. In other words, quality of life may be described as indicative of the situation of the whole inhabitants in a region or country.  Therefore, quality of health is a multidimensional, combined and vague term determining the level of quality of health sector with regard to higher health during the life. The aim of measurement of the index is determination of the ability of provinces to have higher health in the life.
World Health Organization (WHO) has raised the indexes in which these indexes may be classified into groups such as the indexes related to maternal and infants, general indexes of adults, indexes of access to the health facilities and services, health and medical expenditures. In the above mentioned indexes such as pre-childbirth cares such as calling on specialist, the childbirth done by professional personnel, vaccination of children under one year age and the rates of mothers mortality, infants mortality, and children mortality. The general adult's indexes include life expectancy and adult mortality and etc., There are the indexes of access to the health facilities such as access to the healthy fresh water and bathroom fixtures in the cities and villages and the facilities of health sector such as the number of physicians, the number of hospital beds and the number of nurses and etc., Health and medical expenditure include share of expenditures in gross domestic production, share of private-public sector and providing financial sources of health in terms of tax, social security and foreign sources, private insurances and direct payment of people.  The Center of Management, Statistics and information Technology of Ministry of Health also publishes indexes in the groups such as demographic indexes, rate of mortality, welfare indexes, social indexes and etc., The combined indexes include human development and justice, management and health system. 
Standard of biologic life used as the representative of standard of living in health sector is one of the other indexes acquired by grading based on height and weight. In a certain kind called Body Mass Index (BMI), weight is divided into the second power of height according to meter and if the made value was less than 18.5, the concerned person suffers excessive thinness. The value of a normal person is between 18.5 and 24.9 and person with excessive weight has the values between 25 to 29.9 and a person having the values higher than 30 suffers obesity. Of course, there are also other practical indexes such as calorie consumption and etc. 
With regard to theoretical basics, some researches also have been carried out in the health sector indexes and experimental domain. The research done by Tadić, Cvjetković and Milovanović called "Determining and Monitoring of the Therapy Procedures by Application of the Artificial Intelligence Methods Relevant for Acquiring of the Quality Excellence in the Processes of the Medical Treatment" looked at the multidimensional mathematical models in the sophisticated fuzzy systems for decision-making in the curative interference. The findings show that the application of these models has a certain meaning in the clinical uncertainties and priority of possible strategies and may find better way by using these models in the curative trends. 
In their paper called "Multidimensional Measures of Well-Being: Standard of Living and Quality of Life Across Countries", Be'rnger and Verdier-Chouchane used the theory of Sen to estimate two indexes of standard and quality of life with emphasis on health. This research, carried out in 170 countries, includes three main parts, that is, health, education and environment-material well-being in which three variables are used for every part in two phases of quality and standard. The Public health expenditure (% GDP), improved water source (% population with access) and physicians (per 1000 people) were used in the area of the standard of health and under-weight or under-height children under the age five (%), life expectancy at birth and maternal mortality reported (per 100000 live births) were used in the area of the quality of health. Finally, the authors compared the accrued findings from research with human development and per capita income. The findings show that African countries have serious deficiencies and the environment index is only standard index for them. 
Amini, Yadolahi, and Inanloo carried out a research called "Ranking health in provinces" in 1385 in Iran and addressed to identify and choose the variables of health sector with regard to variety of the indexes of health and difficulty in their combination. They used the combined way of analyze factor and taxonomy analysis for 35 available indexes in health, medical and services, fertility, demographic, mortality and nutritious security who removed those having linear correlation and the rest of them played a essential role in calculating the combined index. The results show that the provinces of Esfahan, Tehran, and Markazi were in the better situations and Ardebil, Golestan, and Qom were not in an appropriate situation and at the same time, Khoozestan, Sistan, and Baluchestan and Kohgiluyeh and Boyer - Ahmad were in critical situations. 
In another research carried out by Zarabi, Mohamadi, Rakhshaninasab called "Spatial analysis of health and medical services development indices", the authors addressed to the investigation and spatial analysis of developing health and medical services in Esfahan. Results of this research which used 47 health and medical services indexes showed lack of balance and striking difference among the townships of Esfahan; Khansar and Borkhar and Meymeh have the highest and lowest levels in order. The role of index of specialized manpower is paramount in developing health and medical sector and the role of indexes of non-specialized manpower, institutional manpower, and rural health is less than other variables in predicting development of health and medical. 
With regard to the effect of health on people's welfare and in reference to the promotion of standard and quality of living and health as one of the main goals of economic policymakers in the developed countries, the present paper attempts to address to the regional comparison of provinces and presenting strategic recommendations for reducing inequalities and homogenizing health in the concerned provinces by estimation of standard and quality of health in the provinces.
| Results|| |
Using appropriate method is essential in estimation of any index; the new methods such as Fuzzy logic have been used little in health sector; therefore, in regard to being relative and vague of the subject and the indexes of health, the paper aims to use this method for estimation of standard and quality of health. Based on estimation of various indexes of health, fuzzy method may estimate more exactly. With regard to definition of standard and quality of health, it may be used for calculation of standard of health of provinces from the variables of public health expenditures of household, using water system regard to whole fresh water sources and the number of physicians for every 1000 people.  Public health expenditure is considered as money spent for public services of health and medical sector. The number of physicians for every 1000 people is an index for the facilities of the health sector. Access to the healthy fresh water is raised as the available public facilities and a tool for preventing infectious diseases so that it is used from using fresh water sources in comparison with the whole fresh water sources. Generally, all above three indexes may get standard of health. The used sub-indexes for quality of health also include life expectancy, the percentage of number of health and medical institutions and centers to one million people, the number of insured people of social security and curative services to the population.  Life expectancy represents ability for long life. The proportion of curative institutions and centers to one million people has been used as appropriate health and medical space. The number of insured people to the population also shows the necessary facilities and conditions for offering health quality which may facilitate treatment. Generally, all the above three indexes may get the quality of health. Selection of various indexes presented from the raised discussions in [Table 1] and existence of its data for combining the indexes of standard and quality of health for 30 provinces are based with regard to income per capita and human development. Data of these variables has been provided on the basis of the last census of 2007 and the statistical yearbook of provinces.
The way of estimating the standard and quality of health in the provinces by using the method of fuzzy logic explains as the following:
Step 1: The degree of deprivation for each index
Step 2: Weighted indexes of standard of health and quality of health
Based on Cerioli and Zani, the composite indexes are defined on the basis of the mathematical weight average of membership functions with regard to the indexes of M and M' which are as follows: 
Step 3: Definition of critical values
The composite indexes are usually made in the different levels; these levels include selection of variables, scale, giving weight and method,  however, the main point gives appropriate weight to the indexes. The information may be collected by the same standard by using two methods. One of these methods is called summarizing which is carried out on the basis of arbitrary view and generalized and specialized judgment of scholars. Another method used is consideration of a main goal for weights and then using multidimensional techniques for identification of weights. Analysis of main components may be mentioned as the most fundamental techniques in this area which the weight of components may be accrued by using first main components on the basis of the degree of variation from the set of main explanatory variables. ,
Estimation of combined indexes of health
Fuzzy method has been used for the calculation of standard and quality of health in this survey. The result has been mentioned in [Table 2]. Given that the fuzzy deprivation function has been used, any province having lesser the rate of deprivation may enjoy higher standard and quality of health. This subject may be observed in the following table.
Determination of critical point in the country allows us to identify the provinces faced by some deprivations. The method of Fuzzy logic may calculate the various indexes for 30 provinces. [Table 3] shows statistical indexes and points of critical based on the above mentioned way of calculation.
Chaharmahal and Bakhtiari, Tehran, Semnan, Yazd, Khorasan Razavi and Esfahan are in the primitive ranks and Kohgiluyeh and Boyer - Ahmad, Kerman, Northern Khorasan, Gilan and Sistan and Baluchestan are in the lowest ranks in standard of health. Generally, with regard to [Table 2] and the critical point for standard of health which equals to 0.6144, Northern Khorasan, Gilan and Sistan and Baluchestan suffer from crisis in terms of standard of health which is necessary attention of policymakers to the extensive changes in these provinces, especially Sistan and Baluchestan.
Chaharmahal and Bakhtirai, Yazd, Mazandaran, Hormozgan and Esfahan are in the primitive ranks and Khozestan, Kurdistan, Tehran and Sistan and Baluchestan are in the low ranks in quality of health which the last three provinces are in the critical situations. The important point is the location of Tehran in this rank; although it has the better rank in terms of life expectancy, however, there is a heterogeneous development in the structure of this province with regard to its high population which it has been led to the low values of medical institutions and insured people with regard to the population. Since the majority of people are the immigrants from other provinces, it should be taken the necessary action for controlling population and doing services which may be led to enhancement of the quality of health with regard to the population.
| Discussion|| |
The relationship between standard and quality of health, per capita income and human development may determine the changes of the health sector in comparison with income per capita of provinces and their ranks. Income Per capita may generally have two distinct effects: Less wealth along with more equitable welfare or more wealth along with less equitable welfare. So a province may get better or worse ranking in comparison with income per capita. [Table 4] represents Pearson's correlation coefficient for standard and quality of health, human development and per capita income of 30 provinces and it shows the significant percentage in brackets. Here, the standard and quality of health of provinces have been used from the results of research and human development index made by Sadeghi et al. Research and the per capita income has been used from data of statistical yearbook.  Higher rank in the per capita income for the provinces such as Khozestan, Bushehr, Kohgiluyeh and Boyer - Ahmad and Ilam shows that these provinces are generally per capita more wealthy from their levels of development. Of course, with regard to the extraction of oil and gas production from Khozestan and Bushehr, it should be noted that the number is merely per capita gross production and it is different from an income expended within the province. As it is observed from [Table 4], there is a meaningful relationship between standard of health and human development, but there is no significant relationship between standard of health and per capita income which is based on the above discussion and lack of harmony between the income of provinces and capabilities. It is also observed for quality of health that there is a significant relationship between this index and standard of health, but this index does not have any significant relationship with human development and income per capita stating that the incomes and expenses of the area of health are less led to quality of health in comparison with the standards of health.
These results may be used for more efficient and better allocation of resources for the various areas. Sistan and Baluchestan should increase investment in human capital including improvement of standard and quality of health.
| Conclusions and Suggestions|| |
Health is one of the multidimensional and complicated concepts in the different societies. Based on the rules of fourth and fifth programs of development, the Ministry of Health is obliged to promote the quality of services and standard of health regularly. So the present paper has paid to estimate the standard and quality of health. The results show that Northern Khorasan, Gilan and Sistan and Baluchestan suffer the fundamental deficiencies in all areas of standard of health. Kurdistan, Tehran and Sistan and Baluchestan have critical situations in the quality of health. They have been compared in the investigation of monetary performance (income per capita) with human development and standard and quality of health. The results of Pearson's correlation coefficient show that there is a significant relationship between human development and quality of health in the level of 0.005 and there is also a significant relationship between standard and quality of health in the level of ten percentage; whereas there is no relationship between per capita income and quality and standard of health showing lack of being influenced from income per capita. It can be justified on the basis of decision making from the capital in relation to the policy makings of area of health; it is worth saying that this item may have distinct aspect with the international studies which seems logical.
With reference to the mission of the Ministry of Health for promotion of standard and quality of health in the country, it is necessary to compile, supervise, and evaluate the standards and indexes of improvement of quality of services that is to be made fundamental changes in the different administrations; it should be used from the experiences of progressive provinces and countries in this area.
| Acknowledgment|| |
We express our gratitude to Dr. Mohammad Hossein Yarmohammadian, the presidency of Center of Management Research and Economics of Health and Dr. Karimi, previous head of the faculty of Management and Information of Health and all these people assisted for better performance of the research project.
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[Table 1], [Table 2], [Table 3], [Table 4]