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 Table of Contents  
Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 129-134

Stewardship's illnesses in health system of Iran

1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

Date of Web Publication20-Mar-2014

Correspondence Address:
Vahideh Rostami
Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2347-9019.129128

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The World Health Report 2000 (WHR 2000) identified four core functions that all health systems should carry out in some way, regardless of how they are organized or where they are. They were financing, resource generation, service delivery and stewardship. Stewardship according to WHR 2000, is the most important and key function of health system in generating good performance and responsibility of the government, usually done through the Ministry of Health, is defined as "the careful and responsible management of the well-being of the population", emphasizes the trust and legitimacy with which its activities are viewed by the general public. In this review article, library and internet search were used. In order to search the databases - Springer, Pubmed, Elsevier, ISI web of sciences, Scopus and Google scholar have been used. Six domains/sub-functions that collectively are thought to constitute effective health system stewardship are generation of intelligence, formulating strategic policy framework, ensuring tools for implementation powers; incentives; and sanctions, building coalitions/building partnerships, ensuring a fit between policy objectives and organizational structure and culture, ensuring accountability; responsibility and answerability to the population and consumer protection. The assumption is that, collectively, the better these sub-functions are carried out, the more effective health system stewardship will be and the higher attainment of intrinsic goals. Therefore, to perform better in the healthcare system and create the best and fairest health system, effective stewardship must be developed.

Keywords: Health system, health policy-making, Iran, stewardship

How to cite this article:
Jabbari A, Rostami V. Stewardship's illnesses in health system of Iran. Int J Health Syst Disaster Manage 2013;1:129-34

How to cite this URL:
Jabbari A, Rostami V. Stewardship's illnesses in health system of Iran. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2021 May 15];1:129-34. Available from: https://www.ijhsdm.org/text.asp?2013/1/3/129/129128

  Introduction Top

It is the right of all people, which is to be exercised by state, and a prerequisite for realizing sustainable development to live a healthy and productive life with acceptable quality free from any disease or disability. As the natural law and the basic human needs, Islam and the constitution of the Islamic Republic of Iran have highlighted, and to accomplish this, appropriate facilities must be provided to meet the physical, psychological, social and spiritual needs of man in every walk of life. [1] Further, governments should establish a system, called health system, to meet the needs of health in the society [1] so as defined; the health system consists of all organization and resources that deal with the provision health actions, where "heath action" is defined as any effort, whether in personal health care, public health services or through inter-sector programs, whose main purpose is to promote health. Firmly to say that in today's world, everyone's life is placed in the hands of the health system. The health system plays a continuing critical responsibility in the whole course of their lives. [2]

The WHR2000 [1] identified four core functions that all health systems should carry out in some way to reach their goals (i.e. improving health, response to the non-medical needs and assuring fairness of financial contribution, regardless of how they are organized or where they are). They include financing, resource generation, service delivery and stewardship. [2],[3] Stewardship, which is, according to WHR 2000, the most important and key function of health system in generating good performance, and it ranks above and different from the others. How well or poorly a government executes its stewardship role can influence all aspects of health system performance. [4],[5],[6]

Stewardship means to determine and enforce administrative rules, provide direction and strategy for all actors in this sector, accept macro responsibility and accountability at the highest level that the Ministry of Health and Medical Educations has carried out on behalf of the government. Stewardship is manifested in policy-making (determining policy and the overall direction of the health system), the intrasect oral governance (employing all possible measures to ensure the implementation of policies) and the inter-sector leadership (using legitimate means to influence other parts to achieve the goals and of the health system). [1]

Stewardship, in the healthcare system, is regarded establishing the best and fairest health systems possible [5] and views it as" the effective trusteeship of national health. It can lead to considerable health improvement in the society. [7] Several specific functions are performed under the stewardship of health system including determination conscious and far-sighted policies because on the capacity to think and analyze, establishing the efficient system of health and management information, proportional change in the laws and regulations, and affecting the players in and out of health sector. [8] Overall, health and stewardship play vital roles in developing infrastructures in different sectors in society and achieving the goals in health system, respectively. This study aims to develop a clear understanding of the stewardship and the concepts associated with the use of library and internet search and search databases Springer, Pubmed, Elsevier, ISI web of sciences, Scopus and Google scholar using keyword, stewardship, health policy, governance, and health system functions with the study of 45 sources and choice of 19 references are provided.

  Results and Discussion Top

Definition of stewardship

Stewardship as well the assurance generation, financing and service delivery constitute the four core functions of the health system. [9] It is defined as "the careful and responsible management of the well-being of the population", concerned with the trust and legitimacy with which government activities are viewed by the general public [2] and is described as the very essence of a good government. [9] The underlying components in any given definitions of stewardship are ethical behavior, reliable decision-making, and trust value. [10]

Stewardship is the responsibility of the government, usually done through the Ministry of Health. This does not mean the government should finance, fund and provide all interventions; however, depending on how the healthcare system is organized certain stewardship tasks may themselves be delegated to others. [3]

Three core components of stewardship are formulating the health policy, exerting influence and collecting and using intelligence. [4] An effective stewardship needs a wide focus and a long-term perspective, direct morally and be various. Stewardship needs wide focus because it not only relates to management in health ministry, but also needs to influence on other players in private sector and other ones outside the health system to change positively. Furthermore, it needs to enjoy a long-term perspective not to limit itself to current challenges, but to find long-lasting solutions and providing capacity for the solution of future problems, and a persistent enhancement and development. The codes of ethics should be followed in stewardship, too, because it requires that the interests of citizens be placed above those of people or organizations in positions of power (a good steward work as a servant not a master). The stewardship should also be various to include a wide range of actions and interventions. [11]

The domains/sub-functions of stewardship

The world health organization identifies six domains or sub-functions that constitute effective health system stewardship. The assumption is that, collectively, the better these sub-functions are carried out, the more effective health system stewardship will be and the higher attainment of intrinsic goals. [4]

Generation of intelligence

This dimension, supporting the other ones, relies on the assumption that intelligence helps informed decision; thus, it leads to better outcome in health system. All those are responsible for stewardship in every part of health system needs intelligence. Intelligence is wider than information and is defined as "the identifying and interpreting information necessary to make decision". This dimension is to ensure that all those who play roles in health system, not just stewards, can access the required reliable and up- to-date data. Here, three main categories are suggested: (1) the current and future policies in health and health system performance; (2) major players and important contextual factors like organization, economics, politics and the role of motivation on players specially consumers; (3) possible political alternatives based on national and international evidence and experiences (for example intelligence in regards to different political solutions to similar problems or organizational structure for different performance). In this dimension, the health ministry needs to invest to enhance the underlying health data and the standardization of data collection performance (derivation, coding and auditing) because it is needed to fully understand what is going in the whole health system; otherwise, the health ministry cannot employ strategies to influence the behavior of different related groups so that they can support the goals in the system or, at least, do not oppose them. It is impossible to have an effective stewardship if we are not entirely aware of the health system. [3],[5],[10],[12]

Formulating strategic policy framework

According to WHO, the first role of stewards in health system is to define strategy to reach better health population. To this end, a vision should be defined for the future of health system, the policies and co-ordinated strategies should be planned, and the sources required to achieve the goals should be defined and mobilized. A clear definition of the vision and a strategic framework will lead to a better stewardship and, then, to better outcomes in the health system. The key components to monitor this dimension are: The (general, specific, mid-term, long-term) goals of health system clearly stated according to credible information, ethics and governing values? Are the roles and responsibilities of actors in private, public, voluntary sectors and of citizens, in implementing the strategies and in maintaining health, clearly defined? Is there any clear identification on the tools for policy-making and institutional arrangement needed to produce improvement? Have the authorities developed any strategy to make required changes? Have they provided guidance for prioritizing health expenditures based on realistic resource and needs assessment, and for monitoring effects of changes on performance? Obviously, the health ministry is responsible for preparing, setting and implementing the health policies. [2],[3],[4],[10],[12]

Ensuring tools for implementation powers, incentives, and sanctions

This domain addresses the concern "to what extent is there a regulatory framework that facilitates implementation of health policy. For instance, different actors are led to act within the desired direction? In this regard, a good stewardship includes ensuring that Stewards have powers commensurate with their own responsibilities, and they are used properly, the stewards set fair laws and ensure those involved in provision, financing and resource generation to fairly enforce the rules, incentives and sanctions to achieve the health system goals. To see if a combination of motivations, sanctions and regulations form an effective regulatory framework (a regulatory framework refers to a range of laws, procedures, codes of conduct and standards). As an example, we can refer to a common problem in health sector called "market failure" and see if there are some appropriate policies for them, ensure if the consumers' rights and responsibilities are defined and if a fair mechanism is provided to protect consumers. A national policy-making should specify where we need power and incentives, and where we need limitation and sanctions. As an example, radical approaches like preventing private practice or having free market will harm the health system. [3],[4],[5],[10]

Building coalitions/building partnerships

Although there are many factors which impact health directly or indirectly, over which stewards have little, or any formal authority to have any effect on it. Then, they should build and maintain a wide range of relationships to be effective. This domain is related to implementation capacity, addresses the concerns to what extent does capacity exist to create alliances of individuals, groups or organizations for joint action around strategic health and health system priorities. One function of health ministry is, therefore, to influence all sectors through inter-sector collaboration and actions to enhance better health. Here, the health ministry can play several roles to influence secondary and tertiary health-increasing factors, including building coalition within the government and between non-governmental actors to achieve the goals of the health system, promoting initiatives aimed at improving health, addressing the social determinants of health and integrating health issues in all sectors. [3],[4],[10],[12]

Ensuring a fit between policy objectives and organizational structure and culture

The domain that is related to implementation capacity, ensuring that health system design is aligned with health system goals and that there are structures and processes in place to manage health system performance. In this regard, performance evaluation and assessment play crucial roles in the health system performance management, it first requires that health Ministries ensure a fit between strategy and institutional and organizational structure and attempt to reduce duplication and fragmentation. This also emphasizes the capacity of health system to adapt the strategies and policies with the health priorities and needs, and to answer the question to what extent the conditions created by the government to allow the steward act effectively. [3],[4],[10]

Ensuring accountability, responsibility and answerability to the population and consumer protection

In this domain, it is ensured that all players are responsible for their activities and the accountability mechanism are fair, and it does not exclude a particular group. The national Health Ministries govern the health sector in a way that is fair, ethical and conducive to the attainment of health system goals. The accountability to the population is a tool to affect them, then accountability helps detect and reduces waste, inappropriate use of sources, negligence or malpractice. It also enhances consumer protection. Then, here we are dealing with how much the players are responsible for the stewards or directly to the people. [3],[4],[10]

Stewardship assessment

The six functions of stewardship applied in health care sector are important; but the extent to which these are carried out to achieve the goals of the health system depends considerably to the contextual factors. However, the proposed framework suggests some strategies for assessing completeness of stewardship in national health ministry. [Table 1] represents the key questions according to which we can evaluate the functions of stewardship in health ministry. [10] Today there are no tools for looking at all aspects of stewardship. [12] Essential Public Health Functions (EPHF), which is developed as a part of a broader program to evaluate the steering role of health ministry, provides a comprehensive list of indicators and questions the eleven essential functions of health system can be used to evaluate some aspects of stewardship. [3] Moreover, some work done on governance can be applied as a way to stewardship evaluation. [4]
Table 1: Key questions to assess the completeness and consistency of health system stewardship

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Challenges of stewardship in Iran

The problems of stewardship in Iran include the existence of multiple stewardship and policy-makers, inefficient manager selection, promotion, education and development systems, inefficient information system (poor data collection system, its on-time analysis, and decision-making based on it), preparing unrealistic outdated statistics and not releasing the actual statistics for several reasons. The lack of systematic planning system (lack of attention to the implementation of the plan, the lack of timely and appropriate delegation to universities), poor regulations and administrative instructions, lack of a clear definition of non-governmental sector, conflicts existent in organizational, employment regulations at the macro level to involve non- governmental sectors, especially public sector, [13] lack of priority of needs based upon disease burden, lack of equitable distribution of resources, households facing heavy health expenditure on health costs, focus on the health sector inputs and ignore the output, lack of customer orientation and a reduction in health system level of accountability, slow decision-making system due to its extension and centralization, lack of organized involvement of other sectors in providing health, inefficient current structure to meet today's needs like cardiovascular diseases and cancers, lack of information on national health accounts and utilization of resources, life instability and rapid turnover of managers and experts in the field, lack of motivational tools for recruiting and maintaining skilled experts, lack of a system to evaluate managers' performance, lack of planning and strategic management in organization, lack of necessary satisfaction and motivation, [14] serious weaknesses in monitoring national programs and policies, poor decision making and evidence-based policy-making in health ministry, poor or low attendance of core stakeholders in health policy-making council, weak accountability systems, conflicting interests in decision-making. Inadequate participation and commitment stakeholder to implement policies, lack of specified center (s) to periodically analyze the health system status; related national researches and providing the required information for the policy-makers, the lack of training for skills and techniques in modern management, poor public participation in macro policy-making and decision-making, the need to reinforce educational, research policies and deliver services, [15] inefficiencies in appropriately coordinating and organizing the effective elements within the health sector and inter-sector, inefficient governance mechanism in health system, poor executive guarantee laws and regulations, lack of transparency of accountability, responsibility and answerability levels, the multiplicity of insurer agencies involved in treatment with the same methods and criteria without competition, Multiplicity of decision-makers authorities in health sector but poor accountability of different levels to the adopted policies and implemented programs, numerous parallel, contradictory and inflexible rules available, [16] documentation weaknesses and informing the policy approved by Ministry, low consumers' awareness of their rights, shortcomings in patient bill of rights and lack of consensus between stakeholders, inequitable participation of consumers in financing, relative autonomy of the universities in making decision and lack of a clear way to plan and supervise the work of ministry in this situation, poor rules available to monitor private sector, charities and non-governmental sectors, unclear Health Ministry expectations of other sectors particularly regarding the most significant causes of Mortality and morbidity, low other sectors' awareness of health status and lack of their awareness of their role in promoting such status, poor political relations and coordinated decision making between Health Ministry and Ministry of Welfare and Social Security, lack of a framework for applied researches due to lack of research priorities and decision-makers' questions. [1]

  Conclusion Top

Health systems vary widely in performance and countries with similar levels of of income, education and Health expenditure have different capability to achieve the main goals. Performance variation is a function of a method by which the health ministry organizes four key functions named source generation, financing, service delivery and stewardship. By investigating these four functions and their combination, it is possible not only to understand the proximate determinants of health system performance, but also to contemplate major policy challenges. Stewardship is the most fundamental function of the health system which deeply affects other functions; furthermore, the level of performance, well or poorly, can affect all aspects of health system performance, as well. Moreover, an effective stewardship must be developed to achieve better performance in the health system and establish the best and fairest health system. [Table 2] illustrates challenge of stewardship in Iran's health system, as the researches reveal.
Table 2: Challenges of stewardship in Iran

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Moreover, Jabbari mentions the lack of clear policies in migrating health experts to Asian countries as the reason for brain drain, reducing the number of national working force, and losing the investment in training such persons. [17] In another study, he knows inefficient support of the government, poor inter-sector collaboration and participation at macro and operational level, and lack of a systematic plan including the challenges facing the medical tourism industry in Iran. [18] Also, in his study titled "the analysis of the stakeholders in medical tourism": Providing Effective Strategies in Isfahan, he emphasized developing an appropriate network between the stakeholders, determining the role of each in planning, policy-making, decision-making, supervising and performance as a factor for medical tourism development in Isfahan. [19]

Therefore, to overcome the problems in stewardship, it is helpful to organize a health information management system, develop a participation network to utilize the stakeholders' view on policy-making process defining health research priorities according to operational domains and health service goals, developing knowledge management centers for better use of experience from all over the world, improve collaboration (defining roles and responsibilities of sectors out of health system). Finally, further conceptual and analytic work is required rigorously characterize and delineate stewardship, its sub-functions and suitable tools and methods to assess it.

  References Top

1.Secretariat Council policy and health reform of Ministry of Health and Medical Education .The Status of the health system in Iran: Challenges and Solutions. 2008; [Cited 2013 March 20]. Available from:http://siasat.behdasht.gov.ir/uploads/291_1664_IHS_Chalenges_Solution_final.pdf.[In Persian].  Back to cited text no. 1
2.Ministry of health and medical education. National document of health sector development in the fourth program of economic, social and cultural development;2005. [In Persian].  Back to cited text no. 2
3.Mechanisms of stewardship in the romanian health system in the decentralization context. Public health and management 2010; 2(3)163-166.  Back to cited text no. 3
4.Travis P, Egger D, Davies P, Mechbal A. Towards better stewardship: Concepts and critical issues. Evidence and Information for Policy World Health Organization. 2002. [Cited 2013February15]. Available from: http://www.who.int/healthinfo/paper48.pdf.  Back to cited text no. 4
5.Anand S, Ammar W, Evans T, Hasegawa T, Kissimova-Skarbek K, Langer A, et al. Report on the Scientific Peer Review Group on Health Systems Performance Assessment. Health systems performance assessment: Debates, methods and empiricism Geneva, World Health Organization; 2003.  Back to cited text no. 5
6.The world health report 2000: Health Systems: Improving Performance. [Cited 2013February 10]. Available from: http://www.who.int/whr/2000/en/whr00_en.pdf.  Back to cited text no. 6
7.Poullier JP, Hernandez P, Kawabata K. National health accounts: Concepts, data sources, and methodology 2003. p. 185-93.  Back to cited text no. 7
8.Ogbimi R. Stewardship: A conceptual imperative for managerial effectiveness in the Nigerian health system. Ann Ibadan Postgrad Med 2007;5:68-72.  Back to cited text no. 8
9.Country unit of health system reform. Health sector reform in Islamic Republic of Iran.Tehran: Andishmand;2004. [Book in Persian].  Back to cited text no. 9
10.In: Organization WH, editor. Report on the WHO meeting of experts on the stewardship function of health systems. Meeting on the stewardship function in health systems (HFS/FAR/STW/001) Geneva, Switzerland; 2001.  Back to cited text no. 10
11.Veillard JH, Brown AD, Barýþ E, Permanand G, Klazinga NS. Health system stewardship of National Health Ministries in the WHO European region: Concepts, functions and assessment framework. Health Policy 2011;103:191-9.  Back to cited text no. 11
12.Murray CJ, Evans DB. Health systems performance assessment: Office of Health Economics; 2006.  Back to cited text no. 12
13.Boffin N. Stewardship of health systems: Review of the literature; 2002. p. 13.  Back to cited text no. 13
14.Rajabi F, Majdzadeh R, Rostami N, Kashipour M, Ismailzadeh H, Shryt Y, et al. The Analysis of Challenges and Effective procedures in Health System. The Center of Research and University policies Development in Health System; 2011. [Cited 2013 February 27]. Available from:http://www.siasat.behdasht.gov.ir. [In Persian].  Back to cited text no. 14
15.Ministry of Health and Medical Education. Document of the Policy of Enhancing Primary Health care.2007. [Cited 2013 April 10]. Available from :http://siasat.behdasht.gov.ir/. [In Persian].  Back to cited text no. 15
16.Policy making council. Ministry of Health and Medical Education Achievements, challenges and prospects facing the health system of the Islamic Republic of Iran. Tehran: Ministry of Health and Medical Education; 2010. [Book in Persian].  Back to cited text no. 16
17.Jabbari A, Mardani R. Trading Health Services in Asia; Health Experts migration: Challenges and Opportunities. Health Inform Manage 2012;9:4011-2.  Back to cited text no. 17
18.Delgoshaee B, Jabbari A, Farzin M, Shearbafchizan, Tabibi. Current medical tourism: A case theory in Iran. Payesh 2012;11.  Back to cited text no. 18
19.Jabbari A, Ferdosi M, Keyvanara M, Agharahimi Z. Analysis of medical tourism industry stakeholders: Providing effective strategies in Isfahan, Iran. Health Inform Manage 2013;9.  Back to cited text no. 19


  [Table 1], [Table 2]


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