Original Article

Expanding Fiscal Space for Healthcare System through Efficiency: A Qualitative Study from Iran


Background: Healthcare systems are always facing increasing public demands to provide better services. Therefore, countries always need more resources and are constantly seeking more fiscal space for health. Freeing up resources through improving efficiency can be a practical option for all settings, particularly countries with low resources. This study aimed to identify feasible options for expanding fiscal space through efficiency within Iran’s healthcare system.

Methods: This was a qualitative study. We conducted 29 semi-structured in-depth interviews with stakeholders at various levels of healthcare system in 2017 and 2018. We used mixed method (deductive and inductive) qualitative content analysis. Pre-defined themes extracted from literature and meanwhile new subthemes were developed and added to the initial framework.

Results: We identified three main themes that affect the efficiency of healthcare system in Iran: administration, implementation, and monitoring. Problematic administration, inappropriate implementation and lack of good monitoring in healthcare initiatives may lead to inefficiencies and wasting resources. Recognizing these leakages in every healthcare system can free up some resources.

Conclusion: Irrespective of their economic development, all countries may, to some extent, face limited resources to address ever-increasing needs in their healthcare systems. While generating new resources is not always possible, enhancing efficiency to expand fiscal space might be a feasible option. Healthcare systems should identify the leakages and respond to wastages with appropriate planning. Getting the most out of current resources is possible through proper administration, good implementation and a well-established monitoring system for healthcare initiatives.


Brodie M, Hamel E, Kates J, Altman D, Kohut A, Gross E, et al. A Global Look at Public Perceptions of Health Problems, Priorities, and Donors: The Kaiser/Pew Global Health Survey. Washington, DC: The Kaiser Family Foundation and the Pew Global Attitudes Project; 2007.

Organization WH. Health Systems Financing: The path to universal coverage. 2010. The World Health Report URL: http://www who int/whr/2010/en/. 2012.

Systems ToIIFfH. More money for health, and more health for the money: final report. International Health Partnership Geneva; 2009.

Durairaj V, Evans DB. Fiscal space for health in resource poor countries. World health report. 2010.

Organization WH. The world health report 2000: health systems: improving performance: World Health Organization; 2000.

Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. The lancet. 2003;362(9378):111-7.

Limwattananon S, Tangcharoensathien V, Prakongsai P. Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand. Bulletin of the World Health Organization. 2007;85(8):600-6.

Heller PS. The prospects of creating ‘fiscal space’for the health sector. Health Policy and Planning. 2006;21(2):75-9.

Tandon A, Cashin C. Assessing public expenditure on health from a fiscal space perspective: World bank; 2010.

. Available from: World Bank. [cited 2017 May 11]. Available from: http://data.worldbank.org/income-level/middle-income.



Moradi-Lakeh M, Vosoogh-Moghaddam A. Health sector evolution plan in Iran; equity and sustainability concerns. 2015.

Bloomberg LD, Volpe M. Completing your qualitative dissertation: A road map from beginning to end: Sage Publications; 2012.

Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology. 2013;13(1):117.

Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organization. 2013;91(8):602-11.

Organization WH. Assessing fiscal space for health expansion in low-and-middle income countries: a review of the evidence. 2016.

Thomson S, Võrk A, Habicht T, Rooväli L, Evetovits T, Habicht J. Responding to the challenge of financial sustainability in Estonia's health system: World Health Organization Regional Office for Europe; 2010.

Tandon A. Giving more weight to health: assessing fiscal space for health in Indonesia. Washington, DC: World Bank. 2009.

Belay T, Tandon A. Assessing fiscal space for health in Nepal. Washington: World Bank. 2011.

Mueller N, Rojas-Rueda D, Cole-Hunter T, de Nazelle A, Dons E, Gerike R, et al. Health impact assessment of active transportation: a systematic review. Preventive medicine. 2015;76:103-14.

Lock K. Health impact assessment. BMJ: British Medical Journal. 2000;320(7246):1395.

Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. British Medical Journal. 1999;318(7182):527.

Shamshiri M, Suh BF, Mohammadi N, Amjad RN. A Survey of Adherence to Guidelines to Prevent Healthcare-Associated Infections in Iranian Intensive Care Units. Iranian Red Crescent Medical Journal. 2016;18(6).

Head BW. Toward More “Evidence‐Informed” Policy Making? Public Administration Review. 2015.

NEKOEIMOGHADAM M, AMIRYOUSEFI S, GHORBANI BZ, AMIRESMAILI M. Role of Charities in the Health System: A Qualitative Study. 2013.

Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gaceta Sanitaria. 2012;26:20-6.

Takian A, Doshmangir L, Rashidian A. Implementing family physician programme in rural Iran: exploring the role of an existing primary health care network. Family practice. 2013;30(5):551-9.

Tangcharoensathien V, Limwattananon S, Patcharanarumol W, Thammatacharee J, Jongudomsuk P, Sirilak S. Achieving universal health coverage goals in Thailand: the vital role of strategic purchasing. Health policy and planning. 2015;30(9):1152-61.

Kutzin J, Yip W, Cashin C. Alternative financing strategies for universal health coverage. Handbook of global health economics and public policy. 2016;1.

Figueras J, Robinson R, Jakubowski E. Purchasing to improve health systems performance: drawing the lessons. Purchasing to improve health systems performance. 2005:44.

Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V, et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in “early adopter” hospitals. Bmj. 2011;343:d6054.

Zhou YY, Garrido T, Chin HL, Wiesenthal AM, Liang LL. Patient access to an electronic health record with secure messaging: impact on primary care utilization. Am J Manag Care. 2007;13(7):418-24.

Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Jama. 1998;280(15):1311-6.

Wang SJ, Middleton B, Prosser LA, Bardon CG, Spurr CD, Carchidi PJ, et al. A cost-benefit analysis of electronic medical records in primary care. The American journal of medicine. 2003;114(5):397-403.

Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. Journal of the American Medical Informatics Association. 2005;12(5):505-16.

Yazdani S, Jadidfard M-P. Developing a decision support system to link health technology assessment (HTA) reports to the health system policies in Iran. Health Policy and Planning. 2016:czw160.

Keyvanara M, Karimi S, Khorasani E, Jafarian Jazi M. Experts’ perceptions of the concept of induced demand in healthcare: A qualitative study in Isfahan, Iran. 2014.

Davari M, Haycox A, Walley T. Health care financing in iran; is privatization a good solution? Iranian journal of public health. 2012;41(7):14.

IssueVol 49 No 4 (2020) QRcode
SectionOriginal Article(s)
Fiscal space Efficiency Health financing Iran

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
BAIRAMI F, TAKIAN A, AKBARI SARI A, HARIRCHI I, Alipouri Sakha M. Expanding Fiscal Space for Healthcare System through Efficiency: A Qualitative Study from Iran. Iran J Public Health. 2020;49(4):727-735.