Qom University of Medical Sciences Journal

In 2000, Iran ranked 93 in the healthcare and 58 in health system performance among the world’s health systems and people’s out-of-pocket (OOP) costs accounted for about 50% of the total healthcare expenditure of the country, which indicated the necessity to make fundamental reforms in the country’s health system. In this regard, the health system transformation plan (HSTP) was developed in Iran in 2014 with three main goals of financial protection of patients, justice in access to health services, and improving the quality of services. However, considering the large amount of financial resources used in this plan and the limitation of government resources in the country, the economic analysis of HSTP performance in improving health-related and financial indicators is necessary to help policy makers make the best decisions.
Methods
Econometric tools and techniques were used in this study. Indicators related to assess the performance of HSTP included the HSTP costs (as the independent variable), OOP payment rate, life expectancy, infant mortality rate, under-five mortality rate, maternal mortality rate, total death rate, road death rate, cesarean section rate, and number of hospital beds (as dependent variables). Their time series data were extracted during 2004 to 2019. First, using the ordinary and generalized least squares estimation methods, the impact of the HSTP on the selected indicators were examined. Then, using the structural break tests of Perron, Zivot-Andrews, and Lee-Strazicich, the effectiveness of the HSTP in causing positive changes in the indicators and creating structural break points were examined.
Results
According to the results of estimation by the ordinary and generalized least squares methods, the coefficients of all indicators were significant and acceptable, and the positive effect of the costs of HSTP on the improvement of these indicators was confirmed. The greatest effect was reported on the OOP payment rate with a regression coefficient of 0.7 and the lowest effect was on the total death rate with a coefficient of -0.006 .According to the results of Zivot-Andrews structural break test, the costs of HSTP showed a significant increase in the financial resources allocated to the HSTP in 2014 compared to other times. The structural break points based on Perron, Zivot-Andrew, and Lee-Strazicich tests for the dependent variables were as follows: OOP payment rate: 2009, 2010, 2013-2017; life expectancy rate: 2011, 2012, 2009-2011; infant mortality rate: 2012, 2013, 2010-2014; under-five mortality rate: 2007, 2008, 2007-2010; total death rate: 2011, 2012, 2008-2011; maternal mortality rate: 2011, 2012, 2007-2010; cesarean section rate: 2012, 2013, 2012-2014; road death rate: 2015, 2016, 2006-2017, and number of hospital beds: 2009, 2010, 2008-2016, respectively. According to the three tests, all indicators had recorded structural break points before implementation of the HSTP in 2014, while six indicators recorded the break points after implementation of this plan.
Discussion
The HSTP was effective in improving the selected indicators at the beginning. All indicators showed structural break points before implementation of the HSTP, due to their reduction at the related time points, which emphasized the necessity of implementing the HSTP; however, after implementation of the plan, no positive structural break points were observed to indicate a considerable improvement in the indicators.
Ethical Considerations
Compliance with ethical guidelines
This article is a descriptive analysis, and the available data is not the result of interviews with the participants, and quantitative analysis is based on data extracted from statistical sources such as the official Ministry of Health and Medical Education, World Health Organization, and National Organization for Civil Registration (NOCR). Therefore, it does not have a code of ethics, and of course, matters related to the principles of ethics in research are not related to this article.
Funding
This research is taken from the PhD dissertation of Hadi Hamidi Parsa, majoring in economics, with an econometric orientation in Mofid University, and has not received any financial aid from government, private, or non-profit organizations.
Authors contributions
All authors contributed equally in preparing all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
We are grateful to the Ministry of Health and Medical Education and other authorities who provided and published the statistical data.