1. Background
Health planning is a complex process that involves multiple actors and stakeholders, each with its roles and relationships within the planning cycle (1). Various factors, including values, techniques, and power relations between different groups, influence planning. Health planning can be seen as the art of navigating existing conditions to achieve desired goals (2). Policies provide a framework for decision-making and action, and policymakers implement targeted interventions to achieve specific goals. The development and governance of upstream documents is an example of such targeted efforts to achieve expected outcomes (3). Plans are typically developed to implement or establish policies and consist of actionable steps to implement the policy.
Despite numerous efforts to establish upstream policies, significant challenges and weaknesses are still observed during the institutionalization process (4). When the impacts of a policy do not align with the intended goals, it suggests that challenges exist at various stages of policy interpretation. In other words, when implementing the core concepts of upstream policies, incorrect interpretation can lead to issues and challenges that result in policy failure or non-accomplishment. When macro policies are not translated effectively into actionable plans, inconsistencies can arise between policy and action levels, leading to multiple approaches across different political and executive sectors. This can result in different interpretations of policies and laws and varying preferences among individuals (5).
Planning is generally divided into two main categories: strategic and operational. Operational planning serves as the connection between strategic goals, policies, and the implementation of activities. This type of planning outlines the specific activities that must be undertaken to achieve the strategic plan’s goals. An operational plan includes clear activities that delineate the responsibilities of process owners at each level of the health system. There are several alternatives to operational planning, including executive planning, activity planning, and work planning (6).
Understanding the essential role of operational planning in organizational performance and the need to convert the sixth economic, social, and cultural five-year development plan into practical plans, in 2015, Iran’s Ministry of Health and Medical Education (MoHME) launched the Health Operational Plan (HOP) in the health sector (7). The plan was mandated for all medical universities, blood transfusion organizations, and food and drug organizations throughout the country (4, 8). In the aftermath of this effort, a performance monitoring system named Dashboard was established at the macro level of Iran’s MoHME and at the levels of vice presidents and organizational heads. This system enables monthly progress monitoring of plans and associated actions in specific organizations. The operational planning process for all universities and related organizations was centralized and synthesized into a joint implementation plan developed and approved by the MoHME.
Policy analysis of the implementation plan is critical due to addressing the achievement of the implementation plan objectives at universities and tracking the progress of indicators connected to the plan. To our knowledge, no scientific or comprehensive study on analyzing implementation plans exists.
2. Objectives
This study aims to conduct a retrospective analysis of Iran’s HOP in the country’s health system. The objective is to provide policy options for future policy directions.
3. Methods
3.1. Study Design
This is an exploratory qualitative study with the approach case study. Semi-structured interviews and document reviews were used to collect data for this qualitative study. The present study was conducted in 2021 - 2022.
3.2. Participants
We conducted interviews with 24 individuals who were involved in healthcare policymaking and planning at different levels. Our participants included officials from the MoHME and faculty members with executive and scientific experience in health planning. In addition, we interviewed staff members from the Ministry and universities who had at least two years of experience in health planning or had been involved in designing or implementing healthcare plans (Table 1).
Table 1.Characteristics of Interviewees
| No | Gender | Organizational Position | Field of Expertise |
|---|---|---|---|
| 1 | M | Hospital manager | Health policy |
| 2 | M | Faculty member | Health services management |
| 3 | F | Ph.D. student | Health management services |
| 4 | M | Researcher | Health management services |
| 5 | F | GP / researcher | Providers (GP) |
| 6 | F | Deputy staff | Health economy |
| 7 | M | Hospital staff | Social medicine |
| 8 | M | Ph.D. student | Providers (GP) |
| 9 | F | Faculty member | Social medicine |
| 10 | F | Senior manager | Health policy |
| 11 | F | Health researcher | Health management services |
| 12 | M | Health researcher | Health management services |
| 13 | M | GP / researcher | Health economy |
| 14 | M | Deputy staff | Health management services |
| 15 | F | Ph.D. student | Health management services |
| 16 | M | University manager | Providers (GP) |
| 17 | M | Drug and food organization | Social medicine |
| 18 | F | Hospital Manager | Health policy |
| 19 | F | Health center Manager | Health management services |
| 20 | M | MoHME | Health management services |
| 21 | M | Deputy staff | Health economy |
| 22 | M | University manager | Health management services |
| 23 | F | Faculty member | Health management services |
| 24 | F | Deputy staff | Providers (GP) |
3.3. Data Collection
To collect qualitative data from experts, in the first step, related data were extracted from documents related to the various stages of operational planning, including the project proposal, regulations, instructions, and circulars.
After analyzing the documents, the interviewees were selected and interviewed in the next step. The interview guide was developed based on the literature review and the research team members and revised and finalized after two initial interviews. The purposive sampling method was used for the selection of the participants, and it was tried to select the participants with maximum diversity. The number of study participants increased until data saturation was reached. Semi-structured interviews were conducted. Each interview lasted about 1 - 1.5 hours. Study participants received information about the research and signed an informed consent document developed for this study. After getting informed consent, the audio recording was started. In addition, notes were taken during the interview.
The inclusion criteria for participants included having at least two years of experience in management or executive activity related to health system management and operational planning, faculty members with research experience in the subject, having at least a bachelor’s degree in medical sciences, having sufficient knowledge of the study subject or publication of books, articles or reports related to the study aim.
3.4. Data Analysis
The study employed the framework analysis approach to analyze the data, which involved identifying, analyzing, and reporting categories and themes in the text. The data were analyzed using two frameworks: Walt and Gilson’s policy triangle framework, as well as a heuristic model based on stages. These frameworks served as a guide for the analysis and interpretation of the data, enabling the researchers to identify patterns and themes related to the various stages of the policymaking process (9).
The policy triangle framework comprises four components: Content, context, stakeholders/actors, and process. Content includes the goals and objectives of the intervention, while actors refer to all individuals, groups, and organizations involved in policy development and implementation. Context encompasses the social, economic, political, and cultural setting in which the intervention is being developed and implemented. Process refers to four phases: Agenda setting, formulation, implementation, and evaluation. This study used the policy triangle framework to analyze the development and implementation of a healthcare intervention (10). The data were analyzed by two researchers following a set of stages. These stages included becoming familiar with the data by reading the transcribed interviews and documents multiple times to fully immerse themselves in the data. Next, they identified and extracted the primary codes most relevant to the study objectives and placed them into related categories. They then categorized the categories, reviewed and refined the identified themes, and finally named and defined them. Overall, the data analysis process involved a thorough and systematic approach to ensure an accurate and meaningful interpretation of the data (10, 11).
3.5. Study Quality
To ensure consistency in the study, the researchers applied a criterion proposed in the literature (12). Two research team members, who had experience conducting qualitative studies and analyzing interviews and documents, conducted the interviews. The texts were read multiple times to immerse themselves in the data. To ensure the reliability of the extracted codes and categories, the two coders reached an agreement through discussion and resolved any differences. Additionally, the researchers checked for transparency, triangulation, and repeatability to increase the data quality (12).
4. Results
Through analysis of the qualitative data, four main themes, 14 categories, and 24 sub-categories were identified (Table 2), which are explained in the following.
Table 2.Themes, Category, and Sub-category Related to the Analysis of the Implementation of a Joint Operational Plan in Medical Sciences Universities Policy in Iran
| Theme | Category | Sub-category |
|---|---|---|
| Content | -Linkage of plan goals with upstream policy documents | -Linkage goals with the country’s development plans |
| -Linkage goals with the General Health Policies Announced by the Supreme Leader of Iran | ||
| -Definition and clarity of goals and objectives of the plan | -Well-defined goals | |
| -Specific objectives | ||
| -Megereable objectives | ||
| -Time-banded objectives | ||
| -Consistency between the plan’s goals and visions, and missions of medical universities | -Coordinate with universities | |
| -Engage universities | ||
| Context | -Structural characteristics | -University level |
| -Dedicated planning post | ||
| -Access to planning experts | ||
| -Economic and financial factors | -Economic status of the population | |
| -The total budget of the university | ||
| -Dedicated program budget | ||
| -Social and cultural situation | -Community participation | |
| -Social gradient | ||
| -Social acceptability | ||
| Process | -Priority of the issue | -Politician’s interests |
| -Urgency | ||
| -Demand | ||
| -Design and formulation of the policy | -Participation of experts | |
| -Opinion polling | ||
| -Implementation approach | -Top-down approach | |
| -Low capacity | ||
| -Lack of education | ||
| -Mentoring | ||
| -High workloads | ||
| -Training human resources | -Holding educational courses | |
| -Lack of trained personnel | ||
| -Assessment and evaluation | -lack of external evaluation | |
| -Lack of clearly defined indicators | ||
| -Ambiguity in delegating responsibilities | ||
| -Inappropriate evaluation method | ||
| -Biased evaluation | ||
| Actors/stakeholders | -Owner and leader of the policy | -Limited authority |
| -Interdepartmental communication | ||
| -Political support | -Reluctance of senior managers | |
| -Ambiguity of assigning responsibilities | -Determining the responsibility | |
| -Poor intersectoral collaboration |
4.1. Content
According to some participants, the policy implemented by MoHME was flawed due to a lack of understanding of the health system’s and medical universities’ problems and their solutions. Participants confirmed that MoHME had implemented a policy with the aim of improving the performance of medical universities and health system indicators. However, in practice, the determined goals were not achieved.
“It was noted that some of the plan’s goals were not achievable at our university’s current level and may be more realistic for higher-resourced universities” (P 1).
They argued that simply identifying numerous activities did not guarantee improvements in the performance of medical universities. Additionally, they felt that the plan’s goals were not tailored to the health system’s situation or the unique environments of universities, making it difficult to implement. Participants also noted that MoHME lacked a proper planning structure, making it impossible for universities to achieve the goals through plan implementation.
“The program presenters may lack an appropriate balance of authority and responsibility. Additionally, some plans may not be consistent with the structure and duties outlined, while implementation guarantees and power levels may not be under the program manager’s control in certain cases” (P 5).
Some research participants mentioned that there is no structure for planning in universities, so there is no incentive for managers and staff to implement the plan.
“It appears that this new wave of planning in universities lacks a strong and effective structure and framework to support it” (P 18).
The organizational structure, economic and cultural situation of each university in the country as a context for implementing the plan has an influential effect on the planning. According to the research participants, universities’ budgets in Iran depend on the MoHME and Planning and Budget organization. Pt. 3: “If the budget became clear, many problems will be solved.” Pt. 1: “If we do not trust the managers and do not give them authority, there will be no progress.” So, in this situation, universities, including medical universities, cannot freely act as they want. In this dependency context, planning does not have a meaning. Pt. 2: “There is no structure for planning in universities, so there is no incentive for colleagues to implement the plan.” Pt. 9: “New expectations from staff without providing a balance between authority and responsibility and contrary to the structure and job description and sometimes without having an executive guarantee to advance the plans and considering the necessary motivational factors cause pessimism, a kind of forced and blind movement, a burden in every direction for the executors of the matter” (P 20). Pt. 9: “The non-justification of managers and staff about the plan is considered an additional burden and needs to be considered.”
4.2. Process
According to the participants, the MoHME translates upstream policy documents to plans, monitoring, and supervision.
“The Ministry of Health and Medical Education brought up the issue of translating national policy documents into plans and sought a solution. As a solution, MoHME proposed implementing a joint operational plan in universities, which was considered a suitable option” (P 22).
Participants believed the current planning system was a top-down approach that did not allow for enough input from universities.
“The Ministry mainly regulates the current planning of universities and is mainly focused on headquarters’ issues, and given that the participation of the executive units is not used in the formulation of the plan, its effectiveness is reduced” (P 1).
This approach created a gap between decision-makers and university staff, which hindered the effective implementation of the plan. Participants identified several challenges with the policy’s current formulation and implementation process, including the lack of external evaluation, the lack of clearly defined indicators, and the ambiguity in delegating responsibilities. One of the biggest hurdles in carrying out this policy was the added workload on staff and the time wasted collecting and uploading related documents to designated websites, such as HOP.
“Operational and strategic plans serve as means to improve service quality, reduce workload, and minimize referrals, rather than being the end goal. However, with the increasing complexity of laws and regulations, implementing these plans may pose difficulties, especially when coupled with existing workloads. Consequently, plan implementation can become a burden on human resources, leading to unresolved issues” (P 5).
“There seems to be hidden, inappropriate competition between universities while the plan’s contents are being neglected” (P 11).
The participants also identified the evaluation method of the plan as another main issue.
“I think the best and most necessary option is to identify quantitative indicators to assess universities’ outcomes after implementing the plan” (P 4).
“Evaluation inside the system is not useful. An external entity should do the evaluation. It is not a function of uploading documents, making minutes, and uploading them. It should be an external entity to evaluate and warn the higher authorities whether there is a problem” (P 10).
Despite the documentation supporting the plan, it failed to significantly impact service delivery or population health outcomes. In hospitals affiliated with medical universities, physicians, nurses, and other staff followed their previous routines without adjusting their practices to align with the plan’s activities.
“While there has been progress in certain evaluation indicators in sectors such as the public health and treatment sectors, it appears that this progress has not had a significant impact on the performance of medical universities” (P 11).
4.3. Actors/Stakeholders
The Ministry of Health and Medical Education was the primary actor responsible for the policy, and representatives from medical universities were invited to participate in developing the joint operational plan. However, some research participants expressed doubts about the commitment of medical universities to implementing the plan effectively. According to the participants, the managers were considered the other main actors involved in the plan in universities. However, some felt that the managers’ involvement was not adequately justified.
“The non-justification of managers and staffs in relation to the plan is considered an additional burden and needs to be considered” (P 11).
Participants identified several challenges to implementing the plan, including the lack of support from senior university managers for the establishment of the planning system, the absence of accountability for administrative behavior, the imbalance between managers’ authority and their executive power, and the reluctance of managers to accept the cost of changes and policy interventions.
“If we do not trust the managers and do not give them enough authority, there will be no progress” (P 1).
Pt. 5: “The program presenters may lack an appropriate balance of authority and responsibility. Additionally, some plans may not be consistent with the structure and duties outlined, while implementation guarantees and power levels may not be under the program manager’s control in certain cases.”
5. Discussion
This study analyzed the Iranian health system policy intervention, which involved designing and implementing a joint operational plan for all medical universities. The perspectives of health managers, planners, and other human resources involved in writing and implementing the plan were examined.
The study’s results indicated that despite the intervention’s designers’ good intentions, significant challenges hindered its success. Although there were some improvements in universities’ performance, they fell short of achieving the identified goals. The main obstacles faced by this policy intervention in the Iranian health system included the lack of clear and specific goals and objectives, a focus on general goals rather than the plan’s specified objectives and goals, inadequate output and outcomes of the plan, decreased motivation for planning among staff, insufficient planning structure in both MoHME and medical universities, a weak planning culture in organizations, and inappropriate translation of upstream documents into actionable executive plans.
The study findings indicated that the MoHME lacked a defined policy level for planning. The challenges of this policy included the lack of integration of the operational plan of medical universities with other university plans, insufficient audit and monitoring of the plan’s implementation progress by the MoHME, and a high turnover of managers that impacted the plan’s success.
In Iran, formulating a strategic plan is deemed a critical action. However, national evidence suggests that less attention is given to the quality of the plan and its proper implementation. In healthcare organizations where strategic planning is viewed as a goal rather than a tool for achieving a goal, there is limited success in performance.
5.1. Content
Implementing a strategic or operational plan without upgrading the organizational structures, culture, and processes may result in limited performance improvement and early abandonment of the plan. Additionally, the lack of an appropriate model to guide managers and staff in implementing strategic and operational plans contributes to plan failures. To improve healthcare organizational performance, there is a need for a comprehensive model to formulate and implement strategic and operational plans (13).
The study’s findings implied that during the implementation of the HOP, the MoHME only collected inputs and did not evaluate the outputs or effects of the plan on universities’ performance. This approach can lead to poorly-informed decisions that may not produce the desired outcomes.
5.2. Context
When planning to provide health services, it is essential to consider variables such as organizational culture, beliefs, and employee motivation. In his study, Damari et al. reported that the health planning system in Iran suffers from coordination and evaluation issues (7). Similarly, Ali Akhavan demonstrated no motivation to implement plans in government organizations, as achieving or non-achieving goals do not impact employees’ legal status, welfare, or promotion, including managers (14). Additionally, in another study by Damari et al., the lack of motivation, encouragement, and a sense of ownership among those involved in the operational plan was considered a significant challenge in the Iranian health system (7), which is consistent with the present study’s findings.
5.3. Process
Damari et al.’s research suggests that non-transparent monitoring is a significant problem in the operational planning system (7). Inconsistent structures in health planning at the national level and other challenges in the health planning system also exist (15). A planning team comprising experts in plan content, planning process, and implementation methods is necessary to effectively plan operations in organizations. Before developing an operational plan, an appropriate organizational structure should be established, and key stakeholders should be involved, according to evidence (16, 17). Shahbandzadeh and Mohseni identified the support of senior managers and appropriate policies as influential factors in planning (18). To ensure effective operational planning, Yosofi emphasized the need for planning teams with expert involvement (19). Employee training and involvement in the planning process have also been recommended in studies (20). O’Cathain et al. highlighted the importance of a planning structure, a planning team to set goals, and the support of organizational leaders (21). In his study, Yosofi stated that specific and attainable objectives and goals are essential to improving healthcare service efficiency (19).
5.4. Actors/Stakeholders
According to Nasiripour et al.’s study, a lack of coordination between different units and departments is a pitfall in organizations, and he emphasized the need for involving all levels in the development of plans (16). To improve inter-departmental and intra-departmental coordination and cooperation, the capacity of the Supreme Council of Health and Food Security can be leveraged. Considering that the health sector manages only about 25% of the factors affecting people’s health, the Ministry of Health must establish effective communication and collaboration with other ministries to ensure comprehensive and coordinated healthcare.
Incorporating the perspectives and expertise of human resources and other key stakeholders in the strategic planning process can strengthen an organization’s capacity and ability to respond effectively to changing circumstances. Studies have shown that the success of strategic planning in a health center is closely linked to stakeholder participation, including academic staff, nurses, and managers (22, 23). A report analyzed the role of strategic planning in Turkey’s successful healthcare transformation since 2002 when the 59th Government of Turkey took power. Turkey’s Strategic Plan 2013 - 2017 is significant for implementing the new European policy framework, Health 2020, at the country level. This framework aims to significantly improve population health and well-being, reduce health inequalities, strengthen public health, and ensure people-centered health systems that are universal, equitable, sustainable, and of high quality, with action needed across government and society (24). With input from key stakeholders, such as academic staff, nurses, and managers, Turkey’s strategic planning process has significantly transformed its healthcare system.
5.5. Conclusions
By reviewing the Ministry of Health and Medical Education’s intervention in developing and implementing joint operational plans for medical universities, a policy analysis was conducted to develop evidence-informed options for future decisions in the Iranian health system. The implementation plan’s predetermined objectives were completely unsuccessful since executive factors were neglected during the operational plan’s formulation.
Also, the study findings revealed significant gaps in university staff and managers’ understanding of the need for an operational plan. As a result, it is suggested that empowerment workshops be developed for university staff and senior managers regarding the importance of planning and enhancing their commitment to implementing operational plans. Focusing on outcome indicators rather than input indicators could improve the chance of the operational plan reaching its objectives.
