title: The experience of implementing the board of trustees' policy in teaching hospitals in Iran: an example of health system decentralization.
abstract: BACKGROUND
  In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy of teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in each hospital and significant modifications in hospitals' financing. Since the reform aimed to improve its predecessor policy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as enhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were never realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of trustees' policy did not achieve its perceived objectives.
  
  
  METHODS
  We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 and 10 participants, respectively) with experts at high, middle, and low levels of Iran's health system, using purposive and snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed verbatim and analyzed thematically, following a mixed inductive-deductive approach.
  
  
  RESULTS
  Three main themes emerged from the analysis. The implementation approach (including the processes, views about the policy and the links between the policy components), using research evidence about the policy (local and global), and policy context (health system structure, health insurers capacity, hospitals' organization and capacity and actors' interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization policies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration of the above factors in policy implementation into account.
  
  
  CONCLUSIONS
  The implementation of the board of trustees' policy did not achieve its desired goals in teaching hospitals in Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not prepared appropriately and key stakeholders, particularly the government, did not support the decentralization of Iran's health system.
authors.affiliation: Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran. ; Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran.
authors.forename: Leila
authors.initials: L
authors.lastname: Doshmangir
authors.affiliation: Department of Health Services Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. ; Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Arash
authors.initials: A
authors.lastname: Rashidian
authors.affiliation: School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
authors.forename: Hamid
authors.initials: H
authors.lastname: Ravaghi
authors.affiliation: Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. ; National Academy of Medical Sciences, Tehran, Iran. ; College of Health and Life Sciences, Brunel University London, London, UK.
authors.forename: Amirhossein
authors.initials: A
authors.lastname: Takian
authors.affiliation: Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran. ; School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
authors.forename: Mehdi
authors.initials: M
authors.lastname: Jafari
keywords: Decentralization; Health Policy; Health System; Iran; Organizational Reform; Policy Implementation
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