title: Opening the Black Box: The Experiences and Lessons From the Public Hospitals Autonomy Policy in Iran.
abstract: BACKGROUND
  Policy formulation and adoption often happen in a black box. Implementation challenges affect and modify the nature of a policy. We analyzed hospitals' autonomy policy in Iran that was intended to reduce hospitals' financial burden on government and improve their efficiency.
  
  
  METHODS
  We followed a retrospective case-study methodology, involving inductive and deductive analyses of parliamentary proceedings, policy documents, gray literature, published papers and interview transcripts. We analyzed data to develop a policy map that included important dates and events leading to the policy process milestones.
  
  
  RESULTS
  We identified four time-periods with distinctive features: 'moving toward the policy' (1989 - 1994), disorganized implementation' (1995 - 1997), 'continuing challenges and indecisiveness in hospitals financing' (1998 - 2003), and 'other structural and financial policies in public hospitals' (2004 to date). We found that stakeholders required different and conflicting objectives, which certainly resulted in an unsatisfactory implementation process. The policy led to long-lasting and often negative changes in the hospital sector and the entire Iranian health system.
  
  
  CONCLUSIONS
  Hospital autonomy appeared to be an ill-advised policy to remedy the inefficiency problems in low socioeconomic areas of the country. The assumption that hospital autonomy reforms would necessarily result in a better health system, may be a false assumption as their success relies on many contextual, structural and policy implementation factors.
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, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran, Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
authors.forename: Leila
authors.initials: L
authors.lastname: Doshmangir
authors.affiliation: Department of Health 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. arashidian@tums.ac.ir.
authors.forename: Arash
authors.initials: A
authors.lastname: Rashidian
authors.affiliation: Department of Health Services Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran, Research Center for Health Services Management, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
authors.forename: Mehdi
authors.initials: M
authors.lastname: Jafari
authors.affiliation: Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, School of Health and Life Sciences, Brunel University London, Uxbridge, UK.
authors.forename: Amirhossein
authors.initials: A
authors.lastname: Takian
authors.affiliation: Department of Health Services Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
authors.forename: Hamid
authors.initials: H
authors.lastname: Ravaghi
mesh_terms: D003906:Developing Countries; D018166:Health Care Reform / Q000639:trends*; D006779:Hospitals, Public / Q000639:trends*; D006801:Humans; D007407:Interviews as Topic; D007492:Iran; D011050:Policy Making; D012189:Retrospective Studies