title: The First Stages of Liberalization of Public Hospitals in Iran: Establishment of Autonomous Hospitals and the Barriers.
abstract: BACKGROUND
  Liberalization and decentralization of public sector has been triggered in some developing countries and in Iran by the Ministry of Health and Medical Education (MOHME) that granted autonomy to 54 public hospitals. However, establishment of such a complex organizational reform was rather unsuccessful. We aimed to explore the obstacles and barriers caused such a failure and their mechanisms.
  
  
  METHODS
  Using a qualitative approach in 2013, we consulted key informants at the autonomous hospitals and their affiliating universities. Data collection was done within two phases: (i) 276 unstructured questionnaires asking respondents of barriers, and (ii) 23 semi-structured interviews from the first phase's key respondents. The first phase data were analyzed using thematic analysis and the second's by framework approach based on the frame shaped at the first phase.
  
  
  RESULTS
  Nine obstacles were recognized including "autonomous hospitals' board composition", "delay in announcing autonomous hospitals' charges by the MOHME", "lack of financing by the committed organizations", "poor follow up for implementation of the reform", "irregular board meetings", "lack of an external overseer", "shortage of full-time physicians", "lack of management stability", and "health insurance organizations' delayed payments".
  
  
  CONCLUSIONS
  The MOHME and insurance organizations did not pay the reform expenses. There were some competing motives as well to slow the reform or to shut it down. The stages of policy formulation and implementation were done separately in Iran, so this big organizational reform encountered serious obstacles.
authors.affiliation: Dept. of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran ; Dept. of Public Health, School of Medicine, AJA University of Medical Sciences, Tehran, Iran.
authors.forename: Nader
authors.initials: N
authors.lastname: Markazi-Moghaddam
authors.affiliation: Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran ; Dept. of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
authors.forename: Aidin
authors.initials: A
authors.lastname: Aryankhesal
authors.affiliation: Dept. of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Arab
keywords: Autonomous hospitals; Health policy analysis; Hospital reform; Iran; Privatization