فهرست مطالب haniye sadat sajadi

This study aimed to investigate the performance of senior dental students of the Faculty of Dentistry of Isfahan University of Medical Sciences in the documentation of dental records.

Methods & Materials:

 This cross-sectional study was performed at Isfahan University of Medical Sciences in the Spring of 2021. 200 dental students in their last two years of education participated in this study. A questionnaire was used to examine students’ performance in filling dental records, which included a Likert scale with five options: never, rarely, sometimes, often, and always; A score of 1 to 5 was assigned to each of the answers. Then the results were reported in the form of mean and standard deviation, and with a significance level of 0.05, an independent T-test was used to investigate their relationship with gender and academic year.

The performance of 77% of students was in the range of 2 to less than 4, which was reported as medium performance. Also, 0.5% had poor, and 22.5% had a good performance. Unlike gender, students' performance had a significant relationship with their academic year, so 5th-year students performed better than 6th-year students (p value < 0.001).

According to the findings of the present study, the performance of most of the senior dental students of Isfahan University of Medical Sciences in completing the dental file is at a medium level. It was also seen in this study that the academic year of students, unlike their gender, can affect their performance; So, 5th-year students performed better than 6th-year students.

The evidence-informed deliberative processes (EDPs) guide provides a practical framework for fair priority setting of the health benefits package (HBP) that countries can reasonably use. The steps presented in the EDPs are applicable for prioritising health services in designing HBP and are consistent with practical experience in countries. However, institutionalisation must be considered an element of fairness in the priority-setting process if the aim is to reach broader goals of a health system, such as universal health coverage (UHC). Otherwise, the EDPs for priority setting might not be integrated into the formal health system or impactful, resulting in a waste of time and resources, which is unfair. Institutionalisation means formalising the desired change as an embedded and integrated system so that the change lasts over time. For the institutionalisation of EPDs, four stages are suggested, which are (1) establishing a supportive legal framework, (2) designating governance and institutional structure, (3) stipulating the EDPs processes and (4) individual and institutional capacity building.

In pursuing improving healthcare quality and enhancing efficiency, public hospitals in Iran have undergone numerous reforms over the past two decades. This study aimed to assess the efficiency of all public hospitals in Iran from 2012 to 2016. This study was conducted as a quantitative and descriptive-analytical research project. The authors employed an innovative approach called Extended Data Envelopment Analysis (Extended-DEA), a modification of conventional DEA, to assess the technical efficiency and productivity of 568 public hospitals. They obtained nationally representative data from official annual health reports. The data were analyzed using GAMS software version 24.3. The study found that the average efficiency score for all hospitals was 0.733. Among all the hospitals, 10.1% were deemed efficient, while 2.68% had low-efficiency scores below 0.2. The Malmquist Productivity Index (MPI) showed improvement in 49.3% of hospitals and remained unchanged at 2.3%. In comparison, 48.2% of hospitals experienced a regression in productivity from 2015 to 2016. On average, the MPI was 1.07 throughout the analysis. The findings of this study suggest that there is a need for increased efforts to improve the efficient utilization of resources in public hospitals. It highlights the importance of developing appropriate policy solutions and tools to address these efficiency challenges. In particular, one proposed strategy is the merger of small-sized district hospitals to establish larger and more efficient hospitals in different geographical regions across the country.

Performance evaluation is a useful way to obtain information for decision-making and management of healthcare organizations. The purpose of this study was to assess the performance of health houses in rural areas in Kerman City, Iran during the outbreak of Covid-19.

This cross-sectional study was conducted in 2021-22 using descriptive and analytical methods. The research population included all the health houses in Kerman City (n=57), Iran. The tool for data collection was the Health House Performance Evaluation Checklist of the Ministry of Health and Medical Education developed to supervise the performance of health houses during the outbreak of Covid-19. Data analysis was done using SPSS 26 software, the statistical tests being descriptive statistics (mean and standard deviation) and analytical statistics including independent t-test, one-way analysis of variance and Pearson and Spearman correlations.

The average performance score of the health houses (n =55) in managing Covid-19 was 96.37 out of 136. Installation of the village map on the wall of the health house  (92.3%), screening and following up the positive-test individuals and informing the health care team to track and isolate individuals in close contact (84.6%) were found to have the highest, and injecting the third dose (78.8%) and the second dose (75%) of the Covid vaccine the lowest,  scores. From among the characteristics investigated the variable of native Behvarzes (the personnel of health houses) had a statistically significant positive relationship with the performance score (p=0.01). In addition, the health houses with more than one Behvarz were found to perform better than those with only one Behvarz (p=0.05).

Assessing the performance of health care units at times of crisis, including communicable diseases epidemics, will make it possible to identify the bottlenecks that need improvement for better preparedness in the future. Based on the findings of this  research, the expansion of the coverage of the covid-19 vaccination, updating the disease incidence, the performance of health care teams at home visits, and the progress of the operational plan were the variables that needed improvement most.

The health system's responsiveness to provision of health services displays the ability of the system to meet the non-medical needs of people. The present study aimed to assess Iran's health system responsiveness in providing rehabilitation for people with disabilities (PWD).

This population-based cross-sectional study included 1537 PWD referring to physical rehabilitation centers in all provinces of Iran by using a multistage cluster sampling method in 2019. A valid self-administrated questionnaire was used for data collection. Stata software (version 14.0) was used for data processing and analysis.

The frequency rate of good responsiveness to meet physical rehabilitation needs was 64.5%. The health system's highest and lowest frequency rates of good responsiveness were related to rapid response (74.5%), independence  and participation in decision-making (52.5). Having basic health insurance coverage (OR=1.97, 95% CI:1.20-3.25), severity of disability (OR=2.02, 95% CI:1.14-3.60), economic status of individuals (OR=2.04, 95% CI:1.17-3.56), and household size (OR=0.82, 95% CI:0.72-0.94) were significant determinants in regard to poor responsiveness of the health system.

To maintain and enhance responsiveness and eliminate inequalities, interventions such as expanding the rehabilitation facilities, holding special skills training courses for rehabilitation-related assistants, general practitioners, and health workers, and also, empowering PWD are recommended. Further studies are also recommended to identify the causes of poor responsiveness and take measures that can make the health system more responsible.

The rapid growth of the elderly population requires the design of age-friendly healthcare systems to respond to the complex needs of the elderly. This study aims to assess the hospitals in Isfahan, Iran based on the age-friendly primary health care centers criteria and identify challenges. 

This cross-sequential study was conducted in two phases in 2020-2021. First, using the checklist of Ahmadi et al.’ study, the teaching hospitals in Isfahan were assessed based on the age-friendly primary health care centers criteria. The checklists were completed by observation and based on the opinions of the experts. Data analysis was done in SPSS software, version 26 using descriptive statistics and Pearson correlation test. Qualitative data were collected through a semi-structured interview and were analyzed using Conventional content analysis method.

Most of the hospitals were in good conditions in terms of physical environment, sanitary facilities, and signboards. The lowest scores were related to the areas of admission and payment, appointments, accessibility, and inpatient services. The mean age-friendly score of hospitals was 51.7 out of 100. There was no significant relationship between the characteristics of hospitals (type of ownership, type of activity, specialty, number of beds, bed occupancy rate, degree of accreditation, and manager’s study field) and their age-friendly scores. We identified 9 themes and 27 sub-themes related to challenges of being age-friendly in the hospitals. 

The hospitals in Isfahan have many shortcomings in being age-friendly. Promoting the expertise of geriatric medicine and geriatric nursing, designing a special queuing system for the elderly, considering a special administrator for the elderly in different departments, reducing the costs of treatment for the elderly, promoting consultation/examination/treatment/follow-up programs for the elderly with an emphasis on upstream documents and cooperation between different departments, empowering employees, upgrading physical infrastructure can help solve existing challenges.

Nowadays, beauty practices have attracted the attention of people following the change in lifestyle and social values. Therefore, the present study was conducted with the aim of examining the opinion of experts regarding the challenges and management solutions of the aforementioned practices in Iran.

This qualitative study was conducted through interviews with 26 policymakers and cosmetic surgery service providers in Tehran from April to September 2022. Sampling was purposeful and snowball. The interviews were semi-structured and thematic analysis was used to analyze the data obtained from the interviews. The inclusion criteria for the interviewees' entry were knowledge and experience in the subject and willingness to participate.

Challenges under the four categories of service providers (improper education, non-specialist providers, moral hazards, deficiencies in the way laws are written, and the ineffectiveness of the complaint handling process), service receivers (being influenced by deceptive advertisements, low level of public health literacy and lack of mental health), the place of providing services (performing surgeries in non-standard places and non-integrated information system) and medicines, products and medical equipment (insufficient control over supply, distribution and use and price fluctuations) were categorized. Experts considered the major part of the challenges to be related to the service providers. In the category of service recipients, "being influenced by deceptive advertisements" was the main problem mentioned by the experts. Performing surgeries in non-standard places, including limited surgery centers, non-sterile places, and unauthorized places, is among the unsolved problems regarding the place of providing services. In relation to medicines, products, and medical equipment, the main problem was insufficient supply, distribution, and use supervision.

The main effective measure to solve the challenges is to strengthen the supervision of the health system administrator with internal and external coordination and cooperation. In this regard, it is recommended to develop educational, ethical, and legal frameworks, regulate regulatory laws, public awareness, clinical interviews and psychological counseling, especially before cosmetic surgery, and the establishment of an integrated electronic health record system.

To improve healthcare services’ quality, countries should measure their health systems’ efficiency and performance by robust methods.

We aimed to develop a national study to measure the efficiency of the health system in Iran.

The literature review identified several methods for measuring efficiency; the most common one was data envelopment analysis (DEA). We adopted DEA, but its findings were simplistic and inaccurate, so we began to modify the method by determining the weight of each indicator. We identified the efficiency measurement indicators, in line with international standards and uniformed units, and then readjusted our input/output indicators according to the study context through four expert panels. We collected data and classified the input/output indicators, followed by determining each indicator’s weight and standard limits. Then we rationalized our previous results by applying the revised model. The initial new results of the refined model were valid, accurate, and consistent with previous studies, as approved by experts. We defined proper modeling to achieve the stated objectives. After investigating various DEA models, we finally designed a new model that was consistent with the existing data and conditions, entitled EDEA (extended DEA), to analyze other subprojects.

The conventional DEA methods may not be accurate enough to measure health systems’ efficiency. By modifying modeling process, we propose a modified DEA with a very low error rate. We suggest that others interested in measuring health system efficiency adopt our modified approach to increase accuracy and create more meaningful policy-oriented results.

There is little evidence of access to health services among people with disabilities (PWD) in low- and middle-income countries. This study aimed to examine access to physical rehabilitation services among PWD in Iran.

A population-based cross-sectional survey of 2177 PWD was conducted in all provinces of Iran using a multistage cluster sampling method in 2019. The number of sample zones was determined by dividing the country into four socioeconomic zones and considering the share of the population in each zone. Data were obtained by a valid self-administrated questionnaire and analyzed.

The frequency of need for physical rehabilitation services among PWD is %16.6. Among the types of physical rehabilitation services, the highest frequency of needs was related to physiotherapy services. About 28.1% of PWD did not have access to the required rehabilitation services. The third zone has more need and less access to required rehabilitation services. Lack of access to information and financial inability were the most common reasons for lack of access to services. Basic health insurance coverage, low disability rate, high level of education, and socioeconomic status were the determinants of access to rehabilitation services.

Given the gaps in the fair access of PWD to physical rehabilitation services, it is suggested that policies and programs be designed to increase the coverage of rehabilitation services and their costs to achieve the goal of universal health coverage in Iran. The implementation of these policies should be evaluated.

SASHA, which stands for “evidence-informed health policy-making (EIHP)” in Persian, is a national project to draw a roadmap for strengthening EIHP in Iran. As a part of SASHA, this research aimed to develop evidencebased and context-aware policy options for increasing the capacity of decision-makers to apply EIHP in Iran.

This was a qualitative study, which was informed by a literature review of pull efforts’ capacity building programs. Based on the review, we developed policy options and validated them through an expert panel that involved twelve experts. Data were analyzed using a content analysis method.

We extracted data from 11 articles. The objectives of capacity building programs were: single-skill development, personal/professional development, and organizational development. According to these objectives, the contents and training methods of the programs vary. Capacity building programs have shown positive impacts on individual knowledge/attitudes to use EIHP. However, the impacts of programs at the organizational or the health system level remain under-researched. We followed several threads from the literature review through to the expert panel that included training the management team, instead of training managers, training for problem-solving skills, and designing tailored programs. Barriers of capacity building for EIHP regard the context of the health system (weak accountability and the widespread conflict of interest) and healthcare organizational structures (decision support systems, knowledge management infrastructures, and lack of management team). Experts suggested interventions on the barriers, particularly on resolving the conflict of interests before launching new programs. A proposed framework to increase the capacity of health policy-makers incorporates strategies at three levels: capacity building program, organizational structure, and health system context.

Conclusion :

To prepare the context of Iranian healthcare organizations for capacity building programs, the conflict of interests needs to be resolved, decision-makers should be made more accountable, and healthcare organizations need to provide more knowledge management infrastructures and decision support systems.

The prevalence of emerging and re-emerging diseases has made the need for basic preparations for all health care organizations more crucial. Strengthening preparedness and formulating crisis strategies will have a great impact on reducing casualties. Given the importance of preparing hospitals to deal with such an outbreak and reduce the resulting mortality, the present study was conducted to assess their readiness against Covid-19.

The present study is a quantitative and descriptive cross-sectional research conducted from October to March 2019. Data collection used the standard checklists prepared by the European Center for the Prevention and Control of Coronavirus and the Centers for Disease Control and Prevention, consisting of eight domains and 21 components. The minimum score that each hospital could get in this checklist was 143 and the maximum was 429. The sampling method in the present study was a census, and nine reference hospitals for Corona were included in the study. All hospitals’ directors, managers, quality officers and crisis secretaries and others related to hospital readiness during Covid-19 were recruited by the census.

On average, the hospitals scored 391 out of 429, indicating a fairly "high readiness" in dealing with Covid-19. The highest score obtained by the hospitals was 425 and the lowest score was 349. In terms of preparation areas, the hospitals’ readiness was higher than 80% in all areas. The highest readiness of hospitals was in the fifth  domain, i.e. Hand hygiene, personal protective equipment and hospital waste management. The 7th domain namely, patient placement and relocation, and patient visitor access was of the lowest preparation.

The hospitals were of fairly appropriate readiness to deal with Covid-19. This level of preparedness, despite being desirable, might not reflect the real capacity of hospitals to deal with this disease. Regular evaluation of the Covid referral hospitals could help make these hospitals more prepared. Also, the experiences of hospitals that were more prepared should be used to improve the condition of other hospitals.

Reliance heavily on out-of-pocket (OOP) payments, including informal payments (IPs), has undesired effects on financial risk protection and access to care. While a significant share of total health expenditure is spent on outpatient services, there is scant evidence of the patient's amount paid informally in outpatient services. Such evidence is available for inpatient services, showing the high prevalence of informal payments, ranging from 14 to 48% in the whole hospital. This study aimed to investigate the extent of OOP and IPs for outpatient services in Iran.  

A secondary data analysis of the 2015 IR Iran's Utilization of Healthcare Services (IrUHS) survey was conducted. A sample of 11,782 individuals with basic health insurance who were visited at least once by a physician in two private and public health care centers was included in this analysis. The percentage of OOP was determined and compared with the defined copayment (30%). The frequency of IPs was determined regarding the number of individuals who paid more than the defined copayments. The Mann-Whitney test also investigated the relationships between OOP percentage and IPs frequency with demographic variables.  

The share that insured patients in Iran pay for a general practitioner (GP) visit was 38% in public versus 61% in the private sector, while for a specialist practitioner visit, the figures were 80% and 96%, respectively, which is higher than defined copayment (30%). This share was significantly higher in females, urban areas, highly educated people, private service providers, and specialist visits. The frequency of IPs, who paid more than the defined copayments, was 73% for a GP in public versus 86% in the private sector, while for a specialist practitioner visit, these were 90% and 93%, respectively.   

Informal patient payments for outpatient services are prevalent in Iran. Hence, more interventions are required to eliminate or control the IPs in outpatient services, particularly in the private sector. In this regard, making a well-regulated market, reinforcing the referral system, and developing an equity-oriented essential health services package would be fundamental.

This systematic review protocol is developed with the objective to identify the strategies, facilitators, and barriers to interaction between researchers and policy makers to use research evidence in health policy making. It seems that review of interactive methods between researchers and policy makers can help to understand the role of researchers on evidence‑informed policy making. Moreover, identifying barriers and facilitators of these interactions can help universities and institutions associated to health policy making in planning to improve the interaction between researchers and policy makers to facilitate evidence‑informed policy making.

with the outbreak of Covid-19,  use of E-learning instead of face-to-face education in higher education became inevitable. The present study aimed to assess the students' satisfaction with E-learning provided  by the Isfahan university’s management system  during the COVID-19 pandemic.

The study population included all of the students ,that were studying in the second semester of 1398-1399 at the Isfahan university.  By using a simple random sampling method, 373 persons were determined as the statistical population. The data collection tool was a researcher-made questionnaire, containing 34 questions, that its validity was evaluated using 5 educational management professors. Reliability was calculated by Cronbach’s alpha, and it was equal to 0/95.  The questionnaires were sent electronically to the university student groups and the collected data were analyzed  by descriptive statistics methods in SPSS software.

The results showed that about half of the students (47%) were satisfied with the E-learning provided by the Learning Management System (LMS). The percentage of satisfaction with the content of education, infrastructure and technology, support, communication and assessment was 38, 58, 40, 60, and 32, respectively.  Dissatisfaction of most of the students was related   to the use of dynamic and multimedia facilities for transferring content, internet speed, connection problems, and difficulty in sharing content and learning between students.

 In general, the findings of the present study indicated that more than half of the learners were dissatisfied with E-learning.  Therefore,  it is suggested that  empowering professors, providing the necessary infrastructure, and  determining amounts as financial aid  be considered by the university's educational administrators in order to help improve the conduct of these courses.

Despite the importance and position of evidence‑based policymaking in the proper management of the health system, studies show that the lack or improper and untimely use of evidence are still one of the main challenges of health systems. Knowledge translation as a solution to this challenge is a process that includes a period of time that starts of decision to choose the research topic and continue to publish of research results, in which the interaction of the researchers and stakeholders is the key factor and the main axis of the process. Since the recognition and promotion of knowledge translation processes resulting from research in health system policy‑making will lead to the improvement of the health system, this review protocol was designed to identify factors affecting knowledge translation implementation, including barriers and facilitators of this process. Identifying these factors can be used as a guide for health system decision‑makers and research managers in planning to select appropriate policies for deployment of the knowledge translation process to increase the use of research results in the health system.

This study aimed to examine the knowledge, attitude and practices (KAP) of people with disabilities (PWD) towards COVID-19 in Iran and identify its facilitators and barriers. 

A mixed qualitative-quantitative study was conducted. The researchers collected data using a self-administered online questionnaire which its participants were selected randomly from the entire PWDs in Iran. Quantitative data were analysed using the SPSS. To identify facilitators and barriers of improving KAP, semi-structured interviews were done, in which participants were selected using a purposeful sampling technique, and analysed by content analysis approach.

The mean scores of knowledge, attitude and practice of PWDs were 17.7, 16.6, and 16.9, respectively. We identified 161 codes, which were categorized into three themes and 9 sub-themes. Three themes were identified as facilitators of KAP improvement among study participants: educational contents developed during pandemic and their dissemination using social media; community participation; and the empowerment of PWDs. Weak governance was mentioned as an essential barrier for KAP improvement.

Further interventions are needed to increase the knowledge and improving attitudes and practice of PWDs during the crisis. Among them, the following are in priority: strengthening the governance arrangement of rehabilitation; increasing community participation; providing support packages and their fair distribution; empowering PWDs; preparing infrastructures for tele-rehabilitation; public awareness and, if needed, informing health workers about the specific needs of PWDs and how to treat them respectfully.

Planning to provide safe, equitable, and quality rehabilitation services requires data on the availability of current rehabilitation resources, including rehabilitation facilities and infrastructures. Given the findings of national surveys on available rehabilitation facilities, there are some deficiencies in the number and pattern of their distribution. These deficiencies make it necessary to invest in the expansion of rehabilitation facilities in order to improve access to the required services. To bridge these gaps, allocating part of the existing beds or adding beds for rehabilitation; revising the distribution of outpatient care centers both in terms of center type and geographical area, especially in deprived areas; developing and establishing the multidisciplinary rehabilitation service centers; and expanding rehabilitation home centers, community rehabilitation center and long-stay rehabilitation centers, in collaboration with the primary health care system, strengthening intersectoral relations, and participation of the private sector, and non-governmental organizations are recommended.

The Iran health system has implemented various reforms to provide equitable access to health care for citizens. In addition to its achievements in improving health outcomes, it faced problems, particularly following sanctions and the outbreak of COVID-19. These challenges must be addressed as the high-priority agenda by the new administration in Iran. In this commentary, we introduce the most critical challenges faced by the country. We then describe the main strategies that should be considered to address these challenges.

It is difficult to run current organizations without delegating some of the authority to management levels. Despite the importance of delegating authority to managers, this seems to have been neglected in organizations. The aim of this study was to identify effective strategies for delegation of authority in Tehran University of Medical Sciences.

The present study was conducted in 2019 in two stages. In the first stage, existing strategies to increase the willingness of managers to delegate authority were extracted through a review study. In the second stage, by conducting 18 semi-structured face-to-face interviews and holding a focused group meeting, effective and appropriate solutions were identified to increase the desire of managers to delegate authority at the university from the perspective of stakeholders. At this stage, data were analyzed by thematic analysis method by 2 people.

The review of studies showed two groups of strategies at the organizational and individual levels to increase the willingness of managers to delegate authority. The effect of implementing the solutions has not been fully investigated in previous studies. In the analysis of qualitative findings, three themes (including the importance of delegation at the university management levels, barriers to delegation at university and effective strategies for delegation to administrators at the university) and four sub-themes (including clarification of the delegation process, teaching how to delegate, establishing methods Correct monitoring and evaluation and the use of motivational methods appropriate to the performance of managers) were identified.

with regard to the most important barrier to delegation at the managerial level is process-related, it is suggested that the training method and process of performance appraisal and organizational reward be reviewed to increase skills and motivate further delegation. So that, measure the effectiveness and implementation considerations, it is recommended to conduct further studies on the effective implementation of strategies and to monitor and evaluate the effects of the implementation of strategies.

Following his inauguration in late 2013, President Rouhani aimed to boost quality and equity in thehealth care delivery system. To fulfill this aim, a set of interventions, called Health TransformationPlan (HTP), were implemented. So far, it has been a heated debate whether HTP breathes a spiritof a new reform. HTP has targeted long‑standing historical deficits of the Iranian health systemas well as urgent problems, both of which have been, to some extent, resolved. To decreaseOut‑Of‑Pocket (OOP) health expenditures, HTP has presented new financing mechanisms to expanda safety net to Iranian citizens fundamentally. HTP also encompassed interventions to overcomeproblems in the provision of health care by recruitment of health workforces, establishing newhealth facilities, and expanding primary health care to urban and peri‑urban areas. Furthermore,performance indicators including access, quality, and patient satisfaction have been affected. Giventhese changes, HTP is entitled to be a health system reform. However, a new agenda within HTP isrequired so that the Iranian health system can obtain better value for money that is to be spendingon it.

Reducing maternal mortality is one of the Sustainable Development Goals. Although there is no vigorous evidence that pregnant women are in the high-risk groups in response to coronavirus disease 2019 (COVID-19), it is crucial to respond to the pandemic through providing required action plans for confirmed or suspected pregnant women cases while maintaining routine functions. Iran’s response and preparedness measures to COVID-19 aimed to meet the essential needs required to protect pregnant women and their families. Establishing a national maternal health network, relying on mechanisms for timely reporting, monitoring, and following-up, preparing guidelines and protocols required for COVID-19 management in pregnant women though a multidisciplinary team working approach, and embedding the precautions of reducing transmission in maternity care were the main measures taken to cope with COVID-19 in pregnancy. Iran’s experience in providing maternity care during the COVID-19 can guide other countries affected by COVID-19. However, it should be adapted to local health-care facilities, as well as in response to any further updates on COVID-19.

Health literacy plays a central role in determining health inequalities in society. Considering the important role of university students in the formulation and implementation of future policies and plans of the country, this study aimed to determine the level of health literacy of university students and identify the factors affecting it.

This was a cross-sectional descriptive-analytic study. The study population included 380 university students who were studying at Isfahan University in the second semester of the academic year 2018-2019. They were entered into the study by stratified and available sampling method. The data gathering tool was the health literacy for Iranian adult’s questionnaire (HELIA). Collected data were analyzed using SPSS 23 software and descriptive statistics and logistic regression.

The mean score of health literacy was 77.96±16.96 of 100. 2.4% of students had inadequate health literacy, 32.3% had not so adequate health literacy, 46.4% had adequate health literacy and 18.9% had excellent health literacy. Health literacy was significantly associated with the variables of the educational level and the faculty of studying the students (p<0.05).

The health literacy of the students participating in the study is at a desirable level. Also, health literacy is associated with the variables of the educational level and the faculty of studying the students and graduate students and Basic science students have higher levels of health literacy.

Despite all the problems caused by the imposed war, sanctions and accidents after the Islamic Revolution, materializing primary health care (PHC) in Iran through establishing the National Health Network (NHN) has had substantial gains. Many health indicators in Iran have undergone significant changes. As an example, the change in death of children under the age of 5 years has been studied by adjusting the economic status, and it is estimated that about 2 million deaths in this age group were avoided within 30 years after the Islamic Revolution. Nevertheless, the global experience implies that the PHC has its limitations. By changing the social, economic, and epidemiological patterns of diseases, demands and expectations of community has changed. With the emergence of chronic conditions and new technologies, health expenditures have become a major concern. Meanwhile, in the 2000s, the revision at PHC was aimed at strengthening through the universal health coverage (UHC). Therefore, UHC is along the PHC and not against it.

We thank Joulaei et al (1) for their insightful comments on our paper on Universal Health Coverage in Iran (2). They criticized some parts of Iran's Health Transformation Plan (HTP), and we do not disagree with some of their comments on HTP. However, we think that an evidence-based approach is needed for an in-depth analysis of HTP, which is beyond our correspondence and Joulaei et al.’s comments. Therefore, we only focus on the criticisms made to our correspondence which was related to the starting point of HTP as to whether public hospitals were an appropriate starting point or whether the primary health care (PHC) should have been the starting point for HTP. While we believe that strengthening PHC is a strategic approach and vital to achieve Universal Health Coverage (UHC), at the same time, starting HTP from hospital services was a tactically correct decision, as public policymakers were looking for a showcase of using targeted subsidies funds to do something sensible for people in social welfare. The inpatient services were an urgent challenge which caused extreme public dissatisfaction. Much earlier, the first measure taken in the health transformation plan of Turkey was prohibition of holding the corpse hostage in hospitals due to unpaid hospital costs. While this was not a significant intervention for strengthening the health system, it softened the ugly face of the system and had tangible results for people. The second reason was the ease of implementing interventions in hospital services; 70% of outpatient services are provided by the private sector in Iran, which is not well-manageable by the government. In contrast, the public sector is the largest provider of inpatient services, providing inpatient care to almost 80% of the population. As a result, intervention in public hospitals, compared to outpatient services, has been more feasible. The third reason was the chance of achieving the desired results in a shorter time. The impacts of promotive and preventive measures appear in the long-term, while curative affair measures have short-term impacts.In sum, we entirely agree that reform is useful when it addresses the most fundamental challenges of the health system. However, the progressive realization of UHC is a crucial principle, meaning that the reform should be a long-term plan which must gradually be evolved (3). Starting HTP from the public hospital should not be considered as a disadvantage since, in reality, it has attracted enough attention and support; however, HTP should have not ended up in the hospital, and it had to address other aspects that were essential for a fundamental transformation such as PHC.

Over the last 4 decades, many initiatives have been implemented to accomplish equitable accessible health care for all Iranian citizens. The latest reform to address universal health coverage (UHC) is Health Transformation Plan (HTP), which resulted in significant improvements in health outcomes. Nevertheless, several challenges in the fields of sustainability of resources, service delivery, and health governance continued to exist. These challenges should be addressed in next steps to achieve the defined goals. To tackle these challenges, a number of practical solutions can be proposed, including making health financing more resilient, defining and implementing cost control policies and cost-effective package of services, changing the current method of providers’ payment, and ensuring good governance in the health system.