Change in Costs and Revenues of Public Hospitals in Mazandaran Province Before and After the Implementation of the Health System Reform in Iran

Since 2013, Iran's health system reform has been implemented at the national level with goals such as increasing people's access to health services, reducing direct payments to patients, and improving the quality of services. As this initiative has been associated with significant changes in the financing of hospitals, this study aims to investigate the changes in income and expenses of public hospitals in Mazandaran province, as two important indicators of key hospital financial performance, before and after the implementation of the reform.

This is a retrospective study that was conducted in 2018. Since this study deals with the impact of the intervention carried out by the public sector by comparing the changes before and after the implementation of the intervention, it is therefore considered a type of quasi-experimental study. The statistical population includes all government hospitals in Mazandaran province. The sampling method was census and covered all 24 public hospitals of Mazandaran province. The time frame of the study covers from 2009 to 2016, that is, 4 years before and 4 years after the implementation of the reform. Secondary data that is routinely recorded in the information system of the country's hospital system has been used in this study. To collect the data, a researcher-made checklist was used based on the objectives of the study and the availability of data in the routine information recording system of hospitals, which mainly included the variables of staff cost, non-staff cost, cash income, insurance income, and working year. After collecting the data from the comprehensive and centralized Electronic Information System (HIS), which contains all the financial and functional information of all hospitals in the province, the data were extracted and analyzed using SPSS software and appropriate statistical methods.

In general, after the implementation of the reform, the average costs in the studied hospitals increased from 249,613 to 771,552 million Tomans (2.61 times) and the average incomes increased from 152,738 to 534,804 million Tomans (3.50 times). Therefore, both the average cost and the average income in the 4-year periods before and after the implementation of the initiative have generally increased, but the growth rate of costs and incomes in the period before the implementation of the reform was lower than the period after its implementation, although, in the same period, the gap between expenses and incomes has been widening. In the period after the implementation of reform, due to the rapid increase in income at the beginning of the implementation, the gap between cost and income has decreased relatively, but gradually the rate of income growth has decreased compared to the rate of cost growth, and as a result, the gap between the cost and income of the hospitals studied in the end of the study period has experienced an unprecedented gap. It has also been found that during the years of the study, the staff cost has continued to rise with more or less trends, while the non-staff cost has started to decrease sharply and unprecedentedly since 1995.

Although the implementation of the reform has increased the financial turnover of government hospitals, due to the increase in the average cost compared to the increase in their average income, the implementation of this plan has increased the financial pressure on the hospitals and widened the income deficit compared to their cost. Therefore, the gap between cost and income and the rising trend of this gap in government hospitals can be a challenge for funding hospitals and guaranteeing the relative access of people to these services now and in the future.