Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-ofpocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.

The government’s ability to allocate additional resources to the health sector depends on the country’s macroeconomic condition. The concept of fiscal space helps put health in the broader context of the economic and financial environment. In this study, we explored the fundamentals of the concept of fiscal space for health and provided a brief overview of the different methods for the expansion of fiscal space for health in Iran.

This review study, by using reports and articles published in internal and external databases, examines the theoretical foundations and different methods of fiscal space expansion in health generally and for Iran’s health system specifically.

Fiscal space for health is the availability of budgetary room that allows a government to provide resources for desired public purposes without impairing fiscal sustainability. This space can be generated by a variety of sources, which can broadly be categorized into five categories, including conducive macroeconomic conditions, a re-prioritization of health within the government budget, an increase in the health sector-specific resources, foreign aid, and an increase in the efficiency of existing government health outlays.

The use of fiscal space analysis can help sustainable health financing and increase the alignment of health financing with the goals of the public financial management system.

Healthcare systems are always facing increasing public demands to provide better services. Therefore, countries always need more resources and are constantly seeking more fiscal space for health. Freeing up resources through improving efficiency can be a practical option for all settings, particularly countries with low resources. This study aimed to identify feasible options for expanding fiscal space through efficiency within Iran’s healthcare system.

This was a qualitative study. We conducted 29 semi-structured in-depth interviews with stakeholders at various levels of healthcare system in 2017 and 2018. We used mixed method (deductive and inductive) qualitative content analysis. Pre-defined themes extracted from literature and meanwhile new subthemes were developed and added to the initial framework.

We identified three main themes that affect the efficiency of healthcare system in Iran: administration, implementation, and monitoring. Problematic administration, inappropriate implementation and lack of good monitoring in healthcare initiatives may lead to inefficiencies and wasting resources. Recognizing these leakages in every healthcare system can free up some resources.

Irrespective of their economic development, all countries may, to some extent, face limited resources to address ever-increasing needs in their healthcare systems. While generating new resources is not always possible, enhancing efficiency to expand fiscal space might be a feasible option. Healthcare systems should identify the leakages and respond to wastages with appropriate planning. Getting the most out of current resources is possible through proper administration, good implementation and a well-established monitoring system for healthcare initiatives.

In recent years, many fluctuations in key macroeconomic variables such as growth and inflation, etc. have been observed in Iran.Since the mentioned economic variables have a significant role in the situation of economic stability, so the study of the economic stability of the country have become one of the challenging issues. However, fiscal decentralization as a policy that may increase the country's economic stability has recently been considered by many countries. Therefore, The present study uses the space panel method to investigate the effects of fiscal decentralization on the economic stability of the country (a combined indicator of economic growth, inflation and budget deficit) during the years 2006-2016. The results of the study show a nonlinear relationship between fiscal decentralization and economic stability, they show that a 1% improvement in fiscal decentralization of income does reduce the Combined index of economic stability by 0.63%, however, with increasing fiscal decentralization of income, economic stability increases. The results also show that a 1% improvement in expenditure decentralization has led to a 1.4% increase in the economic stability index, while at high levels of fiscal decentralization of expenditure, the results indicate a decrease in economic stability.

Fiscal Decentralization (FD) in many cases is encouraged as a strong means of improving the efficiency and equity in the provision of public goods, such as healthcare services. This issue has urged the researchers to experimentally examine the relationship between fiscal decentralization indicators and health outcomes. In this study we examine the effect of Fiscal Decentralization in Medical Universities (FDMU) and Fiscal Decentralization in Provincial Revenues (FDPR) on Under-Five Mortality Rate (U5M) in provinces of Iran over the period between 2007 and 2010. We employed panel data methods in this article. The results of the Pesaran CD test demonstrated that most of the variables used in the analysis were cross-sectionally dependent. The Hausman test results suggested that fixed-effects were more appropriate to estimate our model. We estimated the fixed-effect model by using Driscoll-Kraay standard errors as a remedy for cross-sectional dependency. According to the findings of this research, fiscal decentralization in the health sector had a negative impact on U5M. On the other hand, fiscal decentralization in provincial revenues had a positive impact on U5M. In addition, U5M had a negative association with the density of physicians, hospital beds, and provincial GDP per capita, but a positive relationship with Gini coefficient and unemployment. The findings of our study indicated that fiscal decentralization should be emphasized in the health sector. The results suggest the need for caution in the implementation of fiscal decentralization in provincial revenues.

The present paper examines the mitigating effect of monetary and fiscal policies on the “Growth Laffer curve” (GLC) using a panel data of 38 high income countries over the period 2003-2012. Adopting generalised method of moments (GMM) estimators, the paper finds evidence substantiating the presence of an inverted-U GLC. Moreover, the evidence suggests that the GLC shifts downward by employing expansionary monetary and fiscal policies and that the tax rate turning point beyond which economic growth decline is higher in countries with higher level of debt-to-GDP ratio and money supply. These results are robust to addition of alternative controlled variables in the GLC specification. Our results strengthen the case for heterogeneous GLC across countries. As an implication, a government may enhance the efficiency within the “fiscal space” by either raising the productivity of public spending or cutting fiscal debt. Moreover, using money as a financing instrument should be carefully supervised due to its impact in generating large inflation rates and distorting capital accumulation and economic growth.

This paper presents a framework for assessing the fiscal condition index (FCI) and develops a concept to assess fiscal condition of governments and implements it into Iran government as an oil exporting country. The concept consists of four dimensions -revenue, expenditure, budget balance, and debt structure-and each dimension has its own indicators. There are seven indicators examined namely expenditure to GDP ratio, non-oil revenue to total revenue ratio, public debt to GDP ratio, non-oil balance to non-oil GDP ratio, oil revenue to total revenue ratio, capital expenditure to total expenditure ratio, and overall budget balance to GDP ratio. Assessing cycle of fiscal indicators shows that these indicators have been pro-cyclical individually. Then, fiscal policy not only doesn’t have stabilizing role in macroeconomic conditions, but also increases the macroeconomic fluctuations. Likewise, the results indicate that Iran’s fiscal condition index is very volatile and pro-cyclical. Also, assessing this index demonstrate that Iran’s government has experienced fiscal health in 2003, 2006, and 2008. However, it has been in fiscal stress in 2012 and 2013. Iran’s governments did not have fiscal policy discipline in the period 1990-2011. This is because the oil price is the leading indicator of fiscal condition index. In addition, sanction is one of the reasons that caused decrease of FCI in 2010-2012.

 Fiscal discipline provides a mechanism for maintaining financial health and a favorable vision for listed companies by matching revenue and expenses with goal achievement programs (GAP), which, if realized, can ensure the success of these companies. Thus, this study was carried out aimed to identify and explain the factors affecting the fiscal discipline of companies listed on the Tehran Stock Exchange. The present study is considered as an applied research in terms of purpose and as a descriptive survey research in terms of method. In this study, population is listed companies that 114 companies have been selected as a sample using systematic sampling method. Analysis of research data was done using artificial neural network (ANN) and two-layer perceptron and Matlab software. The results show that the most important factors affecting fiscal discipline include financial health, financial stability, debt growth rate, capital expenditures, profitability, and firm value and information uncertainty of companies.

Given the importance of economic effect of governmental expenditure at the national level, several studies has been done to identify the factors affecting the extent and composition of government expenditure.In the present article, the effect of fiscal corruption on government expenditure along with other factors has been studied. For this purpose, a panel which includes the annual data for years 2000- 2007 for 31 selected developing countries has been considered. In the first stage, stationary properties of variables and long-term relation between them is investigated. Then by using the method of panel data regression, the impact of fiscal corruption on the composition of government expenditure has been investigated.Findings of our econometric models show that fiscal corruption has a meaningful effect on composition of government expenditure. In other words, reduction in fiscal corruption index will lead to increase in the relative share of current expenditure, the share of expenditure on human capital and the share of expenditure on education and health in GDP. Also we have found a reduction in the relative share of military expenditure and capital expenditure in GDP.

This article discusses what ethicists have called “unacceptable trade-offs” in health policy choices related to universal health coverage (UHC). Since the fiscal space is constrained, trade-offs need to be made. But some trade-offs are unacceptable on the path to universal coverage. Unacceptable choices include, among other examples from low-income countries, to expand coverage for services with lower priority such as coronary bypass surgery before securing universal coverage for high-priority services such as skilled birth attendance and services for easily preventable or treatable fatal childhood diseases. Services of the latter kind include oral rehydration therapy for children with diarrhea and antibiotics for children with pneumonia. The article explains why such trade-offs are unfair and unacceptable even if political considerations may push in the opposite direction.