Macroeconomic Policies and Increasing Social-Health Inequality in Iran

Background: Health is a complex phenomenon that can be studied from different approaches. Despite a growing research in the areas of Social Determinants of Health (SDH) and health equity, effects of macroeconomic policies on the social aspect of health are unknown in developing countries. This study aimed to determine the effect of macroeconomic policies on increasing of the social-health inequality in Iran. Methods: This study was a mixed method research. The study population consisted of experts dealing with social determinants of health. A purposive, stratified and non-random sampling method was used. Semi-structured interviews were conducted to collect the data along with a multiple attribute decision-making method for the quantitative phase of the research in which the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) was employed for prioritization. The NVivo and MATLAB softwares were used for data analysis. Results: Seven main themes for the effect of macroeconomic policies on increasing the social-health inequality were identified. The result of TOPSIS approved that the inflation and economic instability exert the greatest impact on social-health inequality, with an index of 0.710 and the government policy in paying the subsidies with a 0.291 index has the lowest impact on social-health inequality in the country. Discussion: It is required to invest on the social determinants of health as a priority to reduce health inequality. Also, evaluating the extent to which the future macroeconomic policies impact the health of population is necessary.


Introduction
During the past two decades, the public health attention has shifted toward the Social Determinants of Health (SDH). The World Health Organization's Commission of Social Determinants of Health (CSDH) has defined SDH as the conditions in which people are born, grow, live and work (1). The term SDH includes factors which can influence healthrelated behaviors. Socio-economic factors such as income, wealth, and education fundamentally affect health outcomes (2). Also, social infrastructures and socio-economic policies are the major determinants of health (3). Despite a dramatic growth of research in SDH and health equity and great interest of governments and policy-makers to promote equity in healthcare, there is little evidence that healthy public policies are being adopted and implemented (4)(5)(6)(7). From the early 1990s to 2000, SDH was considered as the main concern of countries, but evidence shows that the social measures taken by these countries, particularly developing countries, to decrease the inequality and promote health justice were unsuccessful (8)(9)(10)(11). Health inequality means inappropriate system functioning which result in inequality in social status and living conditions. CSDH was founded in 2003 to study health justice. The report of CSDH in 2008 encouraged action against health inequalities and fills the gap between socioeconomic and political factors through research on SDH.
The report proposed that inequities in power, money, and resources are responsible for the majority of the inequalities in health within and between countries (11)(12)(13)(14). A toxic combination of poor policies and programs, unfair economic arrangements, and bad governance lead to inequalities in the conditions of daily life: the circumstances in which people are born, grow, live, work, and die (15). Despite the improvement in health status during the past 30 years, health inequalities have caused various problems in different countries (16)(17)(18). Low-and middle-income countries face many challenges to achieve the Millennium Development Goals (MDGs). Developing countries should undertake appropriate efforts to promote maternal education, improve access to clean water and safe sanitation and better living circumstance. In developing countries, macroeconomic policies have a great influence on reducing health disparities (19)(20)(21)(22)(23)(24), but there is little evidence about impact of macroeconomic policies on SDH (19,25,26). One of the main challenges of healthcare systems of Iran is health inequality. Zaboli and colleagues reviewed and prioritized SDH in Iran. They believe, socio-economic status, living facilities such as housing, and social integrity had the greatest effect on decreasing health inequality in Iran (27). Addressing SDH requires an understanding of the impact of macroeconomic policies and social policies on the health. Evidence-based policies must be relevant and integrated into health systems to function efficiently (28)(29)(30)(31). Based on the conceptual framework of social determinants of health inequality, this research aimed to determine the effect of macroeconomic policies on the social-health inequality in Iran based on expert opinion and identify the drivers of SDH in Iran.

Materials and methods
This study is a mixed method research which was conducted in two phases as presented in below:

Qualitative phase
The aim of qualitative phase of this study is to determine the main themes of macroeconomic policies on SDH. In this study, experts in SDH were the study population. Purposive non-random stratified sampling was used. We divided experts into three strata including governmental, academic and independent experts, and purposeful sampling were used based on the inclusion criteria. The aim was to include individuals from a variety of backgrounds. Experts in the areas of health management and policy, clinical, social science and other spatiality were identified and via recommendations from other recruited participants as well as individuals at SDH commission of ministry of health. Experts were defined as individuals whose past or present field contains the subject under study i.e. health policy, epidemiology, and/or clinician. Inclusion criteria followed recommendations which include evidence of expertise, understanding of the problem area, reputation, availability, and willingness to participate. Experts were invited to take part in the research via walkthrough and personal visit that explained the aim, methods, and use of study data. We also used semi-structured interviews to collect qualitative data. The interview guide included a number of main questions regarding the SDH. The conceptual framework of study was based on the CSDH model in Figure 1. A pilot interview was conducted. Interviews were continued to reach the data saturation. The participants in this study were 24 experts. Data were collected during December 2012 and April 2013. The majority of participants were based in Tehran. The interviews were transcribed and the transcriptions were sent to the interviewees for confirmation. Framework analysis technique was used using Nvivo software (QSR International, Australia) for the analysis. The main themes and constructs were extracted in the qualitative phase and in the quantitative phase they were prioritized.

Quantitative phase
The quantitative phase of this study was aimed to prioritize and determine factors with the greatest impact on the macroeconomic policies which result in social-health inequality in Iran. There are various decision-making methods. A Multiple Attribute Decision-Making (MADM) approach was used to obtain feedback from the experts at the study because there are useful and simple methods to deal with decision-making problems. This methodology builds on the frequently-used MADM techniques of Technique for Order Preference by Similarity to Ideal Solution (TOPSIS). TOPSIS methodology has a simple process and easy to use and programmable but it overcomes some typical limitations that exist in relying on these deterministic techniques. It is difficult to weight attributes and keep consistency of judgment, especially with additional attributes. TOPSIS is one of the compensatory classic methods in MADM for prioritization based on similarity to ideal solution. The Simple Additive Weighting (SAW) method was exploited to identify the weights of each factor (33)(34)(35). The experts could use the following nine-points for expressing the intensity of the preference for one criterion versus another: 1= Equal importance or preference 3= Moderate importance or preference of one over another 5= Strong or essential importance or preference 6 The most important structural stratifiers and their proxy indicators include: Income, Education, Occupation, Social Class, Gender, Race/ethnicity. Together, context, structural mechanisms and the resultant socioeconomic position of individuals are "structural determinants" and in effect it is these determinants we refer to as the "social determinants of health inequities." The underlying social determinants of health inequities operate through a set of intermediary determinants of health to shape health outcomes. The vocabulary of "structural determinants" and "intermediary determinants" underscores the causal priority of the structural factors. The main categories of intermediary determinants of health are: material circumstances; psychosocial circumstances; behavioral and/or biological factors; and the health system itself as a social determinant. ∏ Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment. ∏ Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof). ∏ Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors.
The CSDH framework departs from many previous models by conceptualizing the health system itself as a social determinant of health (SDH). The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. The health system plays an important role in mediating the differential consequences of illness in people's lives.
Where w i is the weight of the i attribute or criterion, and Where I' is associated with advantage criteria and I" is associated with cost criteria. 4. Calculate the separation measures, using the n-dimensional Euclidean distance. The separation of each alternative from the ideal solution is given as:

Results
Twenty-four experts, 14 male and 14 female, in the area of health management and policy, clinical, social science, and others spatiality were chosen. Their average age was 49.881 ± 14.263 years, and average years engaged in the work was 24.616 ± 11.542 years. The expert response rate was 100% (Table 1). Based on the qualitative results, macroeconomic policies have an impact on health and health inequalities in the country. All participants believe that macroeconomic factors affect social health inequalities in Iran. "One of the things that have a great impact on the health is the general policies debate in the country including setting the tariffs, share of private sector in the financing and delivery of health services and stewardship". Experts believed that the general economy instability have a big impact on social health inequalities. "Economic uncertainty and high inflation impact on health inequalities and social determinants of health". Some experts highlighted the fact that the macroeconomics policies such as subsides are important in rising inequality "Macroeconomic policies, such as subsidies have made major problems in health financing". There were some discussions regarding private sector policies on health inequalities. It was reported by the majority of the interviewees that expanding the private sector role in health services delivery will have a devastating impact on the concept of justice especially on poor and low-income population. Seven themes and fifteen subthemes of macroeconomic policies were identified in which affect the social-health inequality in Iran ( Table 2). The themes are Inflation and economic instability, public and private sectors policies, overall economy situation, health policy, out-off pocket, policies context and the subsidies. Based on experts' knowledge, we prioritized these factors as follows: Inflation and economic instability has the greatest impact on social-health inequality, with a 0.710 as a TOPSIS Index and the subsidies with a 0.291 as a TOPSIS index has the lowest impact on social-health inequality in the country (Table 3).

Discussion
Despite major advances in medicine and public health during the past few decades, there are disparities in health and healthcare inequities. Evidences show in or der to decrease health inequality, macroeconomic policies in all of the countries must be appropriately considered. Policymakers should attempt to reduce health inequality by paying attention to SDH. Current approaches to SDH generally focus on population-level and policy interventions. Public policy that seeks to achieve sustainable improvements in the SDH,  such as income, education, housing, food security, and area conditions, can create positive and sustainable health effects (36)(37)(38). Significant improvements in population health are likely when the SDH are addressed (39).
There are few studies have been conducted in the health disparities. One of the most important studies is the Urban HEART survey in Tehran city. The results of this study showed that socio-economic inequalities exist in health status in Tehran. Since the root of this avoidable inequality is in outside the health system, a holistic health policy approach which includes social and economic determinants should be adopted to redress the inequitable distribution of health (40).
Results of previous studies suggested that health in all policies is an approach to health promotion. Public health, it was concluded, should be more concerned with social policies and social determinants than with health services and disease control (41). Health Impact Assessment (HIA) serves as a tool for policy-makers and planners when considering a new policy (42)(43)(44)(45)(46). Based on our finding, in Iran the most priorities on macroeconomics which affect health inequalities was economic instability.  (47)(48)(49)(50). Another theme which was founded in this study was private sectors policies. The private sector is making a growing contribution to healthcare in much of developing countries. There has been considerable interest in the growth of the private sectors in delivering of health services instead focusing on determinants of health (51)(52)(53)(54).
The study suggested that the impact of macroeconomic policies on the health of people in the country must be constantly measured and before the implementation of new policies, positive or negative impacts of them must be investigated. Our results based on the experts' opinions showed that weak financial protection plans and inadequate coverage of insurances, a high level of out of pocket in health financing have negative impact on community health (55)(56)(57)(58). Macroeconomic policies such as the subsidies have great impact on the community health in the country and the effects should be measured. The commitment to addressing underlying in often named in the phrase "tackling health inequalities". Focusing of macroeconomic policies on equal distribution of determinants such as diets, housing, workplace condition is important for thinking about policies. Action on the SDH is needed across the life course, and in wider social and economic spheres to achieve greater health equity and protect future generations (11,59,60). Socio-economic inequalities and their effects on health are one of the challenges that have recently attracted attention because improving health in afflicted societies is more difficult than helping patients in a healthy society. The majority of factors caus ing health inequality are distributed all over different social sectors. Therefore, it is necessary to take a multi-disciplinary approach in policy-making and to evaluate the probable effects of policies on health, particularly on the health of the most vulnerable groups of the society. Implications for policy makers • Despite the improvement in health status, health inequalities have caused various problems in different countries. Hence, focus on tackling health inequalities should be the priority of policy-makers. • Addressing Social Determinants of Health (SDH) requires an understanding of the impact of macroeconomic policies and social policies on the health. The main causes of health disparities root in economic and social inequalities. • Social infrastructures and socio-economic policies are the major determinants of health. Policy-makers should improve the socio-economic status of the people. Public health, it was concluded, should be more concerned with social policies and social determinants than with health services and disease control. • From the application of the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) methodology to a real case, the approach proposed proved to an appropriate tool, which makes it possible to easily and effectively rank determinants of health.

Implications for public
Macroeconomic policies exert great impact on the community's health ; hence, its effects should be measured. Focusing of macroeconomic policies on equal distribution of determinants is important for thinking about policies. An improvement of macroeconomic and social indicators in the community will lead to improvements in health indicators.