The Experience of Implementing the Board of Trustees’ Policy in Teaching Hospitals in Iran: An Example of Health System Decentralization

Document Type : Original Article


1 Department of Health Services Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran

2 Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran

3 Department of Health Services Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

4 Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran

5 School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

6 Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

7 National Academy of Medical Sciences, Tehran, Iran

8 College of Health and Life Sciences, Brunel University London, London, UK

9 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran


In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy of teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in each hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor policy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as enhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were never realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of trustees’ policy did not achieve its perceived objectives.
We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 and 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive and snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed verbatim and analyzed thematically, following a mixed inductive-deductive approach.
Three main themes emerged from the analysis. The implementation approach (including the processes, views about the policy and the links between the policy components), using research evidence about the policy (local and global), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity and actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization policies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration of the above factors in policy implementation into account.
The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals in Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not prepared appropriately and key stakeholders, particularly the government, did not support the decentralization of Iran’s health system.


Main Subjects

  1. Mills A, Vaughan JP, Smith DL, Tabibzadeh I. Health system decentralization: concepts, issues and country experience. Geneva: World Health Organization; 1990.
  2. Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med 1998; 47: 1513-27.
  3. Wagstaff A, Bales S. The impacts of public hospital autonomization: evidence from a quasi-natural experiment. Washington, DC: Word Bank; 2012.
  4. Braithwaite J, Travaglia JF, Corbett A. Can questions of the privatization and corporatization, and the autonomy and accountability of public hospitals, ever be resolved? Health Care Anal 2011; 19: 133-53. doi: 10.1007/s10728-010-0152-x
  5. Harding A, Preker AS. Understanding organizational reforms. The corporatization of public hospitals. 2000. [cited 2014 July]. Available from:
  6. La Forgia GM, Couttolenc B. Hospital performance in Brazil: the search for excellence.  Washington, DC: The World Bank: 2008. doi: 10.1596/978-0-8213-7358-3
  7. McPake B, Yepes FJ, Lake S, Sanchez LH. Is the Colombian health system reform improving the performance of public hospitals in Bogota? Health Policy Plan  2003; 18: 182-94. doi: 10.1093/heapol/czg023
  8. Preker AS, Harding A. Innovations in health service delivery: the corporatization of public hospitals. Washington, DC: World Bank; 2003.
  9. Bossert TJ, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy Plan 2002; 17: 4-31. doi: 10.1093/heapol/17.1.14
  10. Abdullah MT, Shaw J. A review of the experience of hospital autonomy in Pakistan. Int J Health Plann Manage 2007; 22: 45-62. doi: 10.1002/hpm.855
  11. Govindaraj R, Chawla M. Recent experiences with hospital autonomy in developing countries: what can we learn?: Harvard school of public health. Department of population and international health. 1996. [cited 2014 February]. Available from:
  12. Collins D, Njeru G, Meme J, Newbrander W. Hospital autonomy: the experience of Kenyatta National Hospital. Int J Health Plann Manage 1999; 14: 129-53.
  13. Hawkins L, Srisasalux J, Osornprasop S. Devolution of Health Centers and Hospital Autonomy in Thailand: A Rapid Assessment. Washington, DC: World Bank; 2009.
  14. Ssengooba F, Atuyambe L, McPake B, Hanson K, Okuonzi S. What could be achieved with greater public hospital autonomy? Comparison of public and PNFP hospitals in Uganda. Public Adm Deve 2002; 22: 415-28.
  15. Lee SY, Alexander JA, Wang V, Margolin FS, Combes JR. An empirical taxonomy of hospital governing board roles. Health Serv Res 2008; 43: 1223-43. doi: 10.1111/j.1475-6773.2008.00835.x
  16. Pfeffer J. Size and composition of corporate boards of directors: The organization and its environment. Adm Sci Q 1972; 17: 218-28.
  17. Molinari C, Morlock L, Alexander J, Lyles CA. Hospital board effectiveness: relationships between governing board composition and hospital financial viability. Health Serv Res 1993; 28: 358.
  18. Hill MJ, Hupe PL. Implementing public policy: governance in theory and practice. London: Sage; 2002.
  19. Buse K, Mays N, Walt G. Making health policy. England: McGraw-Hill; 2012.
  20. Sabatier PA, Jenkins-Smith H. Policy Changes and Learning: An Advocacy Coalition Approach. Boulder, CO: Westview Press; 1993.
  21. Mazmanian DA, Sabatier PA. Implementation and public policy. Glenview, IL: Scott Foresman; 1983.
  22. John P. Analysing public policy. New York: Bloomsbury Publishing; 1998.
  23. Buse K. Addressing the theoretical, practical and ethical challenges inherent in prospective health policy analysis. Health Policy Plan 2008; 23: 351-60. doi: 10.1093/heapol/czn026
  24. Rutten A, Luschen G, von Lengerke T, Abel T, Kannas L, Rodriguez Diaz JA, et al. Determinants of health policy impact: comparative results of a European policymaker study. Soz Praventivmed  2003; 48: 379-91.
  25. Takian A, Doshmangir L, Rashidian A. Implementing family physician programme in rural Iran: exploring the role of an existing primary health care network. Fam Pract 2013; 30: 551-9. doi: 10.1093/fampra/cmt025
  26. Oliyayi AR, Abolhalaj M, Zanganeh M, Zakeri MR, Rasidian A, Kazemian M, et al. [National Health Accounts Islamic Republic of Iran]. 1th ed. Tehran: Fate makers; 2008.
  27. Jafari M, Rashidian A, Abolhasani F, Mohammad K, Yazdani S, Parkerton P, et al. Space or no space for managing public hospitals; a qualitative study of hospital autonomy in Iran. Int J Health Plann Manage 2011; 26: 121-37. doi: 10.1002/hpm.1050
  28. Manavi S, Babashahy S, Sari AA. [The Extra Cost of Granting Autonomy to Public Hospitals]. Journal of Isfahan Medical School 2012; 29: 1-9. [In Persian]
  29. Walker JL. The use of saturation in qualitative research. Can J Cardiovasc Nurs 2012; 22: 37-46.
  30. Pope C, Mays N. Qualitative research in health care: 3rd edition. Hoboken: John Wiley & Sons; 2008.
  31. Rashidian A, Eccles MP, Russell I. Falling on stony ground? A qualitative study of implementation of clinical guidelines' prescribing recommendations in primary care. Health Policy 2008; 85: 148-61.
  32. Carey JW, Morgan M, Oxtoby MJ. Intercoder agreement in analysis of responses to open-ended interview questions: Examples from tuberculosis research. Field Methods 1996; 8: 1-5. doi: 10.1177/1525822X96008003010133
  33. Sajadi HS, Hadi M, Maleki M, Tourani S. Does Transfer of Hospital Governance to Board of Trustees per se Lead to Improved Hospital Performance? International Journal of Hospital Research 2012; 1: 97-102.
  34. Eeckloo K, Van Herck G, Van Hulle C, Vleugels A. From Corporate Governance To Hospital Governance.: Authority, transparency and accountability of Belgian non-profit hospitals’ board and management. Health Policy 2004; 68: 1-15. doi: 10.1016/j.healthpol.2003.07.009
  35. Newhouse JP. Toward a theory of nonprofit institutions: An economic model of a hospital. Am Econ Rev 1970; 60: 64-74.
  36. Anderson JE. Public policymaking. 8th edition. USA: Cengage Learning; 2014.
  37. Birkland TA. An introduction to the policy process: Theories, concepts, and models of public policy making. Gremese Editore; 2005.
  38. Fischer F, Miller GJ. Handbook of public policy analysis: theory, politics, and methods. Boca Raton: Taylor & Francis Group; 2006.
  39. Fretheim A, Munabi-Babigumira S, Oxman AD, Lavis JN, Lewin S. SUPPORT tools for evidence-informed policymaking in health 6: Using research evidence to address how an option will be implemented. Health Res Policy Syst  2009; 7 : S6. doi: 10.1186/1478-4505-7-S1-S6
  40. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci 2008; 3: 1. doi: 10.1186/1748-5908-3-1
  41. Brownson RC, Chriqui JF, Stamatakis KA. Policy, Politics, and Collective Action. Am J Public Health 2009; 99: 1576-83.
  42. Glassman A, Reich MR, Laserson K, Rojas F. Political analysis of health reform in the Dominican Republic. Health Policy Plan 1999; 14: 115-26.