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Abstract Background Cesarean section (C-section) rates, deemed a critical health indicator, have experienced a historical increase. The advent of the COVID-19 pandemic significantly impacted healthcare patterns including delays or lack of follow-up in treatment and an increased number of patients with acute problems in hospitals. This study aimed to explore whether the observed surge is a genuine consequence of pandemic-related factors. Methods This study employs an Interrupted Time Series (ITS) design to analyze monthly C-section rates from March 2018 to January 2023 in Kurdistan province, Iran. Segmented regression modeling is utilized for robust data analysis. Results The C-section rate did not show a significant change immediately after the onset of COVID-19. However, the monthly trend increased significantly during the post-pandemic period (p

Abstract Background The growing trend of informal settlements is a serious humanitarian crisis. Unmet need for health care services is an indicator to measure the state of equality and access to healthcare services. This study, for the first time in Iran, examined the prevalence of unmet needs for outpatient healthcare services and related socioeconomic inequalities among residents of informal settlements in Sanandaj city. Methods This cross-sectional study was conducted on informal settlements of Sanandaj city with a sample size of 1345 people. Data were collected using a questionnaire. Multivariate logistic regression was used to determine significant predictors of unmet needs for healthcare services. Concentration index (C) and concentration curve (CC) were calculated to measure inequality in the prevalence of unmet needs for healthcare services. Results The prevalence of unmet needs for outpatient healthcare services was 31.7%. Financial and physical barriers were the most common reasons for not using the needed services. The highest unmet need was related to dental (80.6%) and rehabilitation services (78.8%). Being elderly with about 2.3 times (OR: 2.37, 95% CI: 1.19–4.75), not having a job with about 1.7 times (OR: 1.70, 95% CI: 1.13–2.57) and having a low economic status with about 4 times (OR: 4.46, 95% CI: 2.39–9.70) increased the odds of experiencing unmet need for outpatient healthcare services. The value of concentration index showed that unmet need for outpatient healthcare services was significantly concentrated among people with lower economic status (C= -0.330, 95% CI: -0.432 to -0.227). Conclusion The unmet need is high among people living in informal settlements of Sanandaj city and a significant part of the residents of these settlements does not have access to required healthcare services. Regardless of the needs of people living in these settlements, who constitute a large population of Iran, access to universal health coverage is not possible in such areas. Removing the identified obstacles and causes behind the unmet needs requires the interdisciplinary participation of all actors, including the government, the nation, and civil society.

Background and Aim: A comprehensive understanding of the current state of geriatric care in Iran is necessary in order to strengthen and align it for responding to the current and future needs of the elderly in the country. The purpose of this study was to identify the challenges and barriers in the elderly care system in Iran. Materials and Methods: This was a qualitative study. Forty semi-structured interviews were carried out with various participants involved in providing care to the elderly across the country in 2019. Participants were selected using maximum variation sampling. Using MAXQDA10 software, data were analyzed by the qualitative content analysis method based on six building blocks of health systems developed by the world health organization. Results: Challenges and barriers in the elderly care system were categorized into six groups: service delivery, health workforce, health information system, access to essential medicine, financing, and governance/leadership. Also, some of the most important challenges of the elderly care system included: absence of a single organization with sufficient power as the steward for providing the elderly services, lack of integration of services for the elderly from primary care to specialized care; shortage or inadequate distribution of skilled manpower; lack of insurance coverage for home care services for the elderly; lack of registry system or database for the elderly; lack of or weakness in elderly-friendly activities in the service centers. Conclusion: The current elderly care system in Iran faces many challenges in all six building blocks of the World Health Organization. Reforming and redesigning the elderly care system based on the findings of this study is necessary and urgent in order to meet the needs of the elderly in the country.

Abstract Background Associations between the COVID-19 pandemic and hospitalizations have not been studied Iran. This study aimed to examine the impact of the COVID-19 pandemic on hospital admissions for nine categories of disease in seven public hospitals in Kermsnahah city, the capital of Kermsnahah province, in the west of Iran. Methods Data on monthly hospitalization rates (number of hospitalizations per 100,000 population) were collected for nine categories of disease for a period of 40 months (23 months before and 17 months after the COVID-19 outbreak in Iran) from the health information systems of all seven public hospitals in Kermanshah city. Categories of disease included those related to pregnancy, childbirth and the puerperium period, neoplasms, diseases of the digestive, respiratory, circulatory, genitourinary and nervous systems, mental and behavioural disorders, and infectious and parasitic diseases. Population data were extracted from the Statistics Centre of Iran. An interrupted time series analysis with segmented regression was used to examine the impact of COVID-19 on hospital admissions. Findings Average monthly hospitalization rates fell for all nine categories of disease included in the study after the onset of the pandemic, with overall rates of 85.5 per 100,000 population in the period before the COVID-19 outbreak and 50.4 per 100,000 population after the outbreak began. The relative reduction in hospitalizations for the nine diseases was 56.4%. Regression analysis of monthly data indicated a sharp decrease in hospitalisations during the first month after the COVID-19 outbreak, which was statistically significant for all diseases (p

Abstract We aim to estimate the prevalence of prediabetes, and diabetes mellitus (DM). We estimated awareness, treatment, plasma glucose control, and associated factors in diabetes, as well as, socioeconomic-related inequality in the prevalence of diabetes and prediabetes. Data for adults aged 35–70 years were obtained from the baseline phase of the Dehgolan prospective cohort study (DehPCS). Diabetes status was determined as fasting plasma glucose (FPG) of ≥ 126 mg/dl and/or taking glucose lowering medication confirmed by a medical practitioner. Prediabetes was considered as 100 ≤ FPG ≤ 125 mg/dl. The relative concentration index (RCI) was used to exhibit socioeconomic inequality in the prevalence of prediabetes and DM. Prevalence of prediabetes and DM, diabetes awareness and treatment, and glycemic control of DM 18.22%, 10.00%, 78.50%, 68.91% and, 28.50%, respectively. Increasing age (p

Abstract Background and Aims Making a judgment only based on formal national reports can be misleading. We aimed to assess the relationship between countries' development indicators and reported coronavirus disease 2019 (Covid‐19)‐related incidences and death. Methods Covid‐19 related incidence and death cases were extracted from the updated Humanitarian Data Exchange Website on October 8, 2021. Univariable and multivariable negative binomial regression were utilized to investigate the relationship between development indicator and incidence and mortality from Covid‐19 by calculating the Incidence rate ratio (IRR), mortality rate ratio (MRR), and fatality risk ratio (FRR). Results Very high human development index (HDI) compared with low HDI (IRR:3.56; MRR:9.04), the proportion of physicians (IRR:1.20; MRR:1.16), besides extreme poverty (IRR:1.01; MRR:1.01) were independently correlated with the mortality and incidence rate of Covid‐19. Very high HDI and population density were inversely correlated with the fatality risk (FRRs of 0.54 and 0.99). The cross‐continental comparison shows Europe and the North Americas, had significantly higher incidence and mortality rates with IRR of 3.56 and 1.84 as well as MRRs of 6.65 and 3.62, respectively. Also, they inversely correlated with the fatality (FRR:0.84 and 0.91, respectively). Conclusion A positive correlation between the fatality rate ratio based on countries' development indicators and the reverse for the incidence and mortality rate was found. Developed countries with sensitive healthcare systems can diagnose infected cases as soon as possible. Also, the mortality rate of Covid‐19 will be accurately registered and reported. Due to more access to diagnostic tests, patients are diagnosed at the initial stages and will have a better opportunity to receive treatment. This leads to higher reports of incidence/and/or mortality rates and lower fatality of COVID‐19. In conclusion, more Covid‐19 incidence and mortality cases in developed countries can result from a more comprehensive care system and a more accurate recording procedure.

Abstract Background and Aims One of the goals of the Islamic Republic of Iran is to reduce the prevalence of catastrophic health expenditures among Iranian households to 1% by the end of the sixth 5‐year development plan (2016−2021). This study was conducted to evaluate the level of access to this goal in the final year of this program. Methods A national cross‐sectional study was conducted on 2000 Iranian households in five provinces of Iran in 2021. Data were collected through interviews using the World Health Survey questionnaire. Data from households whose health care costs were more than 40% of their capacity to pay were included in the group of households with catastrophic health expanditure (CHE). Determinants of CHE were identified using univariate and multivariate regression analysis. Results 8.3% of households had experienced CHE. The variables of being a female head of household (odd ratio [OR] = 2.7), use of inpatient (OR = 1.82), dental (OR = 3.09), and rehabilitation services (OR = 6.12), families with disabled members (OR = 2.03) and low economic status of the households (OR = 10.73) were significantly associated with increased odds of facing CHE (p

BACKGROUND: The present study aimed to evaluate the epidemiology, clinical characteristics, and outcome of confirmed and suspected hospitalized coronavirus disease 2019 (COVID-19) cases in Iran hospitals affiliated with the Kurdistan University of Medical Sciences, Sanandaj, Iran. METHODS: This cross-sectional study was performed on all confirmed and suspected hospitalized COVID-19 cases in hospitals affiliated with the Kurdistan University of Medical Sciences between March and September 2020. Required data were obtained from the Hospital Intelligent Management System of hospitals. Independent t-test, chi-square test, Fisher's exact test, and one-way analysis of variance (ANOVA) were used for univariate analysis. Variables with P-value < 0.3 in univariate analysis were entered into the multivariate model, and the adjusted odds ratio (AOR) was calculated. RESULTS: Out of 9176 cases, 3210 cases (35.03%) were confirmed with COVID-19. The mean and standard deviation (SD) of age of the cases was 56.5 ± 19.3 in the confirmed and 57.5 ± 20.6 in the suspected cases. The confirmed and suspected cases’ mortality rate was 15.0% and 10.2%, respectively. In both groups, the most common symptoms of admission to the hospital were respiratory distress, coughing, fever, and muscular pain. The variables of older age, male gender, being transferred to hospitals by ambulance, intensive care unit (ICU) hospitalization, being intubated, blood oxygen saturation level less than 93, and having an underlying disease were statistically associated with an increased chance of death. CONCLUSION: The mortality rate among both confirmed and suspected hospitalized COVID-19 cases was significant, and this rate was higher for the confirmed cases. Death-related risk factors should be considered in resource allocation, management, and patient prioritization to reduce the outcome of death.

Abstract Background and Aims During the coronavirus disease 2019 (COVID‐19) pandemic, about seven million people were infected with the disease, of which more than 133,000 died. Health policymakers need to know the extent and magnitude of the disease burden to decide on how much to allocate resources for disease control. The results of this investigation could be helpful in this field. Methods We used the secondary data released by the Kurdistan University of Medical Sciences between February 2020 to October 2021 to estimate the age‐sex standardized disability‐adjusted life years (DALY) by the sum of the years of life lived with disability (YLD) and the years of life lost (YLL). We also applied the local and specific values of the disease utility in the calculations. Results The total DALY was estimated at 23316.5 and 1385.5 per 100,000 populations The YLD and YLL constituted 1% and 99% of the total DALY, respectively. The DALY per 100,000 populations was highest in the men and people aged more than 65 years, but the prevalence was the highest in people under the age of 40. Conclusions Compared to the findings of the “burden of disease study 2019,” the burden of COVID‐19 in Iran is ranked first and eighth among communicable and noncommunicable diseases, respectively. Although the disease affects all groups, the elderly suffer the most from it. Given the very high YLL of COVID‐19, the best strategy to reduce the burden of COVID‐19 in subsequent waves should be to focus on preventing infection in the elderly population and reducing mortality.

Abstract Background and Aims The aim of this study was to investigate the prevalence and desire towards performing elective cosmetic surgery and its relationship with socioeconomic, mental, and spiritual health in Sanandaj, the capital of Kurdistan province in the west of Iran. Methods This cross‐sectional descriptive‐analytical study was performed on 492 subjects in Sanandaj using multistage sampling method. Data collection tools included two checklists and two questionnaires. Data analysis was performed using the Chi‐square test and multiple logistics regression model by the help of SPSS software version 20. Results The mean (standard deviation) age of participants was 32.58 (9.67) years. The prevalence of cosmetic surgery and the desire to perform it were 12.8% (n = 63) and 19.1% (n = 94), respectively. The most common type of cosmetic surgery was rhinoplasty with 5.5% (n = 27). The prevalence of symptoms of mental disorders among people with cosmetic surgery and people willing to perform cosmetic surgery was significantly higher than all subjects (p

Abstract Background The structure of the Iranian health system has raised this hypothesis that a part of the Knee Replacement Surgery (KRS) services are provided due to Physician-Induced Demand (PID). Methods This paper used an unbalanced individual panel data covering the steady-state 15,729 KRSs performed by 995 surgeons provided by the Armed Forces Insurance Organization at the provincial level over the 60 months (2014–2018). We use a generalized method of moment’s system (GMM-SYS) to obtain consistent and asymptotically efficient estimates, which provide a vital instrument for our dynamic panel data. Results The outcomes show that with unequal increasing orthopedic surgeons to population ratio, both the number and size of KRS services were increased significantly at a 1 % level. Given that the positive elasticity obtained for the service size was significantly larger than the number of services, the findings give strong support for the existence of PID in the Iran system for KRS care. Also, the raw and population-adjusted number of KRS, cost, and the surgery per active physician increased significantly at the monthly province level. Conclusions This is the first time that the existence of PID in the Iranian health system is investigated using approved econometric models. The findings indicate that the health system structure has been provided the conditions for aggressive, costly, and high-risk services such as KRS to be exposed to PID.

Abstract Background and Aims The aim of this study was to assess unmet needs for health care and its determinants during COVID‐19 pandemic among pregnant women in Iran. Methods This cross‐sectional study was performed among pregnant women in Kurdistan province in 2020 with a sample size of 800 people who were selected by multistage sampling method. Data were collected using a structured questionnaire that was completed through interviews. Also, multiple logistic regression was used to determine the relationship between independent variables and outcome variable. Statistical tests were performed using Stata software package. Results The highest unmet needs for health care were related to dental services with 66%, rehabilitation services with 58.6%, and psychological services with 43.2% and the lowest were related to hospital services with 12%, midwifery services with 15.6%, and physician visit services with 39.1%. The most important reasons for unmet needs for health care were fear of getting COVID‐19 and the cost of the services. The variables of age group and spouse education for physician visit services; age group for midwifery services; age group, education and employment status for dental services; age group, supplementary insurance and economic status for rehabilitation services; and age group and economic status for psychological services were significantly associated with unmet needs for health care (p

Abstract Background COVID-19 is a public health emergency with a high mortality rate and it reduces the patient’s Health-Related Quality of Life (HRQoL) significantly. This effect is measured in the current study. Methods In a cross-sectional study in Iran, 320 randomly selected treated patients from COVID-19 were studied. To collect the required data, we applied a questionnaire that included socio-demographic factors, clinical characteristics, and questions on the patients’ HRQoL. Time trade-off (TTO) approach was used to measure the lost HRQoL attributed to COVID-19. Besides, we applied a two-limit Tobit regression model to determine the effects of the socio-demographic factors on patients’ health utility and the visual analogue scale approach was used to estimate the perceived total current health status. Results The overall mean (SE) and median (IQR) of the health utility values were 0.863 (0.01) and 0.909 (0.21) respectively. These values for the traders (those who were willing to lose a part of their remaining time of life to avoid the disease) were estimated at 0.793 (0.01) and 0.848 (0.17), respectively. The lowest amount of utility value belonged to the elderly (mean (SE) = 0.742 (0.04); median (IQR) = 0.765 (0.42)) and those living in rural areas (mean (SE)) = 0.804 (0.03); median (IQR) = 0.877 (0.30)). The univariate analysis showed that age, place of residence, and household size had a statistically significant effect on health utility. Moreover, findings of the regression analysis indicated that the participants’ age and hospitalization status were the key determinants of COVID-19 health utility value. Conclusion COVID-19 is associated with a substantial and measurable decrease in HRQoL. This decline in HRQoL can be directly compared with that induced by systemic health states.

Objectives The aim of this study was to calculate the burden of stroke in Kurdistan Province, Iran between 2011 and 2017. Methods Incidence data extracted from the hospital information system of Kurdistan Province and death data extracted from the system of registration and classification of causes of death were used in a cross-sectional study. The World Health Organization method was used to calculate disability-adjusted life years (DALYs). Results The burden of stroke increased from 2453.44 DALYs in 2011 to 5269.68 in 2017, the years of life lost increased from 2381.57 in 2011 to 5109.68 in 2017, and the years of healthy life lost due to disability increased from 71.87 in 2011 to 159.99 in 2017. The DALYs of ischaemic stroke exceeded those of haemorrhagic stroke. The burden of disease, new cases, and deaths doubled during the study period. The age-standardised incidence rate of ischaemic stroke and haemorrhagic stroke in 2017 was 21.72 and 20.72 per 100 000 population, respectively. Conclusions The burden of stroke is increasing in Kurdistan Province. Since health services in Iran are based on treatment, steps are needed to revise the current treatment services for stroke and to improve the quality of services. Policy-makers and managers of the health system need to plan to reduce the known risk factors for stroke in the community. In addition to preventive interventions, efficient and up-to-date interventions are recommended for the rapid diagnosis and treatment of stroke patients in hospitals. Along with therapeutic interventions, preventive interventions can help reduce the stroke burden.

BACKGROUND: Asthma is the most common chronic respiratory disease (CRD) and one of the most serious and important pediatric diseases in developing countries. The present study aims to estimate the burden of asthma among children in Kurdistan Province, Iran. METHODS: Disability-adjusted life year (DALY) was used in order to estimate the burden of asthma. In a cross-sectional study, with a sample size of 4000, and using the multi-stage sampling method and Asthma and Allergies in Childhood (ISAAC) questionnaire, the prevalence of asthma was estimated for two 6-7 and 13-14 age groups in Kurdistan Province in 2013. In addition, some necessary data were extracted from the death registration system in Kurdistan Provincial Health Center and Statistical Center of Iran (SCI). RESULTS: Burden of asthma for 6-7 age group was 71.6 DALYs in boys (2.77 DALYs per 1000 population) and 48 in girls (2.22 DALYs per 1000 population) with a total burden of 119.6 DALYs (2.52 DALYs per 1000 population). Moreover, its burden for 13-14 age group was 121.1 DALYs in boys (4.86 DALYs per 1000 population) and 82.3 in girls (3.98 DALYs per 1000 population) with a total burden of 203.4 DALYs (4.46 DALYs per 1000 population). CONCLUSION: Considering the significant prevalence of asthma and its burden among children in Kurdistan Province, it is suggested that prevention and management of this disease be considered as a priority by policy makers and in health programs, in addition to attempting to prevent and reduce its burden by setting out effective interventions.

Abstract Background This study aims to determine the prevalence of physical inactivity in Iranian adolescents aged 10–12 years and the impact of socioeconomic inequality on it. Methods In this descriptive study, the study population consisted of 10–12 years old adolescents from an Iranian population from Kurdistan, Fars and Markazi provinces in 2018. The sample size was 1590 individuals. The sampling method was cluster sampling. Data was collected using demographic questionnaire, modifiable activity questionnaire (MAQ) and socioeconomic questionnaire. Cut points on the MAQ for light activity, moderate activity and heavy activity were MET 6, respectively. Linear and logistic regression were used to estimate the final model and the Oaxaca analysis method was applied. All analyses were performed in Stata/SE 14.0. Results Of the 1590 participants, 52.82% were male. The results showed that 25.79% of the subjects were physically inactive and 7.30% engaged in moderate physical activity during the week. The average physical activity during 1 week was more in boys than in girls (P-value

Abstract Background Despite the goal of horizontal equity in Iran, little is known about it. This study aimed i) to assess socioeconomic inequality and horizontal inequity in the healthcare utilization; and ii) to explore the contribution of need and non-need variables to the observed inequalities. Methods This study used national cross sectional dataset from Utilization of Health Services survey in 2015. Concentration Index (C), Concentration Curve (CC) and Horizontal Inequity index (HI) were calculated to measure inequality in inpatient and outpatient health care utilization. Decomposition analysis was used to determine the contribution of need and non-need factors to the observed inequalities. Result Results showed the pro-poor inpatient services in both rural (C = − 0.079) and non-rural areas (C = − 0.096) and the pro-rich outpatient services in both rural (C = 0.038) and non-rural (C = 0.007). After controlling for need factors, HI was positive and significant for outpatient services in rural (HI = 0.039) and non-rural (HI = 0.008), indicating that for given need, the better off especially in rural make greater use of outpatient services. The HI was pro-poor for inpatient services in both rural (HI = − 0.068) and non-rural (HI = -0.090), was significant only in non-rural area. Non-need factors were the most important contributors to explain inequalities in the decomposition analysis. Conclusion Disentangle the different contribution of determinants, as well as greater HI in rural areas for outpatient and in non-rural areas for inpatient services, provide helpful information for decision makers to re-design policy and re-distribute resource allocation in order to reduce the socioeconomic gradient in health care utilization.

Abstract Background Female genital mutilation/cutting (FGM/C) is a clear violation of women’s rights and can have adverse and irreversible health effects as well. Worldwide, more than 200 million women and girls have undergone FGM/C. Utility value of FGM/C has not been estimated yet, so we designed this study to extract the health utility value of FGM/C for the first time in the world. Methods In a cross-sectional study in Iran, 125 girls and women who underwent FGM/C procedure were examined by the trained midwives in order to determine its type. In addition, a questionnaire was completed for identifying the socio-demographic factors and extracting the health utility of these individuals. Health utility was measured using Time Trade-off method and also to determine the effects of the socio-demographic factors on the health utility a two-limit censored regression model was applied. Results The mean and median of the health utility of women with FGM/C were 0.971 (SE: 0.003) and 0.968 (IQR: 1–0.95), respectively. Number of non-traders was 58 (46.4%) who reported perfect health utility. However, the mean of health utility among traders was 0.946 (SE: 0.002). Only type 1 (Clitoridectomy) and type 2 (Excision) FGM/C were seen in this study. Women with Type 1 FGM/C had significantly lower health utility value (Mean: 0.968, Median: 0.957) than their type 2 counterparts (Mean: 0.987, Median: 1.00). Moreover, women in the age group of 31–45 years (Mean: 0.962, Median: 0.956), single (Mean: 0.950, Median: 0.954), divorced (Mean: 0.951, Median: 0.950), employed (Mean: 0.959, Median: 0.956), and with supplementary insurance (Mean: 0.962, Median: 0.950) had significantly lower health utility than their counterparts. Conclusion FGM/C affects physical and psychological well-being of these individuals, resulting in a lack of personal and marital satisfaction, which ultimately leads to a 3% reduction in their health related quality of life. Therefore, preventing from this practice is very important and should be considered by health system policy makers more than before.

The Dehgolan Prospective Cohort Study (DehPCS) was conducted to examine and identify risk factors for the most prevalent non-communicable diseases (NCDs). In addition, in order to examine participants’ health status, socioeconomic status, behavioral factors, nutritional status, and environmental exposures, the DehPCS collected, analyzed, and stored blood, urine, nail, and hair samples to conduct genetic studies and identify biomarkers and other biological determinants of NCDs. In total, 3,996 adults aged 35 to 70 from the general population participated in the study from February 2018 to March 2019. Of them, 43.7% were women. The first follow-up wave was conducted with 3,995 participants. Information on a wide range of variables was collected, including on socioeconomic status, lifestyle, nutritional status, habits, physical examination findings, medication use, and medical history. Proxy variables such as body mass index, metabolic equivalent task score, wealth index, and macronutrients and micronutrients were calculated. The most common self-reported diseases in descending order were kidney stones, hypertension, and fatty liver. The prevalence of diabetes and hypertension was 9.3% and 33.4%, respectively. All data, samples, and measurements will be collected again at 5-year intervals. Thus, it will be possible to examine time-dependent changes in the risk factors of NCDs. The DehPCS can be used to study the relationships among genetics, lifestyle, socioeconomic status, and environmental risk factors and the most prevalent NCDs in case-cohort studies using a nested case-control design that will be applied to the cohort infrastructure. Researchers can also submit pre-proposals via the following web address: http://c.ddrc.ac.ir/persianaccess/Account/Login.

Background: We aimed at estimating the burden of cancer in Kurdistan Province, western Iran during 2011-2017. Methods: In this cross-sectional study, incidence data extracted from the cancer registry system and death data were extracted from the system of registration and classification of causes of death of Kurdistan Province. We applied the WHO’ methods to calculate the disability-adjusted life year (DALYs). Results: The burden of cancer increased from a DALYs of 12309 in 2011 to 13969 in 2017, the YLL from 11644 in 2011 to 12951 in 2017 and the YLD from 665 in 2011 to 1018 in 2017. The top five cancers, according to DALYs (%) in both sex during 2011-2017 were: stomach (25%), lung (14%), liver (9%), esophagus (6%), and colon (6%). The most burden of cancer related to gastrointestinal tract (54% vs. 45%). Totally, more than 25% of DALYs were related to stomach cancer. Conclusion: The increasing DALYs of cancer in Kurdistan Province is one of the major public health concerns as in most developed countries. More than half of the burden of cancer in the Kurdistan Province is related to gastrointestinal tract. Stomach cancer, is accounting for more than 25% of the burden in both sexes. Urgent policy, management and public health measures such as general education, screening, early detection and effective treatment are recommended to reduce the burden of cancers and especially gastrointestinal tract malignancies.

Background: Calculating the burden of diseases is essential for their monitoring. The burden of cardiovascular diseases in Kurdistan Province has not been reported. This study aimed at calculating the burden of cardiovascular diseases in the Kurdistan Province from 2011 through 2017. Methods: In this cross-sectional study, incidence data were extracted from registration systems. The methods of the World Health Organization (WHO) were employed to calculate disability-adjusted life years (DALYs) of cardiovascular diseases in the Kurdistan Province. DALYs were calculated by summing the years of life lost (YLLs) and the years of life lived with disability (YLDs) for sex, age group, and year. Results: The burden of cardiovascular diseases increased from 18569.1 DALYs in 2011 to 34929.8 DALYs in 2017. The highest increase and the largest decrease in DALY according to the all age-standardized DALYs index were related to acute myocardial infarction and heart failure in women, respectively. The highest DALYs in both sexes were in the age group of over 80 years. Conclusion: The burden of cardiovascular diseases is increasing in the Iranian province of Kurdistan. It is, therefore, essential to implement appropriate and adequate interventions such as lifestyle modification, extensive screening, public education promotion, and operational plan development. We hope our results will aid decision-makers in performing urgent interventions.

Objective: The present study was conducted to evaluate the quality of care for type2 diabetic patients based on the HbA1c in Iran. Materials and methods: This cross-sectional study was conducted in 2019 among patients with type 2 diabetes in Iran. The data were collected through a three-part questionnaire including demographic information, disease-related records, and HbA1C status of patients. Multiple logistic regression was used to investigate the relationship between the outcome variable (HbA1c status) and the independent variables in Stata 12. Results: The mean HBA1c was 8.01 ± 1.76% among 1,198 diabetic patients, and more than 66% of them had HBA1c above 7%, i.e. they had uncontrolled blood sugar levels. HBA1c has the highest average among people with more than 10 years of diabetes (8.47 ± 1.77%), self-employed people (8.36 ± 1.94%), illiterate people or those with elementary education (8.13 ± 1.76%) and people with poor economic status (8.12 ± 1.79%). Also, in the final model, people with more than 10 years of disease history had the highest prevalence of HBA1C > 7 with a chance ratio of 3.28 (P < 0.001, 95%CI: 2.37–4.53) and followed by illiterate people or those with elementary education with a chance ratio of 1.6 (P = 0.020, 95%CI: 1.08–2.39) compared to those with high school diploma or academic education. Conclusion: The prevalence of adverse HBA1c in 66% of the studied subjects indicates an inappropriate status of diabetes control in Iran. This indicates the poor quality of services provided to the diabetics. This is a warning sign and requires appropriate interventions to improve the quality of services provided to diabetic patients.

Summary: Background: Oral rehydration solution (ORS) is a form of oral rehydration therapy (ORT) for diarrhoea that has the potential to drastically reduce child mortality; yet, according to UNICEF estimates, less than half of children younger than 5 years with diarrhoea in low-income and middle-income countries (LMICs) received ORS in 2016. A variety of recommended home fluids (RHF) exist as alternative forms of ORT; however, it is unclear whether RHF prevent child mortality. Previous studies have shown considerable variation between countries in ORS and RHF use, but subnational variation is unknown. This study aims to produce high-resolution geospatial estimates of relative and absolute coverage of ORS, RHF, and ORT (use of either ORS or RHF) in LMICs. Methods: We used a Bayesian geostatistical model including 15 spatial covariates and data from 385 household surveys across 94 LMICs to estimate annual proportions of children younger than 5 years of age with diarrhoea who received ORS or RHF (or both) on continuous continent-wide surfaces in 2000–17, and aggregated results to policy-relevant administrative units. Additionally, we analysed geographical inequality in coverage across administrative units and estimated the number of diarrhoeal deaths averted by increased coverage over the study period. Uncertainty in the mean coverage estimates was calculated by taking 250 draws from the posterior joint distribution of the model and creating uncertainty intervals (UIs) with the 2·5th and 97·5th percentiles of those 250 draws. Findings: While ORS use among children with diarrhoea increased in some countries from 2000 to 2017, coverage remained below 50% in the majority (62·6%; 12 417 of 19 823) of second administrative-level units and an estimated 6 519 000 children (95% UI 5 254 000–7 733 000) with diarrhoea were not treated with any form of ORT in 2017. Increases in ORS use corresponded with declines in RHF in many locations, resulting in relatively constant overall ORT coverage from 2000 to 2017. Although ORS was uniformly distributed subnationally in some countries, within-country geographical inequalities persisted in others; 11 countries had at least a 50% difference in one of their units compared with the country mean. Increases in ORS use over time were correlated with declines in RHF use and in diarrhoeal mortality in many locations, and an estimated 52 230 diarrhoeal deaths (36 910–68 860) were averted by scaling up of ORS coverage between 2000 and 2017. Finally, we identified key subnational areas in Colombia, Nigeria, and Sudan as examples of where diarrhoeal mortality remains higher than average, while ORS coverage remains lower than average. Interpretation: To our knowledge, this study is the first to produce and map subnational estimates of ORS, RHF, and ORT coverage and attributable child diarrhoeal deaths across LMICs from 2000 to 2017, allowing for tracking progress over time. Our novel results, combined with detailed subnational estimates of diarrhoeal morbidity and mortality, can support subnational needs assessments aimed at furthering policy makers' understanding of within-country disparities. Over 50 years after the discovery that led to this simple, cheap, and life-saving therapy, large gains in reducing mortality could still be made by reducing geographical inequalities in ORS coverage. Funding: Bill & Melinda Gates Foundation.

Background One of the objectives of the health transformation plan (HTP) in Iran is to reduce out-of-pocket (OOP) payments for inpatient services and eradicate informal payments. The HTP has three phases: the first phase (launched in May 5, 2014) is focused on reducing OOP payments for inpatient services; the second phase (launched in May 22, 2014) is focused on primary healthcare (PHC) and the third phase utilizes an updated relative value units for health services (launched in September 29, 2014) and is focused on the elimination of informal payments. This aim of this study was to determine the OOP payments and the frequency of informal cash payments to physicians for inpatient services before and after the HTP in Kurdistan province, Iran. Methods This quasi-experimental study used multistage sampling method to select and evaluate 265 patients discharged from hospitals in Kurdistan province. The study covered 3 phases (before the HTP, after the first, and third phases of the HTP). Part of the data was collected using a hospital information system form and the rest were collected using a questionnaire. Data were analyzed using Fisher exact test, logistic regression, and independent samples ttest. Results The mean OOP payments before the HTP and after the first and third phases, respectively, were US$59.4, US$17.6, and US$14.3 in hospital affiliated to the Ministry of Health and Medical Education (MoHME), US$39.6, US$33.7, and US$13.7 in hospitals affiliated to Social Security Organization (SSO), and US$153.3, US$188.7, and US$66.4 in private hospitals. In hospitals affiliated to SSO and MoHME there was a significant difference between the mean OOP payments before the HTP and after the third phase (P < .05). The percentage of informal payments to physicians in hospitals affiliated to MoHME, SSO, and private sector, respectively, were 4.5%, 8.1%, and 12.5% before the HTP, and 0.0%, 7.1%, and 10.0% after the first phase. Contrary to the time before the HTP, no informal payment was reported after the third phase. Conclusion It seems that the implementation of the HTP has reduced the OOP payments for inpatient services and eradicated informal payments to physician in Kurdistan province.

Background & Aim: Cesarean rate has had a rising trend in Iran during the last two decades. Natural childbirth promotion plan has been implemented in the form of health sector evolution plan (HSEP) in order to increase natural childbirth. Present study aimed to evaluate the effect of health sector evolution plan on cesarean rate and the average costs paid by mothers hospitalized in Kurdistan province. Methods & Materials: This descriptive study was conducted as longitudinal and retrospective study. Cesarean rate in all hospitals of Kurdistan province was assessed in 2013 and one year after the implementation of HSEP. Furthermore, data related to the percentage of out of pocket expenditures by pregnant mothers in one of the hospitals of Kurdistan University of Medical Sciences, which was randomly selected, was also studied. Data were analyzed using SPSS v.20. Results: There was a 14.02% reduction in the rate of cesarean in Kurdistan province one year after the implementation of HSEP compared to its basal rate in 2013 (P

Background: Diarrhea is a major cause of public health burden, especially in children under 5 yr of age. This study aimed at estimating the incidence, mortality, burden, and geographical distribution of Acute Watery Diarrhea (AWD) in Iran from 2009 to 2016. Methods: This study was conducted in 2018. The data on the incidence and mortality from 2009 to 2016 was obtained from AWD surveillance system of the Centre for Communicable Diseases Control (CCDC), Ministry of Health and Medical Education (MOHME) of Iran. Disability Adjusted Life Years (DALYs) was used to estimate the burden of AWD. The DALYs-related AWD was calculated using a method developed by WHO. The average duration of the disease and its disability weight, respectively, were set at 5 d (0.0137 years) and 0.093 for all age groups. Results: The incidence of AWD had an ascending trend over the studied period. Forty cases of deaths from AWD were reported. The lowest and highest burdens of AWD, respectively, were 436.1 DALYs in 2010 and 975.9 DALYs in 2015. The incidence and burden of AWD did not have an equal distribution across the country, between the provinces. Conclusion: The incidence of AWD had an ascending trend over the studied period that can be attributed to the improvements in the disease surveillance system. Moreover, the incidence, mortality, and burden of AWD did not have an equal distribution in Iran. Hence, it is recommended to strengthen AWD surveillance system. In addition, it is suggested to adopt proper interventions for controlling the disease in areas with a high burden of AWD.

Background: This study aimed at estimating the incidence, mortality, burden, and geographical distribution of Crimean Congo Hemorrhagic Fever (CCHF) using Disability Adjusted Life Years (DALYs) in Iran 2009-2015. Methods: CCHF-related DALYs was calculated using a method developed by WHO for the investigation of Global Burden of Diseases (GBD). DALYs was calculated through adding years of life lost due to premature death (YLLs) to years lived with disability (YLDs). To calculate YLD, the average duration of the disease and its disability weight were set at 25 d and 0.613, respectively. The data on the incidence and mortality were collected from the CCHF surveillance system from the governmental section. Results: The highest and the lowest incidence rates of CCHF were observed in 2009 (122 cases) and 2010 (254 cases), respectively. Moreover, the lowest and highest mortality rates were reported in 2009 (20 cases) and 2012 (52 cases), respectively. The mean rate of fatality from CCHF observed between 2009 and 2015 was about 21.1%. In addition, the lowest and highest DALYs were observed in 2009 (483 cases) and 2010 (1156 cases), respectively. CCHF incidence, DALYs, and mortality rate over the studied period were higher among males than females. CCHF-related DALYs did not have an equal distribution in all provinces of Iran; some provinces were suffering from a higher burden of the disease. Conclusion: It is recommended to improve the CCHF surveillance system, identify high-risk areas, practice early diagnosis and intervention, develop vaccines, control, and fight tick, and screen livestock to control and prevent the spread of this disease.

Background: This study aimed at estimating the incidence, mortality, and burden of Hepatitis B (HBV) and Hepatitis C (HCV) viruses and their trends from 2008 to 2015. Methods: The Disability Adjusted Life Year (DALYs) index was applied to calculate the burden of the diseases by age, sex, time, and locations. The incidence and demographic data were obtained from HBV and HCV surveillance system, and the data on natural history was extracted from the cohort studies; moreover, the data on the standard life expectancy was obtained from the Iranian life table 2016. The two values of 0.03 and 21.5 yr were set as the discount rate and mean standard duration of the disease for both types of hepatitis. Results: The burden of HBV decreased from 13735 to 78277.6 yr, but there was an increase in the burden of HCV from 5174 to 14395 yr over the studied period. The burden of both types of hepatitis was higher among males than females. The incidence of HBV increased from 46611 to 22996 cases, and the incidence of HCV increased from 1210 to 3939 cases. The HBV decreased from 1925 to 1394 cases; however, the number of deaths caused by HCV increased from 197 to 583 cases over the studied period. The share of YLLs raised from 5% to 10% for HBV whereas it changed from 23% to 62% for HCV over the studied years. Tehran, Khorasan Razavi, and Golestan had the highest and Chaharmahal and Bakhtiari, Kurdistan, and Kermanshah had the lowest adjusted burden of HBV per 1000 population. Conclusion: Although the incidence, mortality, and burden of HBV declined over the eight studied years, these values increased dramatically for HCV.

Background: Human brucellosis is the most common zoonotic disease worldwide. This study aimed at estimating the incidence, mortality, and burden of human brucellosis as well as its distribution in Iran from 2009 to 2015. Methods: Disability Adjusted Life Years (DALYs) index was used to estimate the burden of human brucellosis. To calculate DALYs, years lost due to disability (YLDs) was added to years of life lost due to premature death (YLLs); they were calculated based on the Global Burden of Disease (GBD) formula recommended by the WHO. The data on incidence and mortality were collected from the national surveillance system of brucellosis disease in the Center for Communicable Diseases Control (CCDC), Ministry of Health and Medical Education (MOHME), expert panels, and related literature. Results: There is an increasing trend in human brucellosis-related DALYs (34.6 per 100,000 in 2009, and 71.4 per 100,000 in 2015), incidence (88450 in 2009, and 198030 in 2015), and mortality (244 in 2009, and 578 in 2015) from 2009 to 2015. Human brucellosis-related DALYs, incidence, and mortality were higher among males than females. About 51% of DALYs was attributed to YLLs. The burden of human brucellosis disease was not equally distributed among all provinces of Iran and it was largely concentrated in a number of provinces. Conclusion: Burden of human brucellosis is significantly high in Iran, and it has also increased during the recent years. It is alarming for health system managers and policymakers, and they are recommended to pay more attention to this issue.

Background: Iran is among the first six countries in the world with the highest annual incidence of cutaneous leishmaniasis. This study aimed at estimating the incidence, burden, and trend of cutaneous leishmaniasis at the national level in Iran from 1977 to 2015. Methods: This study was conducted in 2017, used Disability Adjusted Life Years (DALYs) index, recommended by the WHO for assessing the Global Burden of Diseases, to estimate the burden of cutaneous leishmaniasis. The data on the incidence of the disease and the number of cases was obtained from the communicable diseases surveillance system (Center for Communicable Diseases Control (CCDC), Ministry of Health and Medical Education (MOHME) of Iran) that routinely collects data from all over the country; in addition, some data was extracted by reviewing the texts. Considering the views expressed in a panel of experts, to calculate the actual incidence of the disease, the number of registered cases was multiplied by 5. Results: The incidence of cutaneous leishmaniasis varied from approximately 50 to 250 cases per 100,000 population during the studied period. During these years, the incidence of the disease was higher in males than females. Moreover, the burden of cutaneous leishmaniasis varied between 1.18 and 5.7 DALYs per 100000 population during the studied period. The incidence and burden of cutaneous leishmaniasis have not significantly decreased in recent years. Conclusion: Despite the implementation of a program for controlling cutaneous leishmaniasis in Iran since 1977, the incidence and burden of the disease are still high in the country; it is seriously alarming for policy makers and managers of the health system in Iran, indicating the presence of some problems in controlling the disease.

Background: Severe Acute Respiratory Infection (SARI) is responsible for mortality and hospital admissions in millions of people across the world. The present study, for the first time, aimed at estimating the incidence, mortality, and burden of SARI in Iran in 2015. Methods: Disability Adjusted Life Years (DALYs) was used as an index to estimate the burden of SARI. The SARI-related DALYs was calculated using a method developed by the WHO for assessing the Global Burden of Diseases. DALYs are calculated as the sum of the Years Lost due to Disability (YLDs) and the Years of Life Lost (YLLs) due to premature mortality. The data on the incidence and mortality were obtained from the SARI surveillance system of Iran's Ministry of Health and Medical Education. The average duration until remission or death and the disease disability weight were set at four weeks and 0.373, respectively. Results: In 2015, the incidence of SARI was 21309 and 20885 among males and females, respectively. Moreover, 773 males and 737 females died from this disease (Case fatality rate was about 0.035). Total SARI-related DALYs in males and females was 17264 and 16720, respectively. Furthermore, YLLs was responsible for more than 96% of SARI-related DALYs in 2015. Conclusion: There was no significant difference between males and females in terms of the incidence, mortality, and burden of SARI in 2015. Epidemiological data are required to adopt appropriate policies and responses to prevent and control SARI. The incidence, mortality, fatality, and burden of SARI are significant in Iran. It is necessary to develop appropriate strategies, such as vaccination against major pathogens of the disease at least in high-risk groups, strengthening the disease surveillance system, and attracting the attention of policy makers and health authorities of the country.

Background: This study aimed at estimating the incidence, mortality, burden, and geographical distribution of HIV/AIDS in Iran at national and provincial level during 2008-2016. Methods: We applied the Disability Adjusted Life Years (DALYs) index to assess the burden of HIV/AIDS on the basis of Years of Life Lost (YLLs) and Years Lived with Disability (YLDs). We used the Iranian life table of 2016 for treated and a fixed figure of 8 years as remaining length of life in untreated patients, 0.03 as discount rate, and 0.504 as disability weigh in both treated and untreated cases. The primary data was obtained from HIV/AIDS surveillance system. Results: The incidence of HIV/AIDS increased from 4440 cases in 2008 to 4928 cases in 2016. The mortality rate was 259 and 288 cases in 2008 and 2016, respectively, which was always higher among males than females. The burden of HIV/AIDS increased from 26231 DALYs in 2008 to 29114 DALYs in 2016. In addition, the population-adjusted burden of HIV/AIDS was not equally distributed among different provinces of Iran, and it was more concentrated in western regions of the country during the studied period. Conclusion: Although the trend of the national burden of HIV/AIDS did not change significantly over the past decade, it was alarming especially among males and among people living in some provinces such as Kermanshah, Lorestan, Hormozgan, and Tehran.

Background: This study aimed at estimating the incidence, mortality, burden, and geographical distribution of malaria between 2002 and 2015 in Iran. Methods: DALYs index was used to estimate the burden of malaria. DALYs-related malaria was calculated using a method developed by (WHO) for investigating the Global Burden of Disease (GBD); it was calculated through adding Years of Life Lost (YLLs) due to premature death to Years Lived with Disability (YLDs).The data on the incidence and mortality were collected from the malaria surveillance system in the Center for Communicable Diseases Control (CCDC), Ministry of Health and Medical Education (MOHME). Results: The incidence of malaria had a decreasing trend over the studied period and it reduced from 15378 cases in 2002 to 777 cases in 2015. Overall, 28 cases of mortality were observed between 2002 and 2015. In addition, disease burden decreased from 90.78 DALYs in 2002 to 22.38 DALYs in 2015.Overall, there were 949.2 DALYs due to malaria from 2002 to 2015. The incidence and burden of malaria were not equally distributed among all the provinces in Iran and some areas were suffering from the highest burden of the disease. Conclusion: The incidence and burden of malaria have had a decreasing trend over the years of the study and Iran has little to do in order to eradicate malaria. Since the disease is not equally distributed among various provinces of Iran, health policymakers must direct health resources towards specific areas of the country (Sistan and Baluchistan, Kerman, and Hormozgan) with high concentration of cases of malaria.

Background: One of the main objectives of health systems is the financial protection against out-of-pocket (OOP) health expenditures. OOP health expenditures can lead to catastrophic payments, impoverishment or poverty among households. In Iran, health sector evolution plan (HSEP) has been implemented since 2014 in order to achieve universal health coverage and reduce the OOP health expenditures as a percentage of total health expenditures. This study aimed to explore the percentage of households facing catastrophic health expenditures (CHE) after the implementation of HSEP and the factors that determine CHE. Methods: A total of 663 households were selected through a cluster sampling based on the census framework of Sanandaj Health Center in July 2015. Data were gathered using face-to-face interviews based on the household section of the World Health Survey questionnaire. In this study, according to the World Health Organization (WHO) definition, if household health expenditures were equal to or more than 40% of the household capacity to pay, household was considered to be facing CHE. The determinants of CHE were analyzed using logistic regression model. Results: The rates of households facing CHE were 4.8%. The key determinants of CHE were household economic status, presence of elderly or disabled members in the household and utilization of inpatient or rehabilitation services. Conclusion: The comparison of our findings and those of other studies carried out using a methodology comparable with ours in different parts of Iran before the implementation of HSEP suggests that the implementation of recent reforms has reduced CHE at the household level. Utilization of inpatient and rehabilitation services, the presence of elderly or disabled members in the household and the low economic status of the household would increase the likelihood of facing CHE. These variables should be considered by health policy-makers in order to review and revise content of recent reform, thus financially protecting public against CHE.

Background: This study measured socioeconomic inequalities in different types of disabilities in Iran. We also examined the prevalence of disabilities across different socio-demographic groups in Iran in 201 Methods: This was cross-sectional study using secondary data analysis on all Iranian. Data related to disability prevalence and socioeconomic status (SES) of each province was extracted from the 2011 National Census of Population and Housing (NCPH) and the 2011 Households Income and Expenditure Survey (HIES), conducted by Statistical Center of Iran (SCI). The concentration index and concentration curve were used to measure and illustrate socioeconomic inequalities in different types of disabilities. Chi-squared test was also used to examine the relationship between the socio-demographic variables (age-groups, sex, education level, employment status) and disability. Results: The results suggested the existence of socioeconomic inequalities in blindness, deafness, vocal disorders and hand disorders in Iran. The concentration index for these four disabilities were -0.0527 (95% confidence interval [CI]: -0.0881, -0.0173), -0.0451 (CI: -0.0747, -0.0156), -0.0663 (CI: -0.1043, -0.0282) and -0.0545 (CI: -0.0940, -0.0151), respectively. There were also significant associations between the demographic variables such as age-groups, sex, education level, employment status and disability (P

Background: Job satisfaction of physicians in family physician team is considered as one of the important factors for health system. The aim of the preent study was to compare the quality of work life (QoWL) in rural family physicians and general physicians with private clinics in Kurdistan province. Methods: A cross-sectional study was conducted among 103 general physicians including 50 rural family physicians and 53 general physicians with private clinics in Kurdistan province in 2016. The data were collected using QoWL questionnaire and analyzed using SPSS, v. 16. Descriptive statistics including frequency, percentage, mean, and standard deviation (SD) were used to describe the data and to examine the relationship between the variables, T-test was run. Results: The QoWL of rural family physicians with a mean of 55 (SD = 7.6) was higher than average scores. But QoWL of other general physicians with a mean of 47.7 (SD = 13.5) was lower than average scores. The results of t-test showed that there was a significant difference between QoWL of family physicians and other general physicians (t = 82.3, p = 0.001). In rural family physicians, there is a significant association between the QoWL and gender (t=2.7, P = 0.009) as well as native status (t=2.53, P = 0.004). In general physicians with private clinics, the QoWL of native physicians was higher than that of non-native physicians (t = 4.3, P = 0.001). Conclusion: The QoWL of rural family physicians is better than that of others general physicians, even though it is unsatisfactory in both studied groups. Therefore, improving the QoWL of rural family physicians, especially female and non-native rural family physicians, is recommended because promoting the rural family physicians' satisfaction can decrease the likelihood of turnover, and thus increase service quality and responsiveness, as a goal of the health system.

Background: Pabon Lasso model was applied to assess the relative performance of hospitals affiliated to Kurdistan University of Medical Sciences (KUMS) before and after the implementation of Health Sector Evolution Plan (HSEP) in Iran. Methods: This cross-sectional study was carried out in 11 public hospitals affiliated to KUMS in 2015. Twelve months before and after the implementation of the first phase of HSEP, a checklist was used to collect data from computerized databases within the hospitals' admission and discharge units. Pabon Lasso model includes three indices: bed turnover, bed occupancy ratio, and average length of stay. Results: Analysis of hospital performance showed an increase in mean of bed occupancy and turnover ratio, which changed from 65.40% and 86.22 times/year during 12 months before to 69.97% and 90.98 times/year during 12 months after HSEP, respectively. In line with Pabon Lasso model, before the implementation of HSEP, 27.27% and 36.36% of the hospitals were entirely efficient and inefficient, respectively, whilst after the implementation of HSEP, their condition changed to 18.18% and 27.27%, in order. Conclusion: Indicators of bed occupancy and turnover ratio had a 4% increase in the studied hospitals after the implementation of HSEP. Number of the hospitals in the efficient zone reduced because of the relative measurement of efficiency by Pabon Lasso model. Since more than 50% of the hospitals in the studied province have not yet reached their optimal bed occupancy ratio (more than 70%), short-term and suitable strategy for improving the efficiency is to stop further expansion of hospitals as well as developing the number of hospital beds.