Factors Affecting Fair Access to Outpatient Services in Iranian Healthcare System Using Dematel Approach

Abstract 
Background: Outpatient services constitute a major part of healthcare services. Fair access to these services plays an important role in promoting the community health status. Therefore, the purpose of the current study was investigating the factors affecting fair and equitable access to outpatient services in the Iranian healthcare system. 
Methods: This applied study was descriptive using a mixed method (qualitative-quantitative) approach. Semi-structured interviews and a pairwise comparison matrix were used to collect data. The validity and reliability of the interviews were obtained through Lincoln and Guba methods and the validity and reliability of the pairwise comparison matrix were determined based on the inconsistency rate which was less than 0.1. In the first phase, research population included policy makers and health professionals, and in the second phase, hospital managers and faculty members, who were selected by purposive sampling method. The data collected in the first phase were prioritized using MaXQDA software and coding method and in the second phase, using Excel software and Dematel approach. 
Results: Based on the findings of the study, the following indicators had the highest to lowest significance in the fair access to outpatient services in the Iranian healthcare system, respectively. They were physical (effective), financial (effective), manpower (influential), demographic (influential), facilities and equipment (influential), political (influential) factors. 
Conclusion: Policymakers, managers, and planners need to pay special attention to the development of physical infrastructure and the allocation of adequate funding to the outpatient services in the public sector.
Keywords:  Public sector, Iran, Public health, Delivery of health care, Outpatient services, Fairness, Access 

Introduction 
Health is a universal human right and a basic human need. Improving the health of communities is the main goal in healthcare systems, which is created by improving the response to the needs of communities and financial justice (1). 
The basis of most democratic and modern countries is the fair access to health services and all citizens should have fair access to these services regardless of their age, gender, socio-economic status, and ethnicity (2). Access to healthcare services is an issue that has attracted a lot of attention today (3). Fair access to health services is one of the most important goals of health policy makers in many developed countries. Fairness is one of the most important indicators of service quality that is not easily accessible (4). Fair access to health services is a complex and ambiguous issue (5), and has become an important but unattainable goal (6). Also, access to a safe and effective health care system is one of the main determinants of a high-quality health system (1,7). 
Access to healthcare services has been introduced as one of the basic rights of citizenship in many countries and thus, affects health outcomes and life expectancy. Ease of access to health services in the healthcare system is an important factor in providing high quality services (8). Factors affecting fair and effective access to health services are multidimensional and are both influenced by legal and policy-making factors as well as material factors (9). Fair access to health services has two main components of affordability and availability of services, which are the two sides of the same coin (10).One of the most fundamental questions for all health policymakers is how to best allocate public health resources to outpatient and inpatient services (11). There is obvious unfairness in accessing high quality outpatient services (12). 
The outpatient department of the hospital is one of the first environments that patients enter upon arrival at the hospital and is the most important place in which patients’ admission to the inpatient wards is determined. On the other hand, the outpatient department of hospitals is developing rapidly, so the volume of services provided in this department is equal or higher than inpatient departments’ services (13). New challenges and changes in the healthcare system led to new changes in the provision of outpatient services. Delay in the access to health services is an important issue (14).
Three main goals of the health system are to ensure, maintain, and promote the health of the community, meet people expectations and financially support them against health costs. Efficiency, quality, safety, resilience, and justice are also intermediate goals of the health system, prerequisites for achieving the main goals. However, fair distribution of health resources and fair access to these resources are the most important goals of the health care system (15). 
In other words, better provision of the health system services, availability of these services at different times, different places, and different conditions are the necessities of providing health services for individuals in society. In view of the fundamental changes in the world, including the diversity and growth rate of diseases, increasing people’s awareness of safety/related issues, increasing costs in home and teleservices, advances in fields of medicine, bioterrorism, use of wireless and cyberspace, population growth and aging, increasing patient burden, reduced number of health care providers, and equitable access to health services are complex and sometimes unattainable goals (16,17).
Outpatient services are the gateway to services in the health system. Therefore, quality, safety, efficiency, effectiveness, temporal, spatial, and situational availability are very important in terms of physical, equipment, human, information, and specialized resources. All these factors may affect the patient’s attitudes about health care system and will create a financial and work burden for the other wards of hospital. Receiving timely, appropriate, sufficient, effective, and suitable services in the outpatient department may prevent the burden of disease and increase the load of work in outpatient services in hospitals. 
Numerous studies have examined the indicators of equitable access to services, especially outpatient services, which are reviewed below. Malmir et al (18), examined the indicators and barriers to equitable access to outpatient services in health care system in Iran. The results of the study showed that the indicators of equitable access to health services include financial indicators, physical indicators, and demographic indicators. Hosseini et al (19), conducted a review about Equitable Outpatient Services. The results of their study show that justice and fair access to health services is a major challenge not only in Iran but also all over the world. The best solution for assessing justice in a health system is need-based assessment.
Emanuel et al (20), conducted a study entitled “Fair allocation of scarce medical resources in the time of COVID -19”. The results of this study show the importance of prioritizing services in the field of outpatient services to patients. Rahman and Rizavi (21), conducted a study entitled “Survey of patients’ satisfaction with the healthcare services in the outpatient department of military hospitals”. In this study, the factors affecting the satisfaction of outpatients included the services of the paraclinical departments, cleanliness of the environment of the service centers, the treatment provided and its quality, the information provided to patients, and patient information transfer. The purpose of the present study was to determine the causal relationships and the severity of factors affecting equitable access to outpatient services in the Iranian health system. 

Materials and Methods
This applied research was descriptive, and in terms of data type, it was a mixed study (qualitative-quantitative). It was conducted in two stages.  For qualitative research, grounded theory was used and the strategy for analyzing the data was content analysis. The factors affecting equitable access to outpatient services in the Iranian health systems were identified. At this stage, research population included policy makers, managers, and planners of the Iranian health system. In the first stage, purposive sampling was used and the inclusion criteria were having at least a general practitioner degree, at least 5 years of practical experience at high levels and mainly in policy making, decision making, management positions and willingness to participate in interviews. The sampling process continued until reaching information saturation and when no new information was achieved (theoretical saturation) and finally the interview was performed with 33 participants. Data collection tool at this stage was a semi-structured interview form. This form consisted of 4 main questions that were acquired by reviewing the literature and based on the main research questions. In these questions, the interviewees’ opinions on fair access to outpatient services, barriers, strategies, and effective deterrents and promoters in the Iranian healthcare system were queried, and a supplementary question was used about interviewees’ opinions on the fair access to outpatient services, which had been ignored in interview form. Prior to submitting the interview form, the participants were provided with instructions for interview questions. Lincoln and Guba method was used to determine the validity and reliability of the interview. Upon completion, the interviews were conducted and a copy was sent to the interviewee for final approval. Finally, the interviews were transcribed and one copy was sent to the interviewees for approval. To extract the concepts at this stage, open and selective coding was used and the barriers to fair access to outpatient services in the Iranian health system were identified. 
In the second phase of the research (quantitative section), the factors extracted from the interview were prioritized using the Dematel approach and the effective and influential factors were determined. The data collection tool at this phase was a pairwise comparison matrix indicating the relevant, effective, and influential factors in pairs based on the 5-scale Likert spectrum consisting of zero (ineffective), one (very low effect), two (low effect), three (high effect), and four (very high effect). The questionnaire prepared in this section consisted of six items and considering that the inconsistency rate of the respondents’ answers was below 0.1 and that all the factors extracted from the interview phase were examined in this stage, the questionnaire had the required validity and reliability. The research population at this stage was 32 physicians, hospital managers, faculty members and university instructors, policy makers and executives and planners in the healthcare system of the country. 
It is noteworthy that the questionnaires developed at this phase were provided to participants through e-mail, postal correspondence, available and widely used social networks and were completed with a follow-up and reminder by the researcher in a period of three weeks. The data collected in the first phase were analyzed with MAXQDA software using open and selective coding method and the data collected in the second phase was analyzed using Excel Software by the Dematel approach (systematic relationship analysis) to determine affect intensity. 
The Dematel Method was used in 1971 to examine complex issues by using expert judgment. One of the advantages of this method compared to other methods is that it examines the relationship between criteria in a network and also identifies the two-way relationship and the cause and effect between criteria (22).

Results
In the first part of the research, the results of the interview showed that the indicators of the fair access to outpatient services include the 6 main indices of manpower, policymaking, facilities, equipment, finance, and physical and demographic indicators. Of course, each of the main axes were composed of sub-categories, which are provided in table 1. 
Barriers to fair access to healthcare services also included political, resource, manpower, infrastructure, and financial barriers. Each of these main factors is composed of sub-factors, which are described in  table 2. 
In the second section, the pairwise comparison matrix analysis was performed with Excel software using Dematel approach, the results of which were as follows. For this purpose, a direct matrix, a normalized direct relations matrix, and a general relations matrix were formed. Finally, the set of elements of the columns and rows of the T matrix for the main factors and its sub-factors were calculated and named as vectors D (effective) and R (influential). Finally, the degree of interaction of factors (D+R), and the relationship between factors or the net effectiveness or influential (D-R) degrees were determined. Factors with a positive D-R are effective (cause) and factors with a negative D-R are influential (effect) (Tables 3 and 4). 
As shown by the results of the study, in this model, physical and financial indicators are the cause (effective) and policymaking, manpower, facilities and equipment, and demographic indicators are the effect (influential). 

Table 1. Indicators of the fair access to outpatient services

Table 2. Indicators of barriers to access to outpatient services

Table 3. Direct relationship between factors affecting fair access to outpatient services in the health system

Table 4. Effective and influential factors of fair access to outpatient services in the Iranian health system

Table 5. Priorities of factors based on the degree of interaction and effectiveness

Discussion
As shown by the results of the study, physical indicators have the highest priority in the fair access to outpatient services in the Iranian healthcare system. One of the most important parts of the Iranian healthcare system transformation plan in 2014 was the development of infrastructure to admit a wider range of outpatients, and to achieve this, the construction and development of special clinics was one of the most important practical measures. In other words, the construction of special clinics to increase the range of outpatient services was performed by the public sector, but according to the Health Transformation Plan, the integration of outpatient services and creating a high variety of services including visits, tests, paraclinical services, and rehabilitation were among the most important programs. Therefore, according to the results of the present study, the development of these clinics and paying attention to the provision of services around the clock as well as providing incentive mechanisms for full-time activity of general practitioners and specialists in these clinics play a key role in creating and increasing physical access to outpatient services. Equipping these clinics, providing appropriate services, cleaning the physical environment, having comfortable facilities, and taking care of  patients in clinics and hospitals are among the necessities of increasing access to outpatient services in the Iranian health system. According to researchers, this field of study has a high importance and priority.
Keshtkaran et al (23), stated that welfare facilities and physical space are an effective factor in the quality of outpatient services. Karimi et al (24), mentioned that the most important patients’ dissatisfaction with outpatient services is the lack of welfare facilities and physical environment of clinics, such as lack of telephone, bed, proper ventilation, and nurse alarms. 
Karimi et al (25), considered welfare services, including quiet environment, adequate lighting, quality of hospital food, visiting hours, heating and cooling systems and ways to transfer to different departments as effective factors in the quality of outpatient services.
In the study by Pouragha and Zarei (26), physical environment was one of the most important factors affecting the quality of outpatient services.  
Considering these results, it is necessary for managers and policy makers in the healthcare field to allocate appropriate budgets to expand adequate physical equipment, increase government centers providing outpatient services, especially in deprived, remote and affected areas, allocation of more budgets for development of physical environments and equipping these spaces to take appropriate measures to increase equitable access to outpatient services.
The second important factor affecting the quality of outpatient services included financial indicators. Due to the fact that most services are provided in the outpatient sector by the private sector, so deprived and vulnerable people in society do not have the financial affordability to pay for services and therefore, public access is low. So, paying more attention to insurance coverage and allocating more of GDP to developing outpatient public centers is among the key ways to increase access to these services. 
In other words, the healthcare system will be fair, if health care is provided as needed and financed according to the ability to pay. There is lack of fair access for people due to the weakness of the referral system and family system and there is no equal access to services, especially for deprived and remote areas. The uncontrolled expansion of private service centers has caused a significant difference in these services in towns.
It is noteworthy that COVID-19 also played a significant role in increasing unequitable access to outpatient services. There is an urgent need to receive services by patients with coronavirus, to provide emergency services to a large number of patients in the shortest possible time, to reduce the number of medical staff due to COVID-19-indduced death, and to reduce equipment and facilities in government centers. 
Hajimahmoodi (27), believed that a fair health system is a system in which people with equal needs receive equal health care services and people participate in financing in health care according to their ability to pay. In all countries spending on health care is a safe social/ economic investment (28). 
In this regard, strengthening the programs of the Ministry of Health, including the family physician plan and referral system, is an effective factor in preventing the excessive and unprincipled consumption of services and moving toward equal financial distribution of services.
Mehrolhassani et al (29), believe that a strategy should be adopted to provide the necessary resources to spend on the health sector using mechanisms based on prepayments by the people (not direct payment) such as the percentage of taxes, duties, and premiums. Necessary and stable resources should be provided before the onset of the disease in time of health.
On the other hand, the such resources should be financed by government Revenues from oil sales should be reduced and thereby, and attempts should be done to improve insurance system and support packages for disadvantaged groups and areas must be provided; moreover, issues related to land management and also fair distribution of the resources commensurate with the deprivation of the region and its infrastructure are critical concepts.
Jafari et al (30), also compared the satisfaction of clients with outpatient services in the private and public sectors and it was found that clients’ satisfaction with outpatient services in the private sector has been much higher in all factors, including staff attitude, cleanliness of the environment, and quality of services. 
Ameryoun et al (31), also mentioned the physical environment and the facilities and equipment as an important and effective factor in the satisfaction of outpatient services. 
Hadayati et al (32), also mentioned compulsory health insurance as a suitable financial mechanism to increase access to services in Indonesia. Iranian health insurance, which was considered in the Health Transformation Plan, was created to increase financial access to health services, including outpatient services. Abdi et al (33), took health insurance as an effective factor in using outpatient services. 

Conclusion 
The results of this study show that physical factors (highest priority and effective), financial factors (second priority and effective), and anthropogenic and demographic factors, facilities and equipment, and policymaking, are the next priorities and influential factors, respectively. Therefore, based on the results of this study, policy makers and senior managers in the healthcare system should increase access to physical infrastructures and facilities to increase availability of the outpatient services. They should also consider sustainable financing of outpatient services in the public sector to help increase access to the outpatient services in the deprived and semi-deprived sections of the country. Development of special clinics, proper implementation of family therapist plan, development of insurance and increase of public insurance coverage, increase of government outpatient services, development of outpatient treatment roadmap, increase of material and non-material incentive mechanisms for employment of general practitioners and specialists in specialized hospitals and clinics, increase of the share of GDP in the outpatient services, assistance and development of charities in the outpatient services, and increasing the working hours of the special clinics to 24/7 are among the proposed solutions to increase fair access to outpatient services in the healthcare system of Iran. 
Researchers would like to thank and appreciate all the managers and policy makers in the healthcare area and the staff and executive committees of the Ministry of Health and Medical Education, who helped researchers in this study. It is noteworthy that this article is an excerpt from a doctoral dissertation in the field of health services management conducted at the Islamic Azad University, North Tehran Branch, Tehran, Iran.

Conflict of Interest 
All authors declare that there is no conflict of interest.

Funding
We don’t have any funding source.