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Forty years review of upstream Review of

upstream
documents of the Islamic Republic document of
health sector
of Iran’s health sector on strategic
purchasing of advanced-expensive 93
medical equipment Received 12 December 2019
Revised 8 March 2020
27 March 2020
Peivand Bastani Accepted 7 April 2020
Health Human Resources Research Center, Shiraz University of Medical Sciences,
Shiraz, Iran, and
Ali Tahernezhad and Seyyed Mostafa Hakimzadeh
Health Management Research Center, Baqiyatallah University of Medical Sciences,
Tehran, Iran

Abstract
Purpose – According to the importance of strategic purchasing as an effective tool for resource allocation and
service procurement, this study examines national laws, regulations and other related documents related to the
strategic purchasing of health services related to the advanced medical equipment in Iran.
Design/methodolgy/approach – It was a national qualitative document analysis conducted in 2019
applying content analysis approach. The four-step Scott method was used to include the documents in terms of
authenticity, credibility, representation and meaningfulness. After retrieving the related documents, they were
coded with the implicit and explicit approach. MAXQDA10 was used for content analysis.
Findings – The findings show that according to the framework of effective factors on the strategic purchasing
of health services, seven main factors are determined as the main essential factors in purchasing advanced
medical equipment. These factors consist of health care providers, health service buyers, purchaser and service
provider contracts, payment mechanisms, organization and management evaluation of health technology
including expensive medical equipment and technology-related.
Research limitation/implication – The study had some limitations as follows: the proposed method should
be tested and its feasibility has to be investigated through appropriate tools for Iranian insurance companies
and those with the similar settings.
Practical implication – The results of this study can shed more light for policy makers affiliated in Ministry
of Health as the main service provider, Ministry of Welfare and the insurance agencies as the main purchasers
of health services on paying attention to these seven main themes extracted from the upstream documents and
laws and regulations of the Islamic Republic of Iran.
Social implication – The strategic purchasing of expensive high technology-based medical equipment is a
necessity for Iranian public health insurance organizations that is emphasized in national documents in the
way of implementing this necessity.
Originality/value – This study examines all the laws and regulations and all related documents in the
strategic purchasing of health services related to advanced medical equipment, giving an analysis of the most
important challenges and requirements of implementing strategic purchasing in the health services provision
sector with expensive medical equipment.
Keywords Strategic purchasing, National document analysis, Qualitative study, Iran, Medical equipment
Paper type Research paper

Introduction
Iran is a country situated in the Middle East with about 80 million populations that has a
centralized government. The percentage of population living in urban areas was 70% in 2010. International Journal of Health
Governance
Economically, the country is categorized as a higher-middle-income one by the World Bank, Vol. 25 No. 2, 2020
pp. 93-105
© Emerald Publishing Limited
2059-4631
We appreciate Basic Science Research Center for financial support we received in conducting this study. DOI 10.1108/IJHG-12-2019-0077
IJHG with a GDP of US$454bn in 2017. From the healthcare point of view, the Ministry of Health
25,2 and Medical Education has been considered as the steward of the populations` health since
1975. Iran has an obligatory social insurance system and the total population is supported by
one of the four main insurance organizations (Danaei et al., 2019).

Overview of Islamic Republic of Iran health care system

Over the past three decades, the health system of the Islamic Republic of Iran has undergone major
94 reforms, including the design and deployment of a health network in 1985, the establishment of
universal insurance in 1995 and a family physician referral system in 2005 each of which has had
varying degrees of success (Hayati et al., 2019; Nouhi et al., 2019b). In spite of the success of these
reforms, the Iranian health care system has suffered from a fundamental problem in the function of
financing, especially the resource allocation and purchasing the needed health services
(Keshavarzian and Mofidian. 2014). The evidence shows that since 1995, with the adoption of
the Public Insurance Act, Iran’s health care system has targeted the public health insurance
arrangement. Although the changes in the financing system and the increased participation of
people in the costs and sustainability of financial resources can be one of the achievements, in terms
of changing the system of purchasing services and intervening in the demand market, making
informed and optimal purchasing for the insured, little has been achieved (Bastani et al., 2019).
However, insurance systems have inherent complications such as increased moral hazard,
risk selection, adverse selection and the tendency of high-income or low-income groups to
evade payment or withdraw from the public insurance fund, which they must take measures
to eliminate or minimize. In this regard, one of the most important insurance solutions that are
neglected in the health sector is the proper use of tools such as strategic purchasing contracts
(Hakimzadeh et al., 2018). Strategic purchasing is considered as an active, evidence-based and
continuous seeking of needed health services with a real, competitive and fair price applying
the best payment system as the incentives from the best suppliers or providers (Rezapour
et al., 2018). The evidence suggests that strategic purchasing has the potential to significantly
improve efficiency, equity and quality in the health sector (Patcharanarumol et al., 2018).
Because of these potentialities and regarding the problems of the Islamic Republic of Iran in
resource allocation and purchasing the needed health services, many national upstream
documents have been proposed during the years.
Iranian national upstream documents in health care purchasing
A review of the country’s upstream documents shows that strategic purchasing debate has
always been a requirement in the health service provision, for example under Article 32 (c) of the
Fifth Development Plan of the country, a comprehensive health care system based on the
primary health care and the focus Fifth Development Plan on family physicians, the system of
service classification, strategic purchasing of services, assignment of tenure under Article 13 of
the Civil Service Management Act with emphasis on performance-based payment by the
Ministry of Health and Medical Education (Rezapour et al., 2018). In addition, under paragraph z
of Article 38 of this plan, the health insurance organization is required to comply with the system
of referral and classification of services under the policies adopted, to strategically purchase
health services from public and non-governmental sectors (Mehralian and Bastani, 2015).
These upstream documentation requirements have justified the benefits of implementing
health services strategic purchasing as it can maximize profits in the limited resources of
health sector. Through this mechanism, some functions can improve such as adversity in the
country’s health system, equity in health service delivery, resources, quality of health
services, health service payment practices, existing health care utilization practices
particularly in the pharmaceutical and paraclinical services and out-of-pocket payments.
On the other hand, other pieces of evidence show that strategic purchasing may lead to
improve the level of health service delivery and health indicators, and cost benefit and cost
effectiveness in the health system will be provided (Mathauer et al., 2017; Yusefi et al., 2019).
Why national upstream documents emphasize on strategic purchasing? Review of
Reviewing the related literature, it seems that strategic purchasing can bring many benefits upstream
to health care systems. For instance, according to Rezapour et al. (2018), if national purchasers
(the health insurance companies) are able to communicate with providers and to choose the
document of
best providers, receiving price information through competition in the most appropriate health sector
mechanism they can strategically buy the best and the most effective services for its insured
population (Rezapour et al., 2018). Ogbuabor and Onwujekwe (2018) emphasized that some
significant criteria such as strategic vision, participation and consensus, orientation, rule of 95
law, transparency, responsiveness, equity and inclusiveness, effectiveness and efficiency,
accountability and intelligence and information as well as ethics should be considered as
governance framework principles to purchase strategically (Ogbuabor and Onwujekwe.
2018). At the same time, Klasa et al. (2018) have claimed that strategic purchasing is an
ideologically-fueled concept that will always sound positive in political discourse; however,
only a few high-income countries have perused the policies of the insurer–provider
relationship via strategic purchasing. They also emphasized that other low-income and
middle-income countries have tried to use various forms of strategic purchasing to achieve
universal health coverage (Klasa et al., 2018). Furthermore, Ghoddoosi-Nejad et al. (2019) have
pointed to the stewardship as the main challenge in the strategic purchasing of health
services. They also pointed to the lack of management information systems, lack of
enforcement for rules and laws, lack of stewardship units and the conflict of interest between
the Ministry of Health and insurance companies as the main challenges and obstacles in
implementing strategic purchasing of health care in Iran (Ghoddoosi-Nejad et al., 2019)
despite the emphasis of the national upstream documents.
National upstream documents and advanced medical equipment`s strategic purchasing.
As stated before, it seems that the main focus of the strategic acquisition is on cost control
and the rational and fair use of resources. Health services based on advanced medical
equipment are among the most expensive advanced technology-based services in a hospital
system. Evidence suggests that the turnover of advanced medical equipment in Iran is over
$ 1.2bn, which is considerable (health sector and its share in the Iran GDP, 2018) and can be
significantly reduced by implementing the strategic purchasing mechanism (Kieny et al., 2017;
Mathauer et al., 2017). Results of Patcharanarumol’s study (2018) also indicated that in Thailand
the provision of CSMBS as one among civil servant welfare programs that was passively
purchased, resulted in rapid cost escalation and overspending of their annual budget. In
contrast, purchasing for UCS, which undertakes a range of strategic purchasing actions,
resulted in expenditure per CSMBS member being 4 times higher than UCS in 2014
(Patcharanarumo et al., 2018). These pieces of evidences clearly show that strategic purchasing
should be considered in the health policymaking as well as the national documents.
In summary, the above literature review indicates that there are significant shreds of
evidences of decrease in costs and increase in efficiency via implementing strategic
purchasing. In contrast, the conditions of the Islamic Republic of Iran’s health system indicate
that despite the emphasis on upstream documentation and benefits of implementing strategic
purchasing of health services, this has not been achieved at least in the services sector of
advanced medical equipment and medicine. There are problems such as the existence of
different tariffs for the same services, different pricing by different insurance organizations,
and the extent of service packages are provided by insurers at the national level as the most
important strategic shopping centers. Failure will play a role if this continues. It will have a
tangible impact on consumers and insurers (Abedi et al., 2018).
Therefore, this study examines the laws and regulations and related documents in the
strategic purchasing of health services related to advanced medical equipment, giving an
analysis of the most important challenges and requirements of implementing strategic
purchasing in the health services provision sector with expensive medical equipment.
IJHG Method
25,2 This was a national qualitative document analysis applying the content analysis approach
conducted in 2019. There are several ways to collect qualitative data. Frenz and Nielsen
believe that some documents or textual data can be used in conducting qualitative studies.
Textual data and documents in qualitative research mean government guidelines and
circulars such as official documents, programs and policies, communications and periodic
reports (Hayati et al., 2019). Krippendrof also believes that documents or other contextual
96 data such as government guidelines and circulars, official documents, programs and policies
and periodic reports can be incorporated into a hermeneutic approach through a five-step
process involving accessing documents and analyze data, validate documents, understand
documents and use information in a form of extracted themes.
In this study, Scott’s method was used for document analysis. Scott suggests a four-step
approach to document review (Hayati et al., 2019). Accordingly, following the collection of
documents, the subsequent steps are taken:
(1) Determining authenticity
(2) Credibility
(3) Data Representative
(4) Being meaningful
According to Scott’s method in the present study, the research population was determined
according to the purpose of the study. This community includes all reports, organizational
bylaws and upstream documents on strategic purchasing of health services related to
advanced medical equipment at the Iranian Health Insurance Organization, Social Security
Insurance Organization, Ministry of Health and Medical Education, Imam Khomeini Relief
Committee, Health Insurance Armed Forces and the Supreme Insurance Council. The
included organizations and their websites for retrieving the national documents are indicated
in Table 1.
After examining websites to retrieve related documents in the aforementioned
organizations, the issuing authority of the document was first considered to determine the
authenticity of the documents. At this stage, the documents that were somehow approved by
the state authorities, including the Islamic Consultative Assembly, the Government and the
Supreme Insurance Council, were authentic.
In the next step, in order to determine the validity of the documents, all the recovered
documents were reexamined so that these documents should not be misleading and free from
error and bias and generally not for personal or organizational gain. Therefore, all documents
possessing these features were recognized as valid.
In the third step, in order to ensure data representativeness, the keywords used in the
search of the website of the organizations were reviewed again and at this stage, the
documents using one or more keywords “strategic purchase” OR “strategic purchase”

Name of organizations Websites address

Health Insurance Organization http://ihio.gov.ir

Social Security Insurance Organization http: //www.tamin.ir
Ministry of Health and Medical Education http: //www.behda.sht.gov.ir
Table 1. Imam Khomeini Relief Committee https://portal.emdad.ir/
The websites of Health Insurance Armed Forces http://mod.ir/
studied organizations Supreme Insurance Council http://www.mcls.gov.ir
“Health Services” OR “Strategic purchase of Medical Equipment” OR “purchase of Expensive Review of
Medical Equipment-Based Services” were obtained indicating the purpose of the study. upstream
Finally, in the final stage of Scott’s analysis to ensure that the documents obtained were
meaningful, all documents were examined in terms of transparency and completeness of the
document of
document so that only documents with formal and content validity in appearance, format and health sector
the content were included in the study.
Based on the above approach, two documents were retrieved by electronic search and
three by manual search and evidence reference and in-person referral to the insurance agency 97
and Ministry of Health. After reading the title and the abstracts of the documents, three
documents remained relevant, and finally after reviewing the original text of the documents
and screening them using the above four criteria, the two documents had the final entry
criteria. The main reasons for exclusion were that the studies were not original or were not in
the strategic domain of expensive medical equipment, the documents were not authentic,
were not meaningful or did not represent or were not valid (Figure 1).
To increase the transferability and confirmability of the results of the qualitative study,
some approaches have been followed: first the coded data were rechecked by two of the
authors and one expert in qualitative method to confirm the confirmability of the results.
Then, the condition of data collecting and retrieving the documents is clearly defined to
improve the transferability of the study results. Moreover, there was an attempt to select the
included documents based on the purpose of the study without any bias, also, collecting and
analyzing the data occurred simultaneously, Meanwhile, the researchers tried to be fully
aware of the theoretical foundations of the study to increase the transferability.
After satisfying Scott’s four criteria, all content of the imported documents was explicitly
and implicitly studied and coded. The whole-component approach was used for coding. After
coding all the texts, the initial codes were read and finalized and then larger categories were
created to create subthemes, and finally, the main themes were applied by MAXQDA version
10 by two researchers who had no conflicts of interest with the findings of the study.

Findings
As Figure 1 shows, all reports, organizational bylaws on strategic purchasing of health
services related to advanced medical equipment in Iranian Health Insurance, Social Security,
Armed Health Insurance and Imam Khomeini Relief Committee and Ministry of Health and
Medical Education were investigated. From the above insurance companies two by-laws
were obtained as declared in Table 2:

603 Electronic Documents Handheld Documents 32

A total of 635

Irrelevant documents
Screened 587
544

Aer thorough The number of documents was

either not authenc or not
examinaon of the
meaningful or did not
represent or be valid
Figure 1.
Fully Related Strategic
Chart of selected
documents
Purchasing Documents 2
IJHG The findings from the analysis of the two documents above are presented in Table 3. Based
25,2 on the theory of strategic purchasing that was presented in WHO report 2000, the factors
affecting strategic purchasing include seven main themes of “health care providers”, “health
service buyers”, “contracts”, “payment mechanisms”, “organization and management”,
“health technology assessment” and “technological characteristics” as factors that influence
the purchase of expensive medical equipment services. These descriptions are as follows:
98 Service providers
Based on Table 3, “recognition of advanced medical device manufacturers”, “access to
advanced technology at national level” and “selection of appropriate providers” are
considered as the requirements for strategic purchasing.
Recognition of advanced medical device manufacturers. It is clear that a large number of
companies operate as technology importers in the country, and in many areas of high-tech
equipment such as cardiac pacemakers, many orthosis and pelvic and joint prosthesis and
ophthalmic lenses, these companies have monopoly. Obviously, it is challenging to
negotiate and choose the best company that is a strategic buyer. In addition, the current
economic and political sanctions present additional problems, both in banking transactions
and cargo transportation which reduce the possibility of strategic purchasing for imported
equipment.
Access to advanced technology at national level. Achievement of technology at the national
level is of great importance, and despite the emphasis on many national documents, including
1,404 Vision, the General Policy of the Country in the health sector, the supreme leader’s
proclamation and the second step of the revolution’s declaration of self-sufficiency and
prosperity, the dependence on the production of medical equipment is very high. The current
conditions of sanctions can complicate the problem and significantly affect people’s access to
the services.
Selection of appropriate providers. Selecting providers of expensive medical device-based
services from the insurer is another requirement for implementing strategy; this capability is
needed to distinguish reasonable prescriptions and reduce inadequate service delivery in line
with guidelines for better management of costs and proper accumulation of resources among
insurers.
Another findings of Table 3 have identified “the lack of access to online, accurate and
reliable information sources” as an undeniable challenge in the strategic implementation of
these services, which can increase prescriptions for nonasymptomatic services, prescription
based on service delivery rather than actual population demand and resource depletion.
Service buyers
The findings in Table 3 highlight “the lack of after-sales services of advanced medical
equipment due to international sanctions” as the most important requirement and “the small
Iranian medical equipment market, including less than one percent market share in the
world” as the challenge of implementing the strategic acquisition of these services.
As mentioned above, economic–political sanctions, despite claiming that they have
removed vital goods because of disruption to the financial and monetary network, problems

Date of
Name of the document Source of the studied documents publication

Executive Order of Strategic Health Services Subject to Article 38 of the Fifth 15th April 2012
Table 2. Purchasing Development Plan Proposal
The included and Executive Order of Strategic Ministry of Health and Medical Education November 3,
studied documents Purchasing 2010

Strategic purchasing challenges for
expensive medical equipment–based
services
U Lack of access to accurate, reliable
and reliable online information
resources
U Iran’s small medical equipment
market, including less than 1% of
the world’s production and
imports
U Significant increase in the price of
medical equipment
U Medical debt to medical
equipment suppliers
U Multiple and inconsistent
approvals of decision-making and
policy-making authorities
U Lack of macroeconomic currency
policies in 1998
U Incompatibility of organizational
structure with responsibilities
assigned to staff and universities
U Lack of infrastructure and
potential capabilities
U Failure to carry out health
technology assessment results in
equipment purchasing
U Lack of trained people in medical
centers
Strategic purchase
Review of
Strategic purchase requirements for framework for expensive upstream
expensive medical–equipment medical equipment–based document of
based services services
health sector
U Knowledge of advanced medical Providers
equipment manufacturers
U Achieving state-of-the-art 99
technologies at national level
U Choosing the right providers
U Lack of after-sales services of Buyers
advanced medical equipment due
to international sanctions
U Existence of treatment protocols Contract
using advanced medical
equipment
U Marketing of advanced medical
equipment
U How insurance services cover Payment mechanism
advanced equipment-related
services
U Infrastructure needed to use Organization and
advanced medical equipment management
U Cost-effectiveness analysis of Health Technology
advanced medical equipment Assessment
U Making a positive change in the
treatment process (reducing time
or increasing effectiveness)
U Need assessment studies for
equipment entry into the country
U Regional demographic
assessment of deployment of
advanced medical equipment
U Investigate the impact on public
health, therapeutic benefit,
patient benefit
U Technical compatibility of state- Technology specifications
of-the-art equipment with new
technologies
U Comparative advantage of
advanced medical equipment
over other equipment or Table 3.
procedures without it Strategic requirements
U Fundamental of advanced and challenges of
medical equipment expensive medical
U Continued use of advanced equipment based
equipment services
IJHG with international transportation, entry of professionals and activities companies and their
25,2 dealerships on Iranian soil have caused a great deal of trouble in this regard. On the other
hand, practically Iran, as a developing country, has devoted a small portion of its GDP to
medical equipment in the high techs. In addition, due to resource constraints and the
government’s reliance on public funds to sell oil, whose sanctions have greatly reduced the
exports, the probability of importing high-tech medical equipment has been minimized.
100
Contracts
“The existence of therapeutic protocols for the use of advanced medical equipment” and “the
marketing of advanced medical equipment” are identified as the most important strategic
purchasing requirements.
The existence of therapeutic protocols or guidelines for prescribing services. This is of great
importance and can greatly prevent the induction of demand by the service provider and
moral hazards due to the asymmetry of information while in some way helps make the right
use of limited opportunities to create vertical justice.
Marketing of advanced medical equipment. This can also be an important requirement that
helps to allocate foreign exchange resources to the best and most needed equipment and can
certainly prevent the equipment from being illogically selected and unnecessarily prescribed.
Accordingly, the findings in Table 3 have identified the “significant increase in the price of
medical equipment” as the most important challenge for the strategic acquisition of these
services. Price is obviously one of the five leverages of strategic purchasing of medical
supplies and its rationality, competitiveness, bargaining, realism and proportionality with
the purchasing power of society play a vital role in providing strategic services with
insurance companies.

Payment mechanism
“How insurance services are covered by state-of-the-art equipment” is the most important
requirement. Obviously, due to the lack of scientific definition of a comprehensive and
integrated service base package and the difference in package services between different
insurance organizations in the country, this requirement may be of more importance. Also,
“medical debt to medical equipment providers” has been identified as the most important
challenge due to the critical financial situation of hospitals and their dependence on
government funds and resources, which continue to deteriorate as the trend continues.

Organization and management

“The infrastructure required for the use of advanced medical equipment” was the most
important requirement. In other words, in terms of processes and organizational structure,
service centers need to have equipment use infrastructure, and political lobbying or the use of
donor resources should not buy equipment for centers with low population, not need-based
services. The population does not have enough specialists to prescribe equipment-based
services.
The four items of “multiple and inconsistent approvals of decision-making and policy-
making authorities”, “non-determination of macroeconomic policies in 1998”,
“incompatibility of organizational structure with responsibilities assigned to staffs and
universities” and “infrastructure and potential capabilities” were identified as the greatest
challenges for these services. Multiple and inconsistent approvals by different decision-
makers can lead to confusion at the executive level, while reducing the integration required to
formulate a basic service package and strategic purchasing. Macrocurrency policies are also
important in this regard. This is particularly important given the high dependence of the
public budget on the oil and the problems associated with sanctions on oil exports. Review of
Organizational structure is another item whose flexibility and alignment with goals can upstream
greatly help implement policies, including the strategic purchase policy of expensive medical
device services. Finally, infrastructure challenges, both in terms of information and software
document of
infrastructures and in terms of hardware, physical and equipment infrastructures have been health sector
important in failing to meet the strategic purchase objective.
101
Health technology assessment
Table 3 shows “Cost-effectiveness analysis of advanced medical equipment use”, “Positive
change in treatment process”, “need assessment studies for equipment entry”, “regional
demographic assessment on the deployment of advanced medical devices” and “assessing
the impact on public health, health benefits, patient benefits” as the main requirements.
Cost-effectiveness analysis. It is one of the most important tools in evaluating state-of-the-
art technologies, including medicines and medical devices and can point the right way for
policymakers to provide lower-cost or more effective services and products. Needs
assessment studies in the form of health technology assessments before the entry of any
advanced medical technology are introduced at the macro level and the regional level.
Needs assessment studies. At the service providers’ level, need assessment can provide a
better prospect of financing the equipment with managers and policy makers.
The most important challenge in this area is “failure to implement the research results of
health technology assessment in equipment purchases”. In other words, in spite of health
technology assessment studies, in many cases decisions to purchase and import equipment
have not been made based on the results of the evaluation, and other factors such as political
lobbying, benevolent pressure, pressure from people’s representatives and experts have had
a greater impact. This can sometimes lead to a waste of resources and inadequate service
provision.

Technology specifications
“Technical compatibility of state-of-the-art equipment with the present technology”,
“comparative advantage of advanced medical equipment”, “ fundamentality of advanced
medical equipment” and “continuity of use of advanced medical equipment” are as
requirements according to Table 3. Obviously, advanced medical equipment is part of the
technology available in the country that requires the use of knowledge, skills and cultural
infrastructure and technology adoption by users and patients. If these infrastructures are not
provided, even with the introduction of technology into the country, it will not be possible to
utilize the full potential of this equipment, and the dormancy of the capital can create the
opportunity cost and stagnate value-added cycle.
“The lack of trained people in health centers” has been a major challenge in this area,
which increasingly emphasizes the importance of shifting the country from technology
importer and consumer to technology owner and creator.

Discussion
The present findings address the strategic purchasing requirements concerning expensive
medical device-based services in seven main themes including: “health service providers”,
“health service buyers”, “contracting between buyer and service providers”, “payment
mechanisms”, “organization and management”, “health technology assessment of expensive
equipment of medicine” and “the technological features”. Similarly, Gorgi et al. (2018)
summarizes the most important challenges for insurers in strategic purchasing of health
services in Iran in terms of procurement rules, procurement organization, appropriate service
providers, services proper health, appropriate contracts, target groups for service purchase,
IJHG resource allocation, financing and pricing system (Gorji et al., 2018) which are in many cases
25,2 similar to the present findings.
As the present findings show, service providers in terms of “recognizing advanced
medical device manufacturers”, “acquiring state-of-the-art technology” and “selecting the
right providers” are important requirements for strategic purchasing of high-tech medical
equipment. This means that the manufacturers and importers of these technologies need to be
identified in order to execute a strategic purchasing of these services and to be able to select
102 the best provider through the right contract for the insurance companies. In this regard, the
study of Ogbuabor and Onwujekwe of the strategic acquisition of maternal and child health
services in Nigeria also reveals a key factor in the strategic acquisition of these services –
government support activities to establish a system of approval of directives for providers
and direct payment systems. In the same study, the most important obstacle for
implementing the strategic acquisition was organizational conflicts, the lack of separation
of the buyer organization from the service provider and the inability of service providers to
select a contract (Ogbuabor and Onwujekwe, 2018).
The findings of the present study examined the most important requirement for service
buyers in terms of “lack of after-sales service of advanced medical equipment due to
international sanctions”. In this regard, the study by Setayesh and Macky showed that
international sanctions on the Iranian health sector have created challenges for financing,
purchasing and importing medicines and equipment (Setayesh and Mackey, 2016).
Obviously, insurers in Iran are faced with unwanted problems at the macro level with the
present situation which complicates their purchasing mechanism for implementing strategic
purchasing.
Other findings have found that the contract between the insurer and service providers is
an effective factor in the strategic acquisition of high-cost medical device-based services as
well as “existence of therapeutic protocols for the use of advanced medical equipment” and
“the marketing of advanced medical equipment”. They cite this as one of the most important
strategic buying requirements in this area. The potential for a fair contract between the buyer
and the service provider has been emphasized in many studies as a strategic purchasing
requirement. For example, Reza Pour et al. formulated a criterion for the selection of providers
by the insurance organization and the ability to select a service provider and its payment
mechanism, which are among the main terms of the contract as influencing components of the
pragmatic model in purchasing expensive medical equipment (Rezapour et al., 2018).
Dehnouyeh et al. have identified the existence of a retrospective contractual mechanism
between insurance organizations and health care providers as a major problem in the absence
of strategic purchasing in Iran (Bastani et al., 2018; Dehnavieh et al., 2016).
As mentioned above, the payment mechanism is also an important requirement in
strategic purchasing implementation. In this study, “how insurance services are covered by
state-of-the-art equipment” is identified as an important requirement in this area. In this
regard, Hanson et al. believe that designing an appropriate payment method enhances
efficiency, fairness and quality. He argues that if strategic purchasing of services as a missing
link would achieve universal health coverage, appropriate payment mechanisms need to be
designed. In designing the payment system, they also referred to requirements such as
service provider registration and hospital base accreditation (Hanson et al., 2019; Nouhi et al.,
2019a). The necessity of determining the coverage of the service and the mechanism and how
it is covered in the field of services based on expensive medical equipment has also been
emphasized in the present study.
Other findings of the present study suggest that the organization and management of
service buyers and their providers play an important role in the implementation of strategic
purchasing of expensive medical device-based services and the most important requirement
in this area is “the infrastructure required to use the advanced equipment”. In this regard,
Sanderson et al. believe that decision-making independence in the organizational structure of Review of
service providers can enhance the efficiency of resources and innovations in the system while upstream
at the same time providing accurate collaborations to improve performance. Independent
buyer and provider structures can be suggested as the most powerful proposed structure in
document of
this field (Bastani et al., 2018; Sanderson et al., 2019). health sector
Evaluation of health technology using various mechanisms such as cost-effectiveness
analysis of advanced medical equipment, need assessment studies for entry into the country
and regional demographic assessment of deployment of advanced medical equipment and 103
impact on public health, therapeutic benefit and patient benefit are other important
requirements. In the area of strategic deployment, the focus has been on expensive medical
device services. Hakimzadeh et al. have emphasized the importance of economic evaluation
and the use of cost-effectiveness studies in the purchasing of medical equipment (Bahadori
et al., 2012b; Hakimzadeh et al., 2018; Nouhi et al., 2019b).
In summary, the relationship of the service buyer with the provider in terms of
organizational dimensions, service evaluation and contracting is of great importance in the
implementation of strategic purchasing. Etiaba et al. have also identified the most important
themes to right buyer and service provider as accreditation of health care providers,
monitoring of the performance of health care institutions and the use of payment mechanisms
to service providers (Etiaba et al., 2018; Tavana et al., 2015).
Furthermore, the analysis of the related upstream national documents can shed more light
for policymakers to prepare the necessary requirements for implementing strategic
purchasing. In this regard, the scope of high-tech expensive medical equipment might be
emphasized and needs more attention. Although there was no exact study with the present
aim, the study by Bastani et al. (2018) as a national document analysis on the strategic
purchasing of pharmaceuticals shows the lack of identical comprehensive basic benefit
package, the passive reimbursement mechanism, the passive and nonscientific decision-
making process of purchasing medicines and lack of applying appropriate technology and
contract as the main challenges in pharmaceutical purchasing area (Bahadori et al., 2012a,
2012c; Bastani et al., 2018). These areas can confirm the present results of technology
specifications, health technology assessment, payment mechanism, organization and
management and contracts that are considered as the strategic requirements and
challenges of expensive medical equipment–based services.

Conclusion
Strategic purchasing of expensive, high technology–based medical equipment is a necessity
for Iranian public health insurance organizations which is emphasized in national documents.
In the way of implementing this necessity, results of this study can shed the light for policy
makers affiliated in Ministry of Health as the main service provider, Ministry of Welfare and
the insurance agencies as the main purchasers of health services to pay attention to these
the4se main themes extracted from the upstream documents and laws and regulations of the
Islamic Republic of Iran.

Limitations
The study had some limitations as follows: the proposed method should be tested, and its
feasibility has to be investigated through appropriate tools for Iranian insurance companies
and those with the similar settings.

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Corresponding author
Seyyed Mostafa Hakimzadeh can be contacted at: hseyyedmostafa@gmail.com

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