Opening the Black Box: The Experiences and Lessons From the Public Hospitals Autonomy Policy in Iran

Introduction: Policy formulation and adoption often happen in a black box. Implementation challenges affect and modify the nature of a policy: We analyzed hospitals' autonomy policy in Iran that was intended to reduce hospitals' financial burden on government and improve their efficiency. Methods: We followed a retrospective case-study Methodology, involving inductive and deductive analyses of parliamentary proceedings, policy documents, gray literature,, published papers and interview transcripts. We analyzed data to develop a policy map that included important dates and events leading to the, policy process milestones. Results: We identified four time-periods With distinctive features: 'moving toward the policy (1989 1994), 'disorganized implementation' (1995 1997), 'continuing challenges and indecisiveness in hospitals financing' (1998-2003), and other structural:and financial-policies in public hospitals' (2004 to date): We found that stakeholders required different and conflicting objectives, which Certainly resulted in an unsatisfactory implementation process. The policy led to long-lasting and often negative changes in the hospital sector and the entire Iranian health system. Conclusion: Hospital autonomy appeared to be an ill-advised policy to remedy the inefficiency problems in low socioeconomic areas of the country. The assumption that hospital autonomy reforms would necessarily result in a better health system, may be a false assumption as their success relies on many contextual; structural and policy implementation factors.