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.