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Abstract

Objective:

To assess equity in the distribution of hospital beds in northern Iran.

Methods:

In this cross-sectional study, we investigated the degree of equity by using 2016 census data from 16 cities in Guilan province. The hospital beds include burns, intensive care unit, coronary care unit and neonatal intensive care unit beds. We analysed the general status and explored its distribution equity by using the Theil index.

Findings:

We found that Rezvanshahr and Masal had no hospital beds. The utilisation gap was positive only in Rasht, as capital of the province. Neonatal intensive care unit beds were only found in Rasht and Lahijan. Rasht was shown to have a positive gap in using burns, intensive care unit and coronary care unit beds, with a negative gap of 14.68 in coronary care unit beds. The other 15 cities did not have such hospital beds. For intensive care unit, coronary care unit and neonatal intensive care unit beds, nearly 8%, 2% and 14% of cities were deprived of being equipped with these hospital beds, respectively. The highest positive gap and the lowest negative gap were attributed to coronary care unit beds. In the province, there were 0.057 burns beds, 0.137 intensive care unit beds, 0.381 coronary care unit beds and 0.72 neonatal intensive care unit beds per 10,000 population (neonatal intensive care unit beds, per 1000 neonates). In 11 out of 16 cities, the number of coronary care unit beds per 10,000 population was higher than the provincial average. The highest inequality in distribution was shown to be for burns beds (0.8), neonatal intensive care unit beds (0.75), intensive care unit beds (0.55) and coronary care unit beds (0.21), respectively.

Conclusion:

This study revealed high inequalities in the distribution of hospital beds in northern Iran. The local and national policy-makers should design and implement a comprehensive monitoring and evaluation system for tracking and allocating healthcare resources, both qualitatively and quantitatively, which appears to be very necessary to increase the equity in access to healthcare services.

Keywords

Equity hospital beds Iran

Introduction

Health systems play a key role in the health and wellbeing of the population, which is mainly related to their importance in both physical and mental health as well as their economic, social and cultural benefits.^1,2

Once health systems are ideal and equitable, the fair allocation and distribution of human resources and public health funds is the must-have standard for health services expansion.³

On one hand, access to healthcare services is a basic right; and on the other hand, the geographical distribution of healthcare services is a key element for access to services.⁴ The World Health Organization (WHO) has emphasised the measurement of inequality in the distribution of health resources as a worldwide right. According to WHO, the geographical distribution of health resources has resulted in their limited accessibility.^5,6 As health and development are mutually exclusive, addressing the inequality in access is crucial to achieve a desirable level of development.⁷

Access to healthcare services has become a critical issue for public health policy-makers and researchers over the past few decades.⁸ Also, providing equitable access to healthcare services has become a great concern among policy-makers not only in developing countries, but also in other countries around the world, as based on available evidence inequality and injustice can be seen in both developed and developing countries.⁹ It can be concluded that the equitable geographical distribution of health resources such as hospital beds, physicians and equipment can enhance the quality of services and economic efficiency. Furthermore, evidence shows that inequality in the geographical distribution of health resources is correlated with inequality in health outputs.^10,11

It has also been shown that the provision of healthcare services follows a reverse and contradictory pattern. For instance, in regions with higher mortality and morbidity rates there are few healthcare centres, hospitals and providers; and human workforces have to bear a heavier workload than those in other regions.¹²

In recent years, WHO and the Organisation for Economic Co-operation and Development have put emphasis on the measurement and identification of problems and challenges of healthcare centres, focusing on the distribution and quality of health resources.¹³

However in developing countries, due to the lack of viable information and personnel with special skills and specialities in health planning, authorities have failed to distribute the health resources fairly, especially hospital beds,^14,15 which as an indicator for the measurement of equity in the distribution of health resources is of particular importance in providing healthcare services, reducing mortality rate, increasing life expectancy and rate of birth, and even reducing income inequality and other socioeconomic parameters.¹⁶

The current study was designed based on previous reforms to achieve universal health coverage (UHC) in Iran particularly during the past decade,¹⁷ which is a fundamental component not only to increase access to healthcare services (as a dimension of UHC), but also to achieve equitable distribution of health resources. In addition, increasing morbidity rate, higher demands to use expensive medical equipment and their availability in deprived areas, increasing expectations of society, and the scarcity of resources in the health sector have resulted in a greater need for valid scientific evidence to make decisions about the distribution of resources at national and provincial levels. Guilan province as the second most populated province in the north of Iran has 16 cities including Astara, Astane, Amlash, Anzali, Talesh, Rasht, Rezvanshahr, Roodbar, Roodsar, Siahkal, Shaft, Somesara, Fuman, Lahijan, Langrood and Masal. According to the latest national census, it has a population of 2,530,696 people and 851,382 households, which is predominantly urban (1,603,026 people, 63.3%). As a result of having an international border with Azerbaijan through Astara, Guilan province is in a strategic geographical situation. We aimed, therefore, to provide an appropriate understanding about the current distribution of hospital beds for decision-makers in Guilan province, with particular emphasis on equity in distribution.

Methods

The current retrospective study was focused on investigating the distribution of hospital beds including burns-related, intensive care unit (ICU), coronary care unit (CCU) and neonatal intensive care unit (NICU) beds in the Guilan province of Iran in 2016. As the whole region was investigated, sampling was not performed. The data were extracted from annual reports of the Statistical Center of Iran by using a researcher-made checklist comprising the demographic information of each city and the number of hospital beds in each.

In order to analyse resource distribution and trends of included variables, the Theil method was utilised. Regarding the information theory, the Theil method is based on the entropy concept. Accordingly, the possible entropy of acceptable events in an information environment (H) is equal to the sum of weights of information content of events, which is a regressive function of its occurrence possibility, such that the higher the possibility of an event, the lower will be the information content, therefore:

H = \sum_{i = 1}^{n} P_{i} H (P_{i}) = \sum_{i - 1}^{n} P_{i} \log l / P_{i}

(1)

where H is the entropy (information content) of an information environment, P_i is the occurrence possibility of event i, and H(P_i) is the information content (entropy) of the event. Regression of the information content for each event relative to its occurrence possibility is considered as log l/P_i. Accordingly, the resource distribution pattern is equal to the sum of the weighted sum (weighted share of each person from the variable) of the variable entropy of society’s members (inverse logarithm of each person’s share of the variable), which can be defined as follow:

H = \sum_{i = 1}^{n} \frac{X_{i}}{n μ} \log \frac{n μ}{X_{i}}

(2)

Based on what was mentioned about variations in entropy of an information environment, entropy of a distribution pattern that is completely equitable is equal to log n (n = number of those members with that variable) and when extremely inequitable is equal to zero. The inequality index measures the distribution pattern of a variable in society, demonstrating the difference between the entropy of the pattern and the entropy of a variable whose distribution is completely equitable.

T = \log n - \sum_{i = 1}^{n} \frac{X_{i}}{n μ} \log \frac{X_{i}}{μ}

(3)

Therefore, the Theil index can be calculated as follow:

T = \frac{1}{n} \sum \frac{X_{i}}{μ} \log \frac{X_{i}}{μ},

(4)

The final value is between zero (completely equitable) and log n (completely inequitable). Therefore, the index does not have a limited range, which is common for relative indicators. To convert this to a relative index, the adjusted Theil index (T=T/log n) needs to be used.¹⁸ It should be noted that Stata software version 12 was used to analyse data.

Results

Findings were categorised into descriptive and analytics sections. The number of the population and hospital beds has been provided in Table 1. Descriptive findings comprise the percentage share of population in each city relative to the whole province, the difference between the percentage share of hospital beds and the percentage share of the population in each city and the number of hospital beds per 10,000 population (Table 2).

Table 1.

The number of population and hospital beds.

	Population		Number of beds
	All ages	Neonates	Burns	ICU	CCU	NICU
Astara	91,257	1239	0	3	7	0
Astane	108,130	1012	0	0	8	0
Amlash	43,225	416	0	0	2.3	0
Anzali	139,016	1173	0	4.6	8	0
Talesh	200,649	3222	0	4	10	0
Rasht	956,971	9495	14.5	52	22.3	14
Rezvanshahr	69,865	801	0	0	0	0
Roodbar	94,720	1027	0	2	3.7	0
Roodsar	147,399	1332	0	2.7	4	0
Siahkal	46,975	487	0	0	4	0
Shaft	54,226	438	0	0	4	0
Somesara	125,074	1239	0	0	4	0
Fuman	92,310	798	0	0	4	0
Lahijan	167,544	1449	0	8	8	5
Langrood	140,686	1427	0	4	7	0
Masal	52,649	711	0	0	0	0
Gilan province	2,530,696	26,266	14.5	80.3	96.3	19

Table 2.

Percentage share of population in each city relative to the whole province, difference between the percentage share of hospital beds and the percentage share of the population in each city and the number of hospital beds per 10,000 population.

	Population shares (%)	Burns beds			ICU beds			CCU beds			NICU beds
	Population shares (%)	Burns beds shares (%)	Discrepancy	Per 10,000 people	ICU beds shares (%)	Discrepancy	Per 10,000 people	CCU beds shares (%)	Discrepancy	Per 10,000 people	NICU beds shares (%)	Discrepancy	Per 1000 neonates
Astara	3.61	0	−3.61	0	3.74	+0.13	0.33	7.27	+3.66	0.77	0	−4.7	0
Astane	4.27	0	−4.27	0	0	−4.27	0	8.31	+4.04	0.74	0	−3.9	0
Amlash	1.71	0	−1.71	0	0	−1.71	0	2.39	+0.68	0.53	0	−1.6	0
Anzali	5.49	0	−5.49	0	5.73	+0.24	0.33	8.31	+2.82	0.58	0	−4.5	0
Talesh	7.93	0	−7.93	0	4.98	−2.95	0.2	10.38	+2.45	0.5	0	−12.3	0
Rasht	37.81	100	+62.19	0.15	64.76	+35.24	0.54	23.16	−14.65	0.23	73.68	+36.1	1. 5
Rezvanshahr	2.76	0	−2.76	0	0	−2.76	0	0	−2.76	0	0	−3	0
Roodbar	3.74	0	−3.74	0	2.49	−1.25	0.21	3.84	+0.1	0.39	0	−3.9	0
Roodsar	5.82	0	−5.82	0	3.36	−2.46	0.18	4.15	−1.67	0.27	0	−5.1	0
Siahkal	1.86	0	−1.86	0	0	−1.86	0	4.15	+2.29	0.85	0	−1.9	0
Shaft	2.14	0	−2.14	0	0	−2.14	0	4.15	+2.01	0.74	0	−1.7	0
Somesara	4.94	0	−4.94	0	0	−4.94	0	4.15	−0.79	0.32	0	−4.7	0
Fuman	3.65	0	−3.65	0	0	−3.65	0	4.15	+0.5	0.43	0	−3	0
Lahijan	6.62	0	−6.62	0	9.96	+3.34	0.48	8.31	+1.69	0.48	26.32	+5.5	3.5
Langrood	5.56	0	−5.56	0	4.98	−0.58	0.28	7.27	+1.71	0.5	0	−5.4	0
Masal	2.08	0	−2.08	0	0	−2.08	0	0	−2.08	0	0	−2.7	0
Gilan province	–	–	–	0.057	–	–	0.317	–	–	0.381	–	–	0. 72

As shown in Table 2, 37.81% of the Guilan population are living in Rasht, which is the capital of Guilan province. Rezvanshahr and Masal, with a total percentage of 12.5% of the province population had no hospital beds. All burns-related beds were in the hospitals of Rasht. The other 15 cities of the province did not have such hospital beds. For ICU, CCU and NICU beds, about 8%, 2% and 14% of cities were deprived of having such hospital beds, respectively.

The difference between the percentage share of hospital beds and the percentage share of the population for each city is another important indicator (Table 2 and Figure 1).

Figure 1.

Difference between bed shares (%) and population shares (%).

As shown in Figure 1, in terms of burns-related beds, only Rasht had a positive gap. Only Rasht and Lahijan had NICU beds. In Rasht, as the capital of the province, access to burns-related, ICU and CCU beds had a positive gap, while there was a negative gap at a size of 14.68 for CCU beds. Moreover, the highest positive and lowest negative gaps were attributed to CCU beds.

Another important indicator is the number of hospital beds per 10,000 populations (NICU, per 1000 neonates) in each city (Table 2, Figure 2).

Figure 2.

Beds per 10,000 people.

According to Table 2, in Guilan province there were 0.057 burns-related beds, 0.317 ICU beds, 0.381 CCU beds and 0.72 NICU beds per 10,000 individuals (NICU, per 1000 neonates). In 11 out of 14 provinces, the number of CCU beds per 10,000 people was higher than the provincial average. Results of inequality measurement for the distribution of hospital beds using the Theil index and relative Theil index are shown in Table 3. The highest inequality in distribution was for burns-related beds (0.8), NICU beds (0.75), ICU beds (0.55) and CCU beds (0.21), respectively.

Table 3.

Bed distribution inequality measured by the Theil and relative Theil index between the cities of Gilan province.

	Burns beds	ICU beds	CCU beds	NICU beds
Theil index	0.97	0.66	0.25	0.91
Relative Theil index	0.8	0.55	0.21	0.75

Conclusion

A globally equitable distribution of resources is an important factor for achieving development. According to the WHO report (2010), UHC and the equitable provision of resources are critical to accomplish sustainable development goals. Furthermore, physical access is an important element to achieve equitable access to resources. Moreover, the national development plans of Iran and, recently, the health transformation plan, have mainly focused on the equity in access to healthcare services.¹⁹ In recent years, WHO has been emphasising the measurement of equity in the distribution of health resources. In developing countries, mostly due to the lack of necessary information and skills for resource distribution, health resources are usually allocated in an unbalanced manner.²⁰

Based on the findings of the current study, burns-related beds were available in only one city, and the highest negative gap was shown to be for these beds, having the lowest rate per 10,000 population.

Therefore, based on the relative Theil index, the highest inequality in distribution was for burns-related beds, NICU beds (available only in Lahijan and Rasht), ICU beds (only available in eight out of 16 cities), and CCU beds (available in 16 cities), respectively. In Guilan province, CCU beds had the highest rate and the lowest inequality in distribution. Therefore, the utilisation of CCU beds is relatively more equitable than others.

With regard to the high potential of Guilan province for tourism and its natural attractions, it appears that the identification of opportunities regarding the tourism industry and connecting them with the health sector and the equitable distribution of hospital beds could result in sustainable financing to establish the necessary infrastructure in deprived areas or nearby regions.

Guilan province is rich in terms of ethnic, linguistic and religious diversity; which provides it with a great opportunity. For example, Astra as a city with residents predominantly being Turkish can be the hub of healthcare services for those who speak Turkish within or outside of the country.²¹ The inequitable distribution of hospital beds can result in the inequitable distribution of healthcare professionals and equipment, which in turn results in the inequitable distribution of health outcomes. The mortality among infants is an important indicator to assess the health status of a nation. The WHO highlighted the importance of comparisons between countries in terms of health outcomes being performed. Therefore, investing in this area would result in the promotion of child health indicators and the overall health of the country with optimal cost-effectiveness. According to the law of diminishing returns, allocating hospital beds to areas with the highest negative gap may be appropriate and cost-effective; however, in cities with a better status relative to others, further information such as referral from other provinces or cities should be considered to increase the efficiency of resource distribution.²²

The special geography and population distribution in northern Iran, where cities and villages are very close to each other, has made it different from other parts of the country. The lack of ICU beds in Rezvanshahr and Masal is not an indication of inequality, and patients are usually referred to nearby cities such as Talesh, Foman or Anzali, where there are better conditions in terms of ICU beds. Guilan province was shown to suffer from a considerable paucity of burns-related beds, which was consistent with findings of a study conducted by Pakdaman who reported Guilan as a province with the lowest number of burns-related beds in the country.²³ A study on the distribution of CCU beds in 24 hospitals affiliated to universities in The Netherland between 2004 and 2006 showed that the Gini index for the study period was 0.5, 0.6 and 0.5, which was an obvious indication of inequality in the distribution of ICU beds.²⁴ As hospital beds are an important indicator to estimate the need for other resources such as physicians, nurses and equipment, equity in the distribution of ICU beds is implicitly important for the distribution of other resources.²⁵

In addition, regarding the international sanctions and the need for an approach to control healthcare costs, attention to health tourism can bring additional income for the country, which can be a good source to expand healthcare services in the province and the whole country. Moreover, with regard to the high burden of non-communicable diseases in Iran, the necessity for attention to long-term care has increased. The current study, investigating the supply of hospital services (hospital beds) and their distribution, can add to the current concerns about the unbalanced distribution of health resources. Only focusing on the supply side of hospital services and equitable distribution cannot be effective, and simultaneous interventions in public health (including family physicians, primary care, and strengthening self-care), health networks and curative services (strengthening the referral system) need to be taken into account aiming to meet the demand for healthcare services. Considering the high cost of creating health infrastructures as well as the socialisation of healthcare services, the potential of health donors can be used to establish new hospital beds, accompanied by increasing equity in access to health services. Moreover, local and national policy-makers should design and implement a comprehensive monitoring and evaluation system for tracking and allocating healthcare resources, both qualitatively and quantitatively, which appears to be very necessary to increase the equity in access to healthcare services. The main study limitation was that we studied only one year to assess the equity. It is, therefore, recommended that further similar studies should be conducted on longitudinal trends at the province level to provide a holistic and clearer picture. Also further studies should focus more on suggesting the range of a reasonable population to bed ratio, by using need-based assessments.

Footnotes

Acknowledgements

None.

Authors’ contributions

JE was responsible for the design, implementation, analysis and drafting the paper. SSM was involved in the conception, development, implementation and writing the paper. ZM, MHZ, GR, MEA, ZSV and MD were responsible for the intellectual development of the paper. All authors have read and approved the final paper.

Availability of data and materials

Data are available and can be accessed by contacting SSM.

Ethical approval

Not applicable.

Informed consent

Not applicable.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sam Sotodeh Manesh

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Assessing equity in the distribution of hospital beds: evidence from northern Iran

Abstract

Objective:

Methods:

Findings:

Conclusion:

Keywords

Introduction

Methods

Results

Conclusion

Footnotes

Acknowledgements

Authors’ contributions

Availability of data and materials

Ethical approval

Informed consent

Conflict of interest

Funding

ORCID iD

References