A Review on Pathology of the Integration of Medical Education System with Health Services at Iran's Ministry of Health and Medical Education

Introduction

One way of organizational agility is to design an appropriate organizational structure. An agile organization has a unique organizational structure that makes the organization to operate more effective in its own processes (1). Nowadays, one of the main subjects of structural reform in the administrative system is the integration, which, if successful, will be the basis for the success of that organization. But the realization of successful integration requires an examination of its process, a key subject for organizations. Integration activities in the public part have been undertaken over the past decades with the goal of administrative reform (2). In most of Iran's development planning, which has been implemented so far, as well as in Article 28 of the Sixth Development Plan, the integration of governmental organizations has been considered as one of the mechanisms for reforming the administrative system (3). Management thinkers have investigated various aspects of integration in their research, including the relationship between integration and innovation presented by Cefi, and Marsili (4), identity in the integration presented by Tienari, and Vaara (5), the integration process presented by Appelbaum, Gandell, Yortis, Proper and Jobin, F (6), the integration effects provided by Lebudi (7), and the factors affecting integration presented by Pietroburgo and Wernet (8). Pathology helps managers by pointing out their strengths and weaknesses and classifying them in preventing them from providing superficial and simple solutions by predicting variables with the highest returns, this method tries, by offering appropriate feedback, to propose solutions and executive patterns (9). The universities of medical sciences in Iran are responsible for the training of the specialized and committed forces necessary for the health of society (10). Studies have shown that the quality of medical education in many Iranian medical universities is not optimal (11-14).

Historical evidences suggest that the world first medical university was founded in Iran 1800 years ago called Gundi Shapur (15,16). The training of medical personnel over the past centuries has undergone a different course in Iran and has changed from traditional education to modern academic education. Until the early 18th century the medical education was achieved by the presence of a physician (master). After the end of the course, which was determined with the opinion of the professor, the young physician would be able to practice and have students themselves. Modern higher education began with the foundation of the Dar al-Fonoun. The establishment of the Dar al-Fonoun in 1851 has had great impact on the process of the emergence and formation of higher education in all disciplines of science and in particular medical education. The school of medicine and pharmacy in 1880 was separated under the chairmanship of Dr. Loghman Adham, named the Higher School of Medicine, from Dar Al Fonoun, and in 1934 the University of Tehran was formally established. The medical faculty of the University of Tehran was also inaugurated in 1938, and in 1939, the law of delivery of hospitals from medical to university was approved, and clinical education of medical students was transferred from hospitals of Ministry of Health to university hospitals. Medical education in medical faculties in 1940 was named the Ministry of Education, Endowments and Fine Arts under the supervision of the Ministry of Culture and in 1964 its name was changed by the Ministry of Culture under the supervision of the Ministry of Education and in 1967 with the separation of higher education and the establishment of a new ministry it was established as the Ministry of Sciences and Higher Education (17). The project of integration of the medical education system with the health services at the Ministry of Health and Medical Education was happened since late 1985 in the former Ministry of Health of Iran in order to achieve self-sufficiency in medical education and satisfying the needs of the society in health services, desired use of the medical facilities of the country oriented to provide and generalize health, welfare and medical education and research, and realization of Articles 4, 12 and 13 of Principle 3 and that part of the objectives of Article 29 of the Constitution of the Islamic Republic of Iran, related to health and welfare services (18,19). Now this ministry has 65 universities or independent medical faculties across Iran; it has about 18,000 faculty members and about 200,000 students at different levels of education (20). Health Development Project is in progress in Iran since 2014 (21). One of the important steps in this project is to promote medical education (22). In these days, the subject of reintegration of medical education into higher education is proposed once in a while, a case that is never closed; an interesting point is the insistence of one ministry (Ministry of Sciences, Researches and Technology) and the denial of another ministry (Ministry of Health and medical education). Studies show that in the vast majority of countries in the world, there is an integrated educational system; according to reports declared by the Ministry of Health and Medical Education in the early 2000s, the separation of medical education from the Ministry of Sciences is an Iranian experience. Of course, Cuba has also had such an experience, but in terms of what is happening today in the world, the separation of medical education from the Ministry of Sciences is limited to Iran and at last another country (23). In February 2004 in a report, referring to the key role of EDC in Iran's medical sciences universities, World Federation for Medical Education (WFME) has announced the medical education in Iran as consistent with international standards and the medical education reforms in Iran as inspiring all countries of the world (24). In general, there are many disagreements regarding the advantages and disadvantages of the project of integrating the medical education system with health services in the Ministry of Health and Medical Education. Although this project has prevented the multiplicity of health system management, it has been pointed out that the existing educational and therapeutic trends do not have the required standards (25). Also, some reports indicate that the integration of medical education with health areas has led to the development of expert human resources and the improvement of health indices, on the one hand (26). On the other hand, it has led to a decline in the quality of medical education and the provision of health services in educational hospitals (27). The range of discrepancies has been widespread so that in 2002 and 2017, the project of separation of medical education with the system of providing health services was seriously raised by the representatives in the Islamic Consultative Assembly. In addition, some other organizations, such as the Agricultural Jihad, the Ministry of Oil, etc., are demanding the integration of the education part in their affiliated organizations. Therefore, according to the articles published so far, this research as a review deals with the pathology of the project of integrating the medical education system with health services in the Ministry of Health and Medical Education. The findings of this research can be used in the policy-making of integration of governmental organizations; the studied model is effective in promoting the indigenous knowledge of the country in the field of integration.

Methods

Collecting the information of this review has been carried out considering the statements of the former and current ministers of health in Iran, as well as through the search of published articles on Iranian and international valid sites (SID, MAGIRAN, Iranmedex, GoogleScholar, Embase, PubMed, Scupus, Science Direct) and with searching the words “Integration of the medical education system with health services”, without limitation of language and since the beginning of 1985 (since the start of this integration). There have been studied 9 related researches. Also in our research we have used the views of six ministers of health and medical education Iran, who have been responsible for this ministry after the implementation of the project; the final opinion of the Islamic Consultative Assembly's Research Center of Iran has been also expressed.

Results

We try to list the researches done on the project of integration of the medical education system with health services as follows:

 In 2017, Rahavard conducted a research aimed at identifying the factors affecting the successful integration of Iranian government organizations. The statistical population of this research was 35 organizations integrated into Iranian public section. Our findings showed that the integration of Iranian governmental machinery is not successful, and "trust and fairness", "management of differences", " "Conflict and ambiguity" and "knowledge management and convergence" are factors affecting the successful integration in Iranian organizations. Also, the comparison of the integration performance in the four financial, customer, process, and learning dimensions showed that learning dimension has a relatively better position than other dimensions of performance (28).

 In 2009, Marandi conducted a research entitled "Integration of medical education and health services and its effects in Iran." In this research, the problems of medical education and health education have been studied before and after the revolution, including lack of skilled manpower. He believes that in most parts of the country - except in Tehran - the shortage of health manpower was clear. In most of the major cities, a large majority of physicians was resident (18).

 Majdzadeh et al in 2011 conducted a research entitled "link between the research and praxis in Iran: two decades after the integration of Health Ministry and Medical Universities." Conducting a survey, he has concluded that the integration of medical education with health areas has led to the development of specialized human resources and the improvement of health indices, on the one hand. But, on the other hand, because of giving more importance to the treatment, universities have neglected their core mission of producing knowledge (19).

 In 2016, Ebrahimnia et al conducted a research entitled "Pathology of the Integration of the Medical Education System with the Headquarters of a Health Organization." In this qualitative research, 18 senior managers of the organization were selected purposefully. The researchers came to this conclusion that integration in the four areas of focus, mission, coordination, and effectiveness had different strengths and weaknesses. Integration reduced the administrative structure and increased efficiency, but failed to gain much effectiveness. Also, the interference of headquarters and queues weakened the medical education, so that 67% of managers opposed this continuation of integration. At the end, the researchers concluded that the pathology of the status quo and the determination of the goal before the integration seems necessary and the views of the managers of different parts of the organization will help achieve the goals of integration (29).

 In the year 2015, Mirmoghtadaie et al conducted a research entitled a review of the challenges of integrating medical education with the system of providing services in Iran from the perspective of human capital. This research was conducted descriptively and in the form of a review; pointing to the global challenges of human resources, it explored the integration project from this perspective, and, based on the researches carried out, examined the survival and destruction of this project. According to their research, they claimed that the review of existing studies and documents revealed the strengths and weaknesses of the integration system and identified opportunities and threats. Since the integration project of medical education is associated with the delivery of services with a wide range of challenges, the analysis of these components shows that with the advent of global developments and the challenges facing human resources management, this project needs to achieve sustainability changes in the health field for insuring its durability (29).

 In 2015, Azizi conducted a research entitled Challenges and Perspectives of Medical Education. The results of this research showed that 82% of the experts in medical education under question considered to be good the required number of human resources needed in the country. Most often they evaluated good-quality human resources as moderate and good, and believed that breaking the fence of medical faculties and conducting education and research in the society was weak. They also evaluated moderate and weak the promotion of scientific level of human resource in institutions, outpatient centers and hospitals (26).

 In 2011, Shakebaei et al. carried out a research entitled "Studying the achievement of the goals of the system of integration of medical education with the provision of health services from the viewpoint of the faculty members of Kermanshah University of Medical Sciences". The results showed that the achievement of integration goals was 37.52 ± 1.07% (SEM ± Mean) for the members of the faculty as the maximum points for this study. For these members, the highest score was allocated to services and health indices (59.87± 1.21%) and the lowest score was allocated to the research activities and facilities as well as to the level of social successes (49.19 ± 1.20%) of integration project. In this research, in view of faculty members, the success rate of the integration project in achieving the goals is still far from the desired level. Also, the success rate of this project in health areas has been evaluated as to be more than medical and educational, and in the research and social fields (such as changing the vision of graduates and members of the faculty societally) is significantly less than other cases. They conclude in the end that these differences are due to shortcomings of the current system in achieving some of their goals, and have suggested a repeat of the present study in other centers as well as further studies (25).

 In 2002, Abbasi Moghaddam et al. conducted a research entitled "The attitude of academic experts regarding the results of the integration of medical education with health areas". In this research, 556 faculty members and managers of 10 universities of medical sciences in Iran were randomly selected and were asked in the form of questionnaire. The majority of people surveyed, while agreeing on the link between integration and some of the existing achievements, such as establishing a care system and improving health indices, have believed that the quality of medical education has fallen as compared to before integration. Also, the majority of the respondents stated that the reintegration of medical education with the Ministry of Sciences has caused many problems and the ministry does not have readiness to reintegrate. However, despite the above views, 46% of the subjects believed in the reintegration of medical education to the Ministry of Sciences and 40.7% disagreed with this view and 13.3% abstained. They concluded in the end that there was no consensus between the experts under study in the relation of the positive and the negative results of the integration. Also, the lowering of the quality of medical education, that has occurred in this period for many was mainly due to other factors and was not related to the integration itself. Therefore, for them in the assessment of the positive and negative results of integration, considering other factors and working procedures for treating these factors is required (27).

 In 2001, Rajabpour conducted a research entitled "A Review of the trend of Integration of Medical Higher Education in Health Services." He has dealt with historical analysis of the integration project and its ought and non-ought. He concludes that after decades of implementation of this project, taking into account the responsibility of individuals during the implementation of this project, paying attention to the sources in this regard and its achievements, and comparing these three factors from the perspective of the conscious people, it should be evaluated continuously by high-ranking officials of the system and be removed its weaknesses in light of the research carried out (23).

Table 1.  Results of studied articles

The statements of the ministers of health who have been responsible for the Ministry of Health and Medical Education in Iran after the implementation of this project have been listed in table 2.

Table 2. Statements of the ministers of health who have been responsible for the Ministry of Health and Medical Education in Iran after the implementation of this project

Discussion

There are a lot of controversies about the advantages and disadvantages of this project. But most reports indicate that the integration of medical education with health areas has led to the development of specialized human resources and the improvement of health indices, on the one hand (18,26). On the other hand, it has reduced the quality of medical education and the provision of health services in educational hospitals (27). Also, because of giving great importance to the treatment, the universities have neglected their core mission of producing knowledge (19). However, the results of some researches showed that the lowering of the quality of medical education, that some believe it has occurred in this period, may be due to other factors and not related to the integration itself. It is noteworthy that the World Federation of Medical Education, in February 2004, appreciated this project in a report. It has suggested that the integration of education and health services can inspire other countries in the world, given the unique nature of medical education in Iran and the positive nature of this approach (24). Also, six ministries of health and medical education in Iran who have been responsible for the ministry after the implementation of the project, have so far commented on it; of whom 4 minister, including the current health minister, are against the attachment of medical education to the Ministry of Sciences, Researches and Technology. Also, the Iranian National Assembly Research Center announced in a detailed report about the research project on the integration of educational systems in Iran that at present, the integration of educational systems in the country at any level is neither possible nor desirable; the only option in contemporaneous Iranian society can be considered to be a desired option for creating harmony between educational systems is to create an intermediary institution among educational systems that is responsible for coordinating and linking educational systems. Another point to which those who agree with the attachment of medical education to higher education do not pay attention is the superior documents. In all of the superior documents, including health policies declared by the leadership of the Islamic Republic of Iran on the promotion of medical education, the medical education has been seen within the Ministry of Health; Apart from all these discussions, in the present circumstances, Does not seem logical, the displacement of a massive campus with 65 universities or Independent colleges, 200,000 students and 20,000 faculty members.

The transformation of higher education systems is unavoidable around the world. The proponents of transformation and change are naturally global and similar, but their effects vary from country to country and from region to region (17, 30). One of the oldest factors in the transformation of higher education is the pressure of society regarding transparency and responsibility; some new factors include the rapid development of technology, the changing needs of society for new skills in the age of globalization. Changes and transformations in human societies have changed the attitude, values ​​and expectations of the human being, and as a result, they affect the tasks of the health higher education system (31). Undoubtedly, medical education has gained many successes over the last three decades, and faculty members of the medicine have done a great job in providing medical manpower, but it is important to reflect on the fact that social responsibility is essential at all levels of the health system and also at the college level. The health system should be responsive in respect of the quality of services provided by health service providers, and medical universities should be accountable for the knowledge, attitudes, skills, and abilities of providers who they educate them as graduates. The differentiation of clinical and academic areas will minimize this responsibility at two levels. In other words, the health system will not be responsible for the service quality of service providers whom it has not trained them, and medical universities will give their graduates to an independent and separate system and will not be responsible for their next performance (26). Medical education decision-makers and officials of the Ministry of Health and Medical Education, while giving importance to the implications of the integration of medical education and the provision of health services, should address the challenges of responsive medical education; and they should plan for removing the shortcomings and improving the quality of medical education in the country with the help of faculty members. Of course, one of the important steps in the Health Development Plan, which began in 2014 in Iran, is to promote the medical education.

It seems that there is currently no possibility of differentiating the two parts of medical education and health services; the management of this integration is only reasonable way for the medical education and treatment system. Of course, every major national project should be criticized and analyzed after decades and its problems resolved. Realizing this depends on the correct understanding of integration, perceived as a continuous process and management of the resulting change over time. Both systems must play an active and decisive role in other reforms. The educational system should play a leading role and have an active and continuous presence in the formation of a desirable service delivery system and the provision of services in order to transform the educational system and the architecture of an ideal educational system. The participation of each of the two educational systems and the provision of services in other reforms requires that the two systems are so interconnected that they move nearly and are sensitive to their fate. In general, the main goal of integration should be the transformation of the medical education system in order to better respond to the needs and expectations of society and consequently the evolution of the health system. The indices for responding to the societal needs and expectations can be a tool for measuring the achievements and implications of integration. In order to better achieve the success of the integration project, the following practical suggestions (especially in medical education) are noteworthy:

1. In the educational planning of all specialized disciplines, the content of the programs is to some extent be determined on the basis of the health needs of the country.

2. In the Regulations on Promotion of the Faculty Members, the appropriate weight should be given to the various dimensions of their (educational, health, treatment, etc.) mission.

3. In almost all committees related to national programs for the provision of services, the faculty members of the universities should have an active and determinative role.

4. Gradually, the service provision guidelines should be introduced in the training content and evaluation of specialized courses.

5. To apply the results of researches conducted in the country, the articles published in the prestigious medical journals should be included in specialized exam resources.

6. In all universities, some measures are needed to expand the outside of the hospital, although the measures taken may not be adequate.

7. In the decision-making process related to the development of higher education in the Ministry of Health and Medical Education, there should be a very close interaction between the various departments, including educational and health departments.

8. In strategic plans of specialized and subspecialty disciplines, to meet the health needs of the country should be highlighted.

9. Continuing education should take a legal form and take place comprehensively.

Acknowledgements

The authors express their hearty gratitude to the professors of Ahvaz Branch, Islamic Azad University.

Financial support: This research is based on the Ph.D. thesis at Ahvaz Branch, Islamic Azad University.

Conflict of interests: The authors declare that they have no conflict of interests.