This study aimed to evaluate the status of the AFHS in Iran, which scored 111 out of 520, approximately 21% of the total possible score. The parameters pertaining to governance and community engagement, with respective scores of 3.35 and 3.02, attained superior ratings compared to the other parameters assessed. Conversely, the dimension concerning resources was assigned the minimal score, quantified at 1.56. Given the lack of prior studies specifically examining each domain of the AFHS, we highlight the importance of each domain concerning older adults’ health and service provision. The concept is closely tied to the public health system, and we reviewed general studies in this field.
Although “governance” scored higher than other dimensions, it is still inadequate. The study indicates that top health system managers have limited familiarity with the AFHS concept and its importance. Azizi-Zeinalhajlou’s study supports this, showing insufficient planning and legal support for older adults health [14]. Despite warnings about the aging population, macro-level decision-makers lack proper planning and legal support to address this issue. Mossadegh Rad et al. found that in countries with decentralized treatment structures, local health and planning departments play a more significant role in policymaking [15].
In Iran, the involvement of other organizations, the older adults, their families, and specialists in decision-making is weak. In contrast, many countries actively involve patients and society in health policymaking [16, 17]. The MoH’s failure in this area is due to a lack of strategic and scientific approaches to older adults’ issues. Effective planning requires cooperation with other organizations and experts. This study’s findings contradict the present study, which shows neglect of community and older adult’s opinions in policymaking.
To establish a legal and executive basis, an independent, non-profit organization should conduct assessments for planning and policymaking. Currently, Iran’s MoH collaborates with various organizations, including universities, health insurance, and welfare organizations. However, more communication with related organizations outside the Ministry is needed. The government should develop other sectors, such as education, security, housing, and the environment, alongside the health system [15]. For better health system functioning, a documentation system for decision-making and interventions is essential. Continuous monitoring and evaluation with specific standards are necessary. While some clinical guidelines exist, there are no specific guides for the older adults.
Many countries have national licensing, evaluation, and accreditation programs for health institutions. These institutions must meet basic standards to operate and are periodically evaluated [17, 18]. In countries like England, Japan, and Türkiye, government organizations under the MoH handle accreditation [16, 17, 19]. Some countries set quantitative goals for key performance indicators, encouraging health service providers to achieve them [16, 20]. In Iran, there are no comprehensive monitoring systems or specific standards for older adults’ health services, indicating a lack of priority in the MoH’s programs.
Sedaghat’s study highlights the need for management information systems for proper organizational management and decision-making [21]. Hajavi et al. suggest specific guidelines for documentation and health information management in senior centers, to be evaluated and updated annually [22]. The older adults visit doctors more frequently and incur higher medical expenses, necessitating management information systems to support services and improve productivity [21]. Sadoughi et al. found that documentation in Iran’s health centers is manual, with delayed information provision to decision-makers. Most reports are not provided to older adults health managers promptly, leading to decisions based on outdated information [23].
The AFHS should provide services tailored to the older adult’s needs, delivered by specialized, trained, and skilled personnel without financial burden. However, the allocation of human resources has not been evidence-based, leading to potential future issues in service provision due to a lack of expertise and scientific planning.
Studies indicate that rising health costs in old age are due to increased use of health services, longer hospital stays, and high medication costs. The older adults also experience more disabilities, further increasing health costs. In 2005, about 217,000 older adults people (2.4% of Iran’s older adults population) had disabilities [24]. The older adults, comprising one-fifth of the hospitalized population, accounted for one-third of hospitalization expenses [25]. The aging population challenges the social security system by increasing the number of pensioners and affecting insurance organizations’ costs and income [26]. As the population ages, fewer working people contribute to insurance premiums, while pension payments rise, significantly increasing insurance costs [14]. Therefore, insurance organizations must plan for optimal resource management [27].
Many older people require long-term care, increasing health costs [14, 27]. Despite rising health expenses, basic and supplementary medical insurance coverage for the older adults is not universal [14]. Research shows that long-term care and home nursing, rather than acute care, drive increased health expenses [28]. These services often fall outside conventional insurance frameworks, leaving the older adults or their families to bear the costs [14].
Other countries have implemented cost management measures for older adults. In Spain, medications are free for those aged 65 and older, and public health expenditures, including long-term care, are among the lowest in Europe, yet the quality of care is rated “very good” [29]. In contrast, Iranian insurance companies charge the older adults the same fees as other age groups and have not addressed the need for home and long-term care. Improving home healthcare services could reduce hospitalization costs, benefiting the government. Thus, Iran’s social security system needs further development to ensure all older adults have appropriate insurance coverage.
Developing informal care for the older adults, provided by familiar people or family members, can reduce costs and be more accepted by the older adults. However, Iran lacks an informal care system, and initial efforts by the welfare organization are hindered by a lack of trained personnel and inter-organizational cooperation [14]. Coordinated efforts and a dedicated organization could improve access to informal care.
Samimi Sedeh et al.‘s study highlights the need to align human resources strategies with trends in older adults’ health. Despite upstream documents emphasizing needs assessment, land use planning, technology use, and resource distribution justice, Iran’s health system lacks a comprehensive, evidence-based method for human resource allocation. Traditional methods lead to unfair resource distribution and neglect many older adults needs [30].
Demographic changes also impact older adult’s care. Traditionally, families cared for the older adults, but with the rise of nuclear families (73% of Iranian families), the government’s role has expanded [31]. Attention to long-term care principles is crucial for an effective health system [32]. However, the current implementation is inadequate. Hospice care, except for the Kahrizak hospice, is privately run and inaccessible to many older adults due to costs. The welfare organization serves less than 1% of the older adults, mainly those with pre-existing disabilities.
While Iran’s cultural and religious beliefs support family care for the older adults, reducing the need for care centers, the development of part-time and full-time care centers is essential [33]. Evidence shows that family care, supported by government policies, is economically beneficial. However, the quantitative and qualitative development of care centers remains necessary [34].
Integrated service delivery models are not implemented in service provider centers. Despite a program announced by the MoH, significant action has not been taken, and managers scored higher due to this program. The process monitoring system and the time of admission, hospitalization, and discharge of the older adults differ significantly between groups. Although this system is partially implemented in hospitals, it is not consistent across other levels, and managers based their evaluations on this incomplete implementation.
One of the main challenges of population aging is providing health services to the older adults, who are primary consumers due to reduced physical performance and mental vulnerability. Increased older adults population leads to higher demand for health services [35]. Implementing more screening and prevention programs can identify diseases faster, reduce healthcare costs, and protect the older adults from high expenses [36]. Evaluating age-friendly primary healthcare should consider transportation, signs, clinical facilities, physical environment, counseling, costs, access, communication, referral system, health knowledge dissemination, medication management, geriatric care standards, feedback system, and communication skills [37].
Most medical needs of the older adults are costly services, including long-term hospitalizations, rehabilitation, and reduced self-care ability [38]. Zilochi et al. found that the older adults have significantly longer hospital stays [39]. The AFHS should establish service provision methods based on international standards to reduce hospitalization length, improve home care, and continuously monitor the older adult’s condition. The goal is to support the older adults to live in their homes and communities for as long as possible [40]. Daily and short-term care centers help care for the older adults when family members are unavailable. In the U.S., these centers are mostly private, while in Bahrain and England, they are government-run. In Iran, a combined model with private and government tariffs is more common, supported by welfare organizations. One major issue in Iran is the transportation system for these centers [41].
Establishing an integrated care system for the older adults is crucial [42]. Threapleton’s study identifies eight components for integrated care: continuity/transfer of care, policies/governance, common values/goals, person-centered care, multidisciplinary services, effective communication, case management, and evaluation for care and discharge planning [43]. However, Iran lacks an integrated care system, and services are provided separately and discontinuously. Establishing this system requires comprehensive planning and coordination across health departments, which has not been achieved due to a lack of a systemic approach.
Cooperation and participation among humans have been vital for survival. Participation involves people’s intervention and supervision and the system’s social-political ability to achieve development and social justice [44]. In Iran, preparations for older adults’ programs have been long established, with various institutions planning for this group. These include the MoH, the Ministry of Welfare and Social Affairs, universities, research centers, pension organizations, municipalities, NGOs, and the relief committee [45].
Cooperation among official organizations to support the older adults is essential for improving their quality of life. In the U.S., older adults programs are supervised by the public health and geriatric services network, including the Ministry of Welfare and Aging, the Disease Prevention and Control Association, the Association of Aging Agencies, and state geriatric units [46]. Solving aging issues requires combining capabilities and involving all sectors, both public and private, and NGOs. Coordinating relevant organizations is crucial for planning and promoting older adults’ health. Creating coordinated organizations to plan and guide activities can improve support services. Planning within a health network system should establish facilities for providing basic health and treatment services to address older adults’ issues early on. All organizations should be trained to improve life and promote active, healthy aging at the provincial and national levels [47].
In Iran, various service providers, including the welfare organization under the Ministry of Cooperation, Labor and Social Welfare and the MoH, Treatment and Medical Education, are the main providers of services related to the older adults. Greater participation from these organizations and efforts to attract cooperation from other groups will help. There are four types of nursing homes (government, charitable, and private), all licensed by the welfare organization. Home care is primarily done by the private sector, and the public sector should intervene. In Sweden, access to care is determined by the municipal care manager based on needs assessment. All household services are provided by municipalities, including special housing, medical services at home, special transportation, special care, pensions, and benefits for informal jobs and relatives who support the older adults [48].
Health charities play a significant role in financial provision, resource development, health services, and financial support for patients in Iran’s health system. Health Donors’ participation absorbs financial resources through the Health Donors’ Association, health charity institutions, financial aid distribution, social networks, virtual space, and targeted ceremonies. They provide equipment, pay salaries, and cover patient health service costs. Charities have a high capacity to provide health services in Iran. Their participation in preventive services is through individual and group voluntary contributions. The MoH, Treatment and Medical Education documents mention the participation of charities and health volunteers [49]. Lack of public participation has been a main factor in the failure of development plans. Since then, development strategies have emphasized popular participation as a main human need. Informal partnerships have a long history in Iranian society and have always been superior to formal partnerships [44].
Iran has good capacities for using non-governmental organizations, but dependence on the public sector can reduce their efficiency. Creating financial and managerial independence in these organizations can help the health system and facilitate achieving its goals. These organizations can use the abilities of older adults to improve their health. In developed countries, older adults care management includes social responsibility systems, voluntary service systems, time banks, and time bank insurance through interactive systems.
Proper functioning of the health system based on the older adults’ health needs and available resources can bring good outcomes. Older adults’ satisfaction with service provision, appropriate insurance coverage, and long-term care centers with suitable facilities are visible consequences of this system. Evaluators gave higher scores because the older adults feel pleasant about living in these centers due to the facilities and services, although this was based on subjective criteria. Arab et al.‘s study indicates that older adults satisfaction with services is good and acceptable [50]. Tajvar et al.‘s study showed that 30% of older adults’ inpatients had low or moderate satisfaction, while 70% had relatively high satisfaction. A significant relationship was observed between overall satisfaction and variables like employment and supplementary health insurance, with unemployed and uninsured older adults having less satisfaction [51]. A study in Naja hospitals showed 80% satisfaction with inpatient services, but there were defects in equipment, electronic services, and staff attitudes. Despite suitable treatment levels, older adults services in Naja hospitals need improvements to enhance satisfaction [52]. These studies’ results do not align with the present study, which shows that older adult’s satisfaction with health services is not at an appropriate level. Understanding the reasons for dissatisfaction can help improve this satisfaction.
Ghazi et al.‘s study indicates that the satisfaction level of older adult’s residents in non-governmental nursing homes was 40%. Satisfaction with psychological and social care was lower than with physical care, suggesting a need for improved services in these areas. Psychological preparation before admission to nursing homes may enhance satisfaction [53]. This finding aligns with the present study, highlighting inadequate services in these homes. To improve satisfaction, centers should provide comfort, physical facilities, and conditions for psychological and social well-being, along with appropriate staff treatment. The health system should plan with other organizations to enhance long-term care centers, aiming for healthy and active aging.
Different societies have introduced strategies to manage the negative consequences of population aging, particularly on the labor market and quality of life. One such strategy is “active aging,” defined by the WHO in 2002 as maximizing opportunities for health, participation, and security to improve the older adult’s quality of life. This concept emphasizes maintaining a healthy lifestyle, reducing environmental risks, and includes physical, mental, and social well-being [54]. Studies show that Iranian older adults, especially women, lead relatively inactive lives, particularly in the third and fourth domains (safe life and enabling environment) of active aging. Given Iran’s high aging rate, providing a healthy and active aging platform is essential [55].
Another important concept is healthy aging, a continuous process to optimize opportunities for physical, social, and mental health, independence, and quality of life, transitioning successfully through old age [56]. This includes physical, psychological, spiritual, and social well-being. Four elements of healthy aging are functional abilities, inherent capacities, well-being, and social norms. Interaction with the environment determines functional ability and affects well-being. Healthy aging goes beyond disease presence or absence and is influenced by various factors [56]. Park et al.‘s systematic review analyzed factors related to healthy aging, including biological, psychological, behavioral, nutritional, and socioeconomics, many of which are affected by the health system’s performance [57].
The strength of this study lies in its first-time evaluation of Iran’s AFHS by both managers for self-evaluation and external evaluators using a comprehensive, context-based tool, allowing for a comparison of different perspectives. Given that health system functions are common worldwide, and the tool comprehensively addresses various dimensions of an AFHS, the results of this study can be generalized to other similar countries and can serve as an initial model for planning in the field of older adults’ health in countries with aging populations and similar organizational structures. However, the study also has several limitations. Due to the characteristics of certain inquiries stemming from scholarly investigations in the domain of geriatric health, there is a likelihood that participants may provide inaccurate responses and yield diminished scores for the inquiries due to insufficient cognizance and attentiveness towards the findings of academic research. Scholars should take this into consideration in future investigations. Additionally, evaluators often lacked access to comprehensive documentation and substantiation necessary for the assessment and sometimes relied on the testimonies of interviewees to execute the evaluation, which is a limitation of the study. The final evaluation score reflects the efficacy of health system administrators, particularly in the realm of elder care, which may subsequently influence the ratings assigned to them.
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