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Table 2 Environmental impact and certainty (Macro environment-PESTLE analysis)

From: A comprehensive environmental scanning and strategic analysis of Iranian Public Hospitals: a prospective approach

PoliticalRegional competitions− 1− 3
Policy makers’ neglect of the health sector− 4− 3
Centralization in the dominant attitude− 4− 5
Government budget-cutting structure− 5− 5
Implementation of the Family Physician Program+ 2+ 3
Periodic changes of politicians leading to change of plans of directors (political instability)− 3− 5
Lack of appropriate philosophy and viewpoint about health and its various dimensions among political parties and formations− 3− 4
Government downsizing based on various laws, including the 44th principle (privatization development)+ 4+ 3
Government financial corruption− 4− 4
Unreasonable tariffs determined for hospitals products and services− 5− 5
Political sanctions− 4− 5
EconomicImproved payment system structure (strategic services purchase by insurance companies based on quality and price)+ 5+ 3
Improved tariff structures+ 4+ 2
Improved drugs and consumption products purchase control structure+ 5+ 3
Higher inflation in the health sector− 5− 5
Higher expenses (drugs and treatment)− 5− 5
Higher inflation− 4− 5
Higher bank interest rates− 4− 4
Improved financing structure+ 5+ 3
Currency rate fluctuations and multiplicity of currency rates− 4− 5
Supportive role of government financial policies+ 5+ 2
Providing access to capital/loans to develop hospitals’ activities by the government+ 4+ 4
Good market economic growth+ 3+ 1
Availability of required finances (from public government budget, charities, etc.) to produce hospitals products and services+ 5+ 2
Smaller budget share for the health sector− 5− 5
Approved national Iranian pharmacopoeia and the comprehensive list of equipment+ 3+ 3
More budget limitations for the health sector as a result of economic and health load of non-communicable and emerging diseases because of environmental changes− 3− 3
Economic sanctions− 3− 5
Social and culturalHigher population growth− 3− 5
Higher fertility rates− 3− 4
Change of diseases load towards chronic illnesses− 5− 5
Lower physical activity− 3− 4
Higher life expectancy− 3− 4
Higher poverty− 4− 5
Appropriate population distribution (young human resources to total population ratio)+ 2+ 4
Appropriate family size and structure+ 2+ 3
Higher rates of social harms and anomalies, including divorce, crimes, and violence.− 3− 4
TechnologyImproved health information technology (home care, remote medical services, remote training, electronic medical record)+ 4+ 2
LegalLack of legal clarity for hospitals activities development− 4− 4
Tax and employment laws ratified by the government− 4− 4
Inappropriate budgeting system for hospitals (general budget, linear budget, ownership of the remaining budget resulting from frugality)− 5− 4
Deficiency in health technologies evaluation (import permits for high-end technologies and expensive drugs)− 4− 5
Poor supportive laws for attracting domestic and international investors in manufacture, equipment, and renovation of hospitals (including bank laws, facilities, loans, letters of guarantee)− 3− 5
The requirement for hospitals to observe scientific and local guidelines approved by the Ministry of Health and insurance companies+ 5+ 2
EnvironmentalHigher risks and diseases resulting from environment pollution− 3− 4
Higher air pollution in cities in which the hospitals are located− 4− 5
The possibility of unexpected events in the city where the hospitals are located− 4− 3
Greater possibility of man-made disasters in the city where the hospitals are located− 3− 3
Population positive attitude toward green energy+ 3+ 3
Population positive attitude toward green and organic products+ 3+ 3