Futures of elderly care in Iran: A protocol with scenario

Original Articlehttp://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)

Iran University of Medical Sciences

____________________________________________________________________________________________________________________1. Ph.D Candidate, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran, & ResearchCenter for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, [email protected]. (Corresponding author) Professor, Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran,& Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences,Tehran, Iran. [email protected]. Associate Professor, Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences Tehran,[email protected]. Associate Professor, Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran, & Departmentof Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, [email protected]

Futures of elderly care in Iran: A protocol with scenario approach

Salime Goharinezhad1, Mohammadreza Maleki*2, Hamid Reza Baradaran3

Hamid Ravaghi4

Received: 24 October 2015 Accepted: 19 June 2016 Published: 18 September

AbstractBackground: The number of people aged 60 and older is increasing faster than other age groups worldwide.

Iran will experience a sharp aging population increase in the next decades, and this will pose new challenges tothe healthcare system. Since providing high quality aged-care services would be the major concern of the poli-cymakers, this question arises that what types of aged care services should be organized in the coming 10 years?This protocol has been designed to develop a set of scenarios for the future of elderly care in Iran.

Methods: In this study, intuitive logics approach and Global Business Network (GBN) model were used todevelop scenarios for elderly care in Iran. In terms of perspective, the scenarios in this approach are normative,qualitative with respect to methodology and deductive in constructing the process of scenarios. The three phasesof GBN model are as follows: 1) Orientation: Identifying strategic levels, stakeholders, participants and timehorizon; 2) Exploration: Identifying the driving forces and key uncertainties; 3) Synthesis: Defining the scenariologics and constructing scenario storyline.

Results: Presently, two phases are completed and the results will be published in mid-2016.Conclusion: This study delivers a comprehensive framework for taking appropriate actions in providing care

for the elderly in the future. Moreover, policy makers should specify and provide the full range of services forthe elderly, and in doing so, the scenarios and key findings of this study could be of valuable help.

Keywords: Future, Elderly-care, Scenario, Iran.

Cite this article as: Goharinezhad S, Maleki M, Baradaran HR, Ravaghi H. Futures of elderly care in Iran: A protocol with scenario ap-proach. Med J Islam Repub Iran 2016 (18 September). Vol. 30:416.

IntroductionAt the start of the third millennium, the

phenomenon of aging population has beenmanifested as a major universal event morethan ever (1,2). Although aging populationis a natural and inevitable process that isoccurring worldwide, its speed and extentvaries across different countries (3). Indus-trialized countries have had many decadesto adjust to the changes in the aging struc-ture, while developing nations are experi-encing a dramatic growth in the older popu-lation, as mortality and fertility rates have

decreased (4). The UN predictions indicatesthat 8 out of every 10 older people will beliving in developing countries (5). It is clearthat the prevalence of chronic diseases andhealth problems increases sharply in theaging population, leading to an increase inthe costs of medical care, long-term careand social services (6). Therefore, it can beclaimed that providing high quality agedcare services will soon be a major concernin less developed countries (7).

Similar to other developing countries,Iran is also experiencing an increase in its

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http://mjiri.iums.ac.ir/article-1-3948-en.html

Foresight in health care

2 Med J Islam Repub Iran 2016 (18 September). Vol. 30:416.http://mjiri.iums.ac.ir

aging population (8). Based on the nationaland international census, 21.7% of Iran’spopulation will be over 60 years of age in2050 (9,10). WHO in 2015 report has stat-ed, “In the Islamic Republic of Iran in2015, around 10% of the population is old-er than 60 years. In just 35 years’ time, thiswill have increased to around 33% of thepopulation” (11). A combination of im-proving health status, declining birth rates,increasing life expectancy and implementa-tion of population control policies lead toan increase in the older population (12).Currently, (2015), the life expectancy atbirth in Iran is 69.32 years for men and72.53 years for women (13). It is expectedthat with improvements in standards of liv-ing in forthcoming decades, life expectancyat birth, and the percentage of the popula-tion surviving will be more than ever (12).

An important question is whether thesuccess story of longevity will be accom-panied by raises in illness, dependency,frailty, vulnerability and more use of healthservices (14). Taking into account the de-creases in mortality and increases in lifeexpectancy on the one hand and risk factorsfor diseases on the other, three hypotheseshave been proposed: Compression of mor-bidity; Expansion of morbidity: and Dy-namic equilibrium (1). In compression ofmorbidity, it is claimed that the elderly willenjoy healthier lifestyle, effective treatmentand minimum disability and therefore theyenjoy their long life. This hypothesis leadsto a less pressure on the health care system.This scenario has wide popularity becauseof its optimistic implications for the futureaged care (15). In the expansion of mor-bidity scenario, which has been named the“failure of success”, the elderly will havemuch poorer health; and as a result, theyneed more health services (14,16). The lasthypothesis of dynamic equilibrium com-bines the elements of the two previous sce-narios and implies that mortality reductionis accompanied with an increase in chronicdiseases and disability. Based on this sce-nario, the rate of healthcare utilization willremain constant (17). The application of

each of the above scenarios and types ofelderly care will depend on how the popu-lation age. Apart from health factors, socio-economic changes also affect organizationof the elderly care. Societal changes such asless tendency to marriage, voluntarilychildless, higher rates of separation or di-vorce and increase in women’s employ-ment entail fewer options for elderly care(13,18).

Given the problems noted above, it seemsthat the future of elderly care will be a con-troversial issue and will be accompanied byuncertainty. It is of prime importance toconsider a wide range of factors and uncer-tainties that affect elderly care rather thanconsidering the healthcare issue alone.Therefore, we need an approach to dealwith these uncertainties. Scenario planning,by exploring different aspects of the future,enables us to develop different pictures ofthe future and be prepared for it.

This protocol is an applied scenario plan-ning to gain more insight into the need fordifferent types of elderly care in Iran. Themain questions are as follows:1. What trends, driving forces and key un-

certainties affect the future of elderly-carein Iran?2. What are alternative scenarios concern-

ing different types of elderly-care in Iran?

MethodsConceptual FrameworkOver the years, there have been three var-

ying approaches for developing scenarios,each of which derived out of differentschools of thought (19,20). These ap-proaches are as follows: 1) Intuitive logics;2) French school; 3) Probabilistic modifiedtrends (21). One of the best-known ap-proaches, which has widely been cited andfrequently used, is intuitive logics. RandCorporation introduced this approach in the1960s. Thereafter, Peter Schwartz in hisbook “The Art of the Long View” de-scribed the characteristics of this approachin detail (22). One of the overarching mod-els of scenario development that belongs tothis approach is “Global Business Net-

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S. Goharinezhad, et al.

3Med J Islam Repub Iran 2016 (18 September). Vol. 30:416. http://mjiri.iums.ac.ir

work” (21). The GBN model consists of afive-step scenario process, which providesa systematic method to collect and synthe-size information into scenarios. The processis illustrated in Fig. 1.

Study DesignIn this study, the intuitive logics approach

and GBN model were utilized to developscenarios for elderly care in Iran. In termsof perspective, scenarios in this approachare normative; they are qualitative in termsof methodology; and are deductive withrespect to scenario construction process.

Because this project focused on identify-

ing multiple scenarios in the elderly carerather than strategy development, we slight-ly modified the original GBN approach andwaived the “apply and monitor” phase (Fig.2). The following sections provide a de-tailed description of the three phases of thescenario construction process applied inthis project.

Phase One: OrientationThe aim of this phase was to clarify the

scope of the project. A standardized toolentitled “Framing checklist” was developedto reach a conceptual consensus. The fivefollowing key questions should be an-

Fig. 1. Five-step Scenario Planning Process

Fig. 2. The Three Phases of Scenario Development as Proposed in This Study

Phase 1Orient

• Aim: The aim of the first phase of the process is to clarify the focal issue• Tool: “Framing Checklist” a tool that specifies the goal, the involved

persons and time horizon

Phase 2Explore

•Aim: Identifying relevant trends and driving forces that could shapethe focal issue

•Tool: Semi-structure interview and Literature review

Phase 3Synthesize

•Aim: Merge driving forces and identifying key uncertainties•Tool: Structured interview, Impact/uncertainties grid, scenariomatrix

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swered: 1) The purpose of the scenario; 2)Strategic level; 3) Key stakeholders; 4) Par-ticipants; 5) Time horizon. To clarify eachof these items in detail, an orientationworkshop was held for the research team(Fig. 3). Each step is briefly explained be-low:

The Goal of the Scenario Project: In thisproject, we defined the development of el-derly care scenarios for Iranians as the goalof the scenario project.

Strategic Level: Since the aging popula-tion is a national concern, it was agreed todevelop future scenarios at the national lev-el. According to the UN estimation, 21.7%of Iran’s population will be 60 years of ageor older in the next decades.

Definition of Stakeholder: The aim of thisstep was to identify stakeholders that areinvolved in the aged care services. For thisend, we decided to conduct a national doc-uments analysis. Then, a qualitative docu-ment analysis was done to identify keystakeholders associated with the aging pop-ulation. Data from June to May 2014 werecollected through internet search. Thesearch key terms were ‘aging population,‘elder people, ‘senior, ‘adult, ‘law’, “right”and “politics”. The inclusion criterion forthe data was being produced in Iran be-tween 1979 (The establishment of the Is-lamic Republic of Iran (Iranian Revolution)was in 1979) and 2014. The key stakehold-ers who were identified in national docu-ments were as follows; The Ministry ofHealth and Medical Education; MedicalUniversities; the Ministry of Labor and So-cial Affairs; the State Welfare Organization

of Iran; the Secretariat National Council forElderly; the United Nation Population Fundin Iran; the Iranian Imam Khomeini ReliefFoundation; the Iranian Islamic Parliament;the Islamic Studies Center of Parliament;Health Commission of the Parliament; Mu-nicipalities and Non-Profit organizations.

Participants: Participants were stake-holders that were identified in the previousstep. The policymakers, faculty membersand experts who had a direct role in agedcare services were selected purposivelyfrom the macro, meso and micro levels.They participated in all phases of the sce-nario construction.

Time Horizon: We decided to focus on atime horizon ending in the year 2025 basedon the time horizon of Iran 20 Year per-spective document.

Phase Two: ExplorationThe overall goal of the exploration phase

was to identify a comprehensive list oftrends, driving forces, variables and uncer-tainties that could affect and shape the el-derly care. This phase comprised of a two-step survey process.

Step 1- InterviewIn the first step, survey participants were

asked open questions about the mentalmodels and key factors that will shape theissue in the future. A qualitative semi-structured interview method was conductedto identify deriving forces in Iranian con-text (Interview guide 1 is attached in Ap-pendix 1). The key informants includingpolicymakers, faculty members and experts

Goal of Scenario ProjectPossible Futures of Elderly Care in Iran

Strategic Level

Country Level- Since the agingpopulation is a national concern

Stakeholders

All organizations in charge of aged-carein Iran- Based on Document Analysis

Time Horizon

2025 - Based on Iran’s 20-yearperspective document

Participants

From three levels of stakeholdersMacro, Meso and Micro

Fig. 3. Framing Checklist

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who had a direct role in providing agedcare services were selected purposivelyfrom the macro (Ministry of Health, Wel-fare Organization, Health Commission ofthe Parliament, Academy of Medical Sci-ences of Islamic Republic of Iran, Munici-pality), meso (Medical Universities, Non-profit Organizations) and micro (HealthcareNetworks, Nursing Homes, Hospitals) lev-els with considering the maximum diversity(heterogeneity). A minimum of two- yearactivity or experience in aging sphere wasthe inclusion criterion for participation. Allparticipants were informed about the pro-ject objectives, and consent forms were ob-tained prior to the interview; each interviewlasted 15 to 70 minutes. Sampling contin-ued until data saturation. The whole inter-view process was recorded. Then the inter-view was transcribed verbatim, and a codewas extracted immediately throughMaxQDA10 software. Three methods wereused to assess validity: 1) Triangulationthrough document analysis, interviews andliterature; 2) Participants were selectedfrom three levels; 3) Data analysis waschecked by two authors who were expertsin qualitative research. Interviews wereanalyzed through framework analysis.

Step 2- Literature ReviewThe aim of this step was to conduct a

comprehensive literature review on the fac-tors affecting the future of aged care. It wasachieved through an extensive search onGoogle, Google Trends, Google Scholar,AgeLine, HelpAge, Centre for Aging Popu-lation Studies, WHO, EMRO, UN, Rand,World Economic Forum, Institute for Al-ternative Futures, King’s Fund, UNDP,United Nations Economic Commission forEurope, PubMed, ISI Web of Science, Sco-pus, Emerald, EMBASE, ScienceDirect,and so on. The Persian databases includingMagiran, noormags, ensani, ISC, ScientificInformation Database (SID), Irandoc andcivilica were also used. An obvious searchstrategy was developed to find related pa-pers about trends affecting aged care.

Keywords included were ‘trends’, ‘aging

population’, ‘global aging’, ‘aged care’,‘future of aging population’, ‘foresight ofelderly care’, and ‘scenarios of aging popu-lation’. The search process was conductedunder the supervision of a librarian.

Inclusion and exclusion criteria were de-fined based on the following three items:First, the publication had to include social,economic, political, technological and eco-logical trends. Second, the publication hadto be related to the aging population; final-ly, the literature had to be published in Far-si and English from 2000 and 2015. Fur-thermore, publication in specialized clinicalfields such as genetics and cell were theexclusion criteria for this study. The datacollected from studies were analysed basedon SEEPT (Social, Economic, Ecologic,Technological and Political) analysis.

Phase Three: SynthesisThe aim of this phase was to produce a

small number of driving forces and uncer-tainties, which were identified during theexploration phase and scenario construc-tion. This phase was divided into two tasks.

Scenario Framework: In this step, all fac-tors, which were identified and clustered inthe previous phase, were synthesized interms of uncertainty degree and impactrate. For this purpose, structured interviewswere conducted. Participants were asked torank and prioritize each driving force interms of importance and uncertainty on ascale of one (low/weak) to ten (high/strong). In the next step, without manipu-lating the results, the key factors wereplaced on a grid based on their score. Thisgrid is called “impact/uncertainty grid” andhas two dimensions of x- axis, which is un-certainty, and y-axis which is potential im-pact (Fig. 4). The factors with a weak im-pact and low uncertainty were positioned atthe bottom of the grid. These factors arecalled “secondary elements”, which couldbe ignored in the scenario construction pro-cess, as they have a weak impact on the fu-tures of the elderly care. Factors placed onthe upper left are considered as “trends orpredetermined factors”, which have a

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strong potential impact, but are somewhatpredictable. Finally, the upper right of thegrid encompass the factors with a powerfulimpact and high uncertainty, which are re-ferred to as “critical uncertainty”. Thesefactors are difficult to manage and are thebasis of scenario construction in the subse-quent step. When critical uncertainties aremore than two factors, they should be clus-tered into two meta-categories based ontheir similarity to each category.

Scenario Building: The overall goal ofthis step was to develop four different sce-narios. The standardized tool for this step is“scenario matrix”. The two critical uncer-

tainties, which were identified in the previ-ous step, are the basis of the matrix, whichare called “Scenario dimensions”, each ofwhich is positioned in spectrum from ex-tremely positive to extremely negative ontoX and Y axes of the matrix. Thus, fourquadrants will be formed (Fig. 5). Eachquadrant represents a distinct scenario witha concise name, which should be explainedin more detail. To write the stories behindthe scenarios, a chain of cause and effectneeds is developed. Accordingly, a list ofkey forces, factors and trends identified inphase two is used to develop a coherentstoryline for each scenario.

En

T

SCritical Uncertainty

Uncertainty

Pote

ntia

l Im

pact

Low High

Wea

kSt

rong

S

Social T Technological Ec Economic En Environmental P PoliticalS

P

En S

T

T

Source: Schwenker & Wulf, 2013

ST

S

PEc

Ec

S

Secondary Elements

P

S

S T

EnTrends/Predetermined Elements

P

Ec

Fig. 4. Impact/uncertainties gridC

ritic

al U

ncer

tain

ty2

Positive

Scenario 2

Negative

PositiveDimension

Scenario 4Scenario 3

Scenario 1

NegativeDimension

Source: Van der Heijden 2005- Schwenker and Wulf 2013

Fig. 5. Scenario Matrix

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ResultsAt the time of the submission, orientation

and explanation phases of the study werecompleted, but the stages of the synthesisphase are still underway.

DiscussionScenarios as one of the most widely used

tools of foresight provide a comprehensivedecision-making framework that aids poli-cymakers to adopt faster to major changes(23). Scenario planning with synthesizingmental models and events lies in the envi-ronment, providing pictures or stories aboutthe possible futures and help us prepare forunforeseen events (24). These plausible fu-tures are based on a set of consistent andcoherent assumptions about key relation-ships and driving forces that are basicallyformed to be compatible (25). The intuitivelogic approach in scenarios allows the rele-vant stakeholders to engage in the processand it enables the policy makers to beaware of convolutions and uncertainties,which they may encounter in the future.The essence of intuitive logic approach isto identify contextual environment such associal, technological, economic, ecologicaland political (STEEP forces) and internalfactors (21,26).

If the scenario process is limited solely tointernal environment and does not scan theexternal environment, there may be a dan-ger of ignoring critical uncertainties thatcould have a powerful impact on the futuredevelopment. To escape this defect, thecombination of stakeholders with maxi-mum diversity would be required. There-fore, this approach allows integrating andaligning mental models and environmentalfactors to challenge current assumptions.The greatest potential of our approach liesin the fact that it provides multiple and di-verse scenarios rather than a one-dimensional scenario; and thus, with its ho-listic view, this approach enables the poli-cymakers to better deal with the uncertainenvironmental conditions.

This project reveals the potential capabili-ties of scenario development in establishing

and maintaining the future of elderly careservices. Using the findings and assump-tions of the related literature and holdingdiscussions with experts in Geriatrics, Ger-ontology, Health management and Healthpolicy making, four contextual scenarioswere extracted. The scenarios presented inthis research were supported by deep litera-ture review and insight thinking of thestakeholders at three levels. These scenari-os introduce a new perspective on how thesocioeconomic, ecological, technologicaland political and manager’s mental modelscan shape the future of the elderly care.Four robust, flexible and accessible scenar-ios of elderly healthcare services should beformulated; significant scenarios can beused to enhance strategy formulation. Theoutcome of scenario construction in thisproject can be summarized in four compo-nents: Firstly, by conducting scenario exer-cises, which is a multidisciplinary examina-tion, we are able to combine diverse infor-mation to determine priority interventionfor aged people. Secondly, making stronghealth and social policy decisions helps usexplore, anticipate and assess a possibleand desirable future, and we can act fasterin dealing with volatility and uncertainties.Thirdly, specific tools should be providedto empower the policy-makers in the sphereof foresight practice, who have a critiqueview in developing strategies. Finally, byconsidering various aspects of the future,the speed of decision-making can be in-creased. These four contributions make astrong and efficient basis for improving re-lated strategies through managing uncer-tainties and interactions between internaland external environments.

ConclusionDespite the increase in the aging popula-

tion and the importance of aged care andsupport, this issue is not the government’spriority. This protocol intended to encour-age the policy makers to consider and planfor the long term so that pessimistic futuresdo not happen and optimistic ones couldhave a better chance of unfolding. Un-

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doubtedly, appropriate policy decision-making today could provide an assurancethat the elders would live in better condi-tions and be supported by a balanced andintegrated provision of care in the future.We hope that the results of this study couldstimulate a policy dialogue on the future ofthe aging population and would result intaking effective measures that lead us to amore promising future.

Ethical ConsiderationEthical approval for this protocol was ob-

tained from the Ethics Committee of IUMSwith no: 105-2953. The research team hasconsidered the followings to collect dataand conduct interviews with the partici-pants: Obtaining permission from the uni-versity to enter into the research setting;informing the participants about the objec-tives of the study; respecting voluntaryparticipation in the study, Obtaining per-mission to record the interviews.

AcknowledgmentsThis study is the first author’s PhD The-

sis, which has been supported by Iran Uni-versity of Medical Sciences (IUMS_SHMIS: 65/2014). The authors would liketo make special thanks to all participantsfor their kind contributions to this projectand are also grateful to Dr. MohammadAzmal and Dr. Hesam Seyedin for theirinsightful comments on the earlier manu-script.

Conflicts of InterestAll authors have declared that no con-

flicts of interests exist.

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Futures of elderly care in Iran: A protocol with scenario