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A comparative study of cooperation models in city council and municipalities with the health system in Iran and selected countries

AIM: This study aimed to identify models for the participation of the city council and municipality with the health system in selected countries. SUBJECTS AND METHODS: This is a descriptive comparative study conducted in 2020 qualitatively. The countries studied were examined in terms of the following characteristics: type of political structure, type of health system, level of cooperation between local government and health system, municipal financing, type of financial participation of local government and health system, method or institution for participation Created, level of participation, local government influence on health system decisions, advantages and disadvantages of a partnership between local government and health system. Data were collected through valid databases (PubMed, Scopus, Embase, and Google Search engine) and website of the World Health Organization, local government, and the Ministry of Health of countries concerned and analyzed in a framework of analysis. RESULTS: Countries were divided into two groups in terms of a partnership between the health system and local governments, which had a distinct partnership between the health system and local government and without their participation. Factors that contribute to the creating and strengthening of partnerships include beliefs of health authorities and local government, the need for participation, transparency in participatory programs, designing a specific mechanism for participation, local authority, and financing joint participation plans. CONCLUSION: In countries with planned participation, citizens have better access to services. Citizens’ participation, as well as the private sector, is greater in health issues. In these countries, participation in health financing by the private sector and other related agencies has increased. Planning and service delivery increases according to neighborhood needs. The variety of services provided and the use of new methods of service are more, and in these countries, the focus of the Ministry of Health on the preparation of strategies and monitoring the quality of services is increasing.


Introduction
I t is generally accepted that health issue is one of the most important rights of humans, which is a valuable asset for all classes of society. This right has been pointed out in the laws of various countries. [1] In 2000, the WHO divided the responsibilities of world health systems into three levels of the community's health, health accountability, and proportional financial participation at the community level. [1] Currently, given the increasing growth of population, there is an important consensus on how to achieve justice and reduce inequality, promote community health, and improve responding to the justifiable expectations of citizens. [2,3] One of these methods is the strong and planned presence of municipalities and city councils in providing health services to their citizens. [2] In the statement of urban management elements, the World Bank has recognized the major responsibilities of municipalities to be preparing the basic infrastructures for the efficient performance of municipalities, providing the necessary services for human resource development, improving productivity and living standards of urban residents, regulating the activities of the private sector affecting security, health, social welfare, and urban populations, and preparing the necessary services and facilities to support the productive activity and efficient operation of private enterprises in urban areas. [4,5] Considering the importance of access to a healthy city and changing the health-care provision methods, this study aimed to identify the models of cooperation of city councils and municipalities with the health system in selected countries of the world.

Subjects and Methods
This comparative and descriptive study had a qualitative method. In the first stage, the research team identified the items related to the cooperation between the city councils and municipalities and the health system. At this stage, ten items were considered, including the type of political structure, type of health system, levels of cooperation, method of financing by the municipality, the type of financial cooperation between the council and the municipality with the health system, the relevant institution of participation between the council and the municipality with the health system, the level of participation between the council and the municipality with the health system, the level of influence of the council and the municipality in the impact of the approvals of the health system, specific municipal measures on health issues, and the disadvantages and benefits of interactions between the health system and city councils and municipalities. Afterward, five countries were selected to be compared with Iran. The research team selected countries according to three items: 1. Type of health system: The model of service delivery in health-care systems includes insurance-based models, models based on national health, and models based on the private sector. For the three models, Germany, the United Kingdom, and the United States were considered, respectively 2. The similarity to Iran: Turkey was selected from the developing countries that are similar to Iran in terms of various cultural, social, economic, and political conditions 3. Having a powerful municipality system: Municipalities in the Scandinavian countries have a very powerful organization. Denmark was selected from these countries.
In the final stage of the study, a comprehensive review and data analysis and a comparative matrix were used.
To collect the required data, the researchers searched PubMed, Scopus, Embase, Google Search engine, the WHO website, and databases of municipalities and city councils, local governments, and health ministries in the desired country and cities. The information obtained was inserted in the data extraction form based on research objectives. Following that, data were analyzed using the framework analyzed. The ethical code of this research is IR.IUMS.REC.1397.919.

Results
The United Kingdom, the United States, and Germany were selected based on their health system, and Turkey was selected to represent Scandinavian countries with strong municipalities due to their resemblance to Iran and Canada. After the comprehensive overview of the models of cooperation of the health system with councils and municipalities in selected countries, the following results were obtained. The matrix of the results of the comparisons of the countries is also shown in Table 1.

England (UK)
This country has a national health system. Policy-making is carried out by the Ministry of Health while planning is made by the London Health Board, chairman of which is the mayor of London. Also, services are provided by the municipality, and a large source of municipal revenue comes from taxes. From a structural and institutional standpoint, the formation of a group of London colleagues is noteworthy. [3] Following the formation of this group, the collective determination has been made to achieve the general health of citizens.
Moreover, it has led to a strong interaction between all sectors affecting health, including the public sector, the private sector, and the local government (municipalities and city councils), and inclusive and efficient decisions have been made, [6,29] including: assigning a significant portion of the country's budget to health, deciding on the use of unused or less used properties for health purposes, using property income to support new health and care delivery models, attempting to reduce health costs by maintaining the treatment costs, improving the efficiency of the properties and facilities of the health sector by sharing the properties between the health and care sectors, matching all urban plans including housing and buying and selling assets with the policies of the Ministry of Health aimed at providing public health, creating ease and flexibility in the planning of clinical sections through multiyear and location-based budgeting and allocation, creating a financial balance in the field of health through the formulation of targeted and accurate strategic plans by the London team, and signing a cooperation agreement on health and care between the London team and receiving a strong support from the government. [7,29] Also, some of the serious commitments of this group include delegating a part of the Ministry of Health's responsibilities to the local government through a health cooperation agreement, assigning the entire work to the London Health Board under the chairmanship of the mayor, and paying attention to two important principles of the agreement, which involves making decisions at the local level wherever necessary and serious involvement of the London colleagues in London's effective decisions, paying more attention to local priorities and needs due to making decisions at the national level, increasing people's participation in decision-making, and implementing and providing extensive and diverse health services by the local government. [8,9] The United States The health system of this country is based on the private sector. Policy-making is the responsibility of the Ministry of Health, and operational planning at the state level is the duty of the municipality. [1] While the role of the government has diminished due to decentralized planning, the Senate, the deputies, and the president play a major role in the macro-planning of the health system. [10,11] Some of the most important plans include the implementation of the program for creating healthy communities [12] with the serious participation of the private sector, establishing a comprehensive health community of urban neighborhoods with the presence of all sectors effective in promoting public health, especially the private sector, assigning management and leadership of comprehensive health associations to the mayor (unit management), determining the specific strategy [13,14] for promoting general health in comprehensive health associations, and providing a variety of health-care services by the local government. [12,15] Germany This country has an insurance-based health system, and policy-making is at the level of the Ministry of Health, whereas planning is at the sector level and service provision is carried out by municipalities. [16] In this regard, some of the most important issues include delegating a part of the duties of the Ministry of Health to local government, financially supporting the responsibilities assigned with the cooperation of the central and local governments, having full autonomy of the municipality about the assignment of duties, moving based on the policies designed by the Ministry of Health, deciding on the place and approach of construction of hospitals based on local conditions, providing various health (vaccination) and treatment (administration and provision of hospital services) services, and supporting the groups in need by the municipalities. [17,18]

Denmark
The health system of this country is based on insurance. Policy-making is carried out by the Ministry of Health, whereas the planning and provision of services are performed by municipalities.
[1] Some of the features of this country include entrusting the duties of the Ministry of Health with the local government through signing cooperation agreements, making decisions quickly due to the lack of need for the approval of local plans at the regional or national levels (however, the approval of municipal plans by the province is necessary), and developing health and care services based on the needs of citizens (the health committee of the city council and health [similar to other committees] has the authority of decision-making in some areas without having to submit the issue to the council). [3,19] Also, the financing of agreed programs is carried out with the participation of both the central government and the local government. Moreover, service is provided by municipalities in a comprehensive and varied manner in the area of health (public access to services even at home for the needy and the elderly). [20] In this country, there is a clear increase in the financial participation (transfer from central government or central state, local taxes, people's payments, loans, monetary partnerships, and transfers between regions). [21] Turkey This country has employed the Bismarck health-care model. [1] Policy-making, planning, and service providers are carried out by the Ministry of Health. [30,31] Some of the significant points in the study of this country are the lack of complete autonomy of municipalities, [32,33] complete financing of the health section by the central government, the absence of a specific institution for interactions between the local government and the Ministry of Health, the lack of serious involvement of the private sector, and a lack of formalized partnership participation. Therefore, only basic health services are provided by the municipality, and there is no legal obligation even for this number of services. [12,22]

Iran
In Iran, the health system is a combination of a variety of national health, insurance-based, and private-sector-based models.
[1] The Ministry of Health is responsible for policy-making, planning, and providing services. [23] Some of the noteworthy points in the study of Iran are the presence of the Strategic Council of Health Tehran, which consists of all the effective sectors in the health of citizens (except the private sector) under the direction of the administration of the Ministry of Health, and the existence of the General Directorate of Health in the municipality of Tehran. [24,25] Despite the lack of official planned partnership, attempts have been made in recent years to create targeted interactions between the health system and councils and municipalities. While the legal duties for municipal action in the field of health have been set (by Article 111 of the second 5-year plan of the health of the Islamic Council of Tehran), no significant health services are provided by the municipalities. [26,27] To make the comparison of the countries studied easier, all data were provided in matrix form, as shown in Table 1.

Discussion
Obtaining the indicators of a healthy city is not possible without the close and wise interaction between the health system and municipalities and city councils. Innovation in the provision of public services, especially health services, has become popular in urban planning and policy-making, and cities that seek to improve the health of their citizens are changing their methods to understand and decide on health issues. [5] After 10 years of experience in planning and social action, the WHO has come to a good realization of health and the fact that early determinants of health are socioeconomic conditions. [28] The organization has presented the "Healthy Cities" project as a starting point for supporting integrated approaches for the promotion of health at the city level. According to this project, the municipality can manage resources as the lowest level of management and can create and implement intersectoral approaches to health using its political and legal authority. [34] Today, there is a vibrant network of cities around the world that are trying to create new and innovative ways to improve the health of their citizens. In 1989, Copenhagen joined the Healthy Cities Network in the World Health Organization. The city was named "Healthy City" for its great successes. The World Health Organization describes the activities of the city as integrated, professional, and innovative and believes that these programs are consistent with the identity of Copenhagen's citizens. The Copenhagen municipality presented preventive measures and an advanced and important program for promoting health that was unanimously approved by the Copenhagen City Council.
Copenhagen can be a model for Eastern European cities. The structure of the healthy city plan of Copenhagen is on two levels: one focusing on administrative tasks and the other one focusing on field programs. For example, the Copenhagen Centre has made a direct link with the residents of each neighborhood to stop smoking and build healthy stores. The Ministry of Health strongly supports this program and is in constant contact with local authorities. [35] Liverpool, England, was one of the first cities to join the healthy city movement in 1998. In this city, a group was established the main goal of which was to facilitate the development and implementation of public health policies. The second phase began in 1993, which focused on building structures for the development of strategic and operational plans for the city's public health program. Subsequently, a joint Public Health and Joint Advisory Committee were formed. [36] After the publication of a report showing the inadequate health status of Lodz residents, compared to other cities in Poland, and the negative performance of local, government, and private organizations in utilizing resources for health and lack of attention to promoting health and disease prevention, the health association of Poland, which is a nongovernmental organization, launched the Health Promotion Campaign in 1987.
The mentioned organization had diverse objectives, including protecting natural resources and the promotion of healthy diets. This approach led the city to join the global network of healthy cities in the WHO in 1993. The Lodz municipality initially established groups that function in similar fields with similar purposes.
These groups include nongovernmental organizations, universities, business units, as well as public health and health services sectors. This multilateral coalition accepted the cooperation and exchange of information and prevented the "reduction of services despite increased resources." The most significant achievement of the Lodz Healthy City Project was the promotion of success based on a broad health-related perspective, in a way that it remained constant for health despite significant changes in local government budgets for this area. Over the years, the city has gained success in implementing the idea of creating a framework for a healthy city in its local infrastructure and has created a broad vision for health status and innovative partnerships in the successful implementation of healthy projects of Lodz. [37] Since 1994, the Swiss municipality has designed realistic long-term goals titled "a healthy city program." To achieve these long-term goals, the health impact assessment program is designed and implemented.
According to the program, any decision will be analyzed at the Social Security Council before approval. The mentioned program is a set of methods and tools to ensure that the potential effects (positive or negative, direct or indirect) on the population health of a law, a

Financial support and sponsorship
This study was financially supported by the Iran University of Medical Sciences.

Conflicts of interest
There are no conflicts of interest.
public policy, a program, or a project are evaluated. Also, this program is a tool to facilitate decision-making since it allows minimizing the negative effects on the health of any plan which is minimized before the finalization of the decision-making process, and its beneficial effects are improved.
At the same time, this program improves the provision of more information to decision-makers and planners and provides transparency in the utilization trend of the people. This program is a powerful tool for intersectoral collaboration designed according to an approach based on health determinants. There are six main steps in this program that are passed for each proposed decision: screening which determines whether a program for evaluating the impact on health to be implemented for the proposed plan or not. Assessment is to assess the impact of the program on health. Evaluation that evaluates the effects of the program on health and Reports that present the results of the evaluation and relevant evidence. Decision-making involves deciding on the change of the proposal to minimize the negative effects and maximizing its positive effects. Ultimately, monitoring and evaluation are carried out. [38] The summary of the data obtained from the study is presented in Table 2. It should be noted that from the perspective of the research team, the option zero means that the item does not exist in the table, whereas weak, moderate, good, and excellent are interpreted as existing but not active or strong, a stronger but sectional existence, officially existing but without targeted planning, and existing with specific and targeted planning, respectively.

Conclusion
In countries where there is a targeted and planned partnership between the health system and city councils and municipalities, services to the public are more successful.