Applying systems thinking in the prosthetics and orthotics sector: investigating the common challenges in Iran

We sought to explore the common challenges across stakeholder groups and also to recognize interactions among them to improve the Iranian prosthetics and orthotics (P&O) sector.
Interviews were performed from January to June 2019. Participants, including 13 prosthetists/orthotists and six P&O faculty members, were selected using purposive and snowball sampling. The collected data were analyzed using the framework analysis method. Additionally, a systems thinking approach was applied to theorize potential leverage points to improve P&O services in Iran.
Challenges in leadership and governance included lack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers. Financing challenges included high out-of-pocket payments, inadequate insurance coverage, and insufficient governmental funding. Service delivery challenges included lack of prosthetists and orthotists in hospitals and medical centers, corrupt activities and a weak referral system. Human resource challenges included insufficient practical skills of graduates, misalignment of theoretical and clinical training, and inadequacy of continuing education courses.
This study provides the groundwork to develop and implement national strategies to address modifiable barriers and improve prosthetic and orthotic services.Implications for rehabilitation
Lack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers are the governance challenges of prosthetics and orthotics (P&O) and must be managed by the government.
Government resources allocated to P&O services should increase, and P&O insurance coverage should improve.
P&O services should be incorporated in health benefits packages to lessen the reliance on out-of-pocket payments.
Planning should be done toward inclusion of P&O services in universal health coverage.
Up-to-date scientific training and high-quality evidence are needed to enhance the practical skills of P&O graduates and consequently improve the quality of P&O services.
Effective continuing training courses for P&O graduates are recommended.
It is advantageous to provide P&O services in hospitals.

Lack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers are the governance challenges of prosthetics and orthotics (P&O) and must be managed by the government.
Government resources allocated to P&O services should increase, and P&O insurance coverage should improve.
P&O services should be incorporated in health benefits packages to lessen the reliance on out-of-pocket payments.
Planning should be done toward inclusion of P&O services in universal health coverage.
Up-to-date scientific training and high-quality evidence are needed to enhance the practical skills of P&O graduates and consequently improve the quality of P&O services.
Effective continuing training courses for P&O graduates are recommended.
It is advantageous to provide P&O services in hospitals.