The study results indicate the HTP had positive impacts and changed most performance indicators in the hospitals before and after implementation. A comparison of the monthly average performance indicators before and after the HTP also showed significant changes. Similar studies have found that health system reforms can increase hospital workflow, evident in this study through higher inpatient volumes and bed turnover [31]. Several studies, including Sajjadi et al., Yousefzadeh et al., Rezaei et al., Dadgar et al., and Zarei et al., have reported similar findings regarding the impact of health system reform on hospital productivity and bed utilization. These studies have demonstrated that the HTP has had a significantly positive effect on these healthcare performance indicators [31,32,33,34,35].

The implementation of the HTP has had a significant positive impact on the people’s share of hospitalization costs in Iran, as reported by the MoHME. Before the HTP, the people’s share of hospitalization costs was 37%, but this decreased to 4.5% after the implementation of the reform. This has increased people’s access to health services, particularly for low-income groups, and has resulted in increased hospital admissions [32, 36, 37]. It is important to note that while the reduction of payments and the subsequent increase in performance indicators is a positive outcome of health system reform, it should not lead to an increase in induced demand among healthcare providers [37, 38].

The findings of Zarei et al.‘s study indicate a significant increase in outpatient visits, with a 26% increase reported [33]. The reasons for this increase are multifaceted. The development of special clinic programs and the plan to improve the quality of outpatient visits have led to a reduction in the payment of patients in outpatient departments. Additionally, the increase in the number of clinics and staff working hours has improved people’s access to health services. Similar findings have been reported in studies conducted by the WHO in different countries. These studies have shown that the implementation of interventions aimed at removing barriers to the use of health services, such as reducing patients’ payments and increasing accessibility, leads to an increase in the number of outpatient visits.

Rezaei et al. have confirmed the positive impact of the HTP on hospital performance indicators, including the bed occupancy rate, at Hamadan Hospital [39]. Similarly, Yaser et al.‘s study on the implementation of the health reform plan in the Turkish healthcare system found that it resulted in increased bed occupancy rates [40]. The employment rate in hospitals studied has also shown an increase of 10% after the implementation of the HTP. This increase can be attributed to several goals of the reform plan, such as reducing the amount of payment for patients, promoting the residency of physicians in deprived areas, and ensuring the presence of specialist doctors in hospitals affiliated with the MoHME. The plan also aimed to improve the quality of visiting and hospital hoteling services and provide financial protection for incurable patients [41].

The number of paraclinical patients in the current study has increased significantly after the HTP, which is contrary to the results of Farid Far et al.. The reason could be the number of years that have been investigated. In Farid Far et al’s study, only 2013 and 2014 have been considered, but in the present study, 2012 to 2019 are considered [42].

The present study has found a significant increase in the number of surgeries performed after the HTP. This finding suggests that the treatment of patients who required surgery was carried out promptly by doctors in the hospital. It is possible that the increase in the quality of visiting and hoteling services of the hospital after the HTP contributed to this increase in the number of surgeries. These results are consistent with Rezaei et al. and Dadger et al. who found a positive impact of the HTP on the number of surgeries performed in hospitals [39, 43]. Similarly, a study conducted in Turkey reported a significant increase in the number of surgeries after the implementation of the health reform plan [44].

This study has several limitations. One limitation is the lack of control over other influential and confounding factors that may have impacted the study’s performance indicators. Therefore, the changes observed in the indicators cannot be definitively attributed to the HTP alone. However, it is important to note that no other major interventions were implemented during the HTP that could have influenced the results. Additionally, this study only examined three widely used performance indicators, and other important indicators such as accessibility and justice, quality and effectiveness (such as readmission rate, nosocomial infection rates, staff and patient satisfaction, hospital complaints, and the rate of medical errors) were not analyzed. Future studies should consider analyzing these additional indicators to provide a more comprehensive evaluation of the impact of the HTP on the healthcare system.