Reforming nursing reimbursement: direct payment models under Iran's Nursing Service Act in a global context

BACKGROUND: In conventional healthcare systems, nursing services are often integrated into broader institutional or physician billing, limiting visibility of nursing contributions. Direct reimbursement provides itemized compensation, potentially increasing recognition. Iran’s 2007 Nursing Services Tariff and Adjustment of Nursing Fees Act introduced a tariff-based direct reimbursement model. This study explores its observed effects, comparing it to systems in the US, UK, Australia, Canada, Denmark, Japan, and Norway (selected by Beveridge vs. Bismarck typologies). METHODS: A mixed qualitative-comparative design used the PRISM framework for implementation evaluation. Semi-structured interviews with 12 Iranian stakeholders (6 experts, 6 frontline nurses; snowball recruitment; guide on request) underwent reflexive thematic analysis, achieving saturation after 9 interviews. Cross-national analysis applied Walt and Gilson’s Policy Triangle to barriers, with scoping reviews, SWOT, and quantitative triangulation (e.g., salary/satisfaction metrics). RESULTS: Iran’s tariff-based model appears to increase visibility and recognition of nursing work compared with bundled payment or salaried systems. Two primary themes emerged: Professional Development (identity, satisfaction, sense of justice) and Health System Implementation Considerations (observed resource allocation and service organization). These findings are descriptive and contextual, without implying causal effects or universal generalizability. CONCLUSION: The Iranian model provides context-specific insights on itemized nursing reimbursement and observed implementation experiences. Future research may explore longitudinal workforce outcomes, cost implications, and potential adaptation in diverse healthcare systems, while remaining within the limits of the study’s qualitative and secondary-source evidence.