By: AIC Research Associate Carrie O'Foran
MYTH: Iran’s health care system is underdeveloped.
FACT: Iran’s health care system is far more modern than many Westerners expect. Iran’s family planning and legal organ trade programs are examples of Iran’s particularly developed, and even progressive, medical system.
Iran’s health care system includes both public and private organizations. The government’s focus on expanding health care in recent years has made public facilities the main provider for health care for primary, secondary, and tertiary health services, especially in rural areas. Additionally, in public facilities, the government subsidizes some services, such as prenatal care and vaccinations. Separately, the private sector covers secondary and tertiary health services, mostly in urban areas. Although private facilities tend to offer slightly higher quality care, they are also more expensive than public facilities. Finally, in Iran many Non Governmental Organizations (NGOs) offer care for more specialized issues, such as diabetes or childhood cancer.
Primary Health Network
One of the most important parts of Iran’s health care system is the Primary Health Care program. The Constitution of the Islamic Republic of Iran, established following the 1979 Revolution, includes a constitutional mandate to provide universal access to basic health services in Article 29. Subsequently, to address the vast divergence of health care access between rural and urban areas, the Primary Health Care (PHC) program was created in the 1980’s. Prior to the establishment of this program, Iran’s rural population faced a severe lack of health care infrastructure and were forced to travel large distances to receive basic care. Public health indicators illuminated the inequality, as the rural population faced far higher infant mortality rates and maternal mortality rates, and lower levels of vaccination than urban residents. Since the formation of the PHC, Iran’s health care coverage and public health have greatly improved.
The basic structure of the program is as follows:
Rural Areas –
The primary access point for rural residents to obtain health services is through health houses. A health house is a small medical facility that provides basic health services to the surrounding rural community. Most facilities include at least two medical personnel, common pharmaceuticals, and basic medical equipment. There are over 17,000 health houses in Iran, or approximately one for every 1,200 residents. By contrast, according to the Statistical Center for Iran, there were a total of 773 hospitals in Iran in 2006, or the equivalent of one for every 92,100 residents. Thus, health houses have significantly decreased the average distance rural residents are required to travel in order to receive medical care. Behvarz, or trained medical workers, care for the residents in the area. Typically, behvarz handle vaccinations, family planning services, maternal health care, and child health care. They also record public health data and promote health education in the community. Each health house has at least one male and one female behvarz. Although the duties of the behvarz are usually divided by gender, with the male behvarz typically working outside the health house and female behvarz working inside the health house, all behvarz, regardless of gender, are trained to handle all duties.
Most importantly, the behvarz are chosen from their respective communities, and thus are well acquainted with the community and local sensitivities. This improves the ability of the behvarz to obtain thorough and accurate public health information and reach community members effectively. The behvarz are trained at the district level, with tuition covered by the government in return for at least four years of service at their respective health house. The government also provides financial support to students training to be behvarz.
More complex health issues are referred to rural health centers. There is approximately one rural health center for every 7,000 residents, which are staffed by physicians, health technicians, and administrators.
Urban Areas –
In urban areas, there is a similar structure with health posts providing preliminary and basic health care and health centers handling more complex health issues. However, since nearly 75 percent of Iranians live in an urban area, urban areas necessarily have a higher density of health care personnel than rural areas. Although the government has worked hard to eliminate the disparities in coverage between urban and rural areas, urban areas still have better health resources. The 773 hospitals in Iran are located primarily in cities, making access to specialized health issues easier for urban residents. Moreover, the private sector is nearly completely focused in urban areas, so urban residents have the advantage of choosing between public and private facilities.
Still, urban-rural differences in major, basic public health indicators, such as neonatal mortality rates and infant mortality rates, have nearly been eliminated due to the success of the Primary Health Network. In 1974, the infant mortality rate in rural areas was double that of urban areas, yet by 1996, the infant mortality rate of rural and urban areas was almost identical. Therefore, while urban areas still see improved health care access for more serious or complicated health matters, the disparity between urban and rural health care for basic healthcare has dramatically declined over the past 40 years thanks to the health house model.
District Level and the Ministry of Health and Medical Education –
Health concerns too complex for the rural and urban health centers are referred to the district health centers. Along with the district general hospitals, the district health centers are managed by the district health network. Furthermore, each province has a university of medical studies which have specialized schools and teaching hospitals. There are 41 public medical universities with numerous specialized schools and teaching hospitals. The entire medical system is overseen by the Ministry of Health and Medical Education (MOHME).
It is important to note that the MOHME integrates health care and medical education into one organization and system. This approach began in 1985 in order to improve coordination of medical care and education. Although some support this integration saying it has increased medical education’s focus on objective based learning, critics say it has politicized medical education, negatively affecting independent training for medical students. Regardless, such integration has made it easier to place medical students at appropriate health houses, to improve the connection between health houses and their communities.
The impact of the Primary Health Care system in Iran has been undeniably positive. Public health indicators have improved every year since the PHC program was established. In the two decades since 1990, Iran’s life expectancy increased approximately eight years. By 2008, more than 90 percent of the rural population had access to primary health services. Over 90 percent of the population has access to clean drinking water and over 80 percent of the population has access to sanitary facilities. The infant mortality rate has also dropped to 13 per 1,000 live births in 2016, down from nearly 80 in the early 1980’s. For the sake of comparison, in 2016 the United States had an infant mortality rating of around five per 1,000 live births. As in the West, Poliomyelitis is nearly eradicated in Iran due to extensive immunization coverage of pregnant women and children. Finally, immunization of children has become nearly universal, increasing public health indicators tremendously.
Furthermore, some countries, such as the United States, are using Iran’s health house system as a model to solve their own rural health care deficiency. For example, in 2010, Dr. Aaron Shirley, a pediatrician working in Mississippi, founded HealthConnect, an agency that takes inspiration from Iran’s health house model to address the health crisis in rural Mississippi. He argued that Iran’s health house model could be very effective in rural America, saying “The Iranian model eliminated the geographic disparities, so why couldn’t this same approach be used for racial and geographic disparities in the U.S.?.”
Health Care Insurance –
Iran has four main public health insurance options - the Social Security Organization, the Medical Service Insurance Organization, the Military Personnel Insurance Organization, and the Emdade-Emam Committee. The first, Social Security is the most common, available to all Iranians working in the formal sector, apart from government employees. People insured under this program have very low medical costs and are fairly well covered. The second, Medical Service Insurance, is provided for government employees, students, and much of the rural population. Almost all health service providers accept this insurance. The Military Personnel Insurance provides health insurance for members of the military and their families. Finally, the Emdade-Emam Committee provides health insurance for the uninsured low-income population. While approximately 10 – 15 percent of the Iranian population remains uninsured, this number has fallen significantly, from as high as 60 percent in the 1990’s. To put these numbers into perspective, the percentage of uninsured Americans in 2018 is approximately 12 percent.
In 2014, President Hasan Rouhani introduced “Rouhanicare”, a plan to extend medical insurance to all Iranians. He asserted that at least five million uninsured Iranians would be covered. By 2017, almost 11 million Iranians were insured by Rouhanicare. Costs for those covered by government health insurance dropped significantly from an average of 37 percent of total treatment costs to as low as six percent. Still, due to the high government cost of the plan, some critics question whether it is sustainable in the long run. Additionally, many doctors and nurses are growing frustrated with increasing responsibilities yet stagnant salaries.
Medical Tourism –
Iran has become an important country for medical tourism in the region. In 2016, over 100,000 travelers visited to Iran to get medical treatment. Most visitors come for cosmetic surgeries, such as rhinoplasty or hair transplants, infertility treatments, or orthopedic procedures. Moreover, the number of tourists continues to increase. Last year, Iran signed agreements with 13 other countries to make it easier for medical tourists to travel to Iran. For example, in January of 2018, Iran and Iraq agreed to further encourage and facilitate tourism between the two countries. Iran has become a popular location for medical tourism due to low costs and quality of care. Thus, Iran’s growing health care system is attracting more and more patients from nearby countries every year.
One example of Iran’s modernized (even progressive) health care is Iran’s family planning program. Given that Iran’s government is a theocracy, many Westerners may assume that the government is unsupportive of providing access to contraception or family planning information. On the contrary - while the program has faced ups and downs throughout the years - overall, the Iranian government has shown a broad willingness to provide free contraception and other family planning tools, unlike many of its Middle Eastern neighbors.
The first family planning program was created by Shah Reza Pahlavi in 1967. The program took multiple steps to improve women’s status and facilitate the spread of information regarding contraception. Contraception was free, subsidized by the state, family planning was viewed as a human right and medical personnel were trained to have knowledge of contraception, as well as alternative options for birth control. However, this model shifted with the 1979 Revolution.
The Iranian Revolution –
In 1979, the Islamic Iranian Revolution put a hold on the development of Iran’s family planning program. After the Western-placed Shah was overthrown, Iran’s new Islamic government saw the family planning initiative as an unwelcome source of Western influence. Thus, the government quickly dismantled the program. Later, entangled in a bloody war with Iraq between 1980 and 1988, the government saw a booming population as a strategic advantage. Medical personnel were forbidden to provide information about or access to contraception to patients and the government encouraged procreation as patriotic, to create a large, strong “army of 20 million.” Families with more children received financial bonuses and the legal marriage age was decreased to 13 for girls. As a result, Iran’s population grew tremendously, more than doubling from 27 million in 1968 to 55 million in 1988. However, as the Iraq-Iran war came to an end in 1988, the government soon faced a new and different problem associated with this increase in population.
Post Iraq-Iran War –
After the Iraq-Iran war, the Iranian government faced a struggling economy and overcrowded cities. Job shortages and pollution became increasingly pressing issues. As a result, Iran’s government deviated from its previous stance of promoting large families and began, instead, to see large population growth as a problem. Ayatollah Ali Khamenei, who became Supreme Leader in June of 1989, reinstated the family planning program by the end of that year under the motto “Two children is enough.” The program began encouraging smaller families, longer amounts of time between each pregnancy, and restricted maternity leave after three children. Family planning became incorporated into medical education with a curriculum focused on stemming population growth and emphasizing contraception. Religious leaders supported birth control, making it easily accessible to the greater population.
It may seem shocking to many Westerners, but at this time, in both rural and urban public health centers, the government provided contraceptives for free. Condoms, IUDs, the Pill, vasectomies, and various other forms of birth control were free and accessible to the public. During this time period, Iran was home to the Middle East’s only condom factory. Furthermore, university students and engaged couples, both male and female, had to go through family planning counseling mandated by law. Abortions remained illegal except in the case where the mother’s life was at risk or cases of fetal “impairment,” however, the legality of abortions under these circumstances was not exceedingly clear.
As a result of these policies, by 1996 Iran’s birth rate dropped from over six children per woman in 1981 to less than three children per woman, and over 74 percent of couples were using contraceptives. Furthermore, the impressive progress was not limited to urban areas. The inequality of access to family planning resources between rural and urban areas, which plagued the pre-Iranian Revolution program’s success, had been substantially decreased. In 2007, the United Nations presented Dr. Hossein Malek Afzali, the former deputy health minister, with the United Nations Population Award for incredible results of Iran’s family planning program. Iran’s modern family planning program originated following the end of the Iraq-Iran War and lasted over twenty years. Around 2012 however, a revival of calls for strong population growth began again, accompanied by restrictions on access to family planning resources.
Today, Iran’s highly modern family planning program is under attack. In 2012, despite the fact that around 70 percent of Iran’s population is under 35 years old, Ayatollah Ali Khamenei expressed concerns about an aging population and tried to start a program that offered financial assistance for each child a family had. While it failed to make it through Parliament due to high costs, in August 2012, President Mahmoud Ahmadinejad ended the National Family Planning Program, eliminating access to free contraceptives.
While Iranians today still have access to birth control at a cost, increasing the price necessarily reduced their accessibility. Furthermore, moving away from their former “two is enough” messaging, the government began promoting larger families, such as through the “More children, a happier life” campaign. In April 2014, the government proposed “the Bill to Increase Fertility Rates and Prevent Population Decline,” which banned all forms of sterilization, one of the most commonly used forms of birth control in Iran and forbade the distribution or promotion of information about contraceptives. In 2015, the government also introduced “the Exaltation of Family Bill,” which requires employers to give priority to potential employees in the following order: “married men with children, married men without children” and then married women with children. If there are still no qualified individuals then the employer is encouraged to hire a married woman without children. Single women have to face even tougher restrictions, as the bill forbids them to work in certain sectors like education. Thus, between March 2016 and March 2017, Iran’s fertility rating for all Iranian women reached 2.14, above the replacement level needed to avoid population decline. The fertility level for married Iranian women was 3.4, meaning married Iranian women have an average of three children.
Another example of Iran’s modern health care system is the legal organ trade system. Iran is currently the only country in the world with a legal system for organ trade. Although Australia and Singapore have recently allowed financial compensation for organ donors, Iran is the only country with a government-sponsored system that brings together donors and patients and facilitates the payment of donors.
The legal organ trade system was first established in Iran in 1988. The government funded and oversaw the program, and a third-party organization called the Dialysis and Transplant Patients Association handled matching patients with donors. Both of these functions continue today. Thanks to the program, the waiting list for kidney transplants was completely eliminated by 1999. In the United States, by contrast, over 30,000 people have died on the waiting list for kidneys since 1999. Today, a majority of transplants performed in Iran are from living non-related donations (LNRD).
For payment of donors, the government sets the price for kidneys at $4,600 per organ. The government also provides donors with free health insurance, and the patients sometimes give an additional donation to donors. Moreover, for those patients who cannot afford the cost of transplants, there are various charities who cover the costs.
Several problems have arisen over the years with this program. Initially, people from neighboring countries attempted to go to Iran and receive a kidney from an Iranian donor. However, the government quickly responded to this issue, requiring that only Iranian residents could participate in the program to prevent Iranians from being exploited. Refugees are allowed to participate, but they are not allowed to donate to people of ethnicities unlike their own, again in an effort to decrease the likelihood of exploitation. Regardless, many still criticize the potential for exploitation of the lower classes. Most of the donors are extremely poor and are selling their kidneys due to their desperate need of money. Additionally, there is limited information about the long-term health of such donors. Still, the risk of death from these surgeries is as low as 0.02%, and there is not much immediate increase in health risk following such transplants.
Despite concerns, many experts believe that legalizing and regulating the organ trade makes it safer for both donors and patients, especially compared to places where the trade of organs is illegal, dangerous and risky. Thus, while the system might have flaws to work through as the first of its kind, it provides a safer alternative for donors desperate for a way to make money.
Despite the difficult backdrop of years of Western-imposed sanctions that have caused problems in the medical field - especially regarding access to pharmaceuticals - Iran’s medical care overall is surprisingly modern in many ways. First, the Primary Health Network, started in the 1980’s, has greatly expanded access to quality health care to all geographic areas in Iran. As a result, Iran’s public health indicators have substantially improved, showing marked success. Furthermore, although Iran’s family planning program has faced obstacles over the years, the government’s willingness to provide extensive access to contraceptives and family planning information shows Iran’s ability to provide quality health care in all areas. Finally, Iran’s position as a pioneer in the field of legal organ trade demonstrates sophistication and bold leadership in certain controversial areas of the medical field.