ISLAMIC
REPUBLIC OF
IRAN
Acknowledgements
This document was produced as part of the Technical series on primary health care on the occasion of the Global Conference on
Primary Health Care under the overall direction of the Global Conference Coordination Team, led by Ed Kelley (WHO headquarters),
Hans Kluge (WHO Regional Office for Europe) and Vidhya Ganesh (UNICEF). Overall technical management for the series was
provided by Shannon Barkley (Department of Service Delivery and Safety, WHO headquarters) in collaboration with Pavlos
Theodorakis (Department of Health Systems and Public Health, WHO Regional Office for Europe).
This document was produced under the overall direction of Zafar Mirza and Hassan Salah (WHO Regional Office for the Eastern
Mediterranean).
The principal authors were Lauren Spigel, Dan Schwarz and Asaf Bitton, all from Ariadne Labs, Boston, USA.
Valuable comments and suggestions were made by WHO collaborating partners and regional and country office staff, particularly
Alireza Raeisi (Ministry of Health and Medical Education); Mohammadreza Rahbar (Ministry of Health and Medical Education);
Mohsen Asadi-Lari (Iran University of Medical Sciences and Ministry of Health and Medical Education); Mohammad Shariati (Ministry
of Health and Medical Education); Reza Majdzadeh (Tehran University of Medical Sciences); Shadrokh Sirous and Christoph
Hamelmann (WHO Country Office); AliAkbar Haghdoost (Ministry of Health and Medical Education); Nastaran Aslani (Ministry of
Health and Medical Education), and Luke Allen (Consultant, WHO, Geneva).
The views expressed in this document do not necessarily represent the opinions of the individuals mentioned here or their affiliated
institutions.
WHO/HIS/SDS/2018.27
© World Health Organization 2018. Some rights reserved. This work is available under CC BY-NC-SA 3.0 IGO licence.
Background
In parallel with the Declaration of Alma-Ata, the
Revolution of 1979 launched landmark reforms to
the health system of the Islamic Republic of Iran (1,2).
These reforms, which were in line with primary health
care (PHC) (3–6), began in the early 1980s (7) and
continue to the present day (8). The Declaration of
Alma-Ata outlined key tenants of PHC, which the Iranian
government adopted, with the aim of achieving health
for all by 2000 (6,9,10). Over recent decades, Iran has
built a strong PHC system on a large scale, starting with
a rural community health worker (CHW) programme and
then an urban CHW programme. In the past decade,
the family practice system has become a fundamental
element of PHC in the Islamic Republic of Iran. PHC
is highly organized and efficient, and has resulted in
a dramatic decrease in maternal, infant and neonatal
mortality rates. Strategies used by the Iranian health
system to develop efficiency, responsiveness, equity and
movement towards universal health coverage (UHC)
include assessing needs and integrating new health
programmes, then modifying the structure of the service
delivery system based on needs.
1
Intervention
The development of health networks occurred in three phases. The first phase involved developing PHC.
The main feature of this phase was the development of a system for delivering essential health care that
prioritized the allocation of resources to rural areas. The second phase was the development of a family
practice programme in rural areas and in urban communities with a population of under 20 000 people. The
third phase was making progress towards developing family practice in suburban areas and in cities with a
population of more than 20 000 people.
In the first phase, Behvarzes – CHWs based in rural health houses (4,7,13,14) – were the main staff delivering
PHC services. In subsequent phases, the country’s health system used a greater number of health experts
to complete the coverage. The key health experts providing wider and more complex services included
Moraghebe-salamat (multipurpose CHWs in urban areas); nutritionists; experts in mental, environmental and
occupational health; and midwives.
First phase of developing PHC
The health care reforms of the Islamic Republic of Iran began in 1983, with the establishment of the National
Health Network, which put rural communities at the heart of PHC in the country. This rural-focused approach
aimed to improve health equity between urban and rural populations (7,8,10–12). The underlying values of
PHC in Iran, modelled on the Declaration of Alma-Ata, have informed its implementation strategy (6,10).
A key component of the health reforms has been the creation of health houses (Khaneh Behdasht), staffed by
Behvarzes, which provide basic health services; each health house serves about 1500 people within a 1-hour
walking distance (7,13). Selecting local community members as Behvarzes is strategic, because these staff
members are constantly available, and they have long-term commitments and personal connections to their
community. Their origin and place in the locality strengthens the relationship between the health system and
the community (6,14–17).
Behvarzes provide a broad range of services, including annual censuses, health education, family planning,
maternal and child health care (MCH), care for elderly populations, oral health care and occupational
health (7,13).
Training and supervision
The Behvarz training programme is financed entirely by the national and provincial health systems (18).
Cohorts of 7–15 students undergo a rigorous 2-year task-oriented training at the country’s district Behvarz
training centres (17,18). Behvarz candidates who enter training with a university degree in public health or
a related field have a reduced training requirement of about 6–8 months (18). The coursework is broad,
covering the wide range of services that Behvarzes will need to provide to their communities (7,14).
3
Movement towards UHC – the need to implement
a family practice system and improve PHC services
Like many other societies, the Islamic Republic of Iran is experiencing rapid changes in all aspects of
social life; for example, urbanization and lifestyle changes, demographic changes and a changing
socioeconomic environment. The pattern of diseases has also changed. The most important
challenges are:
• demographic transition – an increase in the elderly population with a higher burden of
noncommunicable diseases (NCDs);
• the changing socioeconomic situation of communities, and rising public expectations of the
health system; and
• increased marginalization and lack of adequate coverage of health services in marginal areas.
Providing infrastructure during the past two
decades – events that made the system ready for
new reforms
During the years after the establishment of health care networks, different projects were designed
and integrated into the health system to improve infrastructure and undertake necessary reforms.
Some of the projects implemented can be summarized as follows:
• developing techniques for assessing the burden of diseases and priority-setting for health
problems;
• developing and integrating NCD programmes;
• developing models for community empowerment and participation;
• developing a health informatics and online electronic management information system;
• licensing the health workforce;
• assessing health technology; and
• developing performance-based payment for health staff.
4
Legislations and
macropolicies
The health sector reforms began with the
country’s third development plan, and
continued in the fourth, fifth and sixth plans.
A key point was rural health insurance in the
fourth programme of development, known
as the “family physician and rural insurance
programme”; this important reform was
implemented in 2005 (8,22).
Urban CHWs
Before the establishment of family practice,
the health system benefited from various
cadres of health workers. However, it was
after the family practice programme that more
CHWs entered the health system and started
delivering more services based on new needs.
These CHWs (also known as Moraghebe-
salamat) were accompanied by mental health,
nutritional, environmental and occupational
health experts, and midwifes, allowing the
team to provide more services. Urban CHWs
are typically selected through advertising in
the urban area. They are usually native to
their working area, and have a college degree
(e.g. in public health or midwifery). The
district health centres select CHWs through
competitive examinations, and individuals who
are selected must complete training courses
both before and during their service.
7
Family practice training programmes
Various programmes have been developed to enhance the ability of both family physicians
and other members of the health team. These programmes include reviewing the syllabus for
training health staff (especially physicians), and developing new academic disciplines and on-
the-job training.
Additional graduate courses have been designed and implemented, including a masters of
family medicine (an online modular course) and a family medicine specialty programme.
Integration of new services
To ensure that services are accessible to different groups, new services have been integrated
into targeted group service packages. To optimize the effectiveness of these services, family
doctors and health teams are being trained to deliver the services included in the packages,
which were developed by scientific groups in the Ministry of Health and Medical Education
(MoHME). Also, the health teams have been expanded to include other health professionals
(e.g. experts in nutrition and mental health). The new service packages focus on:
• smoking cessation;
• improving nutrition;
• preventing traffic accidents;
• promoting physical activity;
• preventing cancers;
• preventing cardiovascular disease;
• preventing diabetes;
• improving oral health; and
• preventing mental illness and improving the health status of people with mental
illnesses.
9
Second phase – developing family
practice in rural areas and cities
with a population of under 20 000
To reach UHC targets, the number of PHC services and the coverage
of the population were scaled up. With the statutory requirement for
rural health insurance, the government’s commitment to a comprehensive
referral system and the move towards a family practice approach accelerated.
Along with health sector reforms, the quality of services was enhanced by
the appointment of new health workers, including nutritionists, mental health
experts and midwives. Training courses for general physicians were considered
necessary to develop family and community-based services; therefore, the
MoHME started training specialist family doctors. In addition, the MoHME tried
to expand health services for urban communities, with the aim of regulating the
health market.
Third phase – developing family practice in
suburban areas and cities with a population
of more than 20 000
One target of the programme was populations living in urban areas, including the
marginal population around cities, and cities with a population of more than 20 000. It is
estimated that those living in urban areas total 10.2 million, and those in large cities total
43 million (without considering the marginal population). The programme aims to develop
UHC countrywide, and is based on public–private partnerships and devolution of services to the
nongovernmental sector. The payment in this programme is per capita, adjusted by service.
10
Impact
The Islamic Republic of Iran’s Behvarz programme
has been a critical part of improving the country’s
health outcomes over recent decades. The health
system has improved MCH outcomes (19),
NCD outcomes (11,24) and overall life
expectancy (12,25). The use of a significant
number of service providers in the second and
third phases led to an increase in the coverage of
health services in urban areas, and in the desire
to receive various services including those for
nutrition, mental health and NCDs.
According to the Department for Family,
Population and School Health in the MoHME,
the maternal mortality rate in 2015 was less
than 20 per 100 000 live births. The department
has announced the following results for 2015:
a neonatal mortality rate of 9.5/1000, an infant
mortality rate (IMR) of 13.4/1000 and an under-5
mortality rate of 15.5/1000 live births. The
strength of the PHC system has also helped to
reduce MCH disparities between urban and rural
populations (7,19,26). In 1976, the IMR in rural
areas (123.7/1000 live births) was almost double
the IMR in urban areas (60.4/1000 live births) (7);
however, by 2000, the gap between rural and
urban IMR had was much less (30.2 compared to
27.7/1000 live births) (7,26).
Finally, and perhaps most notably, the population
life expectancy has increased since the inception
of the Behvarz programme, from 55.7 years
in 1976 (19) to 75.5 years in 2015 (25). Other
factors (e.g. economic growth and increased
literacy) have also contributed to the increased life
expectancy (7), but the PHC system played a major
role in this outcome (12).
13
Lessons learned
and implications
for scaling
As the world observes the 40th anniversary of
the Declaration of Alma-Ata, the experience
of the Islamic Republic of Iran highlights the
importance of placing the community at the
heart of the PHC system. Recruiting and training
CHWs has led to a health system that can
respond to the community’s needs, providing
proactive, preventive care to people in their
homes (3,20). The Behvarz training model is a
complete example of a task-oriented instructional
system that has improved its methods over time,
but has remained responsive to community needs
and new opportunities.
The Iranian health system has become more
efficient, responsive and equitable, thanks to
a range of initiatives. These include assessing
needs and integrating new health programmes;
designing the structure of the service
delivery system based on needs; establishing
performance-based payment systems and an
online electronic information system; establishing
a monitoring and evaluation system for services,
and extensive assessment of people’s satisfaction;
developing an appropriate structure of the health
team; and creating basic structures for evaluating
quality and quantity of services. The system has
reaped significant health benefits for the Iranian
people, and serves as an example for other
settings globally, providing lessons for other
countries and communities embarking on their
own paths towards UHC.
14
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