Welfare and health services in Iran

Kourosh Irandoost1, Zeinab Yazdanpanah1, Parisa Torshizi1, Dariush Akhavan1, Mozhdeh Khosravi1, Hadiyeh Afshar Nia1, Omid Yazdani2, Sadaf Poormand2, Niloufar Firouzi2, Nima Fattahi2, Farzaneh Imani2

1Assisting physician, Iran; 2assisting nurse, Iran

Received on invitation on March 26, 2024

Below, you will find a special article discussing the features and qualities of Iran’s national health system (NHS). Why are we presenting this article? In a few words, we aim to provide an overview of the conditions and characteristics of the health system in Iran: a large nation facing the same difficulties and challenges in contemporary healthcare as other countries. This is set in a particularly interesting socio-cultural context, represented by a non-secular state with a religion-based structure.

Unfortunately, many national health systems worldwide are encountering significant difficulties. Often, the lack of resources and the consequent political decisions lead to a reconsideration of the possibility to provide a health system that could help everyone in facing diseases.

Given the profound and complex differences between health systems, we decided to embark on a journey to describe various health systems, starting with Iran. Particular attention was obviously given to the gender issue.

We hope that this article will interest our readers. Based on their reactions and comments, we will proceed with articles on other health systems and countries. We thank all the authors for responding to our questions and requests for clarification.

Giovannella Baggio and Walter Malorni, Scientific Editors J Sex Gender Specif Med

The following report is the result of a collective effort by six physician and five nurse from different regions of Iran. Due to prevailing political sensitivities and concerns about potential repercussions for candidly addressing systemic issues, none of the participants wish to have their identities disclosed in this report, so they used pseudonyms.

Could you describe the structure of public health in Iran? Is there a national health system? Is healthcare provided free of charge? How widespread are public hospitals across the country, particularly in major cities like Tehran or Isfahan?

Generally speaking, the public health system in Iran operates within a hierarchical referral network, prioritizing primary healthcare delivery. This structure ensures a tiered approach to healthcare services, with a focus on prevention and accessibility.

Iran’s public health system is structurally similar to those of some countries, such as the USA, UK, Germany, and France. It also shares similarities and differences with Italy’s public health system. For example, both Iran and Italy emphasize primary and preventive care.

In general, Iran’s health system works very well in some areas (above world standards), while in other areas it is weaker.

Although the overall structure of the health system and the written regulations are designed to be proportionate and similar to Western systems and, in some cases, completely standard, there are problems in practice and during implementation. For example, some law violations are seen in certain executive parts of the system due to ineffective supervision, which sometimes questions the effectiveness of national regulations and highlights the strong need for more effective laws. Here are some examples of these violations of the law; some people accept bribes from pregnant women to determine the type of delivery (natural or cesarean), recommend performing unnecessary surgeries and unnecessary clinical tests to earn more money from patients, prescribe unnecessary drugs, overprescribe antibiotics, have unprofessional behavior with the patient in some cases, such as making the patient feel ashamed when consulting the doctor for unnecessary cosmetic surgery, carrying out group visits or dedicating very little time to the patient.

In detail, we can say that the Iranian public health system is a complex network of public and private entities that interact with each other. Both the public and private sectors are completely obedient to the regulations of the Ministry of Health, similar to what we see in Western countries. In the public sector, there are hospitals and clinics that offer specialized and super-specialized services, much like in Western countries.

The Iranian public health system is like a pyramid with different levels of healthcare facilities.

National level

The Ministry of Health, Treatment, and Medical Education (MoHTME) acts as the central governing body, overseeing the entire healthcare system in Iran. It sets national health policies, allocates resources, and monitors the performance of healthcare institutions. Both the public and private sectors are completely obedient to the laws of the Ministry of Health, similar to what we see in Western countries. Both the public and private sectors are completely obedient to the laws of the Ministry of Health, like what we see in Western countries.

However, some actions of this ministry seem to be dictated by higher and non-professional political sectors in the field of health. For example, during the coronavirus crisis, the ministry started emergency vaccination too late and used vaccines whose effectiveness had not yet been proven, instead of proven vaccines such as Pfizer. They also use quotas in the admission tests for doctors, pharmacists, and dentists, which results in very few ordinary people being accepted. Many people who are members of Iran’s medical staff are accepted in a non-professional way, with some benefiting from special quotas that ordinary people do not have. From this point of view, it can be said that Iran’s health system uses the most unprofessional, strictest, and worst methods of accepting medical personnel, which is a reason for the migration of many Iranians abroad to study in these fields.

Universities and Schools of Medical Sciences and Health Services play a crucial role in developing the healthcare workforce by training doctors, nurses, and other allied health professionals. In fact, the entire treatment staff of Iran’s health system comes from this department, with a minimal presence of non-Iranian treatment staff in this system. The majority of healthcare professionals are Iranians, unlike what is seen in Western countries, where some healthcare staff are foreigners. For example, there are a large number of Iranian physicians and nurses in Germany’s health system, but there are few foreigners in Iran’s health system.

Intermediate levels of the system

Deputy of Education. This department falls under the MoHTME and manages the education and training programs for healthcare professionals within the system.

Deputy of Treatment. This department oversees the delivery of specialized and curative healthcare services in hospitals and other treatment facilities.

Deputy of Health and Head of the Provincial Health Center. This department focuses on public health initiatives and programs throughout the country. It coordinates with provincial health centers to ensure the implementation of national public health strategies.

Local level

Provincial health centers. These centers manage public health activities within a specific province, acting as intermediaries between the MoHTME and local health facilities. They play a vital role in tailoring national health policies to address provincial healthcare needs.

Network management of the country. This level manages the delivery of healthcare services within a particular county.

The system’s healthcare facilities

The system has a network of healthcare facilities delivering care at different levels.

Health posts. These small facilities, primarily located in rural areas, provide basic healthcare services such as vaccinations, screenings, and primary consultations.

Rural health centers. These centers offer a broader range of basic healthcare services to rural communities, including maternal health care, child health services, and minor surgeries.

Urban health centers. Similar to rural centers, they provide basic care in urban areas, catering to the specific needs of the local population.

County Health Centers. These centers offer a wider range of services compared to basic health centers, including vaccinations, family planning, mental health services, and management of chronic diseases.

Specialized (educational) hospitals. These hospitals provide specialized care, such as surgery or cancer treatment, often serving as teaching hospitals for medical universities.

General hospitals. These hospitals offer general medical and surgical care, including primary care and emergency services.

In terms of Iran’s health facilities, Iran is lagging behind the current facilities of the world due to unclear limitations, which are mainly political. For example, hospital facilities are mostly outdated or deteriorating, and replacing these facilities with modern ones is very important. This process is slower than in other countries, which predicts a crisis in this area in the future.

In Iran, medical services are not entirely free for everyone, and patients must contribute to the costs. While the government provides subsidized healthcare services through public hospitals, clinics, and health centers, patients may still need to cover certain costs for treatments, drugs, and services. The amounts of subsidies and costs can vary based on factors such as income level, type of treatment, and specific healthcare facilities.

In Iran, public hospitals are widespread across the country, including major cities like Tehran, Mashhad, and Isfahan. These hospitals are typically run and funded by the government through the Ministry of Health and Medical Education. They provide a range of healthcare services to the population, including outpatient care, inpatient treatment, surgeries, and emergency services. While widespread, public hospitals can experience high patient volume, so wait times might be longer compared to private facilities.

In terms of the number and quantity of hospitals in Iran, they are relatively adequate, but the main problem lies in the quality of the facilities and the availability of specialists, whose numbers have been decreasing in recent years due to an increase in migration to countries such as Germany, the USA, and those around the Persian Gulf. This could pose a problem in the future.

Is there a territorial medicine network in Iran? Are medical professionals available nationwide, and are they associated with public structures or are they private physicians? How are vaccination campaigns managed, and are vaccinations mandatory?

Yes, there is a territorial medical network in Iran named Shabake behdasht va darman. This network consists of public and private health and treatment centers spread across the country. The aim of this network is to provide health and treatment services to people in different parts of the country, especially in deprived and rural areas.

The territorial medical network in Iran was established decades ago by the Ministry of Health, Treatment, and Medical Education of Iran. This network includes five levels of providing health and treatment services.

Level 1: includes health houses and health centers that provide services in rural and urban areas.

Level 2: includes comprehensive health service centers that provide services in small and medium-sized cities.

Level 3: includes general and specialized hospitals that provide services in large cities.

Level 4: includes specialized and super-specialized educational, research, and treatment centers that provide services in metropolitan areas.

Level 5: includes the headquarters of the Ministry of Health, Treatment, and Medical Education, which supervises the performance of the territorial medical network.

Of course, the implementation of this complex network requires good facilities, and there are some problems in this sector, such as: very few rescue helicopters available, and the few available are old; there are few equipped and up-to-date ambulances. There are also few public hospitals in rural areas outside of big cities, a lack of special medicines for serious diseases, or their unusually high prices.

The distribution of general and specialist physicians in Iran is not fair, regular, or adequate. The reasons for this include:

1. The greater attractiveness of large cities: many general and specialist physicians prefer to live and work in large cities such as Tehran, Mashhad, and Isfahan. This is due to the greater availability of amenities, higher incomes, and more job opportunities in these cities.

2. Lack of facilities in deprived areas: many deprived areas in Iran do not have adequate amenities and educational opportunities. This makes physicians less willing to work in these areas.

3. Inappropriate policies: some government policies on the distribution of physicians have not been very successful. For example, the service commitment scheme for specialist physicians, which was implemented in 2005, was not able to completely solve the problem of physician shortages in deprived areas.

The uneven distribution of physicians, especially specialists, in Iran means that people in small towns may not have access to certain specialties and may have to travel to large cities to see a specialist. For example, there is a shortage of certain specialties, such as cardiac surgery, in many small towns in Iran. It is also worth noting that the entire healthcare workforce in Iran is facing a shortage of human resources due to various reasons, including emigration. Most physicians in Iran work in the private sector for reasons such as higher incomes, better working conditions, and more independence.

Overall, the vaccination management framework in Iran is in a moderate state. The problem is the deliberate lack of access (due to political reasons, the Iranian government is reluctant to purchase some Western vaccines) to vaccines with global standards such as Pfizer and Moderna. Most Iranian vaccines may be domestically produced using substandard raw materials, often from China, or outdated equipment. The claimed research results on the efficacy of these vaccines may also sometimes be unreliable. However, there is mandatory vaccination for some vaccines in Iran, while other vaccinations, such as the HPV vaccine, are not provided, and individuals must obtain them independently and at a high cost.

Another issue is that some individuals who wish to receive certain vaccines, such as the HPV vaccine, may not have access to a reliable vaccine within Iran’s vaccination system. There is a possibility of encountering counterfeit vaccines, as they would have to obtain them from the black market located on Naser Khosrow street in Tehran. This poses various challenges such as lack of trust in the seller, failure to comply with vaccine storage conditions, and absence of any supervision or law enforcement in these circumstances.

Are preventive cancer screening tests routinely conducted in Iran? For instance, are pap tests and breast cancer screenings offered to women, along with HPV vaccinations?

Regular cancer screening tests are not routinely conducted in Iran for the general population, and they are not free. In some cases, screenings may be done in a limited way, but they are not well-organized or consistent across all cases. Currently, there is no organized regular screening program for common cancers such as breast and cervical cancer in Iran. Opportunistic screening is done for these cancers, which means that if a person sees a doctor and the doctor considers them at risk for a particular cancer based on their age and risk factors, they may prescribe a screening test. This test is done at the discretion of the physician and mostly at the patient’s expense.

The cost of cancer screening tests in Iran is also a barrier to access. Although these tests are offered opportunistically, they are not generally free. Patients usually have to pay for the tests out of their own pocket. In some cases, health insurance may cover part of the cost. However, many people cannot afford to pay the full cost of these tests, leading to a lack of access to screening tests and, consequently, late diagnosis of cancer.

In very limited cases, insurance may cover a portion of the costs for Pap smears and breast cancer screenings. However, this coverage is generally minimal compared to the overall expenses. Additionally, a substantial portion of the costs may need to be borne privately by individuals. Some insurance plans only offer coverage for a restricted number of tests or may not prioritize timely testing for early detection. Hence, individuals often need to actively seek financial means to cover the expenses of these screenings.

The situation regarding the HPV vaccine in Iran presents several challenges. Firstly, it is not mandatory, which reduces its widespread uptake, and even in an optional form, it is not easily available to those who wish to receive it. Secondly, it is not provided for free and is costly, forcing individuals to resort to purchasing it from the black market on Naser Khosrow Street in Tehran, where safety and authenticity are major concerns. Consequently, the accessibility and usage of this vaccine are significantly hindered. Moreover, acquiring the HPV vaccine from the black market raises serious concerns about its effectiveness and authenticity, potentially endangering public health. Additionally, the lack of a comprehensive government-managed distribution system means that many individuals in Iran remain vulnerable to HPV-related diseases. Even for those who attempt to obtain the vaccine from the black market, the exorbitant cost often renders it unaffordable, particularly given the challenging economic conditions in the country.

Regarding gender considerations, do patients typically receive medical care from physicians of the same sex? Do women and men have the same rights and clinical pathways? How are waiting lists for diagnostics and surgery determined? Are they based on census (social class)? Are there specialized family clinics in Iran? Are equal opportunities available for teenagers and students of both genders seeking admission to universities and medical, pharmacy, or biology programs in Iran?

In Iran, the government has issued orders to medical centers, preferring that in most cases doctors of the same sex treat the patient, unless the patient expresses a preference for a doctor of a different sex or a same-sex doctor is not available. This situation is especially prevalent in medical centers affiliated with government institutions, particularly in cases related to women’s health.

Following the political revolution of 1979, certain specialties and branches of medicine in Iran became exclusively for women, and only female students are allowed to study them, such as obstetrics, gynecology, and midwifery. In Iran, male students are not accepted into these fields under any circumstances.

Therefore, in Iran, there are no male midwives or gynecologists who graduated from universities within the country, unless they completed their studies prior to the political revolution of 1979 or pursued education outside of Iran.

Hospitals and medical facilities in Iran often attempt to accommodate these political preferences by providing same-sex physicians whenever feasible. However, in emergency situations or when a same-sex physician is unavailable, patients may receive care from a physician of the opposite sex. Overall, while there is a political preference for same-sex medical care in Iran, it is not an absolute requirement, and the availability of same-sex physicians may vary depending on the location and specific circumstances.

In summary, except for conditions specific to women and the fields of obstetrics and gynecology, where male doctors are often not accessible and patients usually opt for female physicians, individuals in other medical disciplines typically have the freedom to select a doctor of their preferred gender (if available), unless they are in government-affiliated medical centers with strict same-sex doctor policies aligned with the patient’s gender like Basij’s medical centers.

In Iran, while both men and women have equal access to healthcare services, differences exist in their rights and clinical pathways. For instance, in certain surgeries, particularly those related to women’s health, consent from their husband or family, particularly the father, may be necessary. Similarly, for surgeries involving children, parental consent, often from the father or another male guardian, is typically required. Additionally, in cases where an unmarried woman seeks egg freezing, the father’s permission is typically mandated by law.

Generally, in Iran, waiting lists for diagnostics and surgery are determined based on factors such as the severity of the condition, medical evaluation of urgency, available resources, the complexity of the procedure, and patient preferences. Priority is given to patients with urgent or life-threatening conditions, while those with less pressing needs may experience longer wait times. Ultimately, the goal is to allocate resources efficiently to ensure timely and appropriate care for all patients. However, certain factors, such as a person’s social class, can impact the entire process.

In Iran, social class can indeed influence access to healthcare, including waiting times for treatment, in complex ways. Wealthier individuals may choose to use private medical centers where they can expedite their treatment process. Additionally, a significant concern is the existence of a black market for organ transplantation, where individuals can purchase organs such as kidneys and livers from those in financial need. Unfortunately, there is no legal prohibition against this practice, leading to ethical dilemmas as donors may feel compelled to sell their organs due to poverty. This situation underscores broader issues of socioeconomic inequality and healthcare access in the country, raising moral concerns about exploitation and fairness in the healthcare system.

In Iran there are specialized family clinics, often referred to as ‘Health Houses’ or ‘Health Posts’, which provide primary healthcare services to families and communities. These clinics are typically staffed by trained healthcare professionals, including general practitioners, nurses, and midwives, who offer a range of services including preventive care, health education, maternal and child health services, immunizations, and treatment of common illnesses. However, due to the mandatory policies of the government to increase the population, from about a decade ago until today, contraceptive services have been significantly curtailed in these centers, and in some instances, their usage is even considered illegal. Supplies like condoms, once freely distributed, now encounter restrictions on purchasing and distribution. Even contraceptive counseling has faced limitations, raising concerns about the increased risk of births of children with conditions like Down syndrome.

In Iran, equal opportunities in education are often lacking, presenting challenges for teenagers and students of both genders seeking admission to universities and specialized programs like medicine, pharmacy, or biology. While official education platforms claim few legal barriers exist, practical obstacles contribute to unequal access. Quotas for certain programs and disparities in educational resources exacerbate these inequalities. Consequently, many young people choose to study abroad in these fields. Quotas pose significant challenges in both education and employment in Iran.

The issue of quotas in Iran’s education system is highly significant, particularly in fields like medicine, pharmacy, and dentistry. A large percentage of admissions are allocated to special candidates, often with familial ties to the government, leaving ordinary applicants in fierce competition for the remaining spots. This system has led to a crisis for ordinary individuals without quotas, as many struggle to secure admission. The high prevalence of quotas has created substantial disparities in educational opportunities within the country.

These quotas also exist in the employment sector, where a large number of people selected for employment, especially in government centers, benefit from quotas, making it very difficult for ordinary individuals to be accepted. This issue of quotas has sparked many controversies in Iran, yet it is still implemented by the government. Quotas are present in the majority of admission seats for fields like medicine, pharmacy, and dentistry, leading to extreme injustice in this area.

Addressing social issues, is contraception permitted in Iran? How is pre-marital sex viewed: is it considered a religious concern or a crime? Is homosexuality deemed a crime, a sin, or a shame for both genders?

As previously mentioned regarding contraception, due to government-mandated population growth policies implemented over the past decade, access to contraceptive services has been significantly restricted, and in some cases, their use is even deemed illegal. Supplies such as condoms, once freely distributed, are now subject to purchasing and distribution restrictions. Furthermore, contraceptive counseling has been limited, raising concerns about the birth of children with conditions such as Down syndrome. Overall, it is evident that the government does not endorse contraception and has deliberately made access to related services as difficult, expensive, and limited as possible.

In Iran, pre-marital sex is generally regarded as both a religious and legal issue. From a religious standpoint, pre-marital sex is deemed morally unacceptable in Islam, the predominant religion in the country. Islamic teachings emphasize chastity and modesty, considering sexual relations outside of marriage to be sinful.

In Iran, pre-marital sex is officially viewed as both a religious and legal concern.

Legally, pre-marital sex is prohibited in Iran under the country’s Islamic legal code. Engaging in pre-marital sex is considered a violation of Islamic law and can lead to legal consequences. However, the enforcement of these laws can vary, and the severity of punishment may depend on factors such as the individuals involved, the circumstances of the incident, and the discretion of law enforcement authorities.

Overall, pre-marital sex is viewed as a religious concern due to its contravention of Islamic teachings, and it is also considered a crime under Iranian law. However, the extent of enforcement and the severity of punishment may vary in practice. These two perspectives represent the official stance on the issue. However, considering that Iranian society is modernizing, the acceptance of this traditional view has diminished for many, and attitudes towards pre-marital sex are becoming more similar to those found in Western countries.

In Iran, homosexuality is considered both a crime and a sin. Under Iranian law, consensual same-sex activity is illegal and can result in severe penalties, including imprisonment or even death. Religious teachings also deem homosexuality as contrary to religious morality. Consequently, individuals who identify as homosexual or engage in same-sex relationships may face stigma and discrimination, leading to social shame for both genders in Iran.

Indeed, attitudes towards homosexuality are evolving in Iran, with a growing number of people considering it a personal matter unrelated to others. This perspective emphasizes individual autonomy and respects personal choices regarding sexual orientation. While societal views may still largely condemn homosexuality, there is an increasing recognition of the importance of respecting individuals’ rights to make personal decisions about their own lives.