In the first years after the Islamic Revolution in 1979, primary health care (PHC) in Iran was based on health centres in rural areas and trained community health workers known as Behvartz, with an emphasis on the control of communicable diseases. Since the establishment of a national health network in 1982 there have been notable improvements in a number of health indices, such as population life expectancy, infant mortality, and vaccination coverage.1 However, these improvements have stalled more recently because of factors including immigration from rural areas to big cities, an increase in the burden of non-communicable diseases, changes in the social determinants of health, and changing population expectations of health care. The health network plan has not worked well in many settings, because of a policy focus on treatment rather than health promotion, over-specialisation in medicine and medical education, a poor evidence base, and the commercialisation of medical care.
The main challenges for PHC, however, are related to its current paradigm, that of concentrating mainly on controlling communicable disease and weak inter-sectoral collaboration and patient advocacy. Attempts to control non-communicable diseases have not succeeded.
A family medicine plan, focused on rural areas and small cities, was launched in 2005 in response to these challenges. This plan was partly unsuccessful because the Iranian general physicians, educated mainly in hospitals, did not have sufficient understanding or skills in PHC.2 Patient mobility and direct access to secondary and tertiary care were additional problems.3,4
Social capital is important in effective health systems, particularly in primary care and in attempts to solve the problems of non-communicable disease,5 but social capital in Iran appears to have decreased over recent years.6 The population is less trustful of public plans and even regards free health care with reservation. There is poor collaboration between primary and secondary care, and all of this has been exacerbated by economic instability.7 Essential infrastructure remains a problem and good electronic record keeping is needed to keep track of a shifting population.
Most recently, health transformation plans have been introduced to address these issues, including the promotion of self-care, refocusing to cover and meet health problems of residents living in slums, improving inter-sectoral collaboration, supporting public health, and oral, dental, and reproductive health, addressing both non-communicable (Iran’s Package of Essential Non-Communicable Diseases [IraPEN]) and infectious diseases, such as HIV, and the effects of natural disasters.
A paradigm shift in health policy thinking is now needed, including the development of new health promotion strategies. Better collaboration will be essential, and regulatory, policy, and legislative reforms will be required. Population education is needed for the development of personal skills to improve self-care, particularly in early life, to encourage healthier lifestyles. People need to be well informed about health reforms, such as the plans for family medicine, so that they accept and collaborate better with these new policies. Legislative bodies must be convinced of the need for rules and regulations to encourage health promotion and to prevent non-communicable diseases. For this reason, stewardship of the ministry of health should be redefined based on three new roles including creating and providing reliable and sufficient evidence for policymaking, promoting health advocacy, and powerful leadership to strengthen inter-sectoral collaboration.
- © British Journal of General Practice 2018