Iran's health-care system in transition

Iran's health system has undergone several reforms in the past three decades with many challenges and successes. The most important reform was the establishment of the National Health Network in 1983, which aimed to reduce inequities and expand coverage and access to health care in deprived areas.1 The Iranian Government has since implemented several other reforms, such as the Family Physician Programme, integration of health services and medical education, the hospital autonomy policy, and the Health Sector Evolution Plan, all of which have had benefits and disadvantages.

The National Health Network system proved effective because it provided a unique framework for primary health care in deprived areas, and health indicators increased accordingly. However, the positive effects are not seen in all levels of the health system and are restricted to the level of primary care. Differences in policy management, information flow, structural connection, and continuity of care in various levels of health care have resulted in a poor referral system. Furthermore, urbanisation and migration of people from rural areas to urban areas cause marginalisation and the creation of slum areas in which people do not have equal access to health care.

Integration of health services and medical education, the second major reform, was implemented in 1985. This reform has enabled bilateral achievements, such as increased capacity for the training of health-care providers at all levels, expansion of the health network system, modification of medical education curricula, and increased social accountability of universities. However, not all of the aims of the reform were achieved—education and the health-care system have not been fully integrated, inequitable access and use of health services is still a major challenge, and medical education is not yet community focused.2

Hospital autonomy, implemented in the early 1990s, was a minor reform that allowed hospital authorities to self-govern, self-direct, and self-finance.3 However, this reform did not have any positive effect on the hospitals' quality of care, and has led to increased health-care costs for users.

The Family Physician Programme was established in 2005 and implemented in rural areas and cities with populations of less than 20 000 people to improve the referral system and provide health-care services efficiently and equitably.4 Despite being a promising opportunity to improve the health system, this programme was not successful and is restricted to pilot sites. The gatekeeping system was not properly established, and patients could easily self-refer to specialists. The gap between the programme plan and its implementation, absence of financial support, fragmentation of insurance system, deficiencies in family physician training, and conflict of interests were important challenges in the implementation of this programme.

The Health Sector Evolution Plan, launched in 2014, is the newest reform in the Iranian health system. Hospital-oriented transformation of the health service was launched in all governmental hospitals to help address the substantial increase in health-care costs in the past decade. The main objectives of this reform were to reduce health expenditure for patients, improve hospital organisation and quality of services, and provide equal access to inpatient care.5 In the first year, the reform was welcomed because of a reduction of inpatients payments' at the point of use, and an increase in health-care providers' income. Nevertheless, the presence of some challenges could have a negative effect on the reform in future—eg, heavy financial burden on government, neglect of primary health care, inefficient payment methods, scarce financial sources, unequal distribution of specialists, and disregard of outpatients in public sectors and patients in private hospitals.

Overall, health-sector reforms should include sustainable and purposeful changes to improve efficiency, equity, and effectiveness, otherwise reform could be harmful rather than useful. The three above-mentioned examples clearly show that the health service in Iran has no master plan and is in a state of chaos. The system is fragmented not only in financial resources, but also in leadership. A disparity between public and private service, separated health insurance, and an absence of universal protocols and guidelines is hampering this system. Moreover, an ineffective health information system prevents efficient assessment of health. Public health expenditure as a percentage of gross domestic product is still low and needs to be amplified. A comprehensive, long-term master plan is needed to avoid different or even opposing reforms that have little benefit, high costs, and are beyond the control of the government. Integrated and coordinated stewardship in all parts of the health system should be considered to implement reforms efficiently.