The beginnings of public health in Iran
Until 1904, there was no law or organization to manage health care and medical education in Iran. In that year, a department called the “State health conservation Council” was created which began functioning under the supervision of the Ministry of Science Science. The services of this office, along with 21 hospitals with 906 beds, were provided to eligible parties, while ten hospitals with 650 beds were led by Christian missionaries. Modern medical education in Iran also began for the first time with the training of physicians at the “Dar al-Fonun” School, founded in 1851.1
According to a law passed in the National Assembly in 1910, certain groups of people, such as army and police officers and employees of the Iranian Oil Company, were eligible to receive health care.2 The main health systems at the time included the “Institute for Health in country and cities”, “Institute of Police Health,” and the “Pasteur Institute.” These three organizations merged into the “General Directorate of Health in Country." According to the same law, it was decided that the units affiliated with the health system, including medicine and treatment, would gather in this general office as a subset of the Ministry of Interior. The head of the General Directorate of Public Health was responsible for managing all areas of health, including the preparation and compilation of the budget and the structure of its organization. Saeed Khan Loghman al-Molk was the first person to be appointed as the head of this office.3 The Army Health Department, however, continued its work independently for many years.
In addition to the Ministry of Health, which was directly responsible for public health in Iran, two other institutions, namely the Imperial Social Services Organization and the Iranian Red Lion and Sun Society also supplied healthcare services to deprived and low-income Iranians. The Red Lion and Sun Society of Iran started operating in 1922 and the Imperial Social Services Organization started in 1947. The Red Lion and Sun Society was the first Iranian charitable organization to provide disaster relief for the country. This organization was established in 1922 by Dr. Amir Aalam.
The overlap of the relief work and healthcare activities enabled the Red Lion and Sun Society to provide medicine and medical equipment,4 build hospitals and numerous health clinics, train and educate nurses, and care for orphaned children. After the 1979 Revolution, the name of this institution changed to the Red Crescent Society of the Islamic Republic of Iran. In the classical structure of providing health care services in Iran, and prior to the implementation and expansion of the health network system (before 1978-1997), the main responsibility of clinics, hospitals, and medical centers was to prepare and distribute drugs, and the provision of preventative services was less priority. These units were active in decision-making, planning, and resource allocation, and operated under the management of the Ministry of Health. From its establishment until today, the Ministry of Health and its affiliated units have overseen all matters related to the health of citizens and the preparation and compilation of laws for the supervision of physicians and healthcare workers.
The founding and growth of the Ministry of Health
The bill to establish the Ministry of Health was presented to the parliament by the cabinet in September 1320 (1941) and in November of that year, this bill was approved.5 According to the first article of this bill, the Ministry of Health consisted of several departments to include the Supreme Council of Health, Office of Administrative Affairs, Pasteur Institute, a Finance Department and a Technology Department.
In 1958, the law establishing the provision of healthcare to the public was approved. After reform to this law in 1964, health associations were established in major cities to improve healthcare and medical treatments in suburbs and townships. These health associations were composed of the following members: Chairman of the City Council, Mayor, Head of the Health Center, a physician, three of the trustees of the townships, Chief of the Medical University, the Head of Red Lion and Sun Society and the Director of the Imperial Community Service. These health associations held a four-year term. Meanwhile, all the funding for health affairs of within each state was provided from the budget of the Ministry of Health, the municipalities’ own funds and the endowment revenues that was allocated to the local health department.6
A year later in May 1965, the Government Employees' Concentration and Coordination Act was approved, and under this law all the medical facilities and medical equipment of ministries and governmental and semi-governmental offices were handed over to the Ministry of Health.7 The Ministry of Health now supervised and managed all the medical centers within the country. The Ministry of Health itself was restructured in February 1969, providing for five deputies, including Project Deputy, Parliamentary Deputy, Technical Deputy, Financial Deputy and Deputy of Health and Family Planning. Then in 1976, the Ministry of Health was changed to “Ministry of Health and Welfare” and it acquired other services such as Social Welfare Services, Rehabilitation and Social Security Services, Family Planning and Population Control. Parallel to these changes, all assets and employees of the Health Services Organization, the Welfare Services Organization and the Rehabilitation Association were transferred to the Ministry of Health and Welfare.
Healthcare services were also provided by the Imperial Social Services Organization, which was established in April 1947 under the honorary supervision of Mohammad Reza Shah Pahlavi, as the Chair, and Ashraf Pahlavi, as vice-chair. The purpose of this organization was to improve the overall health of the Iranian public, by treating patients who were poor, while also advancing their welfare status. This was to be done in three different areas, which consisted of treatment and healthcare services, education and cultural services, and social services.
Structural change and continuity after the revolution
After the revolution, the Ministry of Health and Welfare, with some changes in the structure of the Ministry, including renaming the former deputy and setting up seven new departments, began to operate. These departments are the Deputy of Health, Deputy of Planning and Organization, Deputy of Treatment, Deputy of Pharmacy, Food and Laboratory, Deputy of Welfare, Deputy of Administrative Finance, and Deputy of Educational and Research Coordination.
The new structure of the organization was approved by the country’s administrative and employment affairs organization after a short trial period. The first post-revolutionary Minister of Health was Dr. Kazem Sami, a psychiatrist. His brief tenure at the Ministry of Health began on 19 February 1979 and lasted for a few months before the mass resignation of the Provisional Government of Mehdi Bazargan on 5 November 1979. During this period, Dr. Kazem Sami presented a plan called “National Medicine” to the cabinet and demanded that the National Medicine bill be submitted to the parliament. This plan was summarized as follows: The dismantling of private hospitals and the annexation of separate medical departments to the then Ministry of Health and Welfare. During Dr. Sami’s ministry, in addition to combining nine support organizations and seven women’s health centers, he succeeded in transferring all the facilities of the Imperial Social Services Organization, the Iranian Red Lion and Sun Population Society and even all medical and health schools affiliated with the Department of Education and all the charitable organizations to the Ministry of Health and Welfare through legislation. The Welfare Organization was separated again from the Ministry of Health in March 1980.
Despite all the changes in the early years of the revolution, the structure of the Ministry of Health and its organizational goals did not change, although they faced various problems, such as severe shortages of health workers, shortages of health centers, and shortages of medicine. The lack of a comprehensive plan for medical schools persisted as well. Consequently, the number of universities and medical students increased rapidly to address this shortages. Although this move increased the number of medical graduates, the quality of medical education and the distribution of physicians in disadvantaged areas continued to be problematic.
Therefore, the Ministry of Health came up with a plan to address the shortage of health workers. In 1985, six years after the revolution, a new plan implemented new projects, including budget planning, management, and oversight of health and wellness centers, welfare, laboratories, food and medicine safety, pharmacies, and the management of medical schools. The name of the Health Ministry was changed to the Ministry of Health and Medical Education in October 1985.
Many experts and members of parliament opposed the merger of Medical Education and the Ministry of Health. The opponents of combining the two organizations cited the decline in the quality of medical education as the main reason for their objection to the merger. This argument was rooted in the inability of physicians working in the Ministry of Health hospitals to train medical students, and in the lower standard of the Ministry of Health hospitals in terms of equipment, bed occupancy rate, patient rotation and their limited geographical area in providing services. Proponents of the merger, however, were concerned with the inequality of health services for the less affluent communities. They referred to several available statistics from the “Geographical Distribution of Human Resources in the Healthcare Sector” which demonstrated the uneven distribution of medical personnel in those areas:
- 87 percent of specialist doctors were in Tehran and five other major cities, the remaining 13 percent was left for the rest of the country.
- 54 percent of general practitioners were in Tehran and five other major cities and the rest, 6 percent, around the country.
- 66 percent of the dentists were in Tehran and 34 percent in the rest of Iran.
Two decades after combining the Medical Education Organization and the Ministry of Health, some of these inequalities in the distribution of human resources, doctors, dentists, paramedics, nurses, and midwives were reduced, according to the Ministry of Health and Profiles of the World Health Organization. In 2006, the gap in the distribution of health providers reached was reduced by 50 percent. Tehran, Gilan, Mazandaran, Khorasan, Isfahan, and Shiraz still had the highest number of specialists, and among other provinces, Yazd had the highest percentage of medical specialists and Sistan Baluchistan had the lowest number. In the field of construction and equipment, inequality was more noticeable. According to the Department of the Ministry of Health in 2011, there were over 900 active hospitals and 110,846 beds. This statistic was announced in December 2013, noting that 250,000 nurses in the country were working to provide hospital services.
- Total of ICU beds in the country: 5413
- Total of CCU beds in the country: 4509
- Total of beds for burned people in the country: 1055
- Total of psychiatric beds in the country: 7567
- Total of dialysis bed: 3986
- Total of emergency beds: 8040
According to the same source, in 2005 the total number of hospital beds was 97,600 and it projected that by 2014 the number of hospital beds would reach 141,219 beds. These numbers are consistent with the statistics provided by the annually published CIA World Factbook, – which suggests the Iranian statistics in this case are accurate.
The number of schools of nursing and midwifery in the country in 2005 comprised 82 colleges and 160 nurse training centers.8
According to this information, the most important differences between the structure and function of the health system before and after the revolution can be summarized as follows:
- Integration of medical education in health care management
- Expansion of health care networks and quantitative expansion of human resources and equipment
- The ministry’s organizational structure has not changed fundamentally from before the revolution. The addition of welfare services to the Health Ministry in 1976 was reversed after the revolution in 1980, which was one of the major changes in the organizational structure of the Ministry of Health. Other changes in its performance were related to health policy and treatment.
- In the pre-revolutionary organizational structure, health care services were provided in the form of five deputies. In 1978, as the revolution gained momentum, tasks were assigned to seven separate deputies; currently nine deputies are required to provide services.
The Alma-Ata Declaration and the expansion of healthcare in Iran
Iran’s involvement in coordinated international health efforts began in the 1970s. The first Primary Health Care international conference was held under the auspices of the World Health Organization (WHO) in 1978 in Alma-Ata (now Almaty). It articulated the elements of primary health care as a means of raising health standards around the world. The conference issued a resolution, known as the Alma-Ata Declaration, that called on all governments around the globe to strive to improve public health by the year 2000 to such a level that would allow all people to live an effective and productive life. Iran was one of the signatories to the resolution, which meant that even before the revolution Iran pledged to ensure the health of the people by 2000 by providing health care. Finally, in May 1979, the executive strategy of the world-wide goal of “Health for All by 2000” was approved in the 32nd session of the World Health Organization. So, although the Alma-Ata Declaration was agreed upon and signed by the representatives of the Ministry of Health and Welfare before the Revolution, it was in the process of formulating the implementation phase of the “primary health care” that the representatives of the Islamic Republic were involved.
The World Health Organization considers primary care as a service which is affordable and scientific, with eight methods of primary care:
- Health education given the health difficulties in the community and ways to prevent and combat them
- Proper nutrition and promotion of food supply
- Sufficient and safe water supply and basic improvements
- Maternal and child care, including family planning
- Immunization against major infectious diseases
- Prevention and control of regional diseases
- Proper treatment for diseases such as emergency accidents
- Preparation of basic medicines
Under the Alma-Ata Declaration each country can exceed the range of these services according to regional conditions and local facilities. Iran added some others:
- Providing human resources
- Dental and oral health
- Preparation to deal with natural disasters
- Mental health
An important part of Alma-Ata vision, and of the Iranian program to improve basic healthcare entailed the establishment of a referral system. A referral system is a mechanism in which a patient is sent from a low level to a higher level of service if they need to receive more specialized services. A very important and efficient point in this system is to establish a two-way system for sending and returning patients and exchanging information about their health status between different levels. The patient and his information will be returned to the place where he was referred so that the final stages of the follow-up and care can be performed there. This ensures the continuity and quality of the patient’s care and prevents confusion. Comprehensive health care includes three levels of service delivery.
- The first level of primary health care is when people need services from the healthcare system. These services include eight types of services mentioned before, provided by health centers and by health workers. These services in rural areas are offered by nurses and other health workers who have undergone special training. The basic care provided at this level is one of the first priorities of providing services in Iran, because it is needed by all people, and its full implementation will prevent diseases.
- The second or middle level of health care includes services provided at the county health center and city hospitals.
- The third level is specialized care that requires complex equipment and is provided in provincial centers and advanced health care facilities.
Implementation of the plan to provide health for all by the year 2000, articulated in the Alma-Ata declaration, was quickly approved by Iranian policymakers. To justify the need, they cited vital statistics and health indicators, such as high mortality rates of children and pregnant mothers, insufficient vaccination coverage, mortality of children under five years of age due to vaccine-preventable diseases and inadequate and unequal access to health care services and basic drugs.
Several experimental projects had been tested in Iran prior to the approval of Health for All by 2000, with similar objectives. The details of the activities of those projects are included below:
- The Mashhad Health Education Project, which trained medical staff, was launched in1940. After that, in 1946, the training of medical staff began in Isfahan and Shiraz. The main requirement was having a high school diploma. After that, candidates were selected to serve in the villages and rural areas. After four years of training, they were committed to eight years of service in disadvantaged areas. These people, eight years after the end of their service obligations, could attend the fourth year of medical school and continue their education to become a physician. Training of health workers for rural areas expanded through the 1950s and 1960s all around the country.
- After World War II, mobile groups began working to eradicate infectious diseases such as leprosy and smallpox. The formation of these groups took place in the framework of “Point 4” - a program that provided US technical assistance to developing countries. Point 4 trained many young people to work as health workers to eradicate some pandemics like malaria in many rural areas of Iran and expanded children’s vaccinations around the country.
- In collaboration with two Ministries (Health and Defense) the “Health Corps” was formed and implemented in 1964. Deployment of the “Health Corps” was one of the principles of the “White Revolution” aiming to bring health to deprived and rural areas.
- Medical and Health Services Development Plan in Iran: This plan has been in place since 1972, through the World Health Organization in partnership with the Medical school of Urmia University. Known as the Rezaieh project, this plan was to train and use non-physician manpower to provide primary health care. These services were provided in places called Health Houses by teams of both males and females.
The main disadvantage of the first two projects was the lack of a coherent network of services, the lack of proper technology and the neglect of setting measurable goals in the health community. These weaknesses were eliminated in the Rezaieh project. In 1977, the Ministry of Health accepted the Rezaieh project as a suitable model for the development of health services and implemented the preparations for the wider implementation of this project in Hashtgerd of Karaj.
Eventually, between the years 1979 and 1985, the health care system in line with the WHO and the definition provided by the WHO in the Alma-Ata Declaration, made the Welfare Strategy the top priority of the Ministry of Health. This change was implemented in the following 4 steps, based on the Rezaieh model:
- Analysis and assessment of existing facilities was carried out (1979 -1981)
- A detailed description of the rules and duties of the system was prepared separately for all the eight standards and developed for each service. (1981-1983)
- In this stage, those with more health-related work experience in the various provinces and municipalities were categorized in different working groups. After long negotiations and in line with the public opinion, the plan to build, equip and set up 1800 “Health Houses” was approved according to the Alma-Ata’s model until the end of 1985. The above working groups also set up a system to establish the components of the referral system or the units that needed to support health centers.
- During this period which lasted one-year, the desired structure of the country’s health system was organized based on three priorities (1984-1985): The importance of prevention over treatment; the priority of outpatient treatment to inpatient treatment; and the priority of the deprived and rural areas over the urban and affluent areas
Health houses are the smallest units of health care networks in the villages and rural areas, with populations up to 1,500 people. Each Health house is assigned two health workers (a male and a female health worker). It is the duty of the health workers to provide various health-related services to the people; however, the health houses operate under the aegis of a health care center.
The program launched gradually in 1985, with the establishment of roughly 1800 health houses in villages. With the approval of the health-care network expansion plan in the same year and its continuous implementation, the number of health houses currently exceeds 17,000 across the country.
In its 2003 annual report, the WHO said that increasing life expectancy, improving health and reducing child and maternal mortality, controlling and eliminating infectious diseases, and implementing nutrition improvement programs in Iran were the result of the primary health care plan. Some of the important achievements of the primary healthcare system in Iran which have won international awards and recognition are:
- Family Planning and Population Control: The number of child deaths has dropped from 111 per 1,000 to 26, and life expectancy has risen from 58 to 72. The index represents the change in the healthcare system and increases the amount of health services and prevention.
- Production and distribution of iodized salt to eliminate goiter: This program was initiated in 1989 and decreased the prevalence of goiter by 23 to 40 percent. For this reason, the World Health Organization selected Iran as the training center for countries in the Middle East and North Africa in the field of prevention and control of iodine deficiency disorders.
- Improving nutrition by distributing iron supplements to address iron deficiency in high school girls.
- Effective implementation of the immunization expansion plan in the country and compliance with global standards: the percentage of the population receiving vaccinations in Iran increased from 36 percent in 1984 to 95 percent in 2014—a considerable success.
- The implementation of the program to eliminate measles and rubella through vaccinating 33 million in 2003.
Encyclopedia Iranica, entry of “Behdari” ↩︎
Laws and Rules in Iran (in Persian), 1357, p. 13. ↩︎
Saadat, Ebrahim, History of Medical advancement of Red Cross Committee (in Persian), 1377. ↩︎
Based on definitions of health by the World Health Organization. Iran is part of this organization. ↩︎
Aagheli, Bagher, Iranian History from Constitutional Revolution to Islamic Revolution (in Persian), Tehran, 1370 ↩︎
Laws and Rules in Iran (in Persian), 1337. ↩︎
Laws and Rules in Iran (in Persian), 1344. ↩︎
Medical Management, Office of Statistic and informatic. ↩︎