International Medical Community

Health System in Iran

JMAJ 52(1): 69–73, 2009

Ramin MEHRDAD*1

Background

Iran is an ancient country located in the Middle

East, a region between Asia, Europe, and Africa.
Iran is located in a special geostrategic situation
by connecting the eastern and western parts of Iranian Health System Outlook
the world. Persian civilization was established
more than 3,000 years ago. The area of Iran is As an important point, Article 29 of the Constitu-
1,648,195 Km2 which makes it the 17th largest tion of the Islamic Republic of Iran emphasizes
country in the world. Iran is divided into 30 prov- that every Iranian has the right to enjoy the
inces and 336 districts. Tehran, the capital of Iran, highest attainable level of health. The Ministry of
is one of the most populous cities in the world, Health and Medical Education is mandated to
holding a population of 9 million. fulfill this goal through designing and implement-
Iran is bordered on the East by Pakistan ing a national-level health policy. Yet, the Minis-
and Afghanistan, on the North by Turkmenistan, try of Health and Medical Education delegates
Azerbaijan, and Armenia as well as the Caspian its implementation to medical universities across
Sea, on the west by Turkey and Iraq, and on the the country. There is at least one medical univer-
south by the Persian Gulf and the sea of Oman. sity in every province. The president of a medical
Iran with a population of almost 70 million, of university is the highest health authority in the
which more than 65% are urban dwellers, stands province who reports to the Minister of Health
as the 17th populous country in the world.1 Iran’s and Medical Education. The president of the
population is young; almost one third of the medical university is in charge of public health,
population is less than 15 years old and only almost health care provision in public facilities, and
5% is over 60 years. The population annual growth medical education. Health care and public health
rate in 2006 was 1.2%. services are provided through a nation-wide net-
More than 95% of Iranians are Muslim. Iran work (Fig. 1). This network consists of a referral
has an important position in international energy system, starting at primary care centers in the
production and reserves of oil and natural gas. periphery going through secondary-level hospi-
Iran is the fourth producer and the fifth exporter tals in the provincial capital and tertiary hospitals
of oil and has the third main proved reserves of in major cities.
oil in the world. It is also the fifth producer and The public sector provides primary, secondary,
has the second proved reserves of gas in the and tertiary health services. The emphasis of
world. Industry and agriculture are other impor- the government on primary health care over the
tant contributors to Iran’s economy. Iran’s gross last two decades has made the public sector the
domestic product (GDP) at purchasing power main provider of primary health care services
parity (PPP) per capita was 9,200, 9,800, and across the country. Some primary health care ser-
11,700 US $ in 2005, 2006, and 2007 respectively. vices such as prenatal care and vaccination are

*1 Associate Professor of Occupational Medicine, Department of Occupational Medicine, School of Medicine, Tehran University of Medical
Sciences, Tehran, Iran ([email protected]).
Takemi Fellow, Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA ([email protected]).

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Mehrdad R

Ministry of Health and

Medical Education

University of
province

District’s health
Teaching hospitals Schools
network

District health District general

center hospital

Urban health center Rural health center

Health post Health house

Fig. 1 Health system network in Iran

provided free of charge in public facilities. The tive gave rise to considerable controversy, which
public sector also provides a considerable part after more than two decades still lingers in health
of secondary and tertiary health services in the policy debates. The proponents of the policy argue
province. that integration has boosted the quality of health
The private sector plays a significant role in services around the country. They posit that using
health care provision in Iran. The private sector objective-based learning lies at the heart of qual-
mainly focuses on secondary and tertiary health ity improvement. On the other hand, opponents
care in urban areas. There are many nongovern- of the integration maintain that integration has
mental organizations (NGOs) active in health had a negative impact on medical education. They
issues in Iran. NGOs are mainly active in special contend that the political clout behind the care
fields like children with cancer, breast cancer, provision shifts resources away from the training
diabetes, thalassemia, and so on. of health professionals. Moreover, the workload
in teaching hospitals causes attending professors
Health System Organization to reconsider the training priority sets for interns
and residents. Due to a lack of systematic studies
Integration of the health system and to substantiate the arguments, the debate on inte-
medical education gration remains unsettled.
The Ministry of Health (MOH) is responsible for
planning, monitoring, and supervision of health- Medical education
related activities for the public and private sec- As mentioned above, the main part of the mandate
tors in Iran. However, this ministry has a unique of the Ministry of Health and Medical Education
structure that distinguishes it from health minis- is education and training of health care personnel
tries in other countries. In 1986, the government in Iran. This mandate is fulfilled through 41 pub-
integrated medical education into the MOH; lic medical universities, comprising 36 medical
hence, it is now called the Ministry of Health schools, 45 nursing and midwifery schools, 32
and Medical Education. The main purpose of the schools of public health, 13 dentistry schools, 10
integration was to establish a more coordinated pharmacy schools, 22 schools of paramedics, and
approach to health care provision and medical six schools of rehabilitation sciences.2 The medical
education. From the very beginning, this initia- schools offer a wide range of residency programs

70 JMAJ, January / February 2009 — Vol. 52, No. 1

 HEALTH SYSTEM IN IRAN

Table 1 Investment in health in Iran during the last decade 3

1995 2000 2006 % Change
Gross national income per capita
5,550 6,820 9,800 Ⳮ77
(PPP international $)
Per-capita total expenditure on health
231 364 731 Ⳮ216
(PPP international $)
Total expenditure on health as % of GDP
4.7 5.9 7.8 Ⳮ66
(gross domestic production)
Per-capita government expenditure on health
115 135 406 Ⳮ253
(PPP international $)
General government expenditure on health as
49.9 37.0 55.6 Ⳮ11
% of total expenditure on health
General government expenditure on health as
9.3 9.6 9.2 ⳮ1
% of total government expenditure

and fellowships in their affiliated hospitals. Many the last ten years. Table 1 reports the trend of
of these schools have been established during last investment in health in Iran during this period.
three decades, some with questionable quality Accordingly, almost all health investment
of medical education. Azad University is a major indices have improved during the above-mentioned
semi-private university supported by the gov- period; in some cases, the index has tripled. In
ernment. This university has many branches in spite of government spending on health, out-of-
different provinces and districts. Some of these pocket expenditure on health remains as high
branches offer health-related programs. as 55%.
In 2005, there were nine physicians, 16 nurses
and midwives, two dentists, and two pharmacists Health insurance system
per 10 thousand population in Iran. The distri- According to official data, more than 90% of
bution of health care personnel is an important Iranian people are under the coverage of at least
issue. The health care personnel density in urban one kind of health insurance. The main public
areas is more than in rural areas, and that in large health insurers are as follows:
cities is more than in small cities. The Ministry of 1. The Social Security Organization is one of the
Health and Medical Education tries to improve largest health insurers in Iran. All the people
the distribution of health care personnel around employed in the formal sector, except for
the country by obligating young physicians to government officials and service people, con-
work in more deprived areas; nevertheless, there tribute to the fund and receive benefit from
is shortage of health care providers in some parts this organization. This organization owns and
of the country, especially peripheral areas, and a runs many clinics and hospitals in urban areas.
surplus of them in some other parts such as large Medical services in these clinics and hospitals
cities. Medical public universities do not charge the are offered either free of charge or at very low
students. The students are required by law to pro- cost for policy holders.
vide services for a certain time in a place assigned 2. The Medical Service Insurance Organization
by the MOH in return for the tuition provided. provides health insurance for government
The concept of this policy is to cover impoverished employees, students, and rural dwellers. The
areas and marginalized communities by these rural population not covered by any insurance
young graduates. became entitled to receive benefits at will in
2000. Most of the health care providers accept
Health System Financing patients holding this kind of medical insur-
ance. Patients are subject to copayment at the
Investment in health point of service.
Iran has increased investment in health during 3. The Military Personnel Insurance Organi-

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Mehrdad R

Table 2 Comparison of health indices 1990–2006 3

Health Index 1990 2000 2006 % Change
One year olds immunized with three doses of DPT (%) 91 99 99 Ⳮ8.8
One year olds immunized with three doses of hepatitis B (%) 62 99 99 Ⳮ59.7
One year olds immunized with MCV (%) 85 99 99 Ⳮ16.5
Infant mortality rate (per 1000 live births) 54 36 30 ⳮ44.4

Male Female Both sexes Linear (Male) Republic of Iran has made remarkable progress
75
in the health sector with much improvement in
73 various health indices.”4 While some health indi-
71
70 69 cators such as child immunization have consider-
70 68
ably improved, other indicators such as the infant
65 65 mortality rate is still far from the Millennium
65
63
61 Development Goals. Table 2 shows changes in
60 some different indices between 1990 and 2006
and Fig. 2 shows changes in life expectancy for
55 males, females, and both sexes during this period.

50
The most important causes of mortality
1990 2000 2006 Cardiovascular diseases are the first cause of
mortality in Iran. Based on official data, more
Fig. 2 Life expectancy for males, females, and both
sexes in Iran than 45% of deaths in Iran are related to cardio-
vascular diseases. The second cause of mortality
is accidents, accounting for almost 18% of all
deaths. Road accidents are a major cause of
zation provides health insurance for military death, injury, impairment, and disability in Iran,
personnel. especially for the young. Death due to cancers
4. The Emdade-Emam Committee provides comes to 14% of total deaths. The fourth and the
health insurance for the uninsured poor. fifth causes of mortality in Iran are neonatal and
Although a small percentage of Iranian peo- respiratory diseases, each accounting for nearly
ple are not covered by any of the health insur- 6% of deaths.
ance organizations, some people have enrolled in
two different health insurance plans, encouraged Health System Challenges
by a small premium. Different insurance systems
provide different levels of service coverage. So The health condition of Iran has improved dur-
enrollment in different plans makes it easier to ing the last decades; however, many challenges
shop for services at lower cost. threaten the health system. Some of most impor-
There are some semi-public insurance com- tant challenges are as follows:
panies whose policies mainly cover copayments
for costly inpatient services. Almost 5% of the Financial
middle-class population holding any of afore- The Iranian Development Plan set the goal for
mentioned insurances buys their policy. out-of-pocket payment to as low as 30% in 2008.
Nonetheless, almost 55% of health spending is
Health Status still paid out of pocket.

Population health achievements Health status

WHO reports praise on the Iranian health sys- Road accidents as a major cause of death and
tem, saying: “Over the past 20 years, the Islamic injury have a significant impact on Iranians’ life

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 HEALTH SYSTEM IN IRAN

expectancy and cause a lot of disability and impair- ducting systematic analysis of the health system.
ment among people, especially young men. Parallel Apart from analysis of the process and outcome,
with the decrease in the prevalence and incidence patients’ satisfaction is a cornerstone of health
of communicable diseases, non-communicable system performance. Lack of accurate data on
diseases loom large. Cardiovascular diseases, dia- patients’ satisfaction is a major impediment in
betes, osteoporosis, nutritional disorders, and psy- the health policy-making process in Iran. Despite
chological disorders are some examples of diseases efforts to measure patients’ satisfaction, the cur-
that need more attention in the coming years. rent information system is far from optimum. The
quality of services and efficiency of the health
Lack of information in the health system system are two major issues that need more
There is an acceptable registry system for births, attention.
deaths, cancer, and many communicable and
non-communicable diseases and immunization Acknowledgements
in Iran. Lack of an integrated health information My thanks go to Dr. Mansour Farahani and Dr. Farshad
system is a stumbling block on the way to con- Farzadfar for their great comments on this article.

References

1. Statistical Center of Iran, official website. 4. Country Cooperation Strategy for WHO and the Islamic Republic
2. Ministry of Health and Medical Education. of Iran 2005–2009.
3. WHO Statistical Information System (WHOSIS).

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