In a Lancet editorial,1
health systems in middle-eastern countries were described as adopting a “curative, rather than preventive” approach. But this is clearly not the case in Iran; Iran’s health system is mainly designed based on the model of PHC.
In 1978, all WHO members unanimously declared that access to basic health services was a fundamental human right, what was known as “Health for All by the Year 2000 (HFA 2000)”.2,3
PHC, which emphasized community-based preventive services, with substantial community involvement, was advocated as the main strategy to achieve the goals of HFA 2000.2,3
PHC entailed universal coverage of basic services such as safe water supply, promotion of food security, vaccination, family planning, education, control of endemic diseases, and provision of essential drugs.
Studies conducted more than 3 decades ago in Iran had already paved the way for PHC reform.4
However, the political and social changes of 1979, which almost coincided with HFA 2000 declaration, provided strong support for the implementation of PHC. The ideology behind HFA 2000 and PHC closely matched with the values of the time: social justice, equality, universal access to services, giving priority to the most vulnerable and underprivileged, and community involvement.5
PHC methods were carefully planned, and revolutionary fervor encouraged rapid implementation.
At the core of the Iran’s PHC plan was decentralization and empowering the rural areas with community health workers. Health houses were opened in 16,000 villages6
and were run by community health workers (behvarz). The behvarz were selected from the local community and were trained for two years to provide basic health services, including safe water, immunizations, and basic maternal and child care. Training methods involved group discussions, roleplaying exercises, and working in a model health house, rather than exhaustive memorization and other traditional pedagogical models.5
Being born and raised where they live and work, the behvarz typically have intimate relationships with their client community, are familiar with the norms of their society, and actively follow every person on basic health matters. To give an example of the effectiveness of this system, almost 100% of children born in Iranian rural areas receive BCG, diphtheria, pertussis and tetanus (DPT), polio, measles, and hepatitis B vaccines.7
Each health house on average covers four villages, and every few health houses are supervised by a “rural health center”. Iran has a total of 2300 rural health centers that are typically staffed by general practioners, dentists, midwives, pharmacists, nurse assistants, and other health workers.
In urban areas, the peripheral governmental health system generally starts from “urban health centers” that are similar in structure to rural health centers. However, in the very poor neighborhoods of larger cities, there are 600 “health posts” each manned by five health workers. Health posts provide PHC but not higher levels of care. Approximately 50,000 female volunteers aid the personnel of these health posts in pubic health education, family planning, child immunization, and other PHC priorities.6
Both Rural and urban health centers in each province are in turn supervised by medical universities, which have tertiary referral hospitals and medical facilities. Private practice offices and hospitals work in parallel and independently of the governmental system described above.
However, all private systems are also approved and monitored by the Ministry of Health. Private hospitals own < 7% of all 200,000 hospital beds, are located in larger cities, and provide services mainly to the more affluent urban population.
Public insurance plans provide almost free access to a variety of services offered in the governmental sector to approximately 90% of the urban and rural population. These services include tertiary referral procedures, such as coronary artery bypass grafts and renal transplants. Services offered in private practice offices are also covered by governmental insurance systems, but treatments in private hospitals are more expensive and usually require complementary insurance programs.