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The Iran health system has implemented various reforms to provide equitable access to health care for citizens. In addition to its achievements in improving health outcomes, it faced problems, particularly following sanctions and the outbreak of COVID-19. These challenges must be addressed as the high-priority agenda by the new administration in Iran. In this commentary, we introduce the most critical challenges faced by the country. We then describe the main strategies that should be considered to address these challenges.

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Besides remarkable achievements, Iran health system faced challenges, particularly after economic sanctions and the COVID-19 pandemic. The new administration must address these challenges.

→What this article adds

Iran has long-term health plans for health, but challenges raise the need for a paradigm shift into health plans. Iran's new government must prioritize reconstruction of the health system for health security based on lessons learned from sanctions and COVID-19. Health system governance must inevitably be based on internal strength and readiness to deal with global, regional, and country-specific threats. A complementary whole-government and whole-society approach are needed for building such a resilient health system.

Authors’ point of views

The Iran health system has implemented various reforms, including establishing the Primary Healthcare (PHC) Network, to provide citizens equitable access to health care. In addition to its achievements in improving health outcomes, it faced problems.The critical ones were the worn-out health facilities, lack of access to new technologies, and difficulties in procurement of medicines and medical supplies. For instance, almost 60% of the hospital beds were more than 30 years old in 2014 (1), indicating a chronic problem in resources allocated to the infrastructure required for health care.

Sanctions imposed on Iran became multilateral and intensified in the early 2010s. Economic restriction and its effect on trade had severely hit the health sector, including rising prices and shortages of medicines and medical supplies, underutilization of health services, and hardship in health expenditures. At the time of the inauguration of President Rouhani's administration, the health system reform was considered one of the priorities given the challenging situation of the health system and extensive public dissatisfaction (2).

Following efforts to reach the Joint Comprehensive Plan of Action, a deal on lifting the United Nations multilateral sanction, measures were initiated to relieve sanction effects on health. A national plan, entitled the Health Transformation Plan (HTP), was formed to recover the procurement of medicines in 2014, followed by increasing public resources to health. An overhaul of health care infrastructure was started to increase access to health services and reduce financial hardship. The HTP had some achievements; however, it faced challenges because of inefficiencies of the health system and fiscal unsustainability (3). During President Trump's administration, new sanctions were imposed on Iran. While this was unilateral, it much intensified and severely impacted the population's health and wellbeing. The extensive natural disasters, such as floods and then COVID-19, have resonated the harsh effects on health and have been an immense challenge for the entire nation (4). Still, these challenges are pertinent and must be addressed, as the high-priority agenda, by the new administration in Iran.

A spectrum of threats is affecting Iran's health. The first is global threats, such as emerging and reemerging diseases and the impact of climate change. The second includes the Middle East regional issues, such as conflicts and war. The final is country-specific natural disasters and the consequences of sanctions. Many natural disasters have occurred in Iran, including the Bam earthquake, with more than 26,000 casualties and 30,000 injuries. The political tensions and sanctions are continuous potential threats that affected Iran's health whenever intensified for several decades. The existence of these threats indicates that Iran should invest more in building a resilient health system and consider health security with 5 priorities.

First, Iran mustprepare its response to the acute and protracted crisis. An excellent example of this preparation was in China, where field hospitals were built within the shortest time at the beginning of the COVID-19 epidemic (5). Iran's health system needs such capabilities to provide a high volume of services in a wide geographical area in critical situations of a large-scale crisis, such as the Tehran Earthquake, which is possible based on seismic activities.

Second, Iran must prioritize health services, define essential commodities and ensure their access and affordability for its citizens. A sustainableand robust financing mechanism is needed to ensure continuity of essential services in any circumstances with the principles of efficiency and equity.

Third, the learnings from global nationalism in times of the COVID-19 pandemic, especially in accessing a vaccine, the shortcomings of international collaborations and trade oblige Iran for self-reliance, with a minimum dependency on foreign countries.Part of this effort should be on preparing platforms of local production or readiness to switch the pipeline of production to new products in emergencies. An example is adjusting car industry platforms to produce mechanical ventilators in the early stages of the COVID-19 pandemic in the United States (6).

The fourth is bridging the gap between levels of care and revitalizing the PHCapproach. The expansion of the PHC Network was satisfactory at the periphery level. Still, a system of integrated patient-centered services is not established, and care delivery levels are disconnected (7). An improper referral system is a significant shortcoming in health care delivery, causing the inefficiency of the health system (8).

The fifth is strengthening the surveillance system.COVID-19 showed that decision-making based on valid data and timely analysis is vital. The experience of the Western-Pacific region showed how the use of appropriate technology and both backward and forward contact-tracing are instrumental in controlling pandemics (9). The surveillance system must be prioritized as a common good for health (10) and supported intensively by public sources. In this case, a rapid learning system can be formed for wise crisis management (11).

In short, Iran's new government must prioritize the reconstruction of the health system for health security based on the lessons learned from sanctions and COVID-19. The health system governance must inevitably be based on internal strength and readiness to deal with global, regional, and country-specific threats. A complementary whole-government and whole-society approach are needed for building such a resilient health system.

Conflict of Interests

The authors declare that they have no competing interests.