Applying ethical theories to the Iranian health system governance: a critical empirical assessment.

The policies of health systems are inspired by ethical priorities. A critical review of policies can reveal the ethical theories/justice schools behind them. This study aimed to identify the ethical theory(ies) underpinning the Iranian health system governance over the past 50 years. This was a qualitative study conducted in two stages during 2019. First, we identified and constructed the key concepts and distinctive notions of prominent ethical theories/justice schools. Then, we spotted and selected 24 strategic laws and policy documents in the Iranian health system governance during the past 50 years and analyzed their content to surmise their underlying ethical theory. The results showed that the dominant theory affecting the policies of the Iranian health system governance over the past 50 years was egalitarian liberalism and then objective utilitarianism and relativist communitarianism. Retrospective empirical application of ethical theories to health system governance is methodologically doable, and this application reveals the mood or priorities of the politics. Also, highlighting the underpinning ethical theories of health system governance as well as the gap between ambitions versus realization are insightful and may prospectively empower and strengthen egalitarianism.

Introduction

Policymaking and governance of health systems are always influenced by ethical considerations and entail tensions and dilemmas. Although issues such as justice, efficiency, social customs, human rights, and personal choice are taken into account in the adoption of health policies, these issues are rarely systematically analyzed. Taken as an ethical endeavor, policy-making – be it health legislations, programs, or reforms – is inspired by, and maybe evaluated and based on, justice schools (1, 2). Government officials always consider these ethical theories in their decisions, even if they are not explicitly aware of the concepts or do not clearly express them (3).

The major justice schools or ethical theories behind health systems governance are utilitarianism, libertarianism, and communitarianism. While utilitarianism states that a certain policy should be judged based on its consequences, liberalism focuses on the people’s rights and opportunities for enjoying services. Communitarianism, on the other hand, emphasizes the links between individuals and society and states that the judgment of general policies is influenced by the type of society and people that the government desires (4 - 6).

We found no empirical study on this subject in international or Iranian literature. In most studies, justice schools are presented theoretically and are illustrated by anecdotal examples of health systems' programs or policies. Empirical studies that come closest to the subject are those on health system values, e.g., equity, efficiency, patient satisfaction, non-discrimination, responsiveness, etc. (7 - 15). One study analyzed the “Mega Policies for Health” and reported that egalitarianism was the dominant theory (16). Another survey titled “Maximization of Health Benefits vs. Egalitarianism: An Australian Study of Health Issues” reported that policies of maximizing health benefits received little support when they led to unequal access of the elderly and vulnerable groups to health-care services (17).

Events or developments such as “Heath for All by 2000” of Alma Ata Declaration”; the recent commitments to “Universal Health Coverage (UHC)” in a 2018 United Nations general assembly; the “National Health Service (NHS)” in the United Kingdom; “Medicare” in Australia; and the “Medicaid” and the “Medicare” in the United States indicate a deep inclination towards egalitarianism in the health services of different countries and cultures over the past 70 years or so. The primary hypothesis of this study was that the ethical theory inspiring the Iranian health system governance over the past 50 years has also been an intensified orientation towards egalitarian liberalism. We aimed to analyze the content of the nation’s strategic laws and health policy documents to empirically identify the ethical theory/justice school governing the Iranian health system. The study findings can augment and sharpen political analysis, steer the national conversations in the desired direction and enhance the accountability of policymakers.

1. The reader should be reminded that orientation and ambition may not mean actual realization.

Methods

This qualitative study was conducted in 2019 based on a deductive approach to determine the ethical theory prevailing in the Iranian health system governance. The method entailed four distinct tasks as follows.

Task 1: First, we shortlisted and chose a handful of main sources as our primary references on justice (2, 6, 18 - 24). Reviewing these sources, we then established and standardized our concepts of the schools of justice as summarized in table 1.

Table 1

A summary of justice schools/ethical theories

Justice School/Ethical Theory	Description
Subjective Utilitarianism	This orientation compares and evaluates policies based on their total desirability level for all members of society. Accordingly, the cost-benefit analysis (e.g., willingness to pay) is applied to determine the actions with the highest desirability level. The followers of this school are highly optimistic about personal choices and the compliance of social policies with public demands and decisions.
Objective Utilitarianism	According to this orientation, the decisions to improve public health should be taken objectively by a group of specialists. Proponents of objective utilitarianism call for policies that bring the highest collective level of enjoyment of health services. They employ cost-effectiveness analysis, e.g., DALYs, QALYs, and non-comprehensive measures such as infant mortality rate (IMR) and survival rate as a result of interventions to investigate the options.
Libertarianism	Supporters of this orientation believe that only ‘negative’ rights need protection. These rights guarantee individual freedom so people can do what they want and others are not entitled to violate their choices. Proponents of libertarianism emphasize the role of a limited government in protecting property rights and individual freedoms. Some of them seriously oppose taxation for resource redistribution (they sometimes accept limited taxation for the provision of basic government services such as defense and security issues).
Egalitarian Liberalism	Egalitarians believe that individual freedom and human dignity cannot be realized without basic resources and facilities. Therefore, everyone has a positive right to enjoy a minimum level of services and resources needed to ensure relative equality of opportunities, freedom, basic needs and demands, and access to basic amenities. These points inevitably refer to the issue of “redistribution”, which is to the benefit of people who are deprived of even the lowest level of welfare. Proponents of this school state that the government should be responsible for providing the minimum quality and quantity of living and health-care services for all people.
Universalist Communitarianism	Universalist communitarians argue that there is a unique universal model for having good individuals and a good society. Religious and non-religious examples such as monotheistic religions and the feminist movement can be classified to, at least partly, correspond with this school.
Relativist Communitarianism	Relativist communitarianism identifies a wide range of cultural behaviors around the World and the extent to which people are influenced by these cultures. Followers of this view believe that any society should determine its norms and methods of social organization. This group views ethics as an inherently contextual issue and does not believe in a global position outside a society to judge cultural traditions.

Further, we identified and standardized a distinctive notion for each school as presented in table 2. In this regard, we sought comments from three healthcare ethicists to ensure the credibility and dependability of the findings.

Table 2

Distinctive notions of each justice school/ethical theory

Justice School/Ethical Theory	Distinctive Notion	Subcategory	Distinctive Notion
Utilitarianism	Efficiency	Subjective Utilitarianism	Personal choice
		Objective Utilitarianism	The planning and decision-making initiatives by health authorities
Libertarianism	Rights	Libertarianism	Fundamental freedoms
		Egalitarian Liberalism	Fundamental welfare benefits/ entitlements
Communitarianism	Culture	Universalist Communitarianism	Universal equality and fraternity
		Relativist Communitarianism	Community values

Task 2: Based on multiple and numerous national and international norms and practices mentioned before, we assumed egalitarian liberalism to have been a universal component of health system governance in the past 70 years or so in all nations. However, we further recognized the difference not in the egalitarian inclination itself but in the depth of countries’ embrace of egalitarianism. For illustrative and taxonomic purposes, we developed an "egalitarian grid" as presented in figure 1.

Figure 1

The egalitarian grid: Exemplifying the depth of the embrace of egalitarianism in the health system of countries

Task 3: The study was conducted on the strategic policy documents and laws of the Iranian health system. Famous strategic health policy documents and laws, such as “The Mega Policies for Health”, “The Sixth Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act” (2017-2021), and “The 20-Year Vision Document of the Islamic Republic of Iran”, were purposively selected by four of the research team members who have more than two decades of experience in the Iranian health system. We also systematically searched the keywords “health”, “public health”, and “health care” on the legal databases of the Iranian parliament and the “Ministry of Health and Medical Education (MOHME)” to spot the strategic policy documents and laws in the past 50 years (i.e., since 1968). The guiding criteria for selecting the strategic health policy documents and laws were health or therapeutics-related decisions or acts by the “Parliament”, the MOHME, and the “Expediency Discernment Council” with a long-term nature and national scope.

Task 4: Using the deductive framework established in Task 1 above, one of the authors, N Bahmanziari, meticulously explored the content of the identified strategic health documents and laws section by section to determine the ethical undertones and implicit or explicit references to notions of justice as structured in Table 2. Before embarking on this task, N Bahmanziari underwent a deep and iterative orientation and training exercise on the recognition of justice schools in official texts under SM Mohammadi; SM Mohammadi is the recognized authority in the field of justice in health policy. Also, as a pilot, a sample of content was analyzed by N Bahmanziari and the results were validated by SM Mohammadi. At the end, all the processes and results were double-checked and approved by SM Mohammadi and A Takian.

This research was approved by the Ethics Committee of the School of Public Health and Paramedical Sciences of Tehran University of Medical Sciences (ethics code: IR.TUMS.SPH.REC.1398.017).

2 . Disability-Adjusted Life Years

3 . Quality-Adjusted Life Years

4 . These rights usually require no action, either legally or morally, in order to be achieved.

5 . These rights require an action in order to be achieved.

Results

Doing task 3 of the Methods section above, we found 24 strategic health policy-related documents and laws established in the past 50 years as summarized in table 3. It should be noted that some key ministerial or director general-level documents were also included.

Table 3

Strategic health policy documents and laws (25, 26)

Title	Reference of Approval	Year
The Provision of Medical Services to Government Employees Act (PMSGEA)	Parliament	1972
The Establishment of the Ministry of Social Welfare Act (EMSWA)	Parliament	1974
The Social Security Act (SSA)	Parliament	1975
The Constitution of the Islamic Republic of Iran (CIRI)	Assembly of Experts for Constitution	1979
The Establishment of the MoHME Act	Parliament	1985
The Organizations and Duties of the MoHME Act	Parliament	1988
The First Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (the chapter related to health)	Parliament	1989
The Second Five-Year Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (the chapter related to health)	Parliament	1994
Public Health Insurance Act (PHIA)	Parliament	1994
The Third Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (the chapter related to health)	Parliament	2000
Strategic Policies of the MoHME in the Third Development Plan	MoHME	2001
Organizing Health-Care Services Based on Articles 3, 29, and 43 of the CIRI Act	Parliament	2002
The 20-Year Vision Document of the Islamic Republic of Iran (20-YVDIRI)	Expediency Discernment Council	2003
The Fourth Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (the chapter related to health) (FESCDPIRI)	Parliament	2004
The National Document for the Development of the Health Sector, the FESCDPIRI	MoHME	2004
The Structure of the Comprehensive System of Welfare and Social Security Act (LSCSWSS)	Parliament	2004
The Fifth Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (2011 - 2015) (the chapter related to health)	Parliament	2010
The Comprehensive Scientific Health Map (CSHM)	Specialized Committee of Health and Life Sciences of the Supreme Council of the Cultural Revolution, MoHME	2010
The Health System Transformation Map Based on the Iranian-Islamic Progress Model (HSTMBIIPM)	Policy Council of the MoHME	2011
Mega Policies for Health (MPH)	Supreme Leader’s Commands, Expediency Discernment Council	2014
The Health System Transformation Plan Directive (HSTPD)	Deputy for Medical Services, MoHME	2014
The Family Physician and Rural Insurance Program Directive – Version 18 (FPRIPD)	Deputy for Health, MoHME; Iran Health Insurance Organization	2016
The Sixth Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (2017 - 2021) (the chapter related to health) (SESCDPIRI)	Parliament	2017
Obligations of the Health Insurance Organization of Iran to cover and provide health insurance services	Cabinet	2017

We identified 73 distinct sections/articles/paragraphs/notes related to macro health policymaking in these 24 laws/documents that referred to justice-related concepts either directly or indirectly (table 4). Some referred to more than one orientation or theme (table 5).

Table 4

Analysis of the strategic health policy documents and laws

Title	Section/Article /Paragraph/Note	Ethical Theories/Justice Schools
PMSGEA	Article 1 - Note 3; Article 10	Libertarianism; Egalitarian liberalism
EMSWA	Article 1 - Paragraphs A and D	Egalitarian liberalism
SSA	Article 1	Egalitarian liberalism
CIRI	Chapter 1 - Article 3; Chapter 3 - Article 29; Chapter 4 - Article 43	Egalitarian liberalism, Relativist communitarianism; Egalitarian liberalism; Egalitarian liberalism, Libertarianism, Relativist communitarianism
The Establishment of the MoHME Act	Article 1; Article 3	Objective utilitarianism, Egalitarian liberalism; Relativist communitarianism
The Organizations and Duties of the MoHME Act	Article 2; Article 6; Article 7	Egalitarian liberalism; Objective utilitarianism, Egalitarian liberalism; Egalitarian liberalism
The First Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (the chapter related to health)	Section 1 - Part B – 6	Egalitarian liberalism
The Second Five- Year Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (the chapter related to health)	Single Article - Note 94; Section 2 - Article 1	Egalitarian liberalism
PHIA	Articles 4, 5, 9, 11, 12, 14	Egalitarian liberalism
The Third Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (the chapter related to health)	Chapter 5 - Article 36; Chapter 25 – Article 192	Egalitarian liberalism; Objective utilitarianism, Egalitarian liberalism
Strategic Policies of the MoHME in the Third Development Plan	Article 4	Egalitarian liberalism
Organizing Health-Care Services Based on Articles 3, 29, and 43 of the CIRI Act	Single Article	Egalitarian liberalism, Objective utilitarianism
20-YVDIRI	Vision Paragraph; Social, political, defense and security affairs Paragraph – Article 12	Egalitarian liberalism, Libertarianism, Relativist communitarianism
FESCDPIRI	Section 3 - Article 89; Article 90; Article 91	Egalitarian liberalism, Objective utilitarianism
The National Document for the Development of the Health Sector, the FESCDPIRI	Prevention and reduction of poverty and deprivation Paragraph; Promoting health and improving the quality of life and preserving the environment toward sustainable development Paragraph	Egalitarian liberalism
LSCSWSS	Article 1; Chapter 2 - Article 6	Egalitarian liberalism
The Fifth Economic, Social and Cultural Development Plan of the Islamic Republic of Iran Act (2011 - 2015) (the chapter related to health)	Health - Article 32; Health - Article 34; Health Insurance - Article 38	Egalitarian liberalism, Objective utilitarianism; Egalitarian liberalism; Egalitarian liberalism, Objective utilitarianism
CSHM	Important messages and value principles Paragraph; Health system performance index Paragraph	Egalitarian liberalism, Relativist communitarianism; Egalitarian liberalism
HSTMBIIPM	Values Paragraph; Justice Paragraph	Egalitarian liberalism, Objective utilitarianism, Relativist communitarianism
MPH	Article 7; Article 8; Article 9; Article 10	Objective utilitarianism; Objective utilitarianism; Egalitarian liberalism, Subjective utilitarianism, Objective utilitarianism; Egalitarian liberalism, Objective utilitarianism
HSTPD	Directive for the program to reduce the out of pocket payment of patients admitted to MoHME-affiliated hospitals - Article 2; Article 3; Article 4; Article 5; Directive for the program to support the physicians’ retention in the underserved areas - Article 2; Article 3; Directive for the program of residence of the attending specialists in MoHME-affiliated hospitals - Article 2; Article 3; Article 4; Directive for improving the quality of patients' visit services in MoHME- affiliated hospitals - Article 2; Article 3; Directive for the program of hoteling quality improvement in MoHME- affiliated hospitals - Article 2; Article 3; Directive for the program of financial protection of patients with incurable or special diseases, and needy patients – Article 2; Article 3; Article 5; Directive for the program of natural childbirth promotion - Article 2; Article 3; Article 4	Egalitarian liberalism; Egalitarian liberalism; Egalitarian liberalism; Egalitarian liberalism; Egalitarian liberalism, Objective utilitarianism; Egalitarian liberalism, Objective utilitarianism; Egalitarian liberalism; Egalitarian liberalism; Egalitarian liberalism, Objective utilitarianism; Objective utilitarianism; Objective utilitarianism; Objective utilitarianism; Objective utilitarianism; Egalitarian liberalism; Egalitarian liberalism; Egalitarian liberalism; Objective utilitarianism; Egalitarian liberalism; Egalitarian liberalism, Objective utilitarianism
FPRIPD	Introduction; Article 1; Article 45; Article 46; Article 61	Egalitarian liberalism, Objective utilitarianism; Egalitarian liberalism, Objective utilitarianism; Egalitarian liberalism; Egalitarian liberalism; Egalitarian liberalism, Objective utilitarianism
SESCDPIRI	Section 14 - Article 70; Section 14 – Article 72; Section 14 - Article 74; Section 4 - Article 25	Objective utilitarianism; Objective utilitarianism; Egalitarian liberalism, Objective utilitarianism; Objective utilitarianism
Obligations of the Health Insurance Organization of Iran to provide and cover insurance services	Article 1	Egalitarian liberalism

Table 5

Analysis of the strategic health policy documents and laws: a selection

Title	Section/Article /Paragraph/Note	Ethical Theories/Justice Schools
CIRI	Chapter 3 - Nation’s Rights, Article 29 - To enjoy social security and benefits for retirement, unemployment, old age, workers’ compensation, lack of guardianship, destitution, accidents, emergencies, and health and medical treatments through insurance, etc. is a universal right. In accordance with the law, the government is obligated to use the proceeds from the national income and public contributions to provide the abovementioned services and financial support for each and every one of the citizens.	Fundamental welfare benefits/entitlements
The Organizations and Duties of the MOHME Act	6 - Planning for the equitable distribution of manpower and other facilities (medical education and health facilities) throughout the country with emphasis on fulfilling the priorities of health programs and meeting the needs of underserved areas.	The planning and decision-making initiatives by health authorities; Fundamental welfare benefits/entitlements
20-YVDIRI	Social, political, defense and security affairs: 12 - Efforts should be made to achieve social justice, provide equal opportunities, and promote indices such as education, health, food supply, increased per capita income, and fight against corruption.	Fundamental welfare benefits/entitlements; Fundamental freedoms; Community values
MPH	9 - Quantitative and qualitative development of health insurances aiming at: 9-1- providing universal basic health insurance. 9-2- Covering all basic treatment needs for all members of the community and reducing out-of-pocket payments so that patients will have no concern other than the suffering due to their disease. 9-3- Provision of services beyond basic insurance by supplementary insurance companies within the framework of transparent legal instructions to always maintain a desirable quality of basic medical services. 9-4- Determining a package of comprehensive health services covered by both the basic and supplementary insurances under the Ministry of Health and Medical Education, overseeing the purchase of these packages by the insurance system, and supervising the correct distribution of the packages by eliminating unnecessary measures and costs in the process of testing, diagnosis and treatment. 9-5- Strengthening the competitive market for health insurance services. 9-6- Developing evidence-based and value-added tariffs for healthcare services with the same real technical right for governmental and non-governmental sectors.	Fundamental welfare benefits/entitlements; The planning and decision-making initiatives by health authorities; Personal choice

The data presented in chart 1 indicates that the most dominant theories in policies of the Iranian health system over the past 50 years were egalitarian liberalism and then objective utilitarianism and relativist communitarianism. Among the reviewed documents, the “Health System Transformation Plan Directive” referred to egalitarian liberalism and objective utilitarianism 14 and nine times, respectively. In the next position was the “Mega Policies for Health” document, which mentioned objective utilitarianism, egalitarian liberalism, and subjective utilitarianism four, two, and one times, respectively. Lastly, the CIRI, PHIA, the 20-YVDIRI, and the Fourth, Fifth, and Sixth Economic, Social and Cultural Development Plans referred to these concepts more than the other reviewed documents. PHIA referred to concepts of egalitarian liberalism six times, the CIRI and the 20-YVDIRI referred to concepts of egalitarian liberalism three times, relativist communitarianism two times, and libertarianism one and two times, respectively. The development plans of the Islamic Republic of Iran also discussed concepts related to egalitarian liberalism and objective utilitarianism.

Chart 1

Frequency distribution and percentage of justice schools/ethical theories mentioned in the reviewed documents and laws

Discussion

This study aimed to explore the ethical undertones of the Iranian health system governance over the past 50 years and test the hypothesis that egalitarian liberalism has been the dominant undertone. Although there have been previous attempts at characterizing the inclination of a health system’s justice schools, there has been neither a prior attempt at developing a robust measurement instrument for such characterization (as presented in tables 1 and 2 above), nor a comprehensive and systematic assessment of the main health policy documents. Also, most similar studies have focused on social values and principles of medical ethics (7, 8, 10, 12, 16, 27).

Our findings confirmed that the most dominant justice school/ethical theory in policies of the Iranian health system over the past 50 years was indeed egalitarian liberalism, as 60% of the concepts mentioned in documents and laws were related to this justice school/ethical theory. Objective utilitarianism and relativist communitarianism ranked second and third by capturing 28% and 7% of the concepts. One study reviewed the document of “Mega Policies for Health” and identified egalitarianism as its dominant theory. They also stated that policy-making in the field of health and life sciences based on the Islamic culture necessitates the existence of social justice in the light of divine morality (16). Others also believe that the principles of the Iranian health system are influenced by religious values (11). Some experts emphasize the effects of political and cultural systems on health services, for instance, the profound impact of religion on reproductive and sexual health services in Islamic states (e.g., Iran, Afghanistan, Saudi Arabia, and Malaysia) (28). Our findings demonstrated that Islamic norms and values were also among the main concepts taken into account in the health legislation. By contrast, one study in Singapore reported that the philosophy behind healthcare services in that context was a combination of free-market principles and strict governmental control, that is to say, the government usually avoids a completely egalitarian welfare orientation in favor of the free market, but recognizes the failure of the health free market to intervene in the health system whenever necessary (29).

Among the reviewed documents, the “Health System Transformation Plan Directive” mentioned egalitarian liberalism and objective utilitarianism 14 and nine times, respectively. In the next rank was the “Mega Policies for Health” document, which referred to objective utilitarianism, egalitarian liberalism, and subjective utilitarianism more frequently than the other reviewed documents. Finally, the CIRI, PHIA, the 20-YVDIRI, and the fourth, fifth, and sixth economic, social and cultural development plan of the Islamic Republic of Iran (see Table 3) referred to these concepts more than the other documents and laws. It is noteworthy that PHIA solely referred to concepts of egalitarian liberalism. A similar study in Iran showed that policy documents emphasize or refer to some values either explicitly or implicitly. They found that “The Health System Transformation Map” was the most comprehensive document emphasizing the values, and “justice” was the most common term repeated in the reviewed documents (10). The study of the nature and quality of the ethical framework in 24 Canadian health strategy documents (from 1998 to 2005) reported that the ethical framework contained in the documents was generally restricted to a list of principles and values that only differed in justification, coherence, content and form, and played a decorative rather than a fundamental and developmental role (27). The study of Schroder-Back et al. also showed that the health strategy of the European Union is barely documented in scientific literature, and no specific attention has been given to its value base. They concluded that a theory of well-being is needed on a more general level for effective policy-making (30).

Although we based our assessment of the inclination of the health system governance in the last 50 years on the mainstream legal and policy developments in this latter period, the existing policy context should not be ignored. Laws such as “The Medical, Pharmaceuticals and Foodstuff Affairs Act (1955)” and “The Methods of Prevention of Contagious and Sexually Transmitted Diseases Act (1941)” would necessarily shift the national policies and programs of the latter 50-year period.

As mentioned earlier, this research proved that the ethical theory governing the Iranian health system over the past 50 years has been orientated towards egalitarian liberalism – as the perennial theme – mixed with objective utilitarianism and relative communitarianism – as the more recent trends. In spite of this very strong political consensus, there has been a big gap between ambition and real achievement in the past decades. Only recently has the coverage been nearly attained, thanks to the HSTP and “Iran Health Insurance Organization” (31, 32), but in terms of the out-of-pocket component of the UHC, we are dealing with a stubborner situation and have a long challenging way ahead (33 - 35). Finally, it is worth noting that health system reforms such as the family physician program and the health services referral system have been frequent themes in a number of strategic documents in the past three decades without real actualization.

The absence of specific laws and policy documents for some actual reforms and fundamental changes in the Iranian health system was a major issue. For example, the Iranian PHC initially rolled out in the 1980s, although its enormous implications about the populations’ healthcare lacked a formal legislative or cabinet regulation source in its inception. For that reason, despite its enormous relevance to this research, it does not appear as an entry in Table 3. Also, a number of strategic health policy documents including the “Social Security Act (1975)” – that now supports coverage of more than 44 million Iranians – and “The Health Network System” – that now covers all Iranians in some form or shape – constitute the most conspicuous forms and symbols of UHC in the Iranian health system. However, such weighting or grading has not been adopted in this research method.

Conclusion

The study results showed that the dominant ethical theory/justice school in the Iranian health system governance over the past 50 years has been egalitarian liberalism. However, the undertones of objective utilitarianism and relativist communitarianism have also been present. Data shows that despite the ambition, we are far from the realization of egalitarianism. Highlighting the strong inclination of the health system towards egalitarianism should have an enabling role in its political realization too. This may enhance a political push for a higher gross domestic product (GDP) share of healthcare, other attempts at a single-payer national insurance plan, special plans for the vulnerable populations, and similar devices