How the current Iranian primary health care performs in addressing the social determinants of child malnutrition
Themes emerged which contributed to the concept of comprehensiveness in the Iranian primary health care system as understood by the participants. Availability and affordability of primary health care and easy access to maternal and child health services were the central attributes of primary health care identified by almost all interviewees.
The most important thing that our health system has is its availability. Our people can access the health services for free. I do not imagine any place in the region or the world has such a well-structured system. [Person no. 3 = P3, Ministry of Health]
We always bring our child for growth monitoring. Supplements are always available... Behvarzes help us whenever we need them. They are always available, this is very good. [Mother/FG6/Province 2]
The second theme that emerged from the interviews and focus groups as a strength was the contribution of primary health care in improving public, and particularly women's nutritional knowledge. The inclusion of health and nutrition education programs was considered to be an example of a comprehensive primary health care approach which addresses mothers' education as one of the most important underlying determinants of child malnutrition. Ongoing health and nutrition education for mothers, taking the literacy level and practical aspects of the education into account, was an important issue that emerged from the majority of the interviews and focus groups.
In contrast to what is generally believed, I think our health system had less medical and selective approach from the first day of its design. We put education as one of the milestones in nutrition program... I think we were very successful in this area. Actually, we did social-based activities in our system. [P6/Province1]
Members of health provider and parent focus groups concurred with the national and provincial policy makers that nutrition education is one of the highlights of the Iranian health system:
We do have regular health care and nutrition education for mothers before, during and after delivery which increases mothers' knowledge regarding importance of food and nutrition. [Behvarz/FG2/province2]
Behvarz educates us about breastfeeding, and all sorts of foods our child should or shouldn't eat. They also talk about their development stages and growth trend. I learnt a lot from them. [Mother/FG9/province2]
How the current primary health care system in Iran can move towards a more comprehensive approach to address the social determinants of child malnutrition
The study then attempted to explore the perceptions of stakeholders towards the idea of how the Iranian primary health care is able to act more broadly. A wide range of attitudes were held by various participants. These attitudes varied across the spectrum, from a solely top-down approach, including governmental and political reform, to a more bottom-up approach supporting social mobilization and community participation.
Policy makers took mostly a top-down approach when recommending ways to overcome organizational barriers and to ensure sustainability. For example, establishing a proper health management system was recommended to overcome the managerial problems. Issues such as rapid staff turnover, political conflicts, the lack of staff motivation and position insecurity, misperception and ineffective leadership were pointed to as factors that limit the long-term inter-institutional relations that need to be addressed.
The role of managers is very important in national and provincial approaches within the primary health care system. Unfortunately, due to rapid changes in the managerial levels they just follow acute and flash jobs to be able to demonstrate an acceptable outcome at the end of their short management period. [P8/Province2]
If you review the history of the primary health care in Iran, you see that the health deputies have been changed approximately every six months.... A political approach is followed in the selection of managers and less attention is paid to their scientific capabilities and experiences. [P3/Ministry of Health]
Boosting intersectoral collaboration was the second most strongly articulated issues by the study respondents. From their points of view, only with effective collaboration with other sectors could the primary health care system act comprehensively. Health policy-makers mainly believed in a whole of the government reform in order to manage intra and intersectoral processes and stewardship challenges.
The vision and policies at the highest level of the government should change. In this way, each ministry takes a small part of the responsibility in terms of the nutritional status of people... If this happens, collaboration occurs not only at ministerial levels but also at the most peripheral areas. [P2/Ministry of Health]
Turning to the health providers and community stakeholders, fundamental differences were highlighted in terms of the existing weak points and actions to overcome them. They mainly looked from a more bottom-up window to address the social determinants of child malnutrition. From their perspective, horizontal links between various sectors should not necessarily rely on the government reform. Providing a supportive environment for health providers to build collaborative actions was a point frequently articulated by the participants. From the health providers' perspective:
We are tired of telling our problems. There is nobody to hear our voice and no place to complain. High workload, low wage, pile of forms to be completed, low support and encouragement system for behvarz, and no promotion are all our problems that nobody cares. We are not involved in program planning. Having all these problems, make us feel tired. Nevertheless, we work just for our people's sake. [Behvarz/FG 1/province 1]
Self-reliance and local innovations were emphasised at the community level by strengthening the self-help capabilities of the rural disadvantaged. Mothers believed community development initiatives to be more feasible actions to advocate families in need.
We know everybody in the village... The representatives of the other organisations are present in rural health councils, so with minimum advocacy we are able to work with them and introduce needy women and families to them, because nobody knows families better than we do. [Behvarz/FG2/Province 2]
Community self-helping is a big source of support for families in need. Health house and Behvarz can be more involved in this area because they know everybody, and everybody trusts them. In this way, the help can be organised and spent in the best way to meet people's needs. [Mother/FG8/Province2]
The above quotes demonstrate that local actions are mostly commented on by the community members.