Background
Indicator | 1980 | 2020 |
---|---|---|
Life expectancy at birth (year) | 54 | 77 |
Maternal mortality ratio (per 100,000 live births) | 16b | |
Neonatal mortality rate (per 1,000 live births) | 40 | 8 |
Infant mortality rate (per 1,000 live births) | 85 | 11 |
Under-five mortality rate (per 1,000 live births) | 108 | 13 |
Immunization, measles (% of children ages 12–23 months) | 39 | 99 |
Immunization, DTP (% of children ages 12–23 months) | 32 | 99 |
Current health expenditure (% of GDP) | 6.7a | |
Out-of-pocket expenditure (% of current health expenditure) | 40a | |
Hospital bed density (per 1,000 people) | 1.5 | 1.6b |
Physician density (per 1,000 people) | 0.3 | 1.6c |
Nurses and midwives (per 1,000 people) | 2.1c |
Methods
Stage one
Stage two
Stage three
Results
Stage one
The targeted function of the health system | Mitigating measures | Source | Type of measure |
---|---|---|---|
Financing arrangement | 1. Mobilizing latent resources in education and health | [21] | Implemented |
2. Providing additional clarification that Iranian oil revenues can be freely used for medicines procurement without reservations | [9] | Proposed | |
3. Supporting local production | Implemented | ||
4. Price reduction of imported medicines | [22] | Implemented | |
5. Optimizing the domestic market | [15] | Proposed | |
6. Centralized and strategic purchasing | [23] | Proposed | |
7. Rationalization of the prices of medicines | [23] | Proposed | |
8. Strengthening the insurance system | [23] | Proposed | |
Governance arrangement | 9. Establishing uniform criteria and definitions for exemptions as well as operational criteria for sanctions committees to facilitate improved effectiveness of exemptions | [24] | Proposed |
10. Developing dual policies of equity and priority for vulnerable groups | [25] | Implemented | |
11. Mobilizing public participation to compensate for reduced access to capital goods | [21] | Implemented | |
12. The use of public systems to motivate behavioral change, with a focus on the needs of women and children | [21] | Implemented | |
13. Refocusing health policy toward maximizing scarce resources | [21] | Implemented | |
14. Professional organizations, especially those concerned with children's health, must advocate for children in countries experiencing economic sanctions | [26] | Proposed | |
15. Advocating for global health diplomacy to ensure that ongoing multilateral negotiations do not neglect public health and humanitarian need | Proposed | ||
16. Establishing regulatory export harmonization | [9] | Proposed | |
17. Amending the OFAC EAR99 classification system to make it easier for US companies to export medicines | [9] | Proposed | |
18. Exempting vaccine products from stringent export controls | [9] | Proposed | |
19. Allocating a protected SWIFT line specifically for humanitarian medicines trade | [9] | Proposed | |
20. Exempting medicine and medical commodities from “snap back” provisions; | [9] | Proposed | |
21. Providing a national policy with measures to prevent the suffering of people from the adverse effects of sanctions | [12] | Proposed | |
22. Preventing third parties; black market dealers, pharmacies, and health facilities that provided unsafe medicines, as well as smugglers who sent scarce medicine to neighbouring countries | Proposed | ||
23. Refraining from imposing embargos and other measures that restrict the supply of medicine and medical equipment | [12] | Proposed | |
24. Developing policies and laws to alleviate the negative impacts of their agreements on the human rights of the population in the target country | [12] | Proposed | |
25. Designing some international intermediate organizations and certain companies and financial institutions to facilitate the implementation of exemptions | [12] | Proposed | |
26. Permitting immediate release of medicines from customs by minimum financial documents | [22] | Implemented | |
27. Determining a memorandum of understanding (MOU) between the IFDA Iran’s Food and Drug Administration) and the Central Bank | [22] | Implemented | |
28. Determining a memorandum of understanding (MOU) between the IFDA and health insurance organizations for the extra financial protection of special, incurable, and chronic patients with high pharmaceutical expenditures and for allocating the additional budget to over-compensate unaffordable pharmaceutical products based on the equity-based criteria | [22] | Implemented | |
29. Developing the national essential medicines list | [22] | Proposed | |
30. Using use all available political and legal means, such as health diplomacy, to establish humanitarian channels to enhance global convention and remove possible barriers as the sanctions and reduce their adverse consequences for antimicrobial resistance control | [28] | Proposed | |
31. Creating efficient food assistance programs by the government and the international community, funding food banks with the assistance of charities and non-governmental organizations, and participating individuals in nutritional education programs and learning how to plan a cheap and balanced diet | [29] | Proposed | |
32. Boosting the morale, knowledge, skills, and innovation of managers can potentially increase resilience | [15] | Proposed | |
33. Creating mutual trust among different organizations | [15] | Proposed | |
34. Revisions in Iran’s health management | [23] | Proposed | |
35. Delegation and privatization | [23] | Proposed | |
36. Strengthening of inter-sectoral cooperation | [23] | Proposed | |
37. More attention to mass media | [23] | Proposed | |
38. Interactions with neighbouring countries | [23] | Proposed | |
39. Management and development of health tourism | [23] | Proposed | |
Information and evidence | 40. Improving means of monitoring the impact of sanctions on civilian populations in targeted countries, particularly concerning water purity, food availability, and infectious disease control | [24] | Proposed |
41. Advocating prospective studies to generate the data needed to provide better information and monitoring capacity than presently exists | [24] | Proposed | |
42. Strengthening health monitoring systems | Implemented | ||
43. Advocating for the integration of Health Impact Assessments (HIAs) that identify the health consequences of sanctions | [9] | Proposed | |
44. Monitoring human rights situations and utilizing the maximum resources available to eliminate suffering with low-cost programs, international assistance, and cooperation | [12] | Proposed | |
45. Assess the effects of the policies and international agreements on the health of people in the target country | [12] | Proposed | |
46. Observing the situation of human rights and implementing humanitarian and human rights laws | [12] | Proposed | |
47. Employing cost-effectiveness evidence for pricing and reimbursement | [22] | Proposed | |
48. Developing an integrated information system for monitoring the market | [22] | Proposed | |
49. Determining the exact magnitude of the impact | [30] | Proposed | |
50. Electronic health record | [23] | Proposed | |
51. Electronic prescription | [23] | Proposed | |
Service delivery arrangement | 52. Rationing, universal access to primary health care, a highly educated population, and preferential access to scarce goods for women and children | [25] | Implemented |
53. Emphasizing preventative over curative medicine | [21] | Implemented | |
54. Protecting vulnerable groups of the population, such as children and the poor | [12] | Proposed | |
55. Facilitating the delivery of necessary items for life and health, such as medicine, food, and medical equipment | [12] | Proposed | |
56. Proactive inventory control | [22] | Implemented | |
57. Providing clinical guidelines for rational prescribing | Proposed | ||
58. Proper implementation of the referral system | [23] | Proposed | |
59. Medication tracking | [23] | Proposed | |
60. Informing the medical community | [23] | Proposed | |
61. Use of alternative medicines and methods | [23] | Proposed | |
62. Consumer–patient collaboration | [23] | Proposed |
Stage two
“Iran is a country that is actually under sanctions, and many of these sanctions are related to the foreign policy, and the first place that is affected by the sanctions is usually the health sector, and the first place that benefits from the lifting of the sanctions is the health sector, too.” P1.Although efforts to delegitimize sanctions should not be overlooked, the health system must prepare for sanctions to operate better and minimize the damage caused by sanctions.
“At least a series of measures should be taken to delegitimize the system of sanctions in the health sector and show the effects of sanctions on the health sector as well as the violation of human rights and basic rights of Iranian citizens.” P1.
Category (targeted function of the health system) | Subcategory (mitigating measures) |
---|---|
Sustained financing | 1. Using sustained health financial resources 2. Fair and effective resource allocations 3. Systematic costing of medicines and medical devices |
Good governance | 4. Preparedness and planning for sanction 5. Collateral collaborations for procurement of goods 6. Optimizing/shrinking organizational structure 7. Investing in domestic production 8 Strong leadership and management 9. Having constant collaboration and active social networks 10. Empowering the community and increasing their participation 11. Strengthening the health diplomacy |
Integrated and updated health information system | 12. Constant monitoring and evaluation 13. Enhancing surveillance system 14. Strengthening evidence-informed policymaking |
Qualified workforce | 15. Provision of adequate skilled health workforce 16. Motivating health workforce |
Efficient and equitable service delivery | 17. Giving priority to public health intervention 18. Defining tailored health service packages for vulnerable populations |
Sustained financing
Using sustained health financial resources
“You know that national income depends on the sales of oil in Iran. Whenever there is a disturbance in the sales of oil, almost all sectors suffer. The health sector is no exception. We know this, and its effects are also obvious. Now we have to ensure that, as far as possible, the financial resources of the health sector have minimal dependence on oil revenues. We should think about finding more sustainable resources for the health system.” P2.“Our health system should be able to withstand sanctions and make some changes to be less vulnerable during sanctions. For example, do you remember that after the JCPOA, Iran’s income improved a bit, and as a result, the financial resources of the health sector increased? The same health transformation plan was implemented at the same time. It would be better if the health system tried to use these funds to become efficient so that it would not be under pressure if the embargo happened again. For instance, more should be invested in the primary health than hospitals.” P7.
Institutionalizing fair and effective resource allocations
“The embargo there has led to a decrease in our incomes, and economic austerity has been formed after that. These austerity attempts will affect the allocation of resources to our government departments. When the allocation of resources declines, the policies of the Ministry of Health will be revised. How? This revision should be based on the principles of prioritization. Still, because there is no systematic prioritization, priorities are formed based on preferences, which often causes a waste of resources. We need a system that determines how to spend this little money more effectively and efficiently.” P10.
Systematic costing of medicines and medical devices
“We now know the pricing of some medicines, which means it is clear how much this medicine should cost. The same is true for some medical equipment and devices, but this price list is not for all items and is sometimes not updated. If we could have an updated list of prices for drugs and medical equipment available to all Iranian people, in times of crisis like this embargo, traders could not sell drugs to people at any price.” P5.
Good Governance
Preparedness and planning for sanction
“Sanctions will happen now, this round, or the next round. You must have a plan to confront sanctions, and until then, there will never be any discussions of sanctions. We did not look at any outlooks that sanctions might happen while we are forecasting. We did, but we did not consider the embargo. First, we did not look at it from this point of view. We never included these facts related to the embargo in our work, and this is a big problem that the country has.” P7.
Collateral collaborations for procurement of goods
“There is a special bandage that the … company produces only in …, and they no longer sell these to Iran due to sanctions, and we saw what we did and the follow-up we did. We pressured the … ambassador, that is, the … government through … lawyers and in a way forced the … factory to sell, it was not their way, then they said we would not sell to the Ministry of Health, then we said there was no problem, sell it to … Iran, we will give it to the Ministry of Health. Then, because these issues of financial transfer and other things were difficult to solve, … made a donation and got a budget, and with the help of the ... government and the first party, we bought the first party.” P4.
Optimizing/shrinking organizational structure
“After all, one of the emerging issues is the structure. Do the structures change because of this? Some things happened. For example, a deputy was removed. … Or, for example, assume that the Food and Drug Administration changed its organizational arrangement, and the issue of combating pharmaceutical problems and managing corruption was somehow brought up in the Ministry of Health.” P10.
Investing in domestic production
“It can be said that one of the advantages of the embargo is that domestic production has been revived. We produce a lot of vaccines and medicines inside Iran. The more we can strengthen our internal capacities and potential to be producers, the less we will lose during sanctions. Of course, domestic production must be of high quality.” P2.
Strong leadership and management
“We have a lot of experience with this. For example, some ministers and deputies turned their words into actions during the war. Regarding sanctions, it is not possible for the minister not to speak or not to be heard. Look at the COVID-19 pandemic. Whenever they made a decision, they asked the Minister of Health because health is important. Even for sanctions, the words of those who know the bad outcomes for people's health cannot be heard. Health managers need to be charismatic and decisive.” P2.
Having constant collaboration and active social networks
“If you remember the war, these jihadi groups and popular networks played an important role in helping soldiers and supporting the country in many places. Since they had a social base, they could coordinate resources well. The health system should also consider how it can create and improve these networks and communities in the community groups. It is a kind of social capital that can give morale in difficult situations and can do many things instead of the government.” P6.
Empowering the community and increasing their participation
“Undoubtedly, if the society is empowered, the health system can work more effectively, especially in crises. Do you know how much nongovernmental organizations can improve our drug shortages? The truth is that I think if we can work on this community participation, we can get through crises like embargo much better.” P10.
Strengthening health diplomacy
“This all goes back to the field of diplomacy and health diplomacy or the same thing you are doing now. How do you challenge sanctions? This goes back to health diplomacy because the health field is an area that can easily interact. It means that even in the most difficult situations when countries are at war, it is easier to enter from the health sector, interact, and enter into the cooperation process. This field is the field of diplomacy and health.” P1.
Integrated and updated health information system
Constant monitoring and evaluation
“The point was that we never came to see these indicators, how our access is to medicine, equipment, and procedures during the embargo, and the effect of the embargo on the public health was not there to see what their conditions would be. This makes us not have a complete judgment on this whole issue.” P7.“Indicators of malnutrition in children, thinness, short stature, and even overweightness and obesity in children and adults were among of the important indicators that could be affected by sanctions. I did not see very documented statistics. One of the claims made by the Ministry of Health was that we kept it constant, and these indicators had not changed.” P8.
Enhancing surveillance system
“When they create a surveillance system and want to control an epidemic, first of all, you have to see if the prevalence is high or if the economic burden is high, that is. I mean we have criteria for saying which should be the surveillance system. Now in Iran, many information systems are excessive. To be more resilient, we need a surveillance system as needed. For the same women's urine, it is possible to study whether this has changed during the embargo or their treatment and access to treatment have changed.” P7.
Strengthening evidence-informed policymaking
“This is an area that I think you should document in this case, especially in international authorities, to put pressure on this, on this field, and in fact, the argument regarding the international legitimacy of the US sanctions system as a whole. A distinction was made between banking sanctions and sanctions in the health sector.” P1.
Qualified Health Workforce
Provision of adequate skilled health workforce
“It can be good. Sanctions affect the dollar exchange rate, which will harm the outflow of human resources, which means that they are more in demand. See, if we are looking to strengthen the health system, especially we, who are always at risk of sanctions, human resource policies should be changed a bit. We should learn what other societies are doing.” P9.
Motivating health workforce
“There are some factors that are more fundamental and not easily seen, attention to the incentive system, attention to the payment system, attention to the various human resource systems in the health system. These important issues are practically neglected. if they can be used for a strong health system, they can also create motivation, that which we feel in your presence, belonging to patriotism.” P9.
Efficient and equitable service delivery
Giving priority to public health intervention
“The most serious damage caused by sanctions is for drugs and medical supplies mainly used for treatment. The conditions of the patients have worsened with every sanction. It is very simple, for the health system not to be harmed by this issue, for it should focus on prevention. As you said, prevention had priority over treatment at the beginning of the revolution.” P6.
Defining tailored health services package for vulnerable populations
“Experience has always shown that those with incurable diseases and those whose voices are less heard are more harmed during crises. For instance, if patients know some people in high places, their voices will be heard; otherwise, nobody listens to them. Now, suppose the Ministry of Health has the claim of trying to achieve equity in health. In that case, it should sit down and see where the vulnerable groups are in terms of health in society and what minimum services should be provided for them in crises to monitor them regularly.” P7.
Stage three
Code | Mitigating measures | Health System Function towards resilience | Source of data | Delphi |
---|---|---|---|---|
1 | Proactive inventory control | Efficient and equitable service delivery | Review | Accepted |
2 | Developing the list of nationally essential medicines | Efficient and equitable service delivery | Review | Accepted |
3 | Providing additional clarification that Iranian oil revenues can be freely used for medicine procurement without reservations | Sustained financing | Review | Accepted |
4 | Using the capacity of some international intermediate organizations and certain companies and financial institutions to facilitate purchasing medical items | Good governance | Review | Accepted |
5 | Defining tailored health service packages for vulnerable populations | Efficient and equitable service delivery | Interview and gray literature | Accepted |
6 | Establishing and improving a strong surveillance system | Integrated and updated health information system | Review & Interview and gray literature | Accepted |
7 | Price reduction of imported medicines through public resources | Sustained financing | Review | Accepted |
8 | Developing dual policies of equity and priority for vulnerable groups | Good governance | Review | Accepted |
9 | Institutionalizing fair and effective resource allocations | Sustained financing | Interview and gray literature | Accepted |
10 | Considering collateral pathways for procurement of required medical items | Good governance | Review & Interview and gray literature | Accepted |
11 | Extra financial protection for special, incurable, and chronic patients and for allocation of the additional budget to over-compensate unaffordable pharmaceutical products | Sustained financing | Review | Accepted |
12 | Providing clinical guidelines for rational prescribing | Efficient and equitable service delivery | Review | Accepted |
13 | Establishing an appropriate organizational structure to deal with the sanction | Good governance | Review & Interview and gray literature | Accepted |
14 | Having constant collaboration and active social networks at both national and global levels | Good governance | Review & Interview and gray literature | Accepted |
15 | Prioritizing health among public policies | Sustained financing | Review | Accepted |
16 | Strengthening evidence-informed policymaking | Good governance | Review & Interview and gray literature | Accepted |
17 | Preventing third parties, black market dealers, pharmacies, and health facilities that provide unsafe medicines as well as smugglers | Good governance | Accepted | |
18 | Facilitating immediate release of medicines from the customs with minimum financial documents | Service delivery | Review | Accepted |
19 | Adapting exportation laws based on domestic needs | Good governance | Review | Accepted |
20 | Conducting Health Impact Assessments (HIAs) that identify the effects of sanctions on healthcare | Good governance | Review | Accepted |
21 | Founding for health via sustained sources | Sustained financing | Interview and gray literature | Accepted |
22 | Investing in domestic production | Sustained financing | Review & Interview and gray literature | Accepted |
23 | Empowering the community and increasing their participation | Good governance | Review & Interview and gray literature | Accepted |
24 | Strengthening the global health diplomacy | Good governance | Review & Interview and gray literature | Accepted |
25 | Establishing support mechanisms to prevent and control the social harms of the economic outcomes of sanctions (e.g., the protection of working children) | Efficient and equitable service delivery | Review | Accepted |
26 | Improving the system for fair and effective allocation of resources between health plans and relevant executive bodies in health | Sustained financing | Review & Interview and gray literature | Accepted |
27 | Institutionalizing economic evaluation of medicines, medical devices and equipment, and health services | Sustained financing | Review & Interview and gray literature | Accepted |
28 | Optimizing the use of human resources (by improving competencies and making appropriate use of job descriptions, e.g., avoiding specialization in basic services) | Qualified workforces | Interview and gray literature | Accepted |
29 | Preparedness and planning for sanction | Good governance | Interview and gray literature | Rejected |
30 | Strong leadership and management | Good governance | Review & Interview and gray literature | Rejected |
31 | Optimizing the domestic market | Sustained financing | Review | Rejected |
32 | Strengthening the insurance system | Sustained financing | Review | Rejected |
33 | Strengthening of inter-sectoral cooperation | Good governance | Review | Rejected |
34 | Paying more attention to mass media | Good governance | Review | Rejected |
35 | Management and development of health tourism | Good governance | Review | Rejected |
36 | Electronic health record | Integrated and updated health information system | Review | Rejected |
37 | Electronic prescription | Integrated and updated health information system | Review | Rejected |
38 | Proper implementation of the referral system | Efficient and equitable service delivery | Review | Rejected |
39 | Medication tracking | Efficient and equitable service delivery | Review | Rejected |
40 | Consumer–patient collaboration | Efficient and equitable service delivery | Review | Rejected |
Category | Mitigating measures | |
---|---|---|
Short term | Long term | |
I: Effective and feasible | 12 | 11 |
II: Effective but not feasible | 4 | 3 |
III: Feasible but not effective | 4 | 5 |
IV: Neither effective nor feasible | 8 | 9 |
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Group 1: Effective and feasible measures in both short-term and long-term periods. Most of these measures focus on good governance and strengthening and improving supervision.
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Group 2: Measures that are more effective in the short run than the long run.
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Group 3: Measures that are more effective and feasible in the long run than the short run (e.g., funding for health through sustained sources, investing in domestic production, and strengthening global health diplomacy).