Editorial Board:
Editor:
George H. Conklin,
 North Carolina
 Central University

Robert Wortham,
 Associate Editor,
 North Carolina
 Central University

Board:
Rebecca Adams,
 UNC-Greensboro

Bob Davis,
 North Carolina
 Agricultural and
 Technical State
 University

Catherine Harris,
 Wake Forest
 University

Ella Keller,
 Fayetteville
 State University

Ken Land,
 Duke University

Miles Simpson,
 North Carolina
 Central University

William Smith,
 N.C. State University

Editorial Assistants

John W.M. Russell,
 Technical
 Consultant

® 

Volume 9, Number 2

Fall/Winter 2011
 
 

The Transition of Health Care in Rural Iran

by
 

Sara Aghajanian
University of Michigan

and

Shila Hajjehforoosh 
Najafabad Azad University

Background

    Iran, officially known as the Islamic Republic of Iran, is a country in Western-Asia. In the geo-political division of the world, Iran is considered one of the Middle East countries neighboring Turkey and Iraq on the west. Slightly over 99.5 percent of the Iranian population adheres to the different sects of Islam. But Iran's language and culture goes back to Perse, a non-Arab tradition. The official language is Persian (Farsi) but other languages such as Kurdish and Azari are spoken regionally by different ethnic groups.  Historically, Iran developed as a strong and rich civilization with a self-sufficient agricultural economy and cities with administrative and commercial functions. Today the economy is dominated by the export of oil with the majority of employment in the service sector and retail industry.

    According to the 2006 census, the Iranian population was counted at 70,472,846 with 32 percent of the population living in rural areas. A large number of the so-called urban population lives in small towns which have shared the same barriers toward access to health care as small scattered villages. Traditionally, the major barriers toward access to healthcare for the rural population and those living in small towns have been population dispersion, distance from major cities, road limitations, and location in mountainous areas.  In fact, these are some of the major physical factors which are barriers toward providing health care for rural population in many countries of this region. Despite these barriers, access to health care for the rural population in Iran has increased significantly through innovative policies implemented since 1980s. This paper aims to describe these policies and their practical application.

    According to the latest data (Population Reference Bureau, 2010) the major health indicators for Iran are at higher level when compared to the world and the continent of Asia. For example, infant mortality is below 30 per 1000 live births as compared to the 46 and 41 for the World and Asia respectively (Table 1). Only four percent of the population is classified as undernourished compared to 14 and 15 percent for the world and Asia. In terms of life-expectancy, particularly for women, Iran stands above Asia and the world. 

    Based on the data from a large Demographic and Health Interview Survey [1], it is clear that rural urban health indicators in Iran were very minimal at the turn of the 20 century. In many cases there is in fact, no difference between rural and urban areas especially when it comes to infants and women. The lack of these differences is due to significant improvements in access to health care in rural villages and small towns. 

    Traditionally preventive health has been encouraged through proverbs, wise men's statements, religious statements and through statements emphasized by literature, culture and folklore. For example, washing hands before eating is highly emphasized by religion and culture in Iran. Treatment and curative medicine was limited to traditionally trained medicine persons or "Hakims," who depended on herbal material for the majority of diseases. Each local community had a few herbal shops which sold herbal medicine. The herbal treatment choices were either prescribed by a "Hakim" or recommended by the herbal medicine man in the shop. 

    The first exposure of the Iranians to modern medicine was in late nineteenth century when a number of students were sent to Europe to study medicine [2]. They were the first to bring the modern medicine and medications from Europe to Iran. The fist medical school was established in Iran in 1922. The total number of medical schools increased to about 11 in 1970s. These schools were located in the provincial capitals. Three of these medical schools were located in the capital city of Tehran by late 1970s.

    Entrance to the medical schools was very competitive and with a growing population, only less than 5 percent of the participants in the entrance examination were able to attend these schools. These successful candidates were usually from highly prestigious private high schools in Tehran and to a lesser degree from selective high schools in a few large provincial capitals. Applicants from small cities were rarely successful in becoming accepted into medical school. Furthermore, with very limited educational resources in the rural areas, few applicants who had been fortunate to finish high school were able to compete with highly prepared applicants from large cities. Hence the products of medical schools were from the few larger cities and from the upper classes. After the completion of their training, these doctors, either stayed in the large cities or moved to Europe or United States.

    In the first part of the 1980s, the Iranian government introduced policies that changed the situation of access to higher education in general and specifically the training of medical doctors. First and for most, a policy of affirmative action was implemented for enrollment in universities. Given the fact that for many decades the share of the population from rural areas and small towns was very minimal in the total university enrollment, a geographic factor was introduced in the formula for admission to universities and medical colleges. At least 50 percent of the positions were filled by qualified applicants from remote and small towns. These affirmative action candidates were not as prepared as their highly equipped counterparts from large urban areas. Thus, the universities made the commitment to prepare these individuals. Through this policy many of the small towns and rural areas who never had a chance to send their children to medical schools, were given access to medical school training. In addition, the government made sure that the addition to medical schools happened only in the disadvantaged remote provinces. A combination of these factors resulted in an increase in the number of medical doctors who were from remote areas, small towns and villages.

    Another important policy that contributed to the increase of the medical doctors from small towns and rural areas was the allocation of 50 percent of the medical training positions to women. Women were strongly encouraged to apply to medical school. Selection of the candidates for the positions was now based on competition within two groups of applicants: men and women. In most cases despite the fact that women did slightly lower in the entrance examination; women were very successful in completion of their degree and even surpassed men in retention and successful graduation. Today, women have become very competitive candidates to medical schools and form 60 percent of the medical school enrollment every year. This increase has been essential for women's access to health care particularly in regions of Iran where tradition may still prevent women from seeing a male provider. This factor is especially important with respect to reproductive health issues.

    In 1985, the government received support from the Assembly of Representatives, to separate the schools of medicine from the universities which were under the management of the Ministry of Culture and Higher Education. A new university system of medical education was created under the management of the Ministry of Health. The Ministry of Health was later renamed the Ministry of Health and Medical Education [3]. This change had two major impacts on training of medical personnel in Iran that increased the availability of medical doctors in rural and remote areas of the country. One was that the Ministry of Health, the major user and employer of medical personnel, was able to have a direct influence on the curriculum of training and specialties. As a result more personnel and more medical resources were trained based on local and regional needs. Furthermore, this change gave strong power to provincial offices of the Ministry of Health and Medical Education to influence the quality and quantity of medical personnel trained for local communities, small areas and rural villages.

    The control of medical school training and curriculum by the Ministry of Health along with affirmative action based on locality and gender increased the access of rural areas to more training positions for medical personnel. The fact that many of these new trainees were trainees in the institutions in their own region reduced their tendencies to move to large cities in Iran or migrate to other countries. In addition, since the Ministry of Health and Medical Education was in charge of training and the curriculum, most of the trainees were trained in less sophisticated technology intensive medicine and were more focused on local health issues and particularly primary care. Training for these important areas needed fewer resources and more trainees were enrolled. 

    Another important policy which existed to some extent in the past but was strengthened in the 1990s was the government requirement that all the physicians complete a two year primary care practice in a designated rural area or disadvantaged area as a requirement for continuing to receive residency training. For male doctors this filled their required military service and was an additional incentive to receiving a decent salary and housing. The increases in the number of regionally trained medical doctors made it significantly easier to implement this policy. Many of the male medical doctors preferred spending two years practicing medicine in villages or small towns in their region, rather than completing required military service. 

    The opening of a private university system in Iran was another factor in increasing the access of medical personnel for rural areas. In 1982, for the first time the opening of privately funded universities in Iran was approved by the government. This investment can be considered as one of major social innovations in Iran by a group of investors who had the political power and the vision. Support from the government was very positive as the Iranian population was becoming younger and a larger proportion of youth wanted to attend college. 

    The new university system started under the name of Daneshagah Azad Islami, which can literally be translated as Islamic Open University. Despite resentfulness and resistance by the publicly supported universities, it did not take long before the Open University expanded from one campus in Tehran, to nearly hundreds of campuses in the provincial and small towns, where the rural population could easily access them. Higher education was highly demanded and the applicants were ready to pay tuition. Thus, these universities were able to hire faculty of public universities for extra teaching duty, while they started to gather their own faculty. The most important part of this new education enterprise was that the Open University expanded its operation to training medical doctors and established medical schools in small towns where the public universities have never stepped in. Through the opening of these new private medical schools which utilized the local hospitals, medical offices and medical resources for education and development, a large number of general medical doctors from local areas were trained and started to serve their regions and communities.

    Overall within a period of 10 years or less, with medical schools overseen by the Ministry of Health and Education, the opening of private sector medical schools, and the policy of selecting students based on gender and locality, the number of trained medical doctors and especially female medical doctors increased. This increase had significant spillover for access to medical doctors by the rural population of Iran. Table 3 illustrates this shift, based on the medical graduation data. In the academic year 1990-91, the total number of medical doctors (MDs) who graduated from Iranian medical schools was 344 and out this only 84 or 24 percent were women. Within 10 years the number of MDs graduating increased to slightly more than 22 times this number. But the most important part of this change was that 45 percent of these graduates were women. The number of female MDs increased over 40 times within a decade. It is obvious that this large population of MDs were no longer just from the national capital or provincial capitals. Rather many of them came from small towns in less advantaged rural provinces. 

    While the increase in the quantity of MDs trained is acknowledged, some faculty members from the traditional system have criticized the quality of the new MDs. This criticism maybe relevant and the new MDs, especially those graduating from more remote areas, may not be as sophisticated as the ones trained in 1970s. However, the new system has created a critical mass in training and producing MDs from disadvantaged regions, which has resulted in availability of a large number of relatively qualified MDs in these regions. 

    The increase of the medical doctors in small towns and in the large villages has been very important in improving the health care in rural Iran. But the most important innovation which was seriously pursued by the Ministry of Health and Medical education was a strong push to establish and vastly expand an inexpensive community-based primary health care (PHC) system. In this system, care starts with minimum care provided by a medically trained local villager and continues in hierarchy of referrals to MDs and specialists in the larger villages and in towns. A strong focus on primary care and prevention, rather than capital-intensive tertiary care made the rural health network expansion inexpensive. The main element of the program was establishing a strong network of rural health centers (RHC) and smaller units called "health houses" to deliver low-technology PHC through indigenous health care providers at the village level. Training and utilization of local community personnel was a key part of the system.

    Based on the results of a few small-scale experimental studies carried out in the 1970s, the Ministry of Health and Medical Education launched a large-scale PHC system with a focus on rural areas and small towns in the 1980s. The focal point of the activity for this network was the establishment of the health houses (khane behdasht). Each health house was designed to cover a target population of about 1500. Since most Iranian villages have fewer than 1500 residents, each health house also serves several "satellite" villages. Such villages are carefully grouped according to a realistic consideration of their cultural and social compatibility. The distance between the main and satellite villages is also pragmatically defined to be no more than 1-hour's walk manageable in one day. Each health house is staffed by a community health worker (behvarz). The behvarz comes from the same village where he/she is to be stationed in the future. Choosing behvarz from among the local population has been a key policy decision, closely observed throughout the expansion of the PHC network. As a result, the behvarz often knows every mother, child and family who seeks health care at the health house. Such a close relationship between the behvarz and his/her community facilitates the accurate collection of health information, among other things. According to the latest available statistics, there are 16, 340 rural health houses scattered among the 66,000 villages and settlements covering about 85% of the rural population. 

    The main function of a health house is to encourage community participation and offer PHC services to the community including public health education and promotion, provision of family health care, antenatal, prenatal and postnatal care, care of children under 5 years old, care of school-age children, immunizations, family planning services, and disease control services. Each health house is supported by a Rural Health Center (RHC), which is a village-based facility—usually located in a large village with better access to major roads. Each RHC covers about 7500 people on average. Apart from a physician, a RHC includes at least 1 of each of following staff: family health nurse, disease control agent, environmental health agent, oral health specialist, and laboratory technician, nurse-aid(s) and administrative staff. All staff members function under the doctor's leadership. The staffs usually have between a minimum of 6 to 24 months of training in their area. About 3000 RHCs support the network of rural health houses. The chief responsibilities of a RHC are to support health houses and supervise their activities; accept referred cases; and maintain proper contact with the higher levels of the health system. Other major functions include carrying out basic laboratory tests, participating in human resources training, taking samples of food products, monitoring environmental health in schools/workplaces, supporting the implementation of statistical studies and preparing reports. 

    While RHCs provide the infrastructure of support for providers, the soul of the rural health network has been its most outlying facility, the health house, which is run by the behvarz. There are now almost 26 000 of these male and female community health workers serving their residential villages and satellite villages. The female behvarz is generally responsible for the tasks that are performed within a health house. The male behvarz, on the other hand, is predominantly concerned with activities outside the health house (i.e. follow-up of cases with communicable disease, case-finding, immunization, environmental health activities and routine care in satellite villages). This partial division of duties does not mean that either behvarz cannot perform all the duties on his/her own if required. Behvarz have strong community ties with their villages. The behvarz are nearly always chosen from the main village where the health house will be stationed. However, if this is not feasible, a candidate is recruited from one of the satellite villages. The behvarz are selected from among 16- to 24-year-old female candidates, and 20- to 28-year-old males with direct participation from village authorities, such as the village council, local clergy and other influential figures of the community.

    The process of training the behvarz provides a good example of the consistency of the program with the local conditions and needs. Given the low rural literacy rate, candidates for the positions of behvarz are required to have 8 years of formal schooling (now frequently a high-school diploma). Candidates must successfully complete a written examination and interview before enrolment in the training course. Their studies, which span 2 years, are a contrast with traditional pedagogy. Memorization of large amounts of written material has been eliminated. Training is affected through group discussion, role-playing exercises and working at the health houses alongside a carefully selected qualified behvarz. Students receive free training and financial support throughout the 2-year period of the curriculum. In return, they are formally obliged to remain and serve at the village health house for a minimum of 4 years after completing their study. Each student’s progress is assessed by instructors at monthly intervals. Students who successfully complete all the courses, pass the examination at the end of each block, and pass the final examination, receive the “Certificate for Completion of Behvarz Training”. Then they are ready to start providing primary health care in a friendly environment for the population in their home villages and nearby villages, where they usually they have relatives and family acquaintances.

    The hierarchical primary care system starts with the visit to satellite villages and the provision of primary care to the population (see Figure 1). 

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When there is need for support from the Rural Health Center, either the patients will be taken to the RHC or the physician and other staff will visit the patient. The next level is the district level health center. Through this center, the patient will be sent to either specialty clinics for outpatient visit or if needed the patient will be hospitalized at the district level hospital managed by the district level health center. The next level of care in larger hospitals will be provided through the provincial Health Center which is part of the provincial unit of the Ministry of Medical Health and Medical Education in each province.

    Many counties in the developing world are faced with the serious problem of lack of access to health care for rural population. This lack of access is reflected in the extensive rural-urban health disparities where urbanites enjoy significantly higher life expectancy at birth and low infant mortality and high level of care for women and children. This problem exists not only in poor developing countries but some of rich-resource countries in west Asia. At the same time, the medical schools in the capital cities of these countries train highly sophisticated medical doctors well prepared for treatment of degenerative diseases utilizing highly advanced medical technology. In many of these medical schools the language of instruction is a western language with many instructors who received their specialty training abroad. The language of instruction takes over the local language for the medical school trainee and they become accustomed to "the enclave of medical school" and highly technical hospitals. These MDs will be significantly dependent on technology in their diagnosis and dealing with patients and may have difficulties communicating health information with patients due to the takeover of western instructional languages. 

    Poor investment in the health care sector and the training of medical providers is not the primary reason why these countries are facing poor rural health care access. Rather these investments have been happening based on a western model of care and importation of high level medical technology. As experienced in Iran, the rural population will not have access to these highly trained medical personnel from large towns, which often do not even speak the same language. In fact, many of these highly qualified doctors will be eventually absorbed in the continuous stream of immigration to European or North American countries.

     To improve the access of rural population to health care, new and innovative strategies are required to provide the personnel and infrastructure to fill these needs. The majority of the rural population in the developing world is still facing the challenge of infectious disease. Thus, the focus on rural health care investment should be on minimal primary care at first. Women and children are the most vulnerable sector of the population in the rural areas. Rural women have the extra issue of gender barriers even when there is access to male medical doctor. Rural children have a higher probability being born at home and within a traditional environment and have a higher risk for preventable diseases such as diarrhea. The investment in access to health care should focus on gender issues and prevention of infant and children diseases.

    The rural population in many Asian developing countries is scattered. Many rural settlements are small and their access roads are mainly good for walking, riding on animals, or small animal-pulled carts. In addition the rural spoken languages and dialect in many countries are different from urban population particularly when there is ethnic diversity and tribal affiliation. In such environment the locality of health care provider is very important. Although such local health care provider may have low level of training, he/she can communicate with the patient and is accessible. These are two main factors in improving the health of the rural populations. As such, the investment in rural health care must focus on cultural and language competency, physical access, and prevention.

1. [Report of Iran 2000 Demographic and Health Survey]. Tehran, Islamic Republic of Iran, Ministry of Health and Medical Education, 2002 [in Farsi]

2. Menashri, D. Education and the Making of Modern Iran. Ithaca, NY, Cornell University Press, 2002 

3. Shadpoor K. [The network of primary health care in Iran]. Tehran, Islamic Republic of Iran, Ministry of Health and Medical Education, 1993 [in Farsi]

4. [Statistical abstract of Iran, 1991]. Tehran, Islamic Republic of Iran, Statistical Center of Islamic Republic  of Iran,1992 [in Farsi]

5. [Statistical abstract of Iran, 2001]. Tehran, Islamic Republic of Iran, Statistical Center of Islamic Republic of Iran, 2002 [in Farsi]