Country Profile - Iran
A land of mixed blessings

Iran is a fascinating country, at once sophisticated and developing. Callan Emery reports from Tehran on the state of healthcare in the country.



Iran has a heady mix of developed and developing world standards. On one hand, for example, the country has the highest number of road fatalities per capita in the world, while on the other it has a sophisticated medical education system integrated into the health services infrastructure with more than 40 medical higher education facilities countrywide. 

Within a population of nearly 70 million, around 27,000 people are killed and around 250,000 are injured on Iran’s roads each year – that’s 73 road deaths every day on average. These frightening statistics are borne out by the terrifying experience of driving in Tehran – considered the worst city in the world for chaotic traffic. While there I was told, presumably as a word of placation, that due to the heavy traffic and low speed of driving in the city, very few of the accidents were fatal. Most of the fatal accidents, I was informed, occur on the intercity roads. And the toll as expected to increase. According to a report in the Tehran Times in March the deputy chief of Iran’s Police Traffic Department Brigadier Mohammad Rouyanian said he expected the death toll to rise by 7.5% by the end of this year due to the increase in the number of cars on the road and the increase in intercity traffic. 

The Iranian Red Crecent told me in Dubai earlier this year that they were setting up special roadside mobile emergency rescue centres at accident hotspots across Iran to help reduce the high death toll. 

“We know how the traffic works here. We know how to drive in it,” Behzad Elahi, a young doctor who was driving me back to my hotel in Tehran after our meeting told me with a hint of pride in his ability to drive in this apparent chaos. In the three days I was in Tehran I saw five car crashes happen. Fortunately they were all minor with no serious injuries. 

A sickening side-effect of this choking congestion is the intense pall of smog that blankets Tehran in the windless summer and winter months. It was reported in December last year that more 1,600 people sought treatment in Tehran for respiratory illnesses blamed largely on the air pollution. 

Beside these idiosyncrasies, Iran, or the Islamic Republic of Iran as it is formally known, is relatively well developed from a healthcare point of view. People across the country have access to healthcare whether they be small clinics in rural villages or five-star luxury hospitals in the larger cities, such as the newly opened wellequipped Laleh Hospital in Tehran (See page 63). And the medical manufacturing industry is developed to a point where the country is largely self-sufficient when it comes to small medical devices and medical disposables. The medical manufacturing industry has grown to a point where it exports products, largely to the North Africa and Central Asia regions. 



Medical education 

The medical profession is held in high regard in the country. This is reflected in the superior status that medicine and medical education is accorded by the government. Medical education is the only sector of education which does not fall under the Ministry of Education, finding rather a unique and exclusive position within the ministry of health to form what is correctly referred to as the Ministry of Health and Medical Education (MoHME). 

Medical education was incorporated into the government health services in 1985. According to the MoHME some of the benefits are an improvement in the training of sufficient physicians for the country’s needs, elimination of surplus organisational posts by 20% as well as the freeing up of funds for the procurement of new equipment. 

Medical education in Iran goes back a long way. In fact Iran, or Persia as it used to be known, was home to what some historians believe to be one of the oldest schools of medicine – Gundishapur. 

According to some sources the medical academy at Gundishapur was well established by the 6th Century AD. The academy included the world’s oldest known teaching hospital and incorporated a library and university. It was considered the most important medical centre of the known world at the time. (See: Ancient Gundishapur, page 67.) 

Mahssa Mohegh, editor of Iran’s monthly Med & Lab and a mine of information regarding the medical sector, explained to me that there were in fact 42 medical higher education facilities across the country, with six medical universities in Tehran alone. Each of the country’s main cities has a medical science university or two. Besides Tehran other centres include Mashad, Esfahan, Shiraz, Tabriz, Yazd, Kermanshah, Kashan, Ahwaz and others. 

“Some are public institutions and are free of charge. Others are private universities, where students have to pay tuition, such as the Islamic Azad University which has several campuses in cities across Iran,” Mohegh said. 

“The Medical University of Tehran is the most highly respected in terms of research,” she added. 

Dr Elahi explained that medical universities in Tehran are responsible for hospitals within the city. 

“Tehran University of Medical Sciences (TUMS) oversees hospitals in central and southern Tehran. Beheshti University is responsible for hospitals in northern Tehran and Iran Medical University looks after hospitals in west Tehran.” 

However, in Tehran, the capital, where population estimates range between 12 million and 16 million people, there are literally hundreds of hospitals – large and small, old and new, basic and sophisticated. Some of the larger ones include the 1,500-bed Imam Khomeini Hospital, the 1,000-bed Mofid Children’s Hospital and the new 1,000-bed Milad Hospital. 

During the Iran-Iraq war from 1980-1988 the government built many hospitals – the end result being the availability of more than 105,000 beds countrywide. 

According to a recent report by the MoHME, 25 Milestones towards better health, there are 728 hospitals in active service. 

In the report the ministry noted, among a range of reform measures, that they were implementing a plan to optimise the emergency wards at hospitals. Under the initiative universities are bound to provide two hospital emergency centres and accept emergency cases whether they can pay or not. The plan also aims to improve on site treatment and triage and enhance communications between hospital and pre-hospital emergency teams. The ministry says satisfaction with emergency services improved by 60% in the first year of it being implemented in 30 pilot projects. 



The double burden 

In an interview with Dr Riaz Sheikh, WHO representative in Iran, he told me that Iran suffers from a double burden of disease, that is, it has to deal with diseases of the modern world such as cardiovascular disease, the second largest killer in the country after car accidents, and cancer, as well as the age-old diseases still prevalent in the developing world, such as malaria, TB and measles. Dr Sheikh said that for each category there was a national control and preventive programme running. (See interview with Dr Riaz Sheikh, page 68). 

Drug addiction
 

As a neighbour to Afghanistan, the world’s largest producer of illicit opium and the heroin, Iran has a serious problem with drug addiction. Dr Elahi works at the Iranian National Centre for Addiction Studies (INCAS) where he and his colleagues conduct research in drug addiction. There are an estimated two million drug addicts in the country. Most of these are opium addicts, however, INCAS estimates there are 150,000 intravenous (IV) heroin addicts countrywide. 

Dr Elahi and his colleagues are researching methadone maintenance therapy for heroin addicts. The treatment is used to combat heroin addiction by replacing IV drug use with an oral methadone pill. The researchers are studying the long-term affects of this therapy, among other aspects. 

Using functional MRI Dr Elahi and Dr Hamed Ekhtiari, director of the NeuropsychoLab at INCAS, are also doing some interesting research regarding the neurological aspects of addiction, such as the mechanics of craving, the character of imaginary hallucinations and a study of the risk-taking behaviour of addicts. They expect to publish results of some of their studies next year. 

HIV/AIDS 

A major problem associated with IV drug use in Iran is the spread of HIV/AIDS. Dr Elahi told me that according to their studies INCAS estimates that around 15% of male injecting drug users are HIV positive. And according to the recently released UNAIDS 2006 Report on the Global AIDS Epidemic prisons are an important risk factor for acquiring HIV/AIDS. It estimated that nearly half of the prison population are incarcerated for drug-related offences and according to studies one in five prisoners report sharing needles. The UNAIDS report calls for an urgent “expansion of HIV prevention (including methadone maintenance therapy) programmes, especially in correctional settings.” 

UNAIDS Update 2005 notes that most of the drug injectors are sexually active, that many either bought or sold sex and that only 53% of sexually active injecting drug users had ever used a condom. Another study found that about half of injecting drug users were married, and one third had reported extra-marital sex, which suggests a clear possibility of sexual transmission of HIV from infected drug injectors to their sexual partners 

According to UNAIDS report 2006, there are 66,000 people living with HIV in Iran and there have been 1,600 deaths due to AIDS. 

IRIN News reports that last year the Iranian government took a giant leap forward in tackling HIV/AIDS in the country, which has been a taboo subject for many years, by launching a massive campaign alongside the United Nations Children’s Fund (UNICEF) and UNAIDS. Aimed at focusing attention on the impact of HIV/AIDS on children and young people, Iran’s national broadcaster, IRIB, televised public announcements on its popular sports channel. 

Health insurance 

The Constitution of the Islamic Republic of Iran (Article 29) guarantees all citizens the right to health care and the Public Medical Service Insurance Act (1994) is fairly comprehensive covering areas such as government requirements to bring about the necessary conditions to cover all persons in need of medical services, through to the tariffs of diagnostic and therapeutic services; and government payment of insurance premiums in the case of persons who are unable to pay. 

However, although it may appear that those who do not have health insurance are provided healthcare free of charge, several doctors I spoke to told me this was not always the case. 

It is obligatory for employers to buy health insurance for their employees and in this way most of the population is covered even though the government only provides 50% of the cost of healthcare and the patient has to pay the other 50%, according Mohegh and other sources. 

Nonetheless, it is the unemployed who appear to fall through the cracks in the health insurance system, and with unemployment at around 11.6% according to the latest figures from the Economist Intelligence Unit, that amounts to quite a large proportion of the population who potentially lack formal health insurance and thus access to proper healthcare. 

One doctor told me he knew of cases where patients who had been admitted to some of the large government hospitals in Tehran in an emergency had to literally escape after treatment in order to avoid being detained. Patients who cannot pay are allegedly kept in the hospital until they can pay their bill. The irony is that the longer they are detained the higher the bill gets. A 1999 paper prepared by World Bank health economists for the Social Security Research Institute, Health Economic Congress in Tehran reported that around 10% of the population lacked formal health insurance. 

Atyeh Sazan-e-Hafez 

The biggest healthcare reinsurer in Iran is the Atyeh Sazan-e-Hafez Group. I spoke to Dr Amir Naemi, manager of the medical equipment department, who explained that the Group had interests in a number of spheres in the medical industry including insurance services, medical equipment, pharmaceutical products and health tourism. Atyeh Sazan-e- Hafez Group, which receives some support from the government, acts as a gobetween for the private sector and the government to facilitate, for example, the purchase of equipment by government hospitals from the private sector. The Group also acts as an exclusive agent for some Iranian medical manufacturers and pharmaceutical producers to export their products. And in this regard the Group assists these companies to have a presence at various international medical exhibitions. However, its core business is re-insurance with the aim of providing insurance to an expanding and increasingly varied health insurance industry. 



“We are of great benefit to hospitals as we provide a one-stop shop for the provision of healthcare services, whether they be insurance, equipment purchases, pharmaceutical needs or even the facilitating the entry of foreigners seeking treatment in Iran,” Dr Naemi said. (See Atyeh Sazan-e-Hafezpage page 65.) 

WHO
 

Iran works closely with the World Health Organisation (WHO) and has two collaborating centres – WHO Collaborating Centre for Research and Training on Endocrine Science at Shaheed Beheshti University of Medical Sciences in Tehran; and WHO Collaborating Centre for Research and Training in Cardiovascular Diseases Control, Prevention, and Rehabilitation for Cardiac Patients at the Isfahan Cardiovascular Research Centre. The collaborating centres form part of an interinstitutional collaborative network set up by WHO in support of its programme at the country, intercountry, regional, interregional and global levels. (See the interview with Dr Riaz Sheikh, the WHO representative for Iran, page 80.) 

- During our visit to Iran we were kindly taken care of by Yahya Razavi and his staff at Iran’s monthly Med & Lab magazine. They assisted us with setting up meetings with the medical industry and informed us about many of the facets of the Iranian healthcare system. This was all done with a genuine friendliness, which we found true to all the Iranians we met while travelling in Iran.

Ancient Gundishapur

Iran has a long history of medicine dating back to at least the 6th Century AD when by this time the medical academy at Gundishapur, Khuzestan, was already well established. The academy included the world’s oldest known teaching hospital and incorporated a library and university.

The academy offered training in medicine, philosophy, theology, mathematics and science. The faculty were versed not only in the Zoroastrian and Persian traditions, but in Greek and Indian learning as well. According to The Cambridge History of Iran, it was the most important medical centre of the ancient world (defined as Europe, the Mediterranean, and the Near East) during the 6th and 7th centuries. The city was founded by Sassanid King Shapur I in 271 AD and was located in the present-day province of Khuzestan in Iran. 

Sassanian rule at Gundishapur ended with the city’s surrender to the Muslim forces in 638 AD. However, prior to the Islamic Abbasid period Gundishapur was renowned for its superior medical learning. 

Some sources state that Gundishapur played a highly significant role in the development of the hospital system. In addition to systemising medical treatment and knowledge, the scholars of the academy also transformed medical education; rather than apprenticing with just one physician, medical students were required to work in the hospital under the supervision of the whole medical faculty. There is even evidence that graduates had to pass exams in order to practice as accredited Gundeshapur physicians (as recorded in an Arabic text, the Tarikhu l- _ikama. 

According to Lutz Richter- Bernburg, writing for the Circle of Ancient Iranian Studies (www.cais-soas.com/ CAIS Gundishapur’s real fame in the history of Islamic Persia rests on its role in the transmission of Hellenistic learning, or more precisely, of Galenic medicine and the institution of the teaching hospital (bimarestan) to the metropolitan Abbasid society and beyond that to Islamic civilisation at large. The earliest medical testimony from Gundishapur refers to a medical-philosophical disputation convened on King Khosrow II’s orders in about 610, in which the Chief Physician (drustbed) Gabriel of Siggar participated; the hospital itself first finds specific mention in the events of the year 765 AD, when the caliph al- Mansur is said to have summoned the then head of Gundishapur hospital, Bukhtishu to Baghdad. 

It is believed that following Bukhtishu’s departure the hospital fell into ruin as there are few remaining records from the following years. 

According to Wikipedia, an archaeological investigation of the ancient site of Gundishapur by experts from the Archaeological Research Center of Iran’s Cultural Heritage Organization and the Oriental Institute of the University of Chicago was due to start this year
.



Working as partners to improve public healthcare 

Dr Mubashar Riaz Sheikh is the World Health Organisation representative in Iran. Callan Emery asked him about WHO’s role in the country and the major public healthcare challenges faced by the WHO and the Government in Iran. 

Middle East Health: What is the function of the WHO in Iran? 
Dr Riaz Sheikh: WHO by its mandate is a specialised technical agency dealing with the health of citizens. It provides all necessary technical support and experience to member states. In Iran, we are working in close collaboration with the Ministry of Health and Medical Education (MoHME) to achieve the government health goals that contribute to the wellbeing of the people and the achievement of the Millennium Development Goals. 

The main functions of WHO in Iran are: 

1. Build the national technical and financial capacities consistent with WHO and national strategies and priorities. 
2. Develop active partnership with all segments of the civil society including public and private sectors, academia, NGOs, UN agencies and communities. 
3. Initiation of health sector reform to provide universal basic health services through innovative approaches. 
4. Stimulate and advance work to eradicate epidemic, endemic and other communicable and noncommunicable diseases. 

MEH: What are the main health issues/challenges facing Iran at the moment?
RS:
These include certain communicable diseases such as malaria, TB, measles and HIV/AIDS; reducing the burden of non-communicable diseases; reforming the health system to be more responsive to population demands and reducing health inequalities, as well as developing an inclusive health and social insurance system. 

MEH: What is being done (by the Government and WHO) to address these challenges? 
RS:
WHO works in Iran to assist health authorities in addressing the health challenges and emerging priorities through: 
- Providing experts/consultants 
- Fellowships to train nationals abroad or internally 
- National training activities 
- Supplies of developmental nature 
- Research support, particularly operational research 
- Inter-country / Regional meetings 
- Information exchange & support 

MEH: How long are these programmes expected to run? 
RS: WHO has short-term, mid-term and long-term strategic objectives which have been determined by the member states. Therefore some programmes have certain target dates while others (promotive and preventive programmes) have no deadlines and usually time is linked with the achievements of the targets. 

MEH: Regarding the Millennium Development Goals (MDGs), particularly the health-related ones, such as Reduction of Child Mortality; Improvement of Maternal Health in the context of reproductive health; and HIV/AIDS — can you give some indication of the progress Iran is making towards achieving these goals? 
RS: Iran has made considerable progress towards achieving the MDGs. The under-five mortality rate has almost been halved, dropping to 36 in 1,000 live births in 2000 from 68 in 1990. The infant mortality rate decreased by over 54%, from 52.5 in 1,000 live births in 1990 to 28.6 in 2000. The maternal mortality ratio per 100,000 live births has sharply declined to 37.4 deaths in 1997 from 91 in 1989. 

The percentage of medically assisted births has increased from 70% in 1989 to 89.6% in 2000, reaching the recommended MDG target of 90% even before 2015. 

MEH: According to WHO’s 2004 morbidity indicators for Iran – TB, measles, malaria and meningitis are the main diseases. What programmes are in places to reduce incidence of these diseases? 
RS:
For communicable diseases that are relevant in certain areas, there are national programmes eg. DOTS (directly observed treatment, short course) for TB, malaria elimination, etc... Malaria is still a health problem in the southeastern part of the country. WHO facilitated a cross border integrated vector control programme between Iran and neighbouring countries. The DOTS coverage is 100% for TB control. 

It is worth mentioning that Iran is facing a health transition and double burden of diseases. According to the health statistics, the cardiovascular diseases, road traffic accidents and cancers are the main causes of death at present. For each category there is a national control and preventive programme. 

MEH: What is the current situation with H5N1 in Iran? What precautions are being taken to prepare for an epidemic? 
RS: On 15 February this year, H5N1 tested positively on dead wild swans in two sites of Anzali wetland in Gilan province. In the wetland 184 dead birds were found, tissue samples were taken from 24 and two of these tested positive. However, while H5N1 tested positive only in dead swans, it was negative for all other types of birds tested. In response to the situation the national authorities implemented certain measures: 

- 18,400 birds of different varieties were culled and the owners compensated 
- Awareness campaigns have been launched including display of posters, banners, television spots as well as face to face discussions 
- Protocols for case definition and a flowchart for diagnosis and referral were distributed 
- Both public and private physicians were trained 
- An effective data collection and reporting system has been set up and implemented 
- All universities of medical sciences in provinces bordering Iraq, Turkey, Afghanistan and Pakistan are well prepared for possible emergency actions 
- A joint WHO/FAO mission visited areas vulnerable to outbreak 

So far no H5N1 has been reported among the poultry or any domestic birds and no human cases have been reported or even suspected. There is a joint committee at the national level. MoHME and Ministry of Jihad Agriculture are highly involved and co-ordinate very well. A buffer stock of Tamiflu is available, a surveillance system is in place, regular reports are provided to WHO and FAO, and all people at risk (health workers, veterinary officers and workers in poultry farms) are vaccinated against human flu. 

WHO has shared all technical documents and guidelines pertaining to Avian Influenza and the risk of the pandemic, preventive measures, national preparedness, checklist, surveillance, transfer of specimens to WHO reference laboratories and case management with the relevant authorities in MoHME and other organisations. 

MEH: What is the situation with HIV/AIDS in the country? Is IV drug use still considered the main route for the spread of the virus? What is being done to try and halt the spread of HIV? 
RS: Regarding HIV/AIDS, the transmission mode includes 57.4% as injecting drug users, 6.8% through sexual transmission, 2.7% from blood and blood products, and 0.4% as mother to baby while for 32.7%, the mode is unknown. The national strategic plan for HIV control is in place and approved by the cabinet. A US$15-million grant has been received from GFATM (Global Fund to fight AIDS, Tuberculosis and Malaria). MoHME has recently started implementation of second generation surveillance and STIs surveillance for evidencebased planning. Triangular clinics for HIV/AIDS, substance abuse and STIs in addition to walk-in programmes and replacement treatment centers have been documented as best practices by WHO. 

MEH: The WHO EMRO annual meeting is due to be held in Tehran in September this year - what will be the key topics on the agenda? What will WHO Iran present? 
RS:
Iran is going to host the Fifty-Third Session of Regional Committee for the Eastern Mediterranean, from 9 to 12 September this year. Ministers of health from member states, key WHO staff in addition to other partners will participate in the meeting. The key issues that will be discussed in the sessions are: 
- The work of WHO in the Eastern Mediterranean Region - annual report of the Regional Director 2005. 
- Progress reports on HIV/AIDS and the 3x5 initiative; eradication of poliomyelitis; tobacco free initiative; MDGs relating to maternal and child health; emergency preparedness and response; strengthening primary health care and the achievement of health for all; and globally targeted diseases for elimination (TB, measles, leprosy and neonatal tetanus). 
- Role of government in health development. 
- Integration of medical education and health services (Iran experience) 
- Regional strategy on preparedness and response for human pandemic influenza. 
- Other issues related to WHO strategic objectives. 

                                  
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