A new framework for performance analysis
In May 2018, Iran signed the UHC2030 Global Compact and we warmly welcome them to the partnership.
The experience of Iran over past decades and most recently with the Health Transformation Plan (HTP) shows the importance of developing and maintaining health systems with a strong foundation in primary health care and local participatory processes to ensure that health needs are met in an affordable way.
The recently-launched National Health Assembly demonstrates the unique role of civil society and community representatives in mobilizing political commitment for universal health coverage (UHC), providing a viable link from local-level to national participation and decision-making.
We asked Dr Iraj Harirchi, Acting Minister and Deputy General, Ministry of Health and Medical Education some questions about why Iran joined UHC2030 and about their experiences of health system reform for UHC.
What were Iran’s motivations to join UHC2030?
"The Islamic Republic (I.R.) of Iran has a long-standing commitment to universal health coverage (UHC). Over the last three decades, a number of initiatives have been implemented to enhance the referral system, increase capacity for training health workforce, expand access to healthcare services, reduce inequities and promote quality of healthcare services. These in turn resulted in significant improvements in health outcomes. Nevertheless, several challenges continued to exist over time which call for a systematic and harmonized approach to make effective health sector reforms.
"The need for further actions to achieve UHC is strongly highlighted in I.R. Iran’s General Health Policies (lunched by the Supreme Leader) and the National Development Plans (mainly fifth and sixth plans). It is also one of the prominent social priorities of the current Government which is directly supported by the President. Moreover, the results of the latest external evaluation of the recent initiative towards UHC - called the Health Transformation Plan (HTP) - shows the importance of complementary measures for a continued effective health sector transformation.
"To answer what should be done to achieve UHC, we think it is useful to know what other countries have done and which are the best practices in this regard. When we heard about UHC2030, we recognized it as an opportunity for the country to accelerate equitable and sustainable progress towards UHC. This is particularly in terms of engaging with a platform that facilitates exchanges of experience and improves coordination of health system strengthening efforts through synergies with related technical networks."
What do you hope to contribute?
“From our side, we have a lot of experience mainly with establishing Primary Health Care (PHC); developing the National Non-Communicable Disease (NCDs) Plan; optimizing the health information system; expanding health insurance and services coverage, particularly for poor population; training required health workforce; promote using research evidence in health policy making; engaging with the private sector to achieve UHC; and promoting multi-sectoral actions to address the social determinants of health.
“We also have some experience of how deal with challenges caused by the sanctions. Among the main initiatives are: dealing with the private sector in providing health services, establishing new surgery offices to enhance the accessibility of the public to specialized services around the country, eliminating dual practice, reforming payment system and ‘capping’ the payments, and targeting the poor in all policies. We think our experience can be shared with other countries.”
What do you hope to get out of it?
“As mentioned earlier, the current health system suffers from some challenges that, if not solved, would regress the health system towards an unfavorable situation. These challenges can be summarized in three themes: sustainable financing, good governance and comprehensive and fair health service delivery.
“In terms of sustainable financing, President Rouhani set health as one of the main three priorities; therefore there was a significant increase in the health budget. However, the country has difficulties in determining how to spend the health budget in the most effective way. Hence, we are seeking innovative ways to select those health services, products and technologies that should be covered by public money, control the health expenditure in regard to safety and quality of health services, employ the most effective mechanisms for paying health service providers, and have a comprehensive plan to increase the efficiency of the health system and make it more resilient.
“In terms of good governance, the country needs to improve the health policy-making process through active stakeholder participation and proper use of evidence, upgrading the mechanisms of oversight and supervision of the health market, and defining a clear and on-time responsiveness system.
“In terms of service delivery, based on our experience of establishing a health network and following a qualitative and quantitative increase in health inputs (health workforce, health facilities, and information infrastructure), we believe that it is time to invest more in improving the service delivery process. This should concentrate on ensuring the delivery of required health services with respect to continuity, comprehensiveness and quality of health care, for the lowest price with the highest effectiveness in the shortest time.
“We hope that by participating in UHC2030, the country can get more insights and evidence from global experience to address our challenges and also join advocacy efforts for UHC targets, particularly in low and middle-income countries.”
How is UHC progressing in Iran?
“The Health Transformation Plan, as the most recent reform towards UHC, has included different interrelated interventions in the field of both primary and hospital care and is implemented through a gradual, step-by-step process since May 2014. As of October 2016, HTP has conducted multiple interventions and has achieved the following:
- Financial resources to the health system have been increased through raised GDP per capita allocated towards health (6.5% in 2012 to 8.9% in 2015). It is worth noting that the share of General Government Health Expenditure (GGHE) from Total Health Expenditure (THE) increased from 33.3% in 2012 to 51.3% in 2015.
- A number of interventions have brought down the share of out-of-pocket (OOP) expenditure as a proportion of Total Health Expenditure (THE) from 54.8% in 2012 to 38.1% in 2015. Interventions include: decreasing patients’ direct payment for inpatient and outpatient services in 600 public hospitals nationwide; significant revisions in the tariff system for medical services to bring them in line with real inflation aiming to avoid under-table payments; and strategic purchasing to provide required medicines and medical devices at reasonable prices.
- The Health Transformation Plan improved the exemplary primary healthcare (PHC) network that had contributed to significant public health improvements, particularly in rural areas after Iran’s revolution. The innovative approach of HTP’s intervention was to enhance the existing PHC infrastructure through extra services, and to expand active primary care services with particular attention to non-communicable diseases and mental health in urban settings. There was also a specific focus on an extra 10 million marginalized and deprived people who lived in areas around big cities.
- Various services including burns and intensive care units (ICUs) and mental health were included in the existing service package. In addition, 24,000 new hospital beds, 34 air ambulance bases, 16000 physicians, 71,000 nurses and 5300 midwives were added to the health system. All of these enhanced quality and increased access to health services, in line with progress towards UHC.
- The number of insured people significantly increased around 9.7% from 83.3% to 93.0% in 2015."
What lessons so far could you share with other partners in UHC2030?
"Iran has invaluable experience of different reforms to strengthen the health system towards UHC and achieving health for all. Among them, we think that the most relevant relates to the implementation and evaluation of the HTP.
"The country conducted two rounds of HTP evaluation by international teams with great help received from the World Health Organization, aiming to address the impediments that might slow down our progress towards UHC. Iran expresses its willingness to share its experiences with other countries within the framework of UHC2030 to shorten our common path towards UHC."