Debate Article http://mjiri.tums.ac.ir Medical Journal of Islamic Republic of , Vol. 27, No. 1, Feb. 2013, pp. 42-49

Health in the Islamic Republic of Iran, challenges and progresses

Kamran Bagheri Lankarani1, Seyed Moyed Alavian2, Payam Peymani3

Health Policy Research Center, Shiraz University of Medical Sciences. Shiraz, Iran.

Received: 10 October 2012 Revised: 11 December 2012 Accepted: 10 June 2013

ferent provinces reaches 24 years. The same Précis is through for almost all indicators excluding This debate article highlights some charac- the vaccine coverage and access to primary teristics, progresses and challenges of the health care which are above 90% nation- Iranian health system. Integration of medical wide. education and health service provision, con- While the major burden of disease in the trol of some important communicable and country as a whole and specially in the large non-communicable disease, some health ini- metropolitans is non communicable diseases tiatives and health financing system have (NCDs) including been discussed from the viewpoint of ex- (CVD), and injuries, the country is managers of the system. still faced with the problem of infectious diseases which in many instances are some- Introduction how related to its neighbor countries (2,3). The Islamic republic of Iran (Iran) is a In the both recent epidemics of the great country with a wide area and dispersed which occurred in Iran in 2005 and 2007 population. You may find only few countries through fingerprinting of the bacteria it was in the world that neighbor 17 countries in clearly shown that organisms was imported which two of them involved in a concurring from and Iraq respectively (4). war. The weather, culture, the environmental Cremean Congo fever previously not known hazards and the infrastructures and ultimate- in Iran is now a real health hazard with up to ly heath indicators have a great diversity in 250 cases each year affected with a fatality Iran. The specific geographic situation of rate of 25%. All these reported cases were Iran and mass immigration from related to smuggled poultry from neighbor and Iraq, the wars and insecurity after it in countries. Two out of four countries which the region, and illegal drug traffic from east- could not still eradicate poliomyelitis are ern borders with Pakistan and Afghanistan neighbors of Iran. Despite of these challeng- have all affected the health system in Iran es, it is now 12 years that Iran has obtained (1). the certificate of polio eradication and sus- There are noticeable health inequalities tained this success. Malaria although previ- within the country; for instance, the differ- ously endemic in Iran is now confined to ence between between dif- three south eastern provinces which its ma-

______1. (Corresponding author), MD. Health Policy Research Center, Shiraz University of Medical Sciences. Shiraz, Iran. [email protected] 2. MD. Baqiyatallah Research Center for Gastroenterology and Liver Disease, Baqiyatallah University of Medical Sciences, , Iran. [email protected] 3. Pharm.D. Health Policy Research Center, Shiraz University of Medical Sciences. Shiraz, Iran. [email protected]

K. B. Lankarani, et al.

jority of falciparum cases being foreigners then entered the special training program for who entered the country illegally. 2 years and then appointed as Behvarz to the These threats could not stop the success of health house covering up to 1500 people. the Ministry of Health and Medical Educa- The major strength of the administration tion (MHOME) in control of all of epidem- process was introducing the most appropri- ics and even in helping the neighbor coun- ate local people to local health authorities by tries through the so called group 5 initiative rural councils for being a Behavrz. This re- which was launched on 2005 during Eastern sulted in a proper environment that helped Mediterranean regional meeting of the the health system to have support of the world health organization(WHO) between community. Only through this support it was Iran, Iraq, Pakistan, Afghanistan and WHO possible to improve the health indicators with central role of Iran as the secretary. dramatically during a very short period. For This could have been done only through instance, it took only 3 years to increase ne- strengthening of the primary health care onatal vaccine coverage from 33% to over (PHC), active surveillance and frequent 90% nationwide (6). monitoring, vaccination at borders and even Although continuous professional devel- sending free vaccines to the neighbor coun- opment program for all of them were con- tries. ducted and they become experienced and Working for the future is based on our cur- educated further but they had basically only rent capacities. This is through analyzing the elementary education. The health system previous achievements and realizing today's initiatives had to be tailored so that these needs and predicting fluctuating situations in 30,000 Behvarzes as the main acting bodies tomorrow. In this study, we reviewed some could be participated [6]. The reason for of the achievements of Iranian health system choosing vital horoscope as a simple model in the recent decades. of census has turned the Behavrzy into an university degree. Although the central role Integration of Medical education and of people for appointing the Behvarz have service provision been maintained, they are now appointed Iran has applied the principles of Alma Ata from those rural inhabitants who have suc- but this was not just like rewriting a written cessively graduated from high schools. This statement; Iran has had it own model. Inte- promotion in Behvarz activity now has in- gration of the medical education and health creased the capacity of the health system and services and accountability of the education- more sophisticated health programs could al system to match the real needs of the become a reality. For instance screening for population have changed our situation from and now covering al- a country hosting more than 3000 working most in all inhabitants of the cities with less foreign physicians in 1983, to a country ful- than 20,000 population and all rural regions. filling all her needs in higher education in Interestingly using HBA1c as an indicator of the health and medical sciences (5). The ex- blood sugar control it was shown that known pansion of medical education while the diabetic patients of this group have a better country was suffering from an imposed war control of their blood sugar compared to ur- which lasted 8 years and while confronting a ban inhabitants (7,8). sanction lasting now for more than 29 years is a unique experiment in the world. You Hepatitis B Vaccination may see such an expansion in other countries Since 2007, Iran's MOHME carried out a but this usually happened through foreign nationwide hepatitis-B vaccination campaign supports. For the health workers or as is for 17-year-old adolescents in four stages. called in Iran Behvarz, the initial group was then, the second and third stages were done based on those rural inhabitants whom com- targeting adolescents born during 1990 and pleted their elementary educations. They 1991. The National Committee for Hepatitis

MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49 43 http://mjiri.tums.ac.i r

Health in Iran: challenges and progresses selected a passive approach –media educa- sion has covered many other speciality cares. tion – for mass vaccination. The target popu- lations in 2008 and 2009 included 1 709 337 Social determinants of health and 1 673 571 adolescents respectively. In Iran has played important role in many each year, Iran organized three rounds of health initiatives in the world. In social de- vaccination throughout the country. At the terminants of health, Iran is one of the few end of each round, data were collected and pioneer countries. Now all of the families sent to MOHME for analysis. The overall with a low income have some coverage by coverage rate was 74.9 per cent for one dose the governmental societies. This coverage of vaccination, and 62.76 per cent for all includes not only economic support but also three doses in 2008 and 75.7 per cent and capacity building to have them moving them 55.6 per cent, respectively in 2009. Cover- toward a self sufficient within approximate- age rates in rural areas were significantly ly 10 years after starting the support. The higher (p<0.001). The media education ap- only exception are elderly and those suffer- proach achieved acceptable outcomes in that ing from irreversible disabilities or incurable campaign (9). diseases(13). The coverage of HBV vaccination of infan- Evidence based policy making has been the tile vaccination has been very high in IR. basis of all of the initiatives in the recent Iran. And the impact of this vaccination in years. Here we provide few examples: decreasing the burden of have been confirmed (10). Neonatal and Maternal Mortality Before Islamic revolution of Iran, the abso- services in primary health lute number of maternal death was over care 5000 per year, when population was 35 mil- Mental health integration in primary care lion with an estimated annual birth number was started to screen for major psychiatric of 500,000. Now the absolute number of disorders and their referral cases. Since sub- mother deaths is less than 300 annually with stance use is one of the major causes of men- an estimated 1.2 million births per year. Iran tal disorders burden in Iran, the initiatives is one of the few countries in the world who were aimed to integrate the harm reduction reached targets of the millennium develop- programs which are now mainly a vertical ment goal number 5 on 2008, seven years program to the PHC(11, 12). ahead of the planned time. The cause of neonatal mortality has Developing e-health changed in past two decades. While the Computer based health data gathering and share of infectious diseases has been de- e health expansion covering other domains creasing, the importance of prematurity and including referral system, insurance and congenital disorders was increased. One of even telemedicine now could become a re- the main causes for decreasing the burden of ality. Several pilot studies have been done in infectious disease is the accessibility to safe Iran with largest now covering near , proper sewer system and proper toilet 1,000,000 people in Golestan province. usage. Infectious diseases like neonatal tetanus Sophisticated health services have been totally eradicated in past 10 years. On 1982, it was estimated that annually Considering these changes MOHME have more than 4000 Iranian were going aboard changed the educational program for nurses. only for coronary artery bypass graft sur- A special program for intensive care for ne- gery. Now every year at least 18,000 such onates has been started. Meanwhile accord- operations are performed in Iran and 27 out ing to the available demographic features, of 31 provinces have active cardiac surgery birth rates and burden of neonatal diseases in services. This is an example and this expan- different provinces, a program for expansion http://mjiri.tums.ac.ir 44 MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49

K. B. Lankarani, et al.

of neonatal intensive care units was countries is late diagnosis precluding effec- launched in 2006. Within 3 years the number tive treatment because of established com- of beds have increase three times with much plications. Recognizing the importance of wider distribution which expanding the cov- early diagnosis, a national screening pro- erage from less than 30 cities to more than gram for hypertension and diabetes were 100 (13, 14). The program is still running. implemented in rural areas with central role Other activities included a national program played by Behvarz. The success for this pro- for expanding the coverage for prenatal vis- gram led to expansion of this program into its specially for high risk mothers, expanding the urban area since 2010. It is now estimat- the prenatal diagnostic facilities and increas- ed around 30% of the adult population in the ing access to standard delivery system tar- urban areas and more than 80% of inhabit- geting the most needy regions. For instance ants in the rural regions have been screened the number of the neonatal facilities in for , hypertension, diabetes and hy- Sistan – Balochestan province with the high- perlipidemia and were referred for treatment est maternal and neonatal mortality in the when indicated(19,20). Although there are nation was tripled within a two year period problems for referral precluding the appro- while in some of the regions with decreasing priate treatment in some instances, concur- birth rate, the centers have merged. Through rent implementation of the family physician these activities the neonatal mortality in program in the rural area and smaller cities some of the provinces have decreased up to have increased the capacity of the system in 40% and the differences in the death rate providing appropriate treatment of these between provinces and districts nationwide newly diagnosed cases (21,22). have decreased dramatically nationwide (15, 16). Fight against tobacco usage The importance of Tobacco use as a risk Non-communicable diseases factor of NCDs cannot be over emphasized. Burden of the non communicable disease is All the components of the so called increasing worldwide and much of its impact MPOWER strategy to control tobacco con- is now in developing countries and lower sumption were initiated in Iran. The compo- socioeconomic classes within countries. For nents of this strategy include Monitoring this reason the control, prevention and offer- tobacco use and prevention policies, Protect- ing of affordable treatment for these diseases ing people from tobacco smoke, Offering became adopted as the main objectives in the help to quit tobacco use, Warning about the field of disease control in the ministry of dangers of tobacco, Enforcing bans on to- health. Based on World Health Assembly bacco advertising, promotion, and sponsor- (WHA) resolutions specially WHA 53.17 ship, and Raising taxes on tobacco. There (May 2000) several initiatives were started has been an extensive collaboration with in the MOHME in past 11 years. At the min- both governmental and non-governmental istry, a new branch under deputy of health organizations in this regard. Iran has been was established which dedicated to NCD considered as a pioneer in the global fight control on 2006 (4). against tobacco usage and WHO has report- The national health surveillance (NHS) ed Iran as one of the 20th countries with the which is a regular activity was re-organized highest achievement in this regards. For in- to target the monitoring and surveillance for stance Iran is among the only seven coun- NCD. Several reports have been published tries in the world who adopted the strongest based on the results of NHS and these are level of regulations for smokeless tobacco now the basis of the national plans to control warning. Nevertheless strengthening of PHC NCDs (17, 18). for treating tobacco dependency has been One of the main problems in control of piloted in Iran. The initial results of national NCDs with higher burden in developing surveys on tobacco usage show the preva-

MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49 45 http://mjiri.tums.ac.i r

Health in Iran: challenges and progresses lence of regular users have decreased, but Head injury is considered to be one of ma- the problem of water pipe and jor causes of mortality in car accident in smoking among younger adults is still prom- Iran. Implementation of preventive measures inent (23). such as seat belts and air bag could reduce this adverse event. Cholesterol as a risk factor for cardio- Seat belt usage was enforced in Iran vascular disease (CVD) through major campaign in the media and Another important factor in the develop- has gained a good recognition in the past 5 ment of NCDs is . Among dietary fac- years through the central role of police and tors, consumption of saturated fatty acids other parties. Nonetheless law enforcement especially its trans isomer has a great impact obligated the use of the seat belts and it is on later development of CVD and subse- now estimated that more than 85% of divers quent mortality. A national survey on Sep- use seat belts regularly compared to less than tember 2005 in Iran revealed that the more 20% just 10 years ago. But medical care for than 85% of consumed oil by families were those who were injured due to lack of seat saturated fatty acids with an average trans- belt was still a great challenge. Since many isomer of 25%. A legislation was passed in accidents occurred in remote areas, promo- the higher council for health and approved tion of the district hospitals especially in ar- by the president of Iran targeting less than ea of high rates of head injury was planned. 50% consumption of saturated fatty acids In this regards access to computerized to- and less than 5% trans-isomer by Iranian mography (CT), intensive care unit (ICU) families through well defined tasks and in- with provision of appropriate staff were in tersectional actions in ministries of com- need through localization of the hot points merce, industry, economy and health, stand- and their nearby hospitals . While the ard organization of Iran, office of custom equipments were arranged, the training of and with the support of national Iranian mass staff also was started. The training of nurses media. Three years later the estimated use of was rapidly started through a new educa- saturated fatty acids were 52% and share of tional program for master in ICU nursing, trans-isomer was 7.5% (24). however the availability of surgeon was still a problem. The number of residency seasts Achievements in Control of burden of for neurosurgery were increased during a 3 Traffic accidents year period by 75% but it was considered The medical care of trauma patients have that depending on neurosurgeons as the sole been a major challenge for many years. A care provider for head trauma patients would multilevel program for expanding pre- be a waste of a highly trained staff who will hospital emergency services (EMS) and im- become available for service only after 5 proving the related medical care was de- years at minimum .Since most hospitals al- signed and implemented in the past 6 years. ready had working general surgeons, hence a Through this national program the number new program for fellowship in trauma was of EMS has increased dramatically from less designed to promote these surgeon. Through than 600 to near a 2000. The EMS was free an 18 months training course they learned before and this was sustained despite this how to manage the trauma patients with spe- huge expansion. The cost of in hospital care cial emphasis on head injury. They were were also financed through commercial in- trained to do emergency neurosurgery pro- surance companies which provided insur- cedures and decide when to refer to a neuro- ance for vehicles and drivers and victims of surgeon. It is hoped that graduation of these these accidents did not have to pay any more new staff would increase the access to ap- for care when admitted to governmental propriate care for head trauma patients na- hospitals. Also parts of the cost in the private tionwide especially in the remote areas. hospitals were also covered. Moreover a subcommittee of higher health http://mjiri.tums.ac.ir 46 MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49

K. B. Lankarani, et al.

council was devoted to road safety and PHC and other important parts of pyramidal through a collective action of 32 different models such as community, we could fight governmental, public and non-governmental against H1N1 appropriately with organizations a target of reduction of road the least human and financial resources (26). traffic mortality by 25% was set. During the first year on 2006 11% reduction was Thalassemia and primary health care reached despite 13% increase in the number PHC has been a main approach to control of vehicles nationwide but on next years the communicable diseases over past thirty success was much less around 5%. There years. The PHC has generated opportunities was even an increase in mortality by 2% in to non-communicable diseases including ge- 2008. This failure was probably because of netic disorders (27). Progress in controlling surge of vehicles and the roads, some of communicable diseases increases the relative them with low standards including absences importance of non-communicable diseases, of airbag and accelerated break systems. including genetic disorders. In Iran, the de- Though, some other factors may also have velopment of primary health care over the played a role including higher speeds of the past 20 years has greatly reduced infant mor- new vehicles. tality and crude birth rate. Accordingly, in 1991 prevention of non-communicable dis- Swine flu pandemic eases were added to the primary healthcare Since declaration of swine flu pandemic by program, hence a department for the control WHO, Iran has launched a surveillance sys- of non-communicable disease, including a tem to test all suspected cases both in com- genetics office, was established within munity and hospital settings. They con- MOHME. The β Thalassemia, which is an firmed cases of pandemic influenza A important health problem in Iran, was cho- (H1N1) by RT- PCR. For Iran, it is of ut- sen to test the feasibility of preventing non- most importance to strengthen the surveil- communicable disease in primary care set- lance system for such disease and transfer ting. Iran's experience has shown that genet- the generated knowledge appropriately to the ic screening could be successful in lower professionals, stakeholders and general pop- resource countries and also provides some ulation accordingly (25). lessons for high resource nations. The pro- In Iran, the Primary health care (PHC) as gram is economically fruitful because it the first level of contact of all individuals, works through the established primary the family and the community with the na- healthcare and educational systems, which tional health system have a prominent role in focused existing (though scattered) genetic response to different health events such as expertise on a common objective, and added H1N1 pandemic. Pyramidal model could thalassemia screening to the pre-marital combat against H1N1 pandemic. Pyramidal blood tests(28). model puts all key components such as community, NGOs, PHC, hospitals, policy Other issues makers together to confront concurrent There are several other initiatives which H1N1 pandemic and other health issues by a could be discussed including the cancer reg- comprehensive, integrated and organized istry program now covering near 70,000 new approach. This model should be regarded as cases of cancer each year, the program for a continuous, flexible and dynamic solution adolescent vaccination against HBV, the to . The H1N1 pandemic, as a harm reduction program for control of HIV multi-wave and unpredictable event of the and other sexually transmitted diseases and 21st century that involved most countries, many more other examples which we would threatens communities and confronts hospi- not describe them in detail. tals with growing demands of patients for health services. By defining the role of the Challenges

MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49 47 http://mjiri.tums.ac.i r

Health in Iran: challenges and progresses Although many progresses have been made usually faced with shortage of financial re- and more visible changes have occurred but sources for its program. Inefficiency of the there still many shortcomings which make system and high administrative costs has the health system far away from ideal. One augmented to this problem. of the major concerns is to sustain resources The health system is one of the most com- for health system. Although human resource plex systems with many variables and uncer- development has improved greatly in the tainties. The management of this system past three decades and as mentioned before needs trained mangers. One of the current the number of physicians, nurses, midwives shortcomings is lack of those specifically and other health professionals have in- trained for this purpose. The main mangers creased dramatically, the challenge of sus- are usually physicians who are not trained tainability of these man power in the remote for this job. The trained mangers on the oth- under developed area are still prominent. er hand do not understand the realities and The burden of this problem has become less the complexities of the health system in for nurses, midwives and general physicians depth. A discipline of hospital management in the recent years with a policy of indige- was started with Bachelor, Master and PhD nous participation of students in these disci- degrees but still this program is far from the plines. The problem for specialist physicians real needs while the mangers are not always is growing since many of them are married appointed based on their capacities. and they want to live in the larger cities. A The intersectional collaboration in the refinement of policy of using indigenous highest political level for policy making in graduates was made with mandatory 10 year the health system has gained some success service in the remote area but the impact with establishment of the higher council of needs to be seen in future. However the health under direct supervision of the presi- payment system not only could affect the dent, but the new ministry of "work, social sustainability of staff in the remote area but welfare and cooperation" which have re- also affecting their performance. The best placed the ministry of welfare has many model for the payment is yet to be defined. common grounds with MOHME making Currently a mixture of fixed payment and consensus decisions very difficult to be im- pay for performance is the usual payment for plemented. non physician staff, while the physicians are The health system specially the PHC is usually paid through fee for service mecha- aimed at maternal, neonatal and childhood nism. The exception is family physicians in health and is more powerful in rural regions. the rural insurance program that are paid It would take some time to integrate new through per capita payment with bonuses for targets such as NCDs to this system. The performance. The analysis of effects of these system has not a good coverage for suburban different models of payment on outcomes of regions and created a concern among some health system and the costs are beyond the policy makers that increasing social services scope of this paper but the current payment in these areas could increase migration from system needs to be improved. The financial rural regions to larger cities. Despite the resources of the system are also another MOHME has started several initiatives in challenge. While attempts for health tax these regions but most of them still in pilot were made in recent years through taxation stage and needs to rapidly scale up to re- on tobacco and a share of vehicle insurance, sponse to the health needs of this vulnerable but the major financial input of the system is group. still through governmental support for most of the employees in the public domain with a Conclusion small share usually fixed from the salaries. The Health system has progressed dramati- Since the amount of public budget devoted cally in Iran after Islamic revolution. The to health is limited, the health care system is most rapid developments were devoted to http://mjiri.tums.ac.ir 48 MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49

K. B. Lankarani, et al.

Iranian version of the primary health care 12. Noorbala AA, Bagheri Yazdi SA, Yasamy MT, system with central role of the Behvarz. Mohammad K. Mental health survey of the adult population in Iran. Br J Psychiatry. 2004.184:70-3. New threats and requirements have reshaped 13. Naghavi M. Health transition in Iran. Iranian the system and many new initiatives have Journal of Epidemiology 2006;13(1):13-25. been implemented targeting NCDs and road 14. Salarilak SH, Khalkhali HR, Entezarmahdi R, traffic accidents but still there are challenges Pakdel FG, Faroukheslamloo HR. Association be- ahead which mandate a more collective ac- tween the Socio-Economic Indicators and Infant Mor- tality Rate (IMR) in Iran. Iran J . tion with a consensus on what the ideal 2009;38(4):21-8. health system should be in the country. 15. Yunesian M, Chaman R, Naieni KH, Golestan B, Nabavizadeh H. Neonatal Mortality Risk Factors in a Rural Part of Iran: A Nested Case-Control Study. Conflict of Interest Iran J Public Health. 2009;38(1):48-52. 16. Haghdoost AA, Manesh AO, Beheshtian M, The corresponding author was minister of Banihashemi AT, Motlagh M. Progress towards health and medical education of Iran from Health Equity in IR of Iran through Last Three Dec- 2005 till 2009 and Seyed Moayed Alavian ades. Iran J Public Health. 2009;38:130-5. was deputy for health from 2005 till 2008. 17. Esteghamati A, Gouya MM, Abbasi M, Delavari A, Alikhani S, Alaedini F, et al. Prevalence of diabetes and impaired fasting glucose in the adult References population of Iran: National Survey of Risk Factors 1. Asadi-Lari M, Sayyari AA, Akbari ME, Gray D. for Non-Communicable Diseases of Iran. Diabetes Public health improvement in Iran--lessons from the Care. 2008 Jan;31(1):96-8. last 20 years. Public Health. 2004 Sep;118(6):395- 18. Kelishadi R, Alikhani S, Delavari A, Alaedini F, 402. Safaie A, Hojatzadeh E. Obesity and associated life- 2. Alavian SM, Fallahian F, Lankarani KB. Epide- style behaviours in Iran: findings from the First Na- miology of Hepatitis E in Iran and Pakistan. Hepat tional Non-communicable Disease Risk Factor Sur- Mon. 2009 Win;9(1):60-5. veillance Survey. Public Health Nutr. [Research Sup- 3. Mehrdad R. Health System in Iran. JMAJ port, Non-U.S. Gov't]. 2008 Mar;11(3):246-51. 2009;52(1):69-73. 19. Yousefi A, Kermani MS, Ghaderi H. Demand 4. Asgari F, Aghajani H, Haghazali M, Heidarian H. for medical care in the urban areas of Iran: An Non-Communicable Diseases Risk Factors Surveil- empIrancal investigation. Health Econ. 2008 lance in Iran. Iran J Public Health. 2009;38:119-22. Jul;17(7):849-62. 5. Azizi F. The reform of medical education in Iran. 20. Gressani D, Saba J, Fetini H, Rutkowski M, Med Educ. 1997 May;31(3):159-62. Maeda A, Langenbrunner J. Islamic Republic of Iran 6. Javanparast S, Baum F, Labonte R, Sanders D, Health Sector Review: The World Bank Group. Hu- Heidari G, Rezaie S. A policy review of the commu- man Development Sector. and North nity health worker programme in Iran. J Public Health Africa 2007. Report No.: 39970 – IR. Pol. 2011 May;32(2):263-76. 21. Lankarani KB, Alavian SM, Haghdoost AA. 7. Javanparast S HG, Baum F. Contribution of Family physicians in Iran: success despite challenges. Community Health Workers (CHWs) to the Imple- Lancet. 2010 Nov 6;376(9752):1540-1. mentation of Comprehensive Primary Health Care in 22. Takian A, Rashidian A, Kabir MJ. Expediency Rural Settings, Iran. Asian Region - Iran: Institute of and coincidence in re-engineering a health system: an Health population,The Globalization and Health Eq- interpretive approach to formation of family medicine uity Research Unit, 2007. in Iran. Health Policy Plan. 2011 Mar;26(2):163-73. 8. Mehryar A. Primary Health Care and the Rural 23. WHO report on the global tobacco epidemic, Poor in the Islamic Republic of Iran Scaling Up Pov- Warning about the dangers of tobacco. Geneva World erty Reduction: A Global Learning Process and Con- health organization2011. ference; May 25.27; Shanghai, China2004. 24. Mozaffarian D, Abdollahi M, Campos H, 9. Alavian SM, ZamIran N, Gooya MM, Tehrani A, Houshiarrad A, Willett WC. Consumption of trans Heydari ST, Lankarani KB. Hepatitis B vaccination fats and estimated effects on coronary heart disease in of adolescents: a report on the national program in Iran. Eur J Clin Nutr. 2007 Aug;61(8):1004-10. Iran. J Public Health Policy. 2010 Dec;31(4):478-93. 25. Gooya MM, Soroush M, Mokhtari-Azad T, 10. Alavian SM, Fallahian F, Lankarani KB. The Haghdoost AA, Hemati P, Moghadami M, et al. In- changing epidemiology of viral hepatitis B in Iran. J fluenza A (H1N1) pandemic in Iran: report of first Gastrointestin Liver Dis. 2007 Dec;16(4):403-6. confirmed cases from June to November 2009. Arch 11. Sharifi V. Urban Mental Health in Iran: Chal- Iran Med. 2010 Mar;13(2):91-8. lenges and Future Directions. Iranian Journal of Psy- 26. Lankarani KB, Joulaei H, Honarvar B, ZamIran chiatry and Behavioral Sciences 2009;3(1). N, Moghadami M. Introduction of A Pyramidal Mod-

MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49 49 http://mjiri.tums.ac.i r

Health in Iran: challenges and progresses el Based on Primary Health Care: A Paradigm for Management of 2009 H1N1 Flu Pandemic. Iran Red Crescent Me. 2010 May;12(3):224-30. 27. Samavat A, Aghajani H, Haghazali M, Valizadeh F, Sarbazi G. Primary Health Care: An Approach to Community Control of Genetic and Congenital Disorders. Iran J Public Health. 2009; 38:113-4. 28. Samavat A, Modell B. Iranian national thalassaemia screening programme. Brit Med J. 2004 Nov 13;329(7475):1134-7.

http://mjiri.tums.ac.ir 50 MJIRI, Vol. 27, No. 1, Feb 2013, pp. 42-49