Reviewing Six Health System Building Blocks of Traditional & Complementary Medicine in Iran

Reviewing six Health System building blocks of Traditional & Complementary Medicine in Iran

This report is ordered by WHO Country Office in Iran to Persian Traditional

Medicine Association through Agreement for Performance of Work (APW) No. 2019/917184-0, Date from 01-JUN-2019 to 30-DEC-2019 with the exact title “Reviewing six Health System building blocks of Traditional Complementary Medicine in Iran”; edited and authored by the focal point person in Persian Traditional Medicine Association:

Dr. Arman Zargaran

Assistant Professor of Traditional Pharmacy at

School of Persian Medicine, Tehran University of Medical Sciences

October 2019

Reviewing six Health System building blocks of Traditional & Complementary Medicine in Iran

With Acknowledged to

This report is authored and supported by:

Dr. Arman ZARGARAN (as Editor; manager of the project and focal point of Persian Traditional Medicine Association)

Contributors as Author (sorted alphabetically): Dr. Akbar ABDOLLAHIASL (Assistant professor of pharmacoeconomics and pharmaceutical administrations at Tehran University of Medical Sciences) Dr. Goli ARJI (PhD of health information management at Saveh University of Medical Sciences) Dr. Babak DANESHFARD (MD, PhD of Persian Medicine) Dr. Roshanak GHODS (Assistant professor of Persian Medicine at Iran University of Medical Sciences) Dr. Seyed Mohammad Hosein HASANI (PharmD, Managing director of HONAM Pharmed’s Accelarator) Dr. Mansoureh SABBAGH-BANI-AZAD (PhD candidate of pharmacoeconomics and pharmaceutical administrations at Tehran University of Medical Sciences) Sara SHEKALYOU (Secretary at deputy of international affairs, School of Persian Medicine, Tehran University of Medical Sciences) Dr. Samaneh SOLEYMANI (PhD candidate of traditional pharmacy at Tehran University of Medical Sciences) Dr. Arman ZARGARAN (Assistant professor of traditional pharmacy at Tehran University of Medical Sciences)

With Special Thanks to: Dr. Mohammad Reza SHAMS ARDEKANI (Director General of Persian medicine office, Iranian ministry of health and medical education) Dr. Mahmoud KHODADOUST (Former Director General of Persian medicine office, Iranian ministry of health and medical education) Dr. Mahnaz KHANAVI (Director General of Natural and Complementary Medicine of the Food and Drug Administration Dr. Hossein REZAEIZADEH (Dean of School of Persian medicine, Tehran University of Medical Sciences)

iii

Dr. Roja RAHIMI (Associate professor of traditional pharmacy at Tehran University of Medical Sciences) Dr. Majid KHALILI (Executive Deputy of Director General of Persian medicine office, Iranian ministry of health and medical education) Dr. Nafiseh HOSSEINI YEKTA (Vice-President of Persian Traditional Medicine Association) Dr. Alireza ABBASSIAN (Deputy of Director General of Persian medicine office, Iranian ministry of health and medical education)

Table of Contents

INTRODUCTION...... 1 CHAPTER 1 ......

HEALTH SERVICE DELIVERY ...... 5 CHAPTER 2 ......

HEALTH WORKFORCE ...... 21 CHAPTER 3 ......

HEALTH INFORMATION SYSTEMS ...... 33 CHAPTER 4 ......

ACCESS TO ESSENTIAL MEDICINES ...... 42 CHAPTER 5 ......

HEALTH SYSTEMS FINANCING ...... 61 CHAPTER 6 ......

LEADERSHIP AND GOVERNANCE ...... 73 APPENDIXES ......

APPENDIX 1. THE LIST OF ALL CLINICAL CENTERS OF PERSIAN MEDICINE IN IRAN ...... 95 APPENDIX 2. TRAINED HEALTH HOUSES FOR TRADITIONAL MEDICINE AS A PILOT PROJECT ...... 126 APPENDIX 3. THE LIST OF FACULTY MEMBERS IN DEPARTMENTS OF TRADITIONAL MEDICINE AND TRADITIONAL PHARMACY DEPARTMENTS IN IRAN ...... 127 APPENDIX4. THE NATIONAL DOCUMENT OF MEDICINAL PLANTS AND TRADITIONAL MEDICINE...... 130

Introduction Current medicine and public health have too many challenges and any ways to reduce them and help to promote and develop health issues in the countries worldwide is welcome. Traditional and complementary medicines that mostly have deep historical roots in some civilizations and involved in the people’s culture are one of the important alternative methods to help promoting public health. During last decades, people contribution in both developed and developing countries to use these medicines are increased because of people believes to their less side effects, cheaper costs, natural origin and also accessibility of them with their culture and also some disadvantages of conventional medicine for treatment and side effects. Therefore, traditional medicines can be considered as an opportunity to help current public health issues if medical systems pay attention to them for using their safe and effective parts. World Health Organization (WHO) welcomed integrating these traditional medicines into the official public health systems of the countries as “Integrative Medicine” in the published “WHO Strategy for Traditional and Integrative Medicine 2014-2023”.

There are many traditional medicine types worldwide like Chinese Medicine, Ayurveda, Homeopathy, Osteopathy, Thai Medicine, etc. Persian Medicine is one of the such traditional medicines with a great root in history. Persian medicine practice in Iran and neighbor countries dating back to at least 7000 years ago. Persians in Sassanid era (224-637 CE) built great Universities and teaching hospitals and medical centers (like Jondishapour University and hospital in south west of Persia) and gathered medical knowledge from all around the ancient world, like India, Syria, Greece and Rome and merged them together and flourished the medical sciences. This tradition was transferred to the Islamic Caliphate after Islam by Jondishapour’s physicians and Islamic Caliphate supports and finally lead to Islamic Golden Age (9-13th century). During this period of time, there were great (mostly Persian) physicians and

2 polymaths (Hakims) like Holy Abbas, Rhazes, Avicenna, Albucasis, Jorjani, Biruni, etc. that raised up medical knowledge. Many of their books were taught and used as medical texts like Avicenna’s Canon of Medicine and Rhazes’ Liber Continent in the west and the east until 17th century CE.

The paradigm of Persian medicine is holistic view on the body and based on four elements (earth, wind, fire and water) and the balance of temperaments (mizaj) in the bodies. The main focus of Persian medicine for the people’s health is to prevent diseases more than treatment. Therefore, Persian Medicine is a school of Preventive Medicine and Public Health.

On the other hand, current investigations on Persian medicine show that there many good results in evaluations of its therapeutic methods and drugs (in the literature as RCTs and review articles). It shows that there are many opportunities for current medicine and public health to integrate Persian Medicine.

From 2007, Persian medicine started to be integrated in Iranian health and treatment system, officially. In this time, Schools of Persian Medicine and related departments were stablished in main medical universities. Following it, Students for studying Persian Medicine and Traditional Pharmacy majors in PhD levels were started to be accepted for physicians and pharmacists, respectively. Furthermore, official structures in Iranian ministry of health and medical education to promote integration of Persian medicine into the public health and treatment system were stablished.

In current report, the situation of integration of Persian medicine and other complementary systems of medicine (that are practiced in Iran) in Iranian public health system is presented as “Reviewing Six Health System Building Blocks of Persian Traditional Medicine in Iran”.

This report is ordered by WHO Country Office in Iran to Persian Traditional

Dr. Arman Zargaran

Editor, Manager of the Project

October 2019

Chapter 1 Health Service Delivery 1.1. Introduction

Persian medicine is one of the oldest medical schools in the world with a long- lasting history (something about seven thousand years). According to the categorization of WHO, it falls into the traditional medical systems group (just like traditional Chinese medicine and Ayurveda) owing its distinguished theoretical and practical basics.1

This Hikmat (philosophy)-based school of medicine stands on the strong fundamental theories originated from humoral medicine. Iranian sages like Avicenna (980-1032CE), Rhazes (865-925CE), and Haly Abbas (949-982CE) developed and enriched this school of medicine during the centuries, especially Islamic Golden Age (9-13th century). Iranian (Persians) Hakims (scholars) not only consider the physical/material aspects of the human body, but also pay much attention to the spiritual and social aspects, too.

Nowadays, by the emerging of various traditional and complementary medicines all around the world, Persian medicine revived in the Iranian academies in addition to the community. Indeed, disregarding the medical aspect, Persian medicine is intertwined with the Persian culture and history and it has never been totally forgotten. Its basic concepts such as Mizaj (temperament) and qualities (like hotness and coldness) have always been a part of daily conversations of the people. These concepts in addition to the health measure principles have been transferred from generation to generation as a part of culture for a long time.

In addition to hakims who have been considered as physician (sometimes were polymath), other traditional healers and apothecaries were practicing Persian medicine. Other than pharmacotherapy (mostly with herbal formulations), they

1 Heydari M, Hashempur MH, Daneshfard B, Mosavat SH. Bioactive Foods as Dietary Intervention for Diabetes from the Perspective of Persian Medicine. In: Bioactive Food as Dietary Interventions for Diabetes. Academic Press; 2019. pp. 49-68. 6 were applying various manual interventions such as Badkesh (dry cupping), Hijamat (wet cupping), Fasd (venesection), Zaloo (leech therapy), Dalk (massage), Ghams (acupressure), Hoghneh (enema), Ghey (vomiting), etc. Some of these traditional healers were practicing in a specific field like Shekasteband in orthopedics and Ghabeleh or Mama in obstetrics.

In this atmosphere, Attari (traditional herbal shops) was one the main places for Persian medicine service delivery. The person named Attar was responsible for preparing simple or compound drug formulations in the past. Also, sometimes they were practicing medicine, too. It was usually an ancestral occupation in which the knowledge and experience of ethnopharmacology was transferring to the next generations. Nowadays, these Attaris are working but legally only can only sell simple medicinal herbs.

Although, Persian medicine was faded out in the contemporary time, in recent decades, little by little, much more enthusiasm was dedicated to Persian medicine in order to revive it again in the realm of health and medicine. This social movement was such deep and serious that finally forced the government to support it. The goal was a scientific development of Persian medicine to use its potentials in healthcare system and give a rational response to the community demand.

Health service delivery is one of the most important building blocks of the health system which has a crucial role in achievement of its developmental goals. It is the immediate output of the inputs into the health system which includes delivery of interventions to reduce the burden of diseases and improve the community health.2

2 World Health Organization (WHO). Monitoring The Building Blocks of Health System: A handbook of indicators and their measurements strategies. Geneva, Switzerland: WHO; 2010.

Popularity of traditional and complementary medicine (T&CM) in Iran, like other parts of the world, has been dramatically increased in recent decades.3 Such a great enthusiasm for using these unconventional methods is an opportunity for healthcare providers and policymakers to use the potentials of these modalities in the health system as outlined in WHO guidelines.4 However, this also may let the opportunists to put the people’s health at risk by attempt to unauthorized illegal practices. Accordingly, ensuring a qualified and secure access to the health services in this filed is of a very high importance.

1.2. Traditional and complementary service delivery in Iran

Currently, different groups (including legal and illegal bodies) are providing health services in the field of T&CM in Iran. Legal service delivery is provided by the medical universities and related authorized organizations while the others have not been confirmed by the ministry of health. These non-certified physicians and traditional healers have posed a big challenge in service delivery for healthcare system.

1.2.1. Persian medicine service delivery in Iran

The service delivery of Persian medicine in Iran is done by different level of physicians and healers as are introduced in following:

1.2.1.1. PhD level

3 Abolhassani H, Naseri M, Mahmoudzadeh S. A survey of complementary and alternative medicine in Iran. Chinese journal of integrative medicine. 2012;18(6):409-16. 4 World Health Organization. WHO traditional medicine strategy 2014–2023. Geneva: WHO; 2013.

At the highest level, physicians (MDs) who are holding PhD in Persian medicine provide medical services in the private clinics or university affiliated health centers. Beside them, pharmacists (PharmDs) who are holding PhD in traditional pharmacy are considered as official authorities for providing herbal and traditional formulations and serving pharmaceutical services in traditional pharmacies (Table 1.1).

Table 1.1- The number of PhD graduates and students in the fields of Traditional Medicine and Traditional Pharmacy in Iran (September 1, 2019)

Majors PhD Students Graduates

Traditional Medicine 402 246

Traditional Pharmacy 45 56

1.2.1.2. Licensed MDs

At the next level, general physicians who have taken part in training courses (inside or outside the country) authorized and confirmed by ministry of health are allowed to practice in the field, of course, with some limitations in comparison to specialized MD, PhDs.

Traditional Persian Medicine Association 5 is an NGO and the only non-profit research and educational institution authorized by ministry of health in the field of Persian Medicine. Up to now, it has conducted 200-hours courses for 500 physicians allowing them for legal practice of Persian medicine.

5 Available at: https://itma.ir (Accessed on: 1 September 2019)

1.2.1.3. Unlicensed Persons

Other groups of general practitioners (GPs) who have not passed these training courses are also practicing in this field, of course, illegally.

It is to be mentioned that a considerable number of physicians (and other people) have been trained in unauthorized institutions in recent years. For instant, one of these institutions whose activity was banned by the ministry of health, have trained more than 5000 GPs giving them invalid certificates.

There are other parties in Iran’s community who are illegally practicing Persian medicine and even preparing and selling herbal drugs. They include traditional healers, some of the clerics and Attars, and other people without any related academic education. Although, there are rules and regulations regarding medical practice in general and Persian medicine in specific, these unlawful activities still happen in a large scale.

One of the main challenges of illegal practice of Persian medicine is the practice of Attars. There are more than 15000 Attaris (traditional herbal shops) in Iran. Although, they are only allowed to sell simple medicinal herbs, many of them are selling herbal drugs and compound formulations and even practicing Persian medicine. The supervision on their activity has been increased in recent years, but there is still a long way to go.

In forensic medicine organization, a specialized commission has been created for addressing the complaints related to traditional medicine. Most of these complaints are related to the practice of the illegal parties. Specialists of the field are invited to this commission for judging about these unlawful practices before further legal actions.

1.2.1.4. Medical Centers for Delivering Traditional Medicine Services

Regardless of the illegal part, legal part of the health service delivery system in this field which mainly includes university affiliated units other than the private clinics, provide Persian medicine services in 4 levels: hospital ward, health center, health clinic, and health house (Table 1.2 – Appendix 1).

Table 1.2. Number of health service unites for traditional medicine in Iran.

Health service Hospital ward Health centers Health house unite and clinics6

Number in 1 50 575 public sector

Number in 0 14 0 private sector

Total 1 64 575

Health center is an institution established in accordance with the bylaws and other guidelines and regulations of the ministry of health to provide Persian medicine services based on the preventive health measures including natural products, Galenic compounds, and manual interventions independently or in

6 Available online at: http://pm.behdasht.gov.ir/page/salamatkade (accessed in September 1, 2019)

11 combination with other methods for prevention, maintaining health, diagnose, and treatment of the diseases.

Health houses are the most basic units of health service delivery in the health system of the country. As the initial step, 9 medical university including: Mashhad, Hamedan, Golestan, Shahid Beheshti, Kashan, Kerman, Fasa, Mazandaran, and Babol Universities of medical sciences, started to provide Persian medicine services (includes educational and counselling services at this step) in their health houses as a pilot project (Appendix 2).

1.2.1.5. Persian Medicine Services Tariffs

Table 1.3 shows the defined prices of Persian medicine services delivered by the aforementioned legal bodies. These prices were approved by the Council of Ministers along with other medical services tariffs and included in the book of “The relative value of health services”.

Table 1.3. Persian medicine service prices (IR Rial and Euro*)

Title of service Price in public Price in private Price for trained sector for MD, sector for MD, GPs PhDs PhDs

Dry cupping (cold 121200 Rial 283600 Rial 226880 Rial Badkesh) 1.001 Euro 2.344 Euro 1.875 Euro

Dry cupping with 151500 Rial 354500 Rial 283600 Rial

12 massager (hot 1.252 Euro 2.930 Euro 2.344 Euro Badkesh)

Wet cupping 238920 Rial 555000 Rial 444000 Rial

1.974 Euro 4.587 Euro 3.670 Euro

Leech therapy 218550 Rial 501250 Rial Not authorized (first two leeches) 1.806 Euro 4.142 Euro

Each extra leech 99550 Rial 231250 Rial Not authorized

0.823 Euro 1.911 Euro

Venesection 398200 Rial 925000 Rial Not authorized (Fasd) 3.290 Euro 7.644 Euro

Fumigation 121200 Rial 283600 Rial Not authorized (Enkebab) 1.001 Euro 2.344 Euro

Enema (Hoghneh) 333300 Rial 779900 Rial Not authorized

2.754 Euro 6.445 Euro

Massage or 123760 Rial 280800 Rial 280800 manual techniques 1.023 Euro 2.320 Euro (Dalk and Ghamz)

Maggot therapy (in 222900 Rial 516500 Rial Not authorized

13 each area) 1.842 Euro 4.268 Euro

Instructing health 66640 Rial 151200 Rial 151200 Rial surveillance 0.550 Euro 1.249 Euro 1.249 Euro essentials

Nutritional 238000 Rial 540000 Rial Not authorized counselling (in- 1.967 Euro 4.462 Euro patient)

Nutritional 171360 Rial 388800 Rial Not authorized counselling 1.416 Euro 3.213 Euro (outpatient)

Using instruments 102160 Rial 240400 Rial Not authorized for examination 0.844 Euro 1.987 Euro and medical data analysis

* 1 Euro = approx. 121000 IR Rial

1.2.2. Service delivery of other complementary medicines in Iran

For other main complementary medicines in Iran including acupuncture, homeopathy, and chiropractic, there are official scientific associations for the regulation of the related affairs. Outside of this legal realm, physicians and non- physician individuals may have their own illegal practice.

1.2.2.1. Traditional Chinese medicine service delivery in Iran

Acupuncture is one the most popular brands of T&CM worldwide not excluding Iran. As for the public sector, Chinese and complementary medicine department in traditional and complementary school of Mashhad University of medical sciences7 is the only related department in the medical universities responsible for research and educational affairs in addition to clinical service delivery. Moreover, two faculty members of traditional medicine department at school of Persian Medicine, Tehran University of medical sciences are holding PhD in traditional Chinese medicine who are responsible for the related activities in this university.

In the private sector, Iranian Scientific Acupuncture Association (ISAA)8 is the only authorized organization by the ministry of health for research, education, and clinical service delivery of acupuncture in Iran.

The defined prices for acupuncture services in Iran are shown in table 1.4.

Table 1.4. Defined prices for acupuncture services (IR Rial and Euro*)

Title of service Price in public Price in private Price for trained sector for MD, sector for MD, GPs PhDs PhDs

Acupuncture 121200 Rial 283600 Rial Not authorized

1.002 Euro 2.344 Euro

Electrical 151500 Rial 354500 Rial Not authorized

7 Available online at: http://ccmdept.mums.ac.ir/index.php (accessed in September 1, 2019) 8 Available online at: http://isaa.ir/en (accessed in September 1, 2019)

15 acupuncture 1.252 Euro 2.298 Euro

* 1 Euro = approx. 121000 IR Rial

1.2.2.2. Chiropractic service delivery in Iran

Chiropractic profession is relatively a new addition in healthcare system of Iran. However, it has gained a significant popularity and respect in the community. “Iranian Chiropractic Association (IRCA) is the only official Chiropractic association recognized by the Iranian Ministry of Health and Medical Education in Iran. The IRCA was established in 2002 and is currently the largest professional Chiropractic association in the Middle East region.” Its mission is defined as follows: “To advance Chiropractic academic and educational standards, and to promote evidence based clinical practice guidelines in Iran and internationally”.9

1.2.2.3. Homeopathy service delivery in Iran

The Iranian Homeopathic Association (IHA) is a non-governmental nonprofit organization that has dedicated its activities to developing homeopathy in Iran. The association can operate exclusively in specialized scientific and educational research fields.10 This method of treatment has been confirmed by the ministry of health more than two decades ago. Moreover, only those physicians who have been authorized by the IHA and accordingly have permission by ministry of health are allowed to practice in this field.

9 Available online at: http://irca.ir/wp-content/uploads/2019/07/IRCA.ir-Mission-Stat_F.pdf (accessed in September 1, 2019) 10 Available online at: http://homeopathyiran.org/about-iha/ (accessed in September 1, 2019)

1.3. Core indicators

For the evaluation of T&CM health service delivery, following indicators are defined:

A. Number of Traditional medicine specialists (in case of Iran, Persian medicine and pharmacy PhDs) per 10000 populations: Considering the total number of 302 graduated specialists and population of 83000000 for Iran, this indicator would be calculated as 0.03 per 10000 populations. B. Number of certified T&CM healers per 10000 populations: Considering the total number of 1581 certified T&CM healers and population of 83000000 for Iran, it would be calculated as 0.19 per 10000 populations. C. Number of traditional medicine health service units per 10000 populations: Considering the total number of 640 Persian medicine health service units and population of 83000000 for Iran, it would be calculated as 0.07 per 10000 populations. D. Percentage of insurance coverage of traditional medicine services: Unfortunately, this coverage has not been provided yet in Iran.

1.4. Strength points

As it mentioned before, Persian medicine is a part of Iranian culture with a deep historical root. It has caused both a high demand and acceptance rate (although it could be different in various parts of the society) for receiving health services in the field of T&CM.

Moreover, a unique property of Persian medicine in Iran is the fact that its academic education has been initiated from the highest level i.e., PhD, only for physicians and pharmacist who themselves are familiar with mainstream medicine and pharmacy. Consequently, it will pave the way for better integration of conventional and traditional sciences of medicine and pharmacy. Therefore, they are familiar to both traditional and conventional medicines and can use both opportunities to serve the best medical services for the patients.

In addition, it should be kept in mind that despite all problems and difficulties, Persian medicine has experienced a significant progress in last decade. Its establishment in governmental structures, academic movement in providing scientific evidence, and delivering proper clinical and health services in such a relatively short time is impressive.

1.5. Challenges

Also, Different structures in the government were formed to support this scientific movement and provide a proper health service delivery in T&CM. However, there still remained a long way to a desirable state. The main obstacles and weak points can be mentioned as follow:

 Lack of proper infrastructures including laboratories and sufficient instruments.  Lack of enough physical space in the form of hospital wards and health centers for research, education, and health service delivery.  Low number of Persian medicine and pharmacy specialists considering the community demand.  Low number of certified physicians for traditional and complementary medicine services considering the community demand.

 Some illegal traditional medicine services and lack of enough judicial treatment.  Weak international collaborations for increasing the quality and quantity of services.  Lack of insurance coverage for Persian medicine services.

1.6. Future perspectives

Notwithstanding the obstacles and all deficiencies, it seems that there is a great potential for development of Persian medicine and other T&CMs in Iran. Of course, it needs better planning in national and international levels with defining supporting sources in the government.

In this regard, following points should be considered:

 Establishment and supporting the research centers in basic and clinical sciences.  Increasing the number of health service delivering centers in order to meet the community demand.  Financial support of programs in line with national Persian medicine research map to make more evidences for clinical practice.  Supporting the establishment of scientific journals in the field of T&CM and Persian medicine.  Globalization of Persian medicine by the increase of international collaborations including student exchange programs, joint research programs, conducting international Persian medicine training courses, etc.  Supporting the NGOs related to T&CM activities.

 Rational establishment of academic fields related to Persian medicine in the Universities.

Establishing the insurance coverage for Persian medicine services and products.

Chapter 2 Health Workforce 2.1. Introduction

Human resource is the main part of any healthcare system playing an important role in meeting the health goals. In addition to the number of health workers that have shown to have a direct impact on the health outcomes of the community, their performance quality that is directly affected by their knowledge, skills, and enthusiasm, is also of great importance. Any country with skillful and motivated healthcare providers can improve the community health more efficiently.

According to WHO, the health workforce can be defined as “all people engaged in actions whose primary intent is to enhance health”.11 These people not only include those who have been academically educated in medical fields such as physicians, pharmacists, dentists, nurses, etc., but also other staffs like ambulance drivers and managers who do not directly provide health and medical services.

Such categorization also exists in the realm of traditional and complementary medicine (T&CM) as described below.

2.2. Persian Medicine Workforce in Iran

Disregarding those who are not directly involved, different levels of health workers are providing Persian medicine health services from specialists to untrained traditional healers.

11 World Health Organization (WHO). Monitoring The Building Blocks of Health System: A handbook of indicators and their measurements strategies. WHO, Geneva, Switzerland. 2010.

2.2.1. Persian Medicine Specialists

There are two approved majors for Persian medicine practice in Iran including PhD of Persian Medicine (only for Physicians-MD) and PhD of Traditional Pharmacy (only for Pharmacists-PharmD). These persons who have PhD in these two majors are allowed to serve medical and pharmaceutical services in traditional medicine, respectively.

There are schools of Persian medicine or departments located in the schools of medicine and pharmacy that are responsible to educate these majors in the main governmental medical Universities all around the country (Table 2.1- Appendix 3).

Table 2.1. Training of Persian medicine fields in Iranian Universities

Department/School Number of Units

Schools of Persian Medicine 8

Departments of Traditional Medicine located in Persian Medicine 8 Schools

Departments of Traditional Pharmacy located in Persian Medicine 5 Schools

Department of Chinese Medicine located in Persian Medicine 1 Schools

Departments of Traditional Medicine located in Medicine Schools 9

Departments of Traditional Pharmacy located in Pharmacy Schools 2

It is to be mentioned that there are 98 faculty members who work at these departments and schools.

The total number of graduates and students in Persian medicine and traditional pharmacy (PhD) are listed in the Table 2.2.

Table 2.2. Current Persian medicine and traditional pharmacy graduates and students (September 1, 2019)

Major Degree Graduates (N) Students (N)

Persian medicine PhD 246 402

Traditional PhD 56 45 pharmacy

2.2.2. General practitioners

2.2.2.1. Legally trained physicians

Although, a physician is allowed to use any treatment approach for his/her patient, Iranian ministry of health has issued regulations to train physicians for providing traditional medicine services as they have not passed any course for traditional medicine in their MD curricula. These training courses are based on the ministry of health regulations and would be done by the Universities and under the supervision of Persian Traditional Medicine Association. Physicians who have taken part in training courses (inside or outside the country) authorized and confirmed by ministry of health are allowed to practice in the field, of course, with some limitations comparing to specialized MD-PhDs.

As an NGO, Persian Traditional Medicine Association is a non-profit research and educational institution which is approved by the ministry of health. Up to now, it has conducted various training courses for different groups of the society. As for the physicians, it has trained 500 of general practitioners in 200- hours training courses. These trained GPs are allowed for legal practice of Persian medicine in Iran.

2.2.2.2. Illegally trained physicians

Other than legal education and training courses in Iran, a considerable number of physicians (and other people) are training in unauthorized institutions. As an example, one of these institutions have trained more than 5000 physicians and gave them invalid certificates. Although, activity of these institutions have been or is being banned by the ministry of health (especially in recent years), these illegal activities have not been removed totally.

2.2.2.3. Untrained physicians

Another group of general practitioners (GPs) who have not passed any training courses are also practicing in this field, of course, illegally.

2.2.3. Other health service providers

2.2.3.1. Legally trained health workers

At the next level, other health workers including nurses, midwives, and environmental and public health workers are active in Persian medicine service delivery. Although, there is yet no academic course for these fields in Iranian

25 universities, some have been trained by Persian Traditional Medicine Association.

2.2.3.2. Illegally trained health workers

Same as the physicians, some of the health workers are also trained in unauthorized institutions without any permission from the ministry of health. Consequently, their possibly received certificates are invalid and their activity in the field of Persian medicine in unlawful.

2.2.3.3. Untrained health workers

There are health workers who hold their academic degree in their own field but have not passed any training course to be legally prepared for Persian medicine service delivery.

2.2.4. Community-based traditional health workers

As Persian medicine has always been a part of Persian culture and history, its service delivery has not been depended on the governmental authorities nor on the universities and academic institutions. Various groups of traditional health workers have been trained by their ancestors and transfer their experiences to the next generations. Such a social structure was strong enough to keep the heritage of Persian medicine. Although, this method of training is not common today, it has never totally gone.

2.2.4.1. Traditional herbal shops (Attari)

Attari (traditional drug store) has always been one of the main places for Persian medicine service delivery. Historically, for thousands of years, a person named Attar was responsible for preparing simple or compound drug formulations. Furthermore, they were practicing medicine, too. It was usually an ancestral occupation in which the knowledge and experience of ethnopharmacology was transferring to the next generations.

In current era, these herbal shops are supposed to be licensed for their activity in the legal scope and only are permitted to sell medicinal herbs. Total registered and licensed herbal shops in Iran are 15000, approximately.

2.2.4.2. Traditional healers

There have been various groups of people like Shekasteband (traditional orthopedics health worker), Ghabeleh or Mama (traditional obstetrics health worker), etc. with non-academic trainings providing Persian and traditional medicine services. Although, they are not licensed, still in some places (especially rural areas and small cities and towns) there are many people that rely on them for their health and medical needs.

2.3. Workforce of other approved complementary medicines

2.3.1. Traditional Chinese Medicine

As one of the most popular brands of T&CM worldwide, Chinese medicine and acupuncture has a better position in Iran in comparison to others. Mashhad University of medical sciences has the only related department in the medical Universities as public sector. Chinese and complementary medicine department in traditional and complementary school of this University has the aim of

27 clinical service delivery and research and educational activities in acupuncture and Chinese medicine.12

In addition, there are two faculty members in Persian medicine department of Tehran University of medical sciences who have PhD in traditional Chinese medicine as their major. They are responsible for research and educational activities related to this field.

Iranian Scientific Acupuncture Association (ISAA)13 is the only official association in the private sector which is approved by the ministry of health. It is authorized for clinical service delivery in addition to research and education of acupuncture in Iran. Moreover, this association has the responsibility for examining the physicians who have been trained in this field and intend to have a legal practice. Up to now, ISAA have registered 400 physicians in Iran.

It is to be mentioned that the ministry of health does not accept the short term training courses of acupuncture. Only certificates related to the training courses with duration of two years or more from approved centers could be evaluated and then confirmed for issuing the license of practice.

2.3.2. Chiropractic

Chiropractic which has been recently added to Iran’s healthcare system, is becoming a popular branch of T&CM. The only official chiropractic association is the Iranian Chiropractic Association (IRCA) which has been established in 2002. This association which has been recognized by the Iranian ministry of health and medical education is the largest one in the Middle East region.

12 Available online at: http://ccmdept.mums.ac.ir/index.php (Accessed on: 1 September 2019) 13 Available online at: http://isaa.ir/en (Accessed on: 1 September 2019)

IRCA has defined its mission as follows: “To advance chiropractic academic and educational standards, and to promote evidence based clinical practice guidelines in Iran and internationally”.14

Currently, a total number of 119 physicians all of whom have been trained overseas (mostly USA and Canada) are recognized by the IRCA. IRCA is authorized to examine these physicians. Final evaluation of their certificate and issuing their license for practice will done by the ministry of health. After that, they are legally permitted for their professional practice of chiropractic in their private clinics.

2.3.3. Homeopathy

As a NGO, Iranian Homeopathic Association (IHA) is the only official association approved by the ministry of health in the field of homeopathy. Following the goal of developing homeopathy in Iran, IHA has the permission for specialized scientific and educational research activities.15

Moreover, this association has the authority to evaluate the trained physicians who have certified from the abroad institutes. A total number of 260 physicians have been registered in IHA until now. After their examination by IHA, ministry of health will issue their license for practice of homeopathy in Iran.

2.4. Core indicators

The following indicators are defined for T&CM health workforce in Iran:

14 Available online at: http://irca.ir/wp-content/uploads/2019/07/IRCA.ir-Mission-Stat_F.pdf (Accessed on: 1 September 2019) 15 Available online at: http://homeopathyiran.org/about-iha/ (Accessed on: 1 September 2019)

A. Number of Persian medicine and pharmacy specialists per 10000 populations: It would be calculated as 0.03 per 10000 population considering the population of 83000000 for Iran and the total number of 302 graduated specialists. B. Number of certified T&CM healers per 10000 populations: It would be calculated as 0.19 per 10000 population considering the population of 83000000 for Iran and the total number of 1581 certified T&CM healers.

2.5. Challenges and strength points

Great enthusiasm in Iran for working in the field of T&CM has two main reasons: cultural characteristics (making a general belief in traditional medicine) and economical benefits. This has made many to come to the scene for learning and working in this field. Positive aspect is the fact that a great human resource has been formed which should by managed by the policy makers for development of Persian medicine. Negative side is the illegal activities of the opportunistic bodies that could result in harmful consequences for the society.

In this regard, following challenges could be mentioned:

 Insufficient number of T&CM specialists that could not meet the community demand.  Low number of students and graduates of Persian medicine fields.  Lack of recruitment of Persian medicine specialists in Universities and research centers.  Insufficient control over illegal activities of uncertified healers and Attars.

 Lack of sufficient support from NGOs related to Persian medicine fields.  Lack of insurance coverage for Persian medicine visits.

Disregarding the difficulties and deficiencies, one of the positive points regarding the Persian medicine workforce in Iran is the facts that Persian medicine and pharmacy specialists have the highest academic degree. They have primarily trained in conventional medicine and pharmacy and consequently are familiar with the language of modern science. This makes them more competent for integrating the Persian medicine into the healthcare system.

Moreover, the great human resource in the community who are willing to be educated and participate in the Persian medicine development is an opportunity for policymakers to use their potential in their developmental planning.

2.6. Future perspectives

Considering the current situation of Persian medicine in Iran, following suggestions are proposed with the aim of human resource empowerment:

 Increasing the number of medical and research centers employing the specialists and trained persons in the related fields of T&CM.  Increasing the research ability of students and specialists by conducting the training courses and supporting their attendance in additional courses in foreign high level Universities.  Supporting the science-based projects to yield in high quality products.  Increasing the international collaborations with the aim of student exchange programs, inviting the prominent researchers in T&CM fields, attending joint research programs, conducting international Persian medicine training courses, etc.

 Establishment of other academic fields related to Persian medicine such as specialized nurses and nutritionists.  Establishment of academic courses for other T&CMs with international collaborations.  Increasing the number of students in Persian medicine fields.  Better planning for using media in increasing the knowledge of community about T&CM.  Increasing the enthusiasm of students in medical Universities for continuing their education in T&CM fields using incentive policies.

 Establishing the insurance coverage for T&CM services and products.

Chapter 3 Health information systems 3.1. Introduction

Hospital Information System (HIS) is a comprehensive, integrated Information System (IS) designed to manage the administrative, financial, and clinical aspects of a hospital. HIS is defined as integrated electronic systems that collect, store, retrieve and display overall patients’ data and information such as history of patients’ information, results of laboratory test, diagnoses, billing and others related hospital’s procedures which are used in several departments within hospitals.16

HIS has several components, for example, Clinical Information System (CIS), Financial Information System (FIS), Laboratory Information System (LIS), Nursing Information Systems (NIS), Pharmacy Information System (PIS), Picture Archiving Communication System (PACS) and Radiology Information System (RIS). The HIS could have two or more HIS components whereby these components are linked to one another. Each component has different characteristics, based on its usage, department and users.17 The adoption and use of HIS has an important role in cost reduction and enhancing hospital performance.18

Significant evidence exists indicating the satisfactory level of IS adoption in the ambulatory setting within the different countries.3 There are several factors which can have a strong effect on the process of HIS adoption pertaining to each dimension of technology, organization, environment and human experts. A HIS should support the information logistics within a hospital, making the appropriate information – the appropriate knowledge – at the appropriate time – at the appropriate location – the appropriate individuals – in an appropriate and

16 Ahmadi H, Nilashi M, Ibrahim O. Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals. International Journal of Medical Informatics 2015;84(3):166-88. 17 Ismail NI, Abdullah NH, Shamsuddin A. Adoption of Hospital Information System (HIS) in Malaysian Public Hospitals. Procedia - Social and Behavioral Sciences 2015;172:336-43. 18 Ahmadi H, Nilashi M, Shahmoradi L, Ibrahim O. Hospital Information System adoption: Expert perspectives on an adoption framework for Malaysian public hospitals. Computers in Human Behavior 2017;67:161-89.

34 usable form.19 Availability of accurate and timely information and understanding of how to use them effectively in the health system are critical components for evidence-informed decision making, which are provided by the health information systems.20

3.2. Situation in Iran

In the Iran Ministry of Health and Medical Education has designed a new health system since 1979 (Figure 1).

Figure 3.1. Health system in Iran

According to Figure 3.1, PHC in Iran is based on a District Health Network (DHN), one per district, that stand on a well-organized system consists of rural health center, urban health center, and health house. This network especially is well-established in rural areas. The DHN is accountable for managing, planning

19 Hübner-Bloder G, Ammenwerth E. Key Performance Indicators to Benchmark Hospital Information Systems – A Delphi Study. Methods Inf Med 2009;48(06):508-18. 20 Feyzabadi VY, Emami M, Mehrolhassani MH. Health information system in primary health care: The challenges and barriers from local providers’ perspective of an area in Iran. International Journal of Preventive Medicine 2015;6:57.

35 and monitoring of health services at the micro-level. Moreover, this network is accountable to the provincial medical university (PMU). Each PMU encompasses at least more than one district and has the authority of supervising the provision of health care in the entire province. Of course, some provinces have more than one medical university, and the districts are distributed among them for better stewardship.21 Each medical university has several faculties.

After the Islamic revolution in Iran in 1979, attention to Persian medicine began, and, finally, the first schools and departments for traditional medicine (Persian medicine) were established, and PhD courses were founded in 2006. From an academic education point of view, nowadays, there are three related academic fields to traditional medicine in Iran including; PhD course of Persian Medicine, PhD course of Traditional Pharmacy, MSc and PhD courses of History of Medicine.

Traditional Medicine (TM) is one of the accepted and integrated forms of healthcare in many areas of the world. Its vast use has had a great impact on patients, healthcare providers, researchers, and policymakers, but it has never been incorporated into the ICD code set. The involvement of TM in Family of International Classification (FIC) may enable the comparison of diagnostic, clinical, and epidemiological data across the whole health system.

International Classification of Traditional Medicine (ICTM) was created by the WHO, as part of the ICD-11 project and the aim of ICTM is to report various practices of TM in order to strengthen the quality of healthcare and affordable resource allocation. The beta version of ICD-11 contains a TM Module 1 chapter (East Asian TM) consisting of two sections: TM disorders, and TM patterns. China, Korea, and Japan have contributed to the development of this classification system by referencing their own national standards. Although, there is some overlap in Chinese, Korean, and Japanese TM practices because

21 Ibid

36 of their origins and evolution, there are many types of TM practices all over the world, which may be substantially different from each other in theory and practice. Some of these types of TM practice include Ayurveda, Traditional Malay Medicine, Traditional African Medicine, and Persian Medicine.

Classification of disease in Persian medicine is based on the Canon of Medicine (al-Qanon fi al-Tibb), which is similar to the classification of disease in modern medicine. Due to differences in the theories and principles of Persian medicine and Chinese medicine, currently, we have developed a separate classification system for classifying diseases in Persian medicine. Right now, ICD-10 is used for the classification of diseases in Iran, and there is a tendency to use all the chapters of disease along with the module provided for TM in the 11th Edition in Iran.

Furthermore, attention to the classification of TM intervention codes is somewhat low in the different classification systems. In other words, most of the classification systems for intervention does not cover TM concepts, and therefore cannot be used directly as a classification system for intervention. Currently, in Iran, we have developed a classification system for TM interventions.

The aforementioned classification system is web-based and located in the link below: http://tmc.rps.co.ir But, it is not involved to the national health system yet. The traditional medicine health centers and clinics use their own local software to manage their centers and they are not connected to a national system.

3.4. Indicators

The following section lists some of the suggested indicators for traditional medicine clinics:  The number of traditional medicine clinics  Number of the referred patient s to traditional medicine clinics based on the type of services  The number of Traditional Medicine physicians  The ratio of Traditional Medicine services per papulation  The ratio of Traditional Medicine physicians per each province  Percentage of insurance converge of traditional medicine services and products  Percentage of ambulatory patients visit in outpatients clinics  Percentage of mortality in outpatient clinics  Percentage of nosocomial infections in outpatient clinics

3.5. Challenges and Strength Point: One of the main advantage of Persian medicine classification system is that it can be used for both disease and procedure classification in traditional medicine. In the disease classification system all of disease are classified based on body system in 25 chapters and each body system is determined by one of the English alphabetic letters. The code structure is alphanumeric and has subdivision for each disease sub-classifications. In other word, each disease code consists of code number, disease name, parent and child relationship between words and some details about disease sign and symptoms based on Persian medicine. Intervention classification in this system is based on ICHI classification system and code structures are adopted directly from ICHI classification system. In this way, each code consists of three main parts including target, action and means. Inclusion and exclusion terms also included in this classification system. This

38 classification system has the possibility of expanding of subgroup in future if necessary. This classification is computer-based and can be utilized in conjunction with another electronic system such as electronic health record, hospital information system and any other system in insurance companies for health care payments. There are other areas that need to further improve for this classification system such as developing coding rules and guidelines for physician, researchers and clinical coders. Translating this classification system to English is also essential. Creating the ontological structure for this system for interrelating concepts and terms is necessary. The other step that should be done to vast adoption of this classification system is field trial of this system and evaluating the code accuracy and end-user satisfaction.

3.6. Future Perspective Iran is a developing country that has national plans such as Iranian electronic health record (SEPAS) as well as organizational projects such as HISs in hospitals where they have been implemented or are under development. In Iran, the government plays an active role in planning, leadership, and supervision in a centralized manner. Furthermore, the Iranian government has the responsibility of planning and supervision of these IT projects in health care. Hospitals in Iran are administrated by both Ministry of Healthcare and Medical Education, and the Ministry of National Welfare. It is known that the hospitals under the administration of Ministry and Healthcare and Medical education are developing their HIS without any well-defined approaches. It is observed that in some hospital HIS are selected on the basis of observation and analysis of different available HIS proposed by different vendors in the country and they have not paid attention to the optimal requirements of their hospital needs. Thus, the ministry should manage teams of experts with previous experience aimed to first define a clear IT strategy on this matter for HIS in the hospitals,

39 and then collect general e-Health requirements of hospitals and define a clear strategy to select vendors to propose their HIS according to hospital needs. Currently, there is no hospital information system in Iran for traditional medicine clinics. Available systems are merely used to patient’s admission in clinics and to recording demographic data. Therefore, there is little and sparse electronic information about patients, their diagnosis and treatment. Available information is more related to the number of traditional medicine universities, the number of Persian medicine students and Persian medicine specialists, and public and private clinics. Clinical data collection in Persian medicine clinics is usually paper-based or with local software and usually with the aim of determining the patients’ medical history, determining the Mizaj condition and nutritional recommendations for treatment, prevention of disease. Therefore, in the current situation, there is no integrated platform for collecting patient data from Persian medicine clinics and reporting it to universities and the Ministry of Health. Currently, some efforts are being made to create electronic infrastructures such as the implementation of electronic medical records for patients, the development of a hospital information system consistent with the principles and concepts of Persian medicine, the development of a classification system for diseases and interventions in Persian medicine, as well as determining indicators for monitoring the quality of Persian medicine services in the Ministry of Health. But there is some future direction that should be investigated for full adoption of electronic systems in Persian medicine. Patients medical record documentation principals education for Persian medicine practitioners should be considered as one of the main objectives. Furthermore, preparing a strategic plan for implementation of any IT project in Persian medicine essential. Business process re-engineering and change management principles should be followed in Persian medicine clinics to acquisition of any electronic systems. In order to facilitate successful adoption of electronic medical record, the

40 involvement of physicians and other caregivers would be essentially required during the IT projects designing, implementation and usage phases. Identification of the needed financial and human recourses are the most important factors that should be considered. Moreover, communication between different healthcare providers can enable hospitals to properly plan, select, implement and integrate different health IT projects. Defining clear vision to staff members and communicating with vendors about the process and the expected outcome, training new staff members, and applying tailored training materials are essential for EHR adoption and utilization.

Chapter 4 Access to essential medicines 4.1. Introduction

Although, the beginnings of the twentieth century and chemical drugs creating, the use of plants in the treatment gradually is lost, but still the importance of plants usage in treatment has not lost in many countries, towns and villages. The increase of natural medicines in the pharmaceutical market and contribution of various countries, demonstrates that medical societies return to traditional and complementary medicine.

According to a study conducted in 2015, the pharmaceutical market in the world was $ 1100 billion, of which $ 100 billion belonged to the market for natural products and plant materials. In this study, the annual growth of natural products and plant materials was estimated at 15%.22

Traditional medicine maintains its popularity in all parts of the developing world, and its use in industrialized countries is rapidly expanding.

A national survey conducted by the National Center for Complementary and Alternative Medicine (NIDC) in 2007 showed that 17.7% of adults use at least one natural product (especially herbs) in a year1.

Considering the extensive use of medicinal herbs and traditional methods of treatment in Iran, familiarity with Persian medicine and its introduction has national and international importance.

According to the present capacities in Iran and the increasing popular interest in Persian medicine and the use of traditional and natural medications, the natural and traditional pharmaceutical market has seen remarkable growth in recent years.

22 Mojahedian MM, Zargaran A, Ayati MH. A decade of providing pharmaceutical services in Persian medicine, achievements, challenges and future horizons. Tehran: Iranian Teb; 2018. p.56

The causes of increased general interest of using natural and traditional drugs include historical use of these drugs, high costs of common drugs, in some cases ineffectiveness of treatment results in comparison with common drugs.

On the other hand, the number of companies producing these medicines is increasing.

The evaluation of natural and traditional pharmaceutical products aims to increase the availability of high-quality information on structures, processes and outcomes of natural and traditional pharmaceutical sectors of countries. This information will be collected via a questionnaire and is meant to be used by country decision-makers, pharmaceutical experts, international partners and regional reports.

4.2. Situation in Iran

Iran with 1.64 million km2 areas is located in the Middle East, with 33% of the land cultivable, 14 million km2 pasture, 60 million km2 steppe and 16 million km2 desert. Iran has 11 climates out of 13 world climates. The geographic location of Iran and the special condition of the climate and altitude, 26 meters below sea level up to 1774 meters in Damavand mountain top, provides a suitable environmental situation for the growth of various and unique plant species.23 There are 8000 kinds of Herbs in Iran that probably contains 2250 medicinal plant species. Also, 450 kinds from which are on sale in the traditional herbal shop (Attari) throughout Iran. Distillates are from the most common usages of the plants.24

23 Rezaei A. A Survey on the Situation of Traditional Iranian Medicine and its History in Iranian Herbal Research. Med Hist J 2017;9(32):71-84 24 Nikbakht A, Kafi M, Haghighi M, editors. The abilities and potentials of medicinal plants production and herbal medicine in Iran. VIII International People-Plant Symposium on Exploring Therapeutic Powers of Flowers, Greenery and Nature 790; 2004.

According to the Law on medical, pharmaceutical, and food and drinking regulations, adopted by the Islamic Consultative Assembly in 1955, the ministry of health, treatment and medical education is responsible for policy making in the field of natural and traditional products25.

The activities of the ministry of health in the field of plant products began in 1981 at the same time as the start of activity of the pharmaceutical companies for natural products in Iran.

Due to the increase of production of herbal and natural medicines and the country's capacity to enter the global trade market, the regulatory system and structures to control of the natural and traditional products was formed. This structure is a general directorate for Monitoring and Evaluation of Natural, Traditional and Supplemental Products Administration in the Iranian Food and Drug Organization, since 2013, and has continued its activities at a wider level until now.4

The activities of this administration include issuing, renewal and correction of the licenses for the establishment, production, registration of raw materials, import, assessment and supervision of factories and monitoring of distribution.26

Use of medicinal plants in the treatment of disease in Iran are performed in two ways: 1- Standard pharmaceutical products in various dosage forms such as tablets, syrups, ointments, drops, etc. for distribution in the pharmacies and prescribing by physicians. 2- Traditional medicine products that is based on the regulation of the preparation and distribution of traditional medicine products announced in December 2006 and usually prescribed by Persian medical specialists.

25 https://www.fda.gov.ir/ (accessed in September 1, 2019) 26 Report of head of Monitoring and Evaluation of Natural, Traditional and Supplemental Products Administration. 2017

Although, medicinal plants are used as self-medication (without prescription) in bulk and are available in “Attari” which is not under the control of ministry of health.

According to the statistics of 1396 HA (2017), the permits ratio of natural products to synthetic drugs is 21.9%, traditional drugs to synthetic drugs are 9.2% and the proportion of total natural and traditional drugs is 31.1%. According to the same report, in 59 categories of diseases, there are related natural drugs that are most focused in respiratory, digestive and sedative diseases. Also, in 39 categories of diseases, there are licensed traditional drugs in Iran.5

In the field of natural medicines, 2868 products are licensed for production, and 1132 traditional products are licensed until now.27

Also, the number of permits for the manufacturing of raw herbal materials (extracts and essential oils) is 406 licenses.6 Moreover, the number of plants used in these natural products is 326 plants.1

At present, only 56 of the natural medicines are covered by insurance, and none of the traditional medicines are covered by insurance.6

Total number of licensed manufacturers for natural products and traditional medicines are 103 and 86, respectively.6

Table 4.1 demonstrates number of natural products and the number of licenses of raw materials production (extracts and essential oils) from March 2000 to July 2018. Moreover, number of traditional products from March 2000 to July 2018 is summarized in table 4.2.

In the following, the information on natural, traditional medicines is classified in 12 sections.

27 Report of Monitoring and Evaluation of Natural, Traditional and Supplemental Products Administration. 2019

Table 4.1. Number of natural products and licenses for raw materials production (extracts and essential oils) from March 2000 to July 2018

Number of Number of Number of Number of natural products added natural licenses for added in the list products, per raw licenses for year materials raw production materials, per (extracts year and essential oils)

2000 74 30 16 16

2001 96 22 33 17

2002 105 9 37 4

2003 112 7 41 4

2004 123 11 49 8

2005 134 11 56 7

2006 217 83 78 22

2007 301 84 105 27

2008 382 81 131 26

2009 489 97 158 27

2010 587 69 187 29

2011 718 131 208 21

2012 938 220 260 52

2013 1050 112 297 37

2014 1283 233 331 34

2015 1597 314 357 31

2016 2066 469 382 25

2017 2416 350 390 8

2018 2485 69 390 0

Table 4.2. Number of traditional products, licensed by Iranian FDA from March 2000 to July 2018

Number of traditional products Number of added traditional in the list products each year

2007 2 2

2008 7 5

2009 25 18

2010 50 25

2011 69 19

2012 190 121

2013 298 108

2014 446 148

2015 655 209

2016 885 230

2017 1025 140

2018 1031 6

4.3. Indicators

A. Total natural and traditional pharmaceutical expenditure

Definitions: The sum of the price paid for natural and traditional pharmaceutical products multiplied by the amount of each item purchased.

Statistics: Total expenditure in pharmaceutical market except natural and traditional pharmaceutical is 230,000 billion Rial. It is estimated that the total market size for medicinal herbs and natural and traditional pharmaceuticals is about 5% of total pharmaceutical market that is about 12000 billion Rial.

There is no data about market size of natural and traditional pharmaceuticals.

B. Total public expenditure on natural and traditional pharmaceuticals

Definitions: The amount of money that is spent by government or insurance companies for natural and traditional pharmaceutical products

Statistics: There are different public insurance companies. One of the most important insurance organization is Iran health insurance organization which cover 50% of Iranian medical care. There are about 56 generic code in insurance list. They are different dosage forms and brands of 22 herbal medicine.

Percentage: There isn’t sufficient information on the amount of sales of herbal medicines (Rial)

C. Total private expenditure on natural and traditional pharmaceuticals

Definitions: The amount of money that is spent by people as out of pocket (OOP) for natural and traditional pharmaceutical products.

Statistics: Cost of most of herbal and traditional medicine are paid by people as (OOP)

D. Total number of natural and traditional pharmaceuticals licensed/registered

Definitions: Each drug must be licensed by the IRAN Food and Drug Administration before entering the market and prescribed by physicians and sold in pharmacies. This is number of legal and licensed natural and traditional pharmaceuticals.

Statistics: Number: 2868 (natural pharmaceuticals until now)

Number: 1132 (traditional pharmaceutical until now)

Trend:

Total number of traditional pharmaceuticals licensed

1200 1101 1025 1000 885

800 655 600 446 400 298 190 200 50 69 2 7 25 0

1386 1387 1388 1389 1390 1391 1392 1393 1394 1395 1396 1397

Total number of natural pharmaceuticals licensed

3000 2794

2416 2500 2066 2000 1597 1500 1283 1050 938 1000 718 587 489 500 382 217 301 123 134 26 44 74 96 105 112 0

1377 1378 1379 1380 1381 1382 1383 1384 1385 1386 1387 1388 1389 1390 1391 1392 1393 1394 1395 1396 1397

E. Annual growth rate of total natural and traditional pharmaceuticals market value (%)

Definitions: The trend of value derived from natural and traditional pharmaceuticals market (Rial)

Statistics: No data

F. Number of licensed natural and traditional pharmaceutical manufacturers in the country

Definitions: Each company must be licensed by the IRAN Food and Drug Administration before manufacturing any medicine. This is number of legal and licensed natural and traditional pharmaceutical companies.

Statistics: Number of natural pharmaceuticals: 103 (until now)

Number of traditional pharmaceuticals: 163 (until now)

G. Number of natural and traditional pharmaceutical manufacturers that are Good Manufacturing Practice (GMP) certified

Definitions: Good manufacturing practices (GMP) are the practices required in order to conform to the guidelines recommended by agencies that control the authorization and licensing of the manufacture and sale of natural and traditional pharmaceutical

Statistics:21 manufacturers are GMP certified

H. Percentage mark-up between manufacturers’ and consumer prices

Definitions: Markup is the difference between the selling price of natural and traditional pharmaceuticals and their cost. It is often expressed as a percentage over the cost. markup = gross profit/wholesale cost.

Statistics: Mark up for natural and traditional pharmaceuticals is about 22% in pharmacies of health centers.

I. Existence and year of last update of a published national medicines policy

Definitions: Existence of an official National Natural and Traditional Medicines Policy, expressed as a yes/no indicator, and updated within the past five years.

Statistics: Yes

J. Average dispensing time

Definitions: This is waiting time from the time the prescription is delivered to the pharmacy until pharmacy delivered the natural and traditional medicine to the patient with recommendation about their usage.

Statistics: Average dispensing time in Tehran pharmacies of health centers is 5.5 minutes.

K. Total number of traditional pharmacists per1milion population

Definition: The number of PhD graduates and students in the fields of Traditional Pharmacy in Iran (September 1, 2019)

Statistics: There are 45 students of traditional pharmacy and 56 graduated in Iran. Totally 101 people are qualified to deliver service in traditional pharmacy. It is about 1.26 traditional pharmacist per 1 million people in Iran.

L. Total number of traditional medicine Experts per1 million population

Definition: The number of PhD graduates and students in the fields of Traditional Medicine in Iran (September 1, 2019)

Statistics: There are 402 students of traditional medicine and 246 graduated in Iran. Totally 648 people are qualified to deliver service in traditional medicine. It is about 8.1 traditional medicine expert per 1 million people in Iran.

M. Total number of traditional pharmacies

Definition: Every traditional health center has a traditional pharmacy to prepare and deliver natural and traditional medicine to patients.

Statistics: There are 50 public health centers and traditional pharmacies and 14 private health centers and traditional pharmacies in Iran.

N. Number of annually ADR (Adverse Drug Reactions) reports

Definition: Reports of adverse drug reaction of medicine are compiled by ADR center in Iran FDA.

Statistics: Data for ADR of natural and traditional medicine aren’t available systematically.

O. Availability

Definition: Number of medicines shortage in traditional pharmacies

Statistics: Except 14 ITEM which imported from India, there is no shortage in traditional pharmacies.

These 14 medicines are on registration process to produce in Iran.

P. Affordability

Definition: The affordability of treatment was estimated as the number of days’ wages the lowest-paid government worker would be required to pay to purchase from the private sector a one-month course of medicine at the standard or common dose.

Statistics: Lowest-paid government workers receive 15170000 Rial monthly and 505000 Rial daily. The average price of visit is 265000 Rial and average price for a prescription is 900000 Rial. For a period of 1-month treatment, the patient should pay 2.3 day of his wage.

Q. Geographical accessibility

Definition: Average distances to get to the traditional pharmacies

Statistics: In Tehran it’s estimated to be 8 km.

R. Average number of medicines prescribed per encounter

Definition: The number of natural and traditional medicine in a prescription.

Statistics: 4.7 medicine per prescription.

S. The patient’s knowledge of consumption instruction

Definition: After consulting with pharmacist, patients were asked about correct dosage, duration of medical therapy, time to next visit and consumption instruction and then They were rated as poor, medium and good on the Likert scale.

Statistics: 38% of patients were good

39% of patients were medium

23% of patients were poor

T. Average consultation time

Definition: Average time spend for Getting a biography and consulting patients about their disease and administration of medicine.

Statistics: This is about 3.1 minutes for traditional pharmacists and 17 minutes for traditional physicians.

W. Supervision status of traditional pharmacies

Definition: Inspection of traditional pharmacies is under the supervision of IRFDA. Also traditional medicine department in universities of medical science evaluate these pharmacies for their quality of service delivery.

Statistics: IRFDA inspect these pharmacies quarterly

Department of traditional medicine inspect these pharmacies monthly.

X. Trend of giving license to health centers

Definition: Number of health centers in the first year of establishment of faculty of traditional medicine vs now

Statistics: 10 years ago, in the first year of establishment of faculty of traditional medicine there were 5 health centers and today there are 64 health centers in Iran.

4.4. Challenges and strength points

Persian medicine is a valuable treasure of the scientific achievements and experiences of Persian physicians and pharmacists over the centuries from the ancient to the Islamic era. Also, it is a great source of health and therapeutic ideas for finding ways to improve lifestyle, treatments and prevention methods, and find new medications based on indigenous knowledge. One of the most prominent features of the Persian medicine from the past until now is the availability of medications for the treatment of various diseases.

However, due to the increasing Persian medicine physicians who administer Persian medicine medications for treating their patients, as well as increasing the people request for usage of these medications, supplying, distributing and consuming Persian medicine medications should be improved by appropriate policies and regulations.

The following is a list of the strong and weak points of the existing traditional and natural products of Iran.

4.4.1. Strength points:

. Ancient history of Persian medicine as well as a wide variety of native medicinal plants. . The support of the sovereignty of the country from the subject of Persian medicine. . The presence of active professors and researchers in the field of medicinal plants, traditional pharmacy and their effectiveness. . The existence of research centers for medicinal plants and traditional medicine related to the ministry of health and ministry of science . Existence of supportive regulations and policies.

. The various climate of Iran, herbal cover 2 to 3 times all species in Europe. . Feasibility to grow plants that are not native to Iran. . The feasibility of producing pharmaceutical raw materials from medicinal plants of the country. . Increasing people's tendency to usage of natural and traditional medicines. . Geographic location of the country to export natural and traditional products. . Ability to export and in the field of medicinal herbs or natural remedies . The presence of Persian medical specialists and their increase in the country and the administration of more natural and traditional remedies.

4.4.2. Challenges:

. Lack of insurance coverage for many natural and traditional medicines. . Not paying enough attention to production standards. There is not make much progress in exporting these medicines. . Lack of primary standardization of domestic and imported natural resources (medicinal plants) in the manufacture of natural and traditional products. . Lack of proper investment in the production and export of natural and traditional products . The lack of a comprehensive drug index of natural and traditional drugs. . The lack of a comprehensive pharmacopoeia of natural and traditional drugs. . The lack of monitor the correct and accurate execution of national policies in the field of natural and traditional products.

. Absence of exclusive distribution companies for national and traditional products . The lack of available and accessible natural pharmacies to people. . Lack of management information system (MIS) about natural and traditional products. . Deficiency of proper guidelines for herbal therapy. . Lack of necessary indicators for making decision in this field (demographic index, distance index, …) . Deficiency of patents for natural and traditional products . Uncontrolled harvesting and post-harvest wastage of plants . Deficiency of quality control methods . The loss of people who had mastered the science of traditional medicine from their ancestors. . Attari's supervision are different from pharmacies and it is not under the control of the ministry of health.

4.5. Future perspectives

There are some subjects should be corrected or improved like:

Galenic remedies should be converted to the standard commercialized products. It needs to distribute traditional and natural products by special companies for them. Mostly, common distribution companies do not enough interest to do it and it lead to some problems to accessibility of traditional and natural products. Also, special pharmacies for traditional and natural products should spread in the society, especially as private sector. It needs to facilitate accessibility of such drugs and also to replace some Attaris illegal activities selling natural products. The insurance coverage for traditional and natural products should be

59 increased. A comprehensive pharmacopoeia of natural and traditional product should be written by Iranian FDA.

Chapter 5 Health Systems Financing 5.1. Introduction

Health financing is fundamental to the ability of health systems to maintain and improve human welfare. On the other hand, health financing refers to the “function of a health system concerned with the mobilization, accumulation and allocation of money to cover the health needs of the people, individually and collectively, in the health system. At the extreme, without the necessary funds no health workers would be employed, no medicines would be available and no health promotion or prevention would take place.

The purpose of health financing is to make funding available, as well as to set the right financial incentives to providers, to ensure that all individuals have access to effective public health and personal health care”28.

Today, due to sedentary jobs, changing lifestyles, aging populations and consequently increasing disease rates especially life-style diseases, cost- effective prevention and treatments are required.

As the uptake of traditional and complementary medicine (T&CM) increases, there is a need for its closer integration into health systems. Policy makers and consumers should consider how traditional and complementary medicine may improve patient experience and population health.29

The T&CM sector now plays a significant role in the economic development of a number of countries. At the same time, with prevailing current global financial constraints, use of T&CM for health promotion, self-health care and disease prevention may actually reduce healthcare costs.2

These goals cannot be achieved without some form of prepayment and the subsequent pooling of the collected revenues, i.e. people pay into a pool when

28 In 2005, WHO Member States endorsed a resolution urging governments to develop health financing systems aimed at attaining and maintaining “universal coverage” — described as raising sufficient funds for health in a way that allows access to needed services without the risk of a financial catastrophe. 29 WHO Traditional Medicine Strategy, 2014-2023

62 they are healthy and can draw on these funds when they are sick. Participated funds can be derived from tax or health insurance contributions and in most countries; they come from a mix of sources.

On the other hand, when payment from the patient is out of pocket, treatment may not be complete and resistance may develop, so that patients continue treatment is required to insurance coverage.

5.2. Situation in Iran

The relation between medicine and economy had a long history since ancient times. The system of paying physician fees for office visits since at least the Achaemenid Kingdom (550-330 BCE) in ancient Persia. This system was based on the economic status of people and free insurance, were founded for the benefit of the patient. In this history, the social and economic status of physicians was very important and the fee for the office visit was paid before the doctor started the treatment30. Also, numerous facilities are provided for patients in the ancient Persia. This may be because of the effect of religious texts which recommended providing facilities for patients. The aim of Persian social politics was providing of free and accessible health care for everybody31.

The WHO has defined three types of health systems to describe the degree to which T&CM is an officially recognized element of healthcare: the integrative system, the inclusive system and the tolerant system32. In countries with a tolerant system, the national health care system is based entirely on allopathic medicine, but some T&CM practices are tolerated by law. It seems that T&CM is part of the tolerance system in Iran.

30 Tadjbakhsh H. The history of veterinary and medicine in Iran. Tehran: Tehran University. 2000. [in Persian] 31 Yarmohammadi H, Mojahedian MM, Zargaran A. Medicine and Economy in Ancient Persia. Research on History Medicine. 2012; 1(3). 32 World Health Organization (2002). Traditional Medicine Strategy 2002–2005. Geneva: WHO

The health sector is one of the key sectors of a country's economy that is considered to be the underlying sector in the process of economic development, with most countries paying particular attention to this sector.

In 2018, the total budget of the country reached 1 trillion dollars, of which 5.5% is allocated to the Ministry of Health.

The diagnostic and treatment tariffs in Iran are approved by ministry of health and declared annually based on the book of “Relative Value of Health Services”. Introducing Persian medicine services to the book of Relative Value of Health Services in the last years is a valuable achievement of the Persian Medicine Office at the Ministry of Health and Medical Education. Tariffing these services is actually recognized in the country's health system and is a prerequisite for insurance coverage (Table 5.1). But, none of them are covered by public insurance in Iran at present time.

Table 5.1. Persian medicine service prices (IR Rial)

Title of service Price in public Price in private Price for trained sector for MD, sector for MD, GPs PhDs PhDs

Dry cupping (cold 121200 Rial 283600 Rial 226880 Rial Badkesh) 1.001 Euro 2.344 Euro 1.875 Euro

Dry cupping with 151500 Rial 354500 Rial 283600 Rial massager (hot 1.252 Euro 2.930 Euro 2.344 Euro Badkesh)

Wet cupping 238920 Rial 555000 Rial 444000 Rial

1.974 Euro 4.587 Euro 3.670 Euro

Leech therapy 218550 Rial 501250 Rial Not authorized (first two leeches) 1.806 Euro 4.142 Euro

Each extra leech 99550 Rial 231250 Rial Not authorized

0.823 Euro 1.911 Euro

Venesection 398200 Rial 925000 Rial Not authorized (Fasd) 3.290 Euro 7.644 Euro

Fumigation 121200 Rial 283600 Rial Not authorized (Enkebab) 1.001 Euro 2.344 Euro

Enema (Hoghneh) 333300 Rial 779900 Rial Not authorized

2.754 Euro 6.445 Euro

Massage or 123760 Rial 280800 Rial 280800 manual techniques 1.023 Euro 2.320 Euro (Dalk and Ghamz)

Maggot therapy (in 222900 Rial 516500 Rial Not authorized each area) 1.842 Euro 4.268 Euro

Instructing health 66640 Rial 151200 Rial 151200 Rial surveillance 0.550 Euro 1.249 Euro 1.249 Euro essentials

Nutritional 238000 Rial 540000 Rial Not authorized counselling (in- 1.967 Euro 4.462 Euro patient)

Nutritional 171360 Rial 388800 Rial Not authorized counselling 1.416 Euro 3.213 Euro (outpatient)

Using instruments 102160 Rial 240400 Rial Not authorized for examination 0.844 Euro 1.987 Euro and medical data analysis

At present, only 56 of the natural medicines are covered by insurance.33 (Table 5.2.)

Table 5.2. List of herbal medicines covered by insurance Name Dosage form Lab/ Company

1 Alpha Ointment Alpha

2 Leucorex Vaginal cream Barij Essence

33 Report of Monitoring and Evaluation of Natural, Traditional and Supplemental Products Administration in 2019

3 Figitol Syrup Darou Darman Pars

4 Figplus Syrup Darou Darman Pars

5 Spinal-Z Capsule Daru Pakhsh

6 C-Lax Tablet Dineh Iran

7 Calendula Ointment Dineh Iran

8 Psyllium Sachet Dineh Iran

9 Gripe water Oral solution Dineh Iran

10 C-Lax Tablet (Blister) Dineh Iran

11 Phytho-lax Capsule Gol Daru

12 Prostatan Drop Gol Daru

13 Sankol Drop Gol Daru

14 Perforan S.C Tablet Gol Daru

15 Prostatan F.C. Tablet Gol Daru

16 Senaline 7.5 S.C Tablet Gol Daru

17 Memoral Capsule Gol Daru

18 Senagole Syrup Gol Daru

19 Golgripe Oral solution Gol Daru

20 Odorata Syrup Gol Daru

21 Mycocin Vaginal cream Gol Daru

22 Herbilax Capsule Herbi Darou

23 Psyllium Sachet Herbi Darou

24 Anethum Tablet Iran Darouk

25 Psyllium Sachet Iran Darouk

26 Psyllium Powder Iran Darouk

27 Musylium sugar free lime Powder Iran Darouk flavor

28 Caraway mixture Oral solution Iran Darouk

29 Senagraph Syrup Iran Darouk

30 Senalax Tablet (Jar) Iran Darouk

31 Senalax Tablet (Blister) Iran Darouk

32 Anethum Tablet (Blister) Iran Darouk

33 Musylium Sachet Iran Darouk

34 Musylium with orange Sachet Iran Darouk flavor

35 Musylium with banana Sachet Iran Darouk flavor

36 Musylium with strawberry Sachet Iran Darouk flavor

37 Psyllium musciloid Powder Niak

38 Hesa-A F.C. Tablet Osveh

39 Gripe mixture Syrup Pars Minoo

40 Angi pars Capsule+Cream Pars Roos

41 Boldulax F.C. Tablet Pursina

42 Figsin Syrup Pursina

43 Hypiran F.C. Tablet Pursina

44 Hypiran Drop Pursina

45 Psyllium (orange flavour) Sachet Pursina

46 Psyllium (banana flavour) Sachet Pursina

47 Carmint Drop Pursina

48 Molayen Hemoroid Capsule Rashtchi

Ghadimi- Javad

49 Fijan (60ml) Syrup Razak

50 Fijan (120ml) Syrup Razak

51 Angi Pars Capsule Rosepharmed

52 Angi Pars Cream Rosepharmed

53 Psyllium orange Sachet Rouz Darou

flavored

54 Rouz-psyllium Sachet Rouz Darou

Husk

55 Rouz-psyllium Seed Granule Rouz Darou

56 Samilax Tablet Samisaz

5.3. Indicators

A. Total natural and traditional pharmaceutical expenditure

Definitions: The sum of the price paid for natural and traditional pharmaceutical products multiplied by the amount of each item purchased.

There is no data about market size of natural and traditional pharmaceuticals.

B. Percentage mark-up between manufacturers’ and consumer prices

Statistics: Mark up for natural and traditional pharmaceuticals is about 22% in pharmacies of health centers.

C. Affordability

D. Total public expenditure on natural and traditional pharmaceuticals

Definitions: The amount of money that is spent by government or insurance companies for natural and traditional pharmaceutical products

Percentage: There isn’t sufficient information on the amount of sales of herbal medicines (Rial)

E. Total private expenditure on natural and traditional pharmaceuticals

Definitions: The amount of money that is spent by people as out of pocket (OOP) for natural and traditional pharmaceutical products.

Statistics: Cost of most of herbal and traditional medicine are paid by people as (OOP)

5.4. Challenges and weak points

Iran has increased investment in health during the last ten years. According to official data, more than 90% of Iranian people are under the coverage of at least one kind of health insurance. But traditional medicine services are not covered by any insurance. However, traditional medicine could potentially account for a high share of household expenditure on healthcare. Accordingly, almost all health investment indices have improved during the above-mentioned period; in some cases, the index has tripled. Nonetheless, almost 100% of traditional

71 medicine spending is paid out of pocket. There is an acceptable registry system for births, deaths, cancer, and many communicable and non-communicable diseases and immunization in Iran. Lack of an integrated health information system is a stumbling block on the way to conducting systematic analysis of the traditional medicine system. Apart from analysis of the process and outcome, patients’ satisfaction is a cornerstone of health system performance. Lack of accurate data on patients’ satisfaction is a major impediment in the traditional policy-making process in Iran. The quality of services and efficiency of the traditional system are two major issues that need more attention that insurance coverage can help a lot.

5.4.1. Strength point:

 Introducing traditional medicine services to the book of Relative Value of Health Services 

5.4.2. Challenge:

 Lack of insurance coverage for traditional pharmaceutical products and traditional medicine services

5.5. Future perspectives

Traditional medicine practice and services and also more natural and traditional products should be covered by public insurance in the future.

Chapter 6 Leadership and governance

6.1. Introduction The use of natural medicines, especially traditional and complementary medicine, has enjoyed widespread and growing reception in different communities throughout the world over the past decades, and this has led to the requirement for health systems in many countries to focus on these structures that are mostly deeply-rooted in the history and cultures of various countries. Meanwhile, countries like Iran with medical systems rooted in their civilization, history and culture have a higher privilege in using and taking advantage of this opportunity to transfer part of the burden of community health on these traditional structures, which are based on ethnic and acceptable knowledge from a cultural and social point of view. The economic, therapeutic and cultural potential of traditional and ethno medicine is, on the one hand, a very important opportunity for health policy and can be used to adjust the health of society from the perspective of either prevention and or treatment. On the other hand, this growing opportunity can be a threat to regarding possible misuses and endangering the health of the community. Therefore, considering these two important aspects in traditional medicine, as well as the principle of democracy in choosing a treatment method, one can neither reject nor ignore this opportunity, nor can one accept the unconditional practice of this method by anyone claiming clinical ability. Therefore, at various international levels, especially in relevant international organizations as well as developed countries, regulatory and policy-making structures, as well as policy documents for defining and regulating this important issue have been generated.

In Iran, traditional medicine has entered the academic system since 2007. For two years, this course was in master degree, but then, due to the wide range of topics and the need for more time to reach the desired level of information in this field, this course has changed from master to Ph.D. and up to now, has

74 trained many students at the PhD level. As a result, traditional medicine in Iran since 2007 is under the supervision of the Ministry of Health and is governed by it.

6.2. Situation in Iran

6.2.1. Governmental documents related to Persian medicine

There are many governmental documents to support and promote Persian medicine, medicinal herbs and natural products in high levels, in the country. Some of the most important ones are given as follows:

6.2.1.1. General Health Policies Announced by the Supreme Leader Paragraph 12 of the General Health Policy, issued by the Supreme Leader (April 2014), deals with the subject of traditional medicine as follows:

12. Recognition, explication, promotion, development and institutionalization of traditional Persian medicine.

12.1 Promoting of the cultivation of medicinal plants under the supervision of the Ministry of Agriculture and supporting the development of scientific and technical innovations in the production and supply of traditional pharmaceutical products under the supervision of the Ministry of Health, Treatment, and Medical Education.

12.2 Standardization and updating of diagnostic and therapeutic methods of traditional medicine and related products.

12.3 Exchange of experiences with other countries in the field of traditional medicine.

12.4 Supervision of the Ministry of Health, Treatment and Medical Education on the provision of traditional medicine services and herbal medicines.

12.5 Establishing a logical interaction and exchange between traditional medicine and modern medicine for the synergy of experiences and therapeutic approaches.

6.2.1.2. Sixth Five-Year Plan of Economic, Social and Cultural Development of the Islamic Republic of Iran (1396-1400 AH) released by Parliament Bill of the Sixth Five-Year Plan of Economic, Social and Cultural Development of the Islamic Republic of Iran (1396-1400 AH)

The items related to traditional medicine in the bills of the 6th five-year plan of economic, social and cultural development of the Islamic Republic of Iran (1396-1400 AH) are as follows:

Article 72 – Clause C – Note 2: The Ministry of Health, Treatment, and Medical Education is required to make a list of traditional herbal remedies and herbal products.

Article 74 – Clause G: In order to comply with Clause (12) of the General Health Policy, the Ministry of Health, Treatment, and Medical Education, as the trustee of traditional Persian-Islamic and complementary medicine, is required to integrate approved Persian-Islamic traditional medicine in the health system. It also is responsible for organizing and developing educational, research and therapeutic services in this field.

6.2.1.3. National Document of Medicinal Plants and Traditional Medicine released by Supreme Council for Cultural Revolution The approval of “The National Document of Medicinal Plants and Traditional Medicine”, with reference to Section A, Clause 5-1, Chapter 5 of the Scientific Comprehensive Plan of the Country, has been finalized on Tuesday, 2013/02/30, at the 32nd council meeting of the Committee for the Implementation of the Comprehensive Scientific Plan and approved on 2014/4/25 has been approved by the Supreme Council of the Cultural Revolution. It is a top level document that is a road map for the country to promote Persian Medicine in Iran (Appendix 4).

6.2.2. Organizations and structures related to Traditional and Integrative Medicine in Iran

There are many structures for promoting and making policy as well as scientific and educational activities for traditional medicine in the government of Iran and also as NGOs or in the Universities.

6.2.2.1. Governmental structures of the executive and policy-making constituency

6.2.2.1.1. Headquarters for the Development of Science and Technology of Medicinal Herbs and Traditional Medicine

Head of the Department: Dr. Mohammad Hasan Assareh (Ph.D. in Plant Biotechnology, Faculty Member, Seed and Plant Certification and Registration Research Institute)

Website: http://chtm.isti.ir/

Since October 2008, the "Headquarters for the Development of Science and Technology of Medicinal Herbs and Traditional Medicine", by becoming the intersection, convergence point, and connecting loop of all the actors in the field of medicinal herbs and traditional medicine, has started its activities in the Office of Vice-President for Science and Technology. As a national meta- organization, this headquarters, which is the coordinator of related government agencies, popular organizations and institutions, as well as private organizations, can follow-up and implement inter-organizational interactions to achieve specific goals.

6.2.2.1.2. Persian Medicine Office of the Ministry of Health, Treatment, and Medical Education

Director General of the Office: Dr. Mohammad Reza Shams Ardekani (Ph.D. of Pharmacognosy, Professor, School of Pharmacy, Tehran University of Medical Sciences)

Website: http://pm.behdasht.gov.ir/

In 2013, with the decision of the Special Representatives of the President in the Task Force on the Recovery and Development of the Traditional Medicine System based on Article 130 of the Constitution of the Islamic Republic of Iran and the directive of the First Vice-President of the Islamic Republic of Iran, the Deputy Directorate of Iranian-Islamic Traditional Medicine was formed in the Ministry of Health, Treatment, and Medical Education, being renamed as the Iranian-Islamic Traditional Medicine Council, chaired by the Minister of Health, Treatment, and Medical Education. This Deputy Directorate downsized into a General Directorate in March 2016 (Persian Medicine Office). Follow up and management of the affairs related to traditional medicine and complementary medicine in the Ministry of Health, Treatment, and Medical Education, as well as interacting with the relevant structures within the Ministry's body are the responsibilities of this General Directorate.

6.2.2.1.3. General Directorate of Natural and Complementary Medicine of the Food and Drug Administration

Director General: Dr. Mahnaz Khanavi (Ph.D. of Pharmacognosy, Professor, School of Pharmacy, Tehran University of Medical Sciences)

Website: http://www.fda.gov.ir/item/1110

Simultaneous with the commencement of activities by plant production units, the expert group of plant products started to officially supervise plant products from the Food and Drug Administration at the Ministry of Health, Treatment, and Medical Education since 1981. In 1997, the Office of Herbal Medicine was recognized in the chart of the Food and Drug Administration as one of the subsidiaries of the General Directorate of Monitoring Food and Drug. With the increasing variety of natural products, in order to focus more on these products, in January 2006, the Office of Herbal Medicines was renamed to the Office of Natural Medicine. In accordance with Article 34, paragraph 5 of the Law of the Fifth Development Plan and the Promotion of the Document on the Development of Iranian-Islamic Traditional Medicine, and the increasing development of these products in May 2013, the General Directorate for Monitoring and Evaluation of Natural and Traditional Medicines was formed, and, in October of the same year, with the merger of the Complementary products, the General Directorate of Natural, Traditional and Complementary Products was created. One of the subsidiary offices of this General Directorate is the "Administration of Traditional Medicines". According to the definition, Iranian medicine products are products that have been mentioned more frequently in reference books of traditional Iranian medicine, and the

80 preparation of these products is limited to those mentioned in reference books of Persian Medicine.

The principal task is to monitor the quality, safety and effectiveness of these products through the examination of production records for domestic and imported production and issuance or licensing of production and entry, monitoring domestic production, imports, production under license, contract manufacturing, transfer of technical knowledge, extending license or license to manufacture and import products. The issuance of licenses for the establishment of production companies and correspondence related to these matters, as well as the preparation and establishment of rules and regulations, are also the responsibility of this General Directorate. The purpose of this department is to make high quality, safe and effective products for humans.

6.2.2.2. NGOs and Non-governmental Organizations

6.2.2.2.1. Medical Council

Commission Chairman: Dr. Mahmoud Fazel (Pharmacist)

In the Medical Council of the Islamic Republic of Iran, as the largest and most important group of Iranian medical practitioners who oversee the current affairs of this profession and its related sciences, a Commission has been established as the Consultative Committee on Traditional and Complementary Medicine and Cultural Heritage of Health, which, with the presence of experts and activists in this area, and in accordance with the defined missions, provides the necessary guidance to the Supreme Council of Medicine.

6.2.2.2.2. Traditional Persian Medicine Association

Chairman of the Board of Directors: Dr. Abdollah Bahrami (Internal Medicine Specialist and Professor of Mashhad University of Medical Sciences)

Website: http://www.itma.ir/

The Traditional Persian Medicine Association joined the Ministry of Health, Treatment, and Medical Education in 2007. This association is a non- governmental organization that works in accordance with the common statute of the scientific associations of the Ministry of Health. The target group and its members are graduates of the field of traditional medicine, pharmacy, and affiliated disciplines. This community is a scientific institution about the specialties of Persian medicine. The Traditional Persian Medicine Association is

82 a colleague to the School of Persian Medicine of Tehran University of Medical Sciences in the publication of a scientific-research journal in English titled Traditional and Integrative Medicine.

6.2.2.2.3. Persian Medicine Foundation

Chairman of the Board: Dr. Ali Akbar Velayati (Specialist in Infectious Diseases of Children and Professor of Shahid Beheshti University of Medical Sciences)

Website: http://ipmf.ir

The Persian Medicine Foundation (non-governmental and non-profit) is headed by Dr. Ali Akbar Velayati, and is in cooperation with the Health Assistance Society of the country that is chaired by Dr. Shahriari and is formed by the presence of a number of experts in the country. The Foundation's statutes are based on the positions of the Supreme Leader and matches Paragraph 12 of the General Health Policy as announced by the Supreme Leader and approved by the Ministry of Interior.

6.2.2.3. Academic and academic structures

6.2.2.3.1. Group of Wisdom, Islamic Medicine, and Traditional Medicine in Academy of Medical Sciences

Head of Group: Dr. Ali Akbar Velayati (Specialized Infectious Diseases of Children and Professor of Shahid Beheshti University of Medical Sciences)

/حکمت-،-طب-اسالمی-و-طب-سنتیWebsite: http://www.ams.ac.ir/index.php

The Iranian Academy of Medical Sciences, as a scientific institution in the field of medical sciences in Iran, has a group called "Wisdom, Islamic Medicine, and Traditional Medicine" which is active regarding scientific activities, consisting of relevant specialists in the form of two sub-groups, namely the Department of Basic Sciences and History of Iranian Medicine, and the Department of Medicinal Herbs. One of the major scientific programs of this group is the holding of specialized meetings in the fields of history and philosophy of medicine and Persian medicine, the publication of the encyclopedia of traditional medicine, and the publication of the Farsi Journal of Traditional Medicine of Islam and Iran.

6.2.2.3.2. Educational groups at universities

Since 2006, with the license of establishing of the field of traditional medicine, academic structures in the form of Persian Medicine Schools or related groups in schools of medicine and pharmacy have been formed, responsible for training students in the field of Persian medicine.

Specialized education in the Ph.D. level has been defined for three fields of Traditional Medicine in Iran (especially for medical graduates – M.D. – as applicants for this field), Traditional Pharmacy (especially for pharmaceutical graduates – Pharm.D. – as applicants for this field), and History of Medicine (the possibility of entering from different majors such as Pharm.D., M.D., D.D.S., Veterinary Medicine, as well as the Master of History of Medicine and Master of History of Science) the last of which accepted students on only one single occasion. There is also a Master Program of History of Medicine. This model, by limiting medical and pharmaceutical groups to the specialized responsibility of traditional medicine and pharmacy, has a high potential for integrating traditional medicine and pharmacy with conventional medicine, which is of the strengths of this model in Iran compared to other types of models in other parts of the world.

The number of graduates of these fields are given in Table 6.1. The introduction of Iranian schools of Persian Medicine and related groups is presented in the next chapter.

Table 6.1. The number of PhD graduates and students in the fields of Traditional Medicine and Traditional Pharmacy in Iran (September 1, 2019)

Majors PhD Students Graduates

Traditional Medicine 402 246

Traditional Pharmacy 45 57

Apart from specialized training, for the lower levels, two virtual compulsory courses of traditional medicine and pharmacy have been determined for the majors of medicine, pharmacy, dentistry, nutrition, rehabilitation, nursing and midwifery, the provision of which is assigned to Virtual University of Medical Sciences, in collaboration with the Office of Persian Medicine at Ministry of Health, Treatment, and Medical Education. In this regard, the Department of Virtual Traditional Medicine at the above-mentioned university has been formed, and the educational content has been developed for the commencement of studies in these courses.

6.2.2.3.3. Research Centers in the Field of Persian Medicine

The formation of related research centers bears the responsibility of advancing the research goals of Persian medicine at universities. In the structure of the Ministry of Health, Treatment, and Medical Education, the Department of Scientometrics and the Monitoring and Evaluation Unit at the Office of Deputy- Minister for Research have begun working since 2007. According to the goals of the health-related research system, the evaluation of medical research centers since 2000, as one of the policies, was placed on the agenda of the Office of

Deputy-Minister for Research and Technology. This group deals with the evaluation of all medical research centers of the country on an annual basis by codified forms and related instructions. The latest report is for 2015-16, the results of which will be presented below. Of course, after this year, centers have been set up, or they have bene run in the form of offices of studies, which are not on this list, but will be introduced in the chapter on the introduction of research centers.

Based on the assessment score of 2015-16 and the z score, medical research centers of the country are categorized by this group as follows:

- Centers with clinical activities of 1 to 3 years (125 centers)

- Centers with clinical activities of over 3 years (193 centers)

- Centers with biomedical activity of 1 to 3 years (88 centers)

- Centers with biomedical activity of over 3 years (168 centers)

- Centers with an independent budget line (clinical) (23 centers)

- Centers with an independent budget line (biomedical) (13 centers)

The status of research centers related to Iranian medicine in the country is described in the table 6.2:

Table 6.2. Status of Clinical and Biomedical Research Centers Related to Traditional Medicine in the Country

Name of University Rank Total Number of Research Center Research Centers in Relevant

Category

Centers with clinical activities of 1 to 3 years

Centers with clinical activities of over 3 years

Centers with biomedical activity of 1 to 3 years

Centers with biomedical activity of over 3 years

Traditional Shiraz University 60 154 Medicine and of Medical History of Sciences Medicine Research Center

Traditional Tehran University 65 154 Medicine and of Medical Pharmacy Sciences Research Center

History of Tabriz University 75 154 Medicine of Medical Research Center Sciences

Traditional Shahid Beheshti 76 154 Medicine and University of Medicinal Plants Medical Sciences Research Center

Ethics and History Tehran University 103 154 of Medicine of Medical Research Center Sciences

Herbal and Kerman 104 154 Traditional Drugs University of Research Center Medical Sciences

Addiction- Mazandaran 109 154 Oriented University of Traditional and Medical Sciences Complementary Medicine Research Center

Traditional Shahed University 127 154 Medicine Clinical Trial Research Center

Centers with an independent budget line (clinical)

- - - -

Centers with an independent budget line (biomedical)

Research Institute Iran University of 11 11 for Islamic and Medical Sciences Complementary Medicine (RICM)

6.3. Indicators

A. National health strategy linked to national needs and priorities for Persian medicine: “The National Document of Medicinal Plants and Traditional Medicine” document (Appendix 4) released by Supreme Council for Cultural Revolution and signed by President and the Head of the Supreme Council for Cultural Revolution in July 2013 is the last national health strategy about Persian medicine in Iran.

B. Last update of a published national medicines policy: Document number 1 titled “General Health Policies Announced by the Supreme Leader” issued by the Supreme Leader (April 2014), section 12-1,

Document number 2 about the bill of the Sixth Five-Year Plan of Economic, Social and Cultural Development of the Islamic Republic of Iran (1396- 1400 AH) released by parliament, Article 72 – Clause C – Note 2,

Document number 3 titled “The National Document of Medicinal Plants and Traditional Medicine”, with reference to Section A, Clause 5-1, Chapter 5 of the Scientific Comprehensive Plan of the Country, which has been finalized on Tuesday, 2013/02/30, at the 32nd council meeting of the Committee for the Implementation of the Comprehensive Scientific Plan and approved on 2014/4/25 by the Supreme Council of the Cultural Revolution, Article 4: “Macro Policies” number 1,2,5,8,9,11, and in Article 5: “Objectives, Strategies and Measures”, article 5-1 is totally about the field of medicinal plants and herbal products.

C. Policies on medicines procurement that specify the most cost-eﬀective medicines in the right quantities; open, competitive bidding of suppliers for quality products

Document number 1 titled “General Health Policies Announced by the Supreme Leader” issued by the Supreme Leader (April 2014), section 12-1 and C section (Measures) in document number 2, titled “The National Document of Medicinal Plants and Traditional Medicine”, number 9, 11-16, 18, 20, and especially number 19 is related to policies on medicines procurement in Persian medicine and traditional pharmacy.

D. Key health sector documents that are disseminated regularly (such as budget documents, annual performance reviews and health indicators) “The National Document of Medicinal Plants and Traditional Medicine”, section 5-2 (Field of Traditional Medicine and Traditional Pharmacy), part A (Objectives), number 1-3 is related to budget goals which should be achieved.

E. Existence of mechanisms, such as surveys, for obtaining opportune client input on appropriate, timely and eﬀective access to health services There are a few scattered surveys which evaluated client situations in traditional medicine health systems which have done by academics and published as scientific articles which are available in reputable databases such as ISI and Scopus.

For example, a cross-sectional study was conducted on 260 patients with history of at least two referrals to the clinics of Iranian traditional medicine affiliated to TUMS in 2014. All participants completed the Persian version of Patient Satisfaction Questionnaire (PSQ-18). According to the results of this study,

91 more than 60% of the patients were satisfied with the provided services. The most common cause of patient dissatisfaction was poor technical quality (e.g., inadequacy of diagnostic and therapeutic equipment, inappropriate diagnostic methods, unsuitable patient examination and lack of confidence in physician’s ability for patient treatment), financial aspects of care (e.g., high costs of traditional medicine treatments) and poor doctor-patient communication (e.g., lack of attention and clear explanation of patient conditions on behalf of the physician).

In another cross‑sectional study that was conducted between July 2014 and July 2015 for assessing adherence to prescribed medications of Iranian traditional medicine in a group of patients with chronic disease, its sample size was 320 patients referring to the clinics of traditional medicine affiliated with governmental medical universities in Tehran (Tehran, Iran, Shahed and Shahid Beheshti Universities of Medical Sciences), Iran. Results showed that about 90% of participants had a low or moderate adherence and only 10% of patients reported high medication adherence. Forgetfulness, unavailability, bad taste, and high costs of drugs were reported as the most common factors influencing adherence. Age, marriage, and duration of disease are directly related to adherence during the number of prescribed drugs conversely influenced adherence.

6.4. Strength points:  The support at the highest levels of government in the form of at least three valid documents issued by the Supreme Leader, the Parliament and the Supreme Council for Cultural Revolution (presidency), in this area which was mentioned.  Have a clear road map for promotion of traditional medicine in Iran

 Existence of executive structures in the Ministry of Health (Persian medicine office), Parliament (Traditional medicine fraction), medical council and structures of public institutions (NGOs), scientific associations, universities and research centers.

6.5. Challenges:  Little authority of Persian medicine office in Ministry of Health.  The existence of multiple executive infrastructures, due to the lack of a unit management policy, sometimes leads to a parallel work or tasks interference with the other units.  The lack of a specific enough budget line for traditional medicine in the country

6.6. Future perspective Integration of the management policy of existing parallel structures and dedicating a clear budget line for traditional medicine promotion and development. Stablishing “Traditional Medicine Organization” with enough authority and budget and merging all the related structures into this can lead to better leadership and executive activities for traditional medicine in Iran.

Appendixes Appendix 1. the list of all clinical centers of Persian Medicine in Iran

1. Hospital ward

Currently, the only hospital center of Persian medicine is the following center:

1.1. Hospital Wards of Persian Medicine in Shaheed Rahnemoon Hospital

Address: Dr. Rahnemoun hospital, Farokhi St., Yazd

Tel.: (+98 35) 3626 0001

The Hospital ward of Persian Medicine has been established at the Shahid Rahnemoon Educational Hospital in Yazd with the aim of communicating and interacting directly with other specialists and using the therapeutic strategies of Persian medicine. In this way, the patient, in agreement with the doctor of modern medicine, is advised to use this medicine in accordance with the scientific rules of Persian medicine and in line with the usual treatment.

Number of Persian medicine specialists: 20

Number of Persian medicine students who visit the patients: 14

Number of trained personnel: 3

Number of active visiting rooms: 4

Number of rooms for manual interventions: 4

Average of daily/monthy visits: 10/-

Number of pharmaceuticals: -

2. Health centers

There are 23 university affiliated health centers all over Iran for Persian medicine service delivery as follows:

2.1. Behesht Health Center Affiliated with Iran University of Medical Sciences

Address: School of Traditional Persian Medicine, No. 847, Behesht St., Vahdat- e Eslami St., Hasan Abad Sq., Tehran

Tel.: (+98 21) 5558 0388

E-mail: [email protected]

Website: stm.iums.ac.ir

Introduction of Pharmacy: A traditional medicine drug store located on the ground floor of the School of Traditional Persian Medicine, serving since August 2012 under the supervision of the Iran University of Medical Sciences and trained by traditional pharmacy experts. The supply of specialized herbal medicines based on traditional medicine, herbal medicines, herbal substances, herbal distillates, herbal oils, honeys and pastes, specialized books on nutrition and health, and pharmaceutical consultation in the field of traditional medicine by traditional pharmacy experts are included in the services of this pharmacy.

Technical Officer: Dr. Lili Abdi (Ph.D. of Traditional Pharmacy)

Number of Persian medicine specialists: 15

Number of Persian medicine students who visit the patients: 12

Number of trained personnel: 8

Number of active visiting rooms: 10

Number of rooms for manual interventions: 2

Average of daily/monthy visits: 55/1210

Number of pharmaceuticals: 1100

2.2. Health Center of Babol University of Medical Sciences

Address: Shahid Qasemi St., Shahid Keshvari Sq., Babol

Tel.: (+98 11) 32253526

In 2012, the traditional medicine health center was opened in the presence of Dr. Seyyed Ali Mozaffarpour at the Shahid Beheshti Educational Hospital in Babol. The center began its activities with one day per week, which, following the public demand, was increased to two days per week early 2013.

With numerous efforts, the first independent Persian medicine health center of the country was established in February 2014 under the supervision of the Babol School of Persian Medicine, with the presence of Dr. Khodadust (adviser to the Minister and Head of the Persian Medicine Office of the Minister of Health) in an area of approximately 150 square meters. This health center is located on Shahid Qasemi Street, adjacent to the International Branch of the University. In addition to Dr. Seyyed Ali Mozaffarpour, 4 other traditional medicine specialists from among the faculty members also visit patients. In this center, there are two doctor's room, 2 specially-designed rooms for hand treatments (massage, hijamat, bloodletting, phlebotomy, and leech therapy) available for both men and women, as well as a pharmacy dedicated to medicinal plants and herbs.

Pharmacy of the Health Center:

Technical Officer: Dr. Narjes Gorji (Healthcare Manager)

Number of Persian medicine specialists: 5

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 4

Number of active visiting rooms: 3

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 40/880

Number of pharmaceuticals: 170

2.3. Baharan Health Center Affiliated with Tabriz University of Medical Sciences

Address: 7th Floor, Baharan Health Center, Azadi St., Tabriz

Tel.: (+98 41) 3335 9098 & 99

E-mail: [email protected]

Website: www.bsalamatkade.com

Baharan Traditional Medicine Health Center is the first of its kind in the northwest of Iran. Since 2015-16, it has been providing services at the site of Baharan Physicians' Building through the equipment of specialized medical units of Persian medicine with the help of trained and experienced personnel.

Active units in the health center include the units of triage, hygiene, dalk and qamz, gynecology and midwifery, enema, hand techniques and actions, etc., providing services to the patients thanks to the experienced staff, admitting 150 patients in two morning and afternoon shifts each day.

The research unit of this health center has recently been opened with the aim of expanding and developing explanatory and clinical research in the field of

98 traditional medicine. It has expanded its field of activity by recruiting Ph.D. students of traditional medicine and practicing specialist physicians.

The technical staff member of the health center is Dr. Seyyed Mustafa Araj Khodaei, a traditional medicine specialist and faculty member at the School of Traditional Persian Medicine, Tabriz University of Medical Sciences.

Number of Persian medicine specialists: 2

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 4

Number of active visiting rooms: 4

Number of rooms for manual interventions: 4

Average of daily/monthly visits: 40/1000

Number of pharmaceuticals: 950

2.4. Health Centers Affiliated with Tehran University of Medical Sciences

2.4.1. Ahmadiyeh Health Center

Address: N Sarparast St., Taleghani St., Tehran

Tel.: (+98 21) 8837 6529

Number of Persian medicine specialists: 10

Number of Persian medicine students who visit the patients: 4

Number of trained personnel: 3

Number of active visiting rooms: 6

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 45/900

Number of pharmaceuticals: 400

2.4.2. Tooba Health Center

Address: Tooba Health Center, Felestin St., Tehran

Tel.: (+98 21) 6697 0869-72

2.4.3. Khark Health Center

Address: Khark Health Center, Khark St., Enghelab Sq., Tehran

Tel.: (+98 21) 6675 4151-4

Number of Persian medicine specialists: 10

Number of Persian medicine students who visit the patients: 3

Number of trained personnel: 2

Number of active visiting rooms: 4

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 38/600

Number of pharmaceuticals: 400

2.4.4. Heravi Health Center

Address: Heravi Health Center, W Jamali Alley, Vafamanesh St., Heravi Sq., Tehran,

Tel.: (+98 21) 2298 8551-5

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2.5. Doctor Shariatpanahi Health Center Affiliated with Shahid Beheshti University of Medical Sciences

No. 8, School of Traditional Medicine

Tel.: (+98 21) 88776028

Email: [email protected]

The Traditional Medicine Clinic of Shahid Beheshti University of Medical Sciences, named after Dr. Shariatpanahi, was managed, from 2013 to 2018, by Dr. Mozhgan Tansaz and is currently managed by Dr. Mina Movahed, providing educational and research services.

According to a scientific survey, this organization is one of the most successful clinics in the field of traditional medicine is from the perspective of patients in the field of diagnosis, treatment and provision of services.

Address: Vali-e Asr Ave, opposite Tavanir St. (Shahid Abbaspour), Shahsab Blvd,

Introduction of Pharmacy:

Technical Officer: Dr. Shirin Fahimi

The pharmacy produces natural medicinal products as well as herbal and traditional byproducts as per the need of the traditional medicine physicians, and offers them to patients on the basis of prescription. These drugs are evaluated through quality control tests before entering the pharmacy and are available to consumers after confirmation of quality.

Number of Persian medicine specialists: 9

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Number of Persian medicine students who visit the patients: 20

Number of trained personnel: 2

Number of active visiting rooms: 6

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 30/600

Number of pharmaceuticals: 483

2.5. Health Center of the Traditional Persian Medicine School of Ardakan

Address: School of Traditional Persian Medicine, Imam Khomeini Street, Ardakan, Iran

Tel.: (+98 35) 3223 8915

Pharmacy: The Daroogia Pharmacy

Technical Officer: Dr. Rahele Zarehshahi

Tel.: (+98 35) 3225 9631

The clinic includes separate examination rooms for men and women, separate rooms for men and women for hijamat, a massage room, and a leech therapy room in an area of 1200 square meters.

2.6. Masoumieh Health Center Affiliated with Qom University of Medical Sciences

Address: 44th Alley, 15th Khordad Blvd., Qom

Tel.: (+98 25) 3776 4073

Website: www.tramed.muq.ac.ir

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This health facility was launched in 2018. Nowadays, the clinic is active every day in two shifts in the morning and in the afternoon. Apart from the therapeutic measures, planning is under way to hold healthy lifestyle education and nutrition workshops. In this clinic, apart from the public health clinics, there are special treatments for diabetes and women's diseases. The clinic has several guest rooms, a traditional pharmacy, and hand treatment facilities (cupping, phlebotomy, massage, leech therapy), specialized for men and women. The pharmacy is also being set up.

Number of Persian medicine specialists: 6

Number of Persian medicine students who visit the patients: 5

Number of trained personnel: 0

Number of active visiting rooms: 4

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 8/160

Number of pharmaceuticals: 0

2.7. Health Centers of Kerman University of Medical Sciences 2.7.1. The Traditional Medicine School’s Health Center

Tel.: (+98 34) 3211 0360

E-mail: [email protected]

Website: kmu.ac.ir/fa/tebirani

The clinic affiliated to the School of Traditional Medicine of Kerman University of Medical Sciences was established in February 2011 and is currently operating in its new location on Jomhuri Boulevard at Amirkabir

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Intersection in two morning and afternoon shifts. The services provided at this center include patient visits, hand treatments (massage, cupping, leech therapy, phlebotomy) and pharmaceutical services.

Number of Persian medicine specialists: 8

Number of Persian medicine students who visit the patients: 4

Number of trained personnel: 1

Number of active visiting rooms: 5

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 6/120

Number of pharmaceuticals: 89

2.7.2. Nafis Kermani Health Center

Address: 1st Alley, Imam Jom’e St.

Tel.: (+98 34) 3246 6167

E-mail: [email protected]

Nafis Kermani Clinic was established under the supervision of Kerman University of Medical Sciences in 2006. This center has been established with the technical responsibility of Dr. Haleh Tajeddini, a faculty member of the university. The services provided by this health facility include patient visits and hand treatments (massage, cupping, leech therapy, acupuncture).

Number of Persian medicine specialists: 1

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 3

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Number of active visiting rooms: 2

Number of rooms for manual interventions: 5

Average of daily/monthly visits: 25/500

Number of pharmaceuticals: 150

2.7.3. Iranian Health Center

Address: No. 6, 1st Floor, Aseman Bldg., 11th Alley, Ayatollah Salehi Ave., Kerman, Iran

Tel.: (+98 34) 3253 2052-3

E-mail: [email protected]

Iranian Health Center, under the supervision of Kerman University of Medical Sciences, was opened in 1395 AH with the presence of Dr. Khodadust, Director General of the Office of Persian Medicine of the Ministry of Health. This clinic is under the supervision of Dr. Mehrzad Mehrabani, a traditional medicine specialist, provider of diet treatment based on temperament, treating diseases with herbal medicines, acupuncture, massage therapy, phlebotomy, bloodletting, hijamat and leech therapy. The center, with an area of 160 square meters, has a room for hand treatment, a doctor's room, a sterilization room, and a patient room.

This center is ready to provide services to the visitors from Saturday to Wednesday, from 4:00 to 8:00 p.m.

Number of Persian medicine specialists: 1

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 2

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Number of active visiting rooms: 1

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 14/280

Number of pharmaceuticals: 100

2.8. Health Centers of Mashhad University of Medical Sciences 2.8.1. Tanin Tose’e Tandorosti Health Center

Address: 1st South Motahari St., Takhti Sq.

Tel.: (+98 51) 3713 1032

Technical Director: Dr. Hamideh Naghedid

Number of Persian medicine specialists: 11

Number of Persian medicine students who visit the patients: 8

Number of trained personnel: 3

Number of active visiting rooms: 3

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 53/1350

Number of pharmaceuticals: 200

2.8.2. Khoshghalb Toosi Health Center

Address: No. 27, 40th Imam Khomeini St., Lashkar Intersection

Tel.: (+98 51) 3858 2041

Technical Director: Dr. Younes Najafian

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Number of Persian medicine specialists: 4

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 4

Number of active visiting rooms: 2

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 17/555

Number of pharmaceuticals: 367

2.8.3. Pardis Health Center

Address: 1st Pasteur St., Ahmad Abad

Tel.: (+98 51) 3833 1031

Technical Director: Dr. Mehdi Eslami

Number of Persian medicine specialists: 7

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 3

Number of active visiting rooms: 2

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 15/200

Number of pharmaceuticals: 100

2.8.3. Barg-e-Sabz Health Center

Address: Vakilabad blv., Mashhad

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Tel.: (+98 51) 3867 0007

Number of Persian medicine specialists: 7

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 3

Number of active visiting rooms: 1

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 15/200

Number of pharmaceuticals: 100

2.9. Comprehensive Center for Integrated Medicine affiliated with AJA University of Medical Sciences

Address: W Fatemi St., Before Chamran Hwy. Intersection

On the orders of the Commander-in-Chief of the Army of Islamic Republic of Iran, the construction of this specialized building began in 2015, and it is on the verge of opening. This complex will accommodate clients who seek the various services of Persian medicine (health lifestyle counseling for everyone, visiting patients, cupping, winding, Dalk and Qamz (Persian massage), leech and bloodletting treatment, etc.). It also has a specialized laboratory and library for conducting research on Persian medicine subjects as well as providing general and specialized training in Persian medicine to different audiences (including the public, as well as doctors and specialist assistants in the field of Persian medicine). The core staffs of this complex are all faculty members of the university as experienced and specialist physicians in the fields of traditional medicine and pharmacy.

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3.10. Traditional Persian Medicine Clinic affiliated with Shahed University of Medical Sciences

Address: No. 17, Jafari Alley, Dashtestan 3rd, Shariati St., Tehran

Tel.: (+98 21) 2288 2521 – (+98 21) 2288 2596

Number of Persian medicine specialists: 4

Number of Persian medicine students who visit the patients: 11

Number of trained personnel: 2

Number of active visiting rooms: 5

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 15/300

Number of pharmaceuticals: 100

3.11. Hakim Emadeddin Shirazi's Clinic affiliated with Shiraz University of Medical Sciences

Address: No. 49, 3rd Alley, Felestin St., Shiraz

Tel.: (+98 21) 3234 0460

Website: http://shiraztm.sums.ac.ir

E-mail: [email protected]

This clinic was established in the summer of 2015 with the presence of Dr. Khodadust and the President of Shiraz University of Medical Sciences, Dr. Imaniyeh, and other university authorities, with the aim of providing health services, medical treatment and education. This Clinic has three physicians’

109 offices, the manager’s room, the medical and administrative documents room, the resuscitation room, the hand treatment room, and the massage room. More than 16200 electronic files have been created at this center. The Clinic has three technical staff.

The Pharmacy located at the health center is under the supervision of the Traditional Pharmacy Department of the Shiraz University of Medical Sciences.

Number of Persian medicine specialists: 8

Number of Persian medicine students who visit the patients: 12

Number of trained personnel: 2

Number of active visiting rooms: 4

Number of rooms for manual interventions: 4

Average of daily/monthly visits: 44/923

Number of pharmaceuticals: 130

3.12. Martyr Fatahi Health Center affiliated with Kermanshah University of Medical Sciences

Address: Shahid Shiroodi Blvd., Kermanshah

Tel.: (+98 83) 3427 4618

Number of Persian medicine specialists: 2

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 1

Number of active visiting rooms: 2

Number of rooms for manual interventions: 2

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Average of daily/monthly visits: 10/200

Number of pharmaceuticals: 30

3.13. Baghban Traditional Medicine Clinic (Tooba) affiliated with Mazandaran University of Medical Sciences

Address: Passed E Bahman Crossway, Mahdieh St., Sari

Tel.: (+98 11) 3311 5481 & 82

Introduction: In 2016, a traditional medicine clinic with all the facilities needed for a standard clinic was opened in the form of a Memorandum of Understanding with Mazandaran University of Medical Sciences with private sector expenses. Now, it has 3 separate treatment rooms for patient treatment or counseling services, 2 separate rooms for women and men for hand treatment, one pharmacy, two separate bathrooms, and a pantry, serving the patients inside and outside the province.

The pharmacy is under the supervision of the 13th of Aban Pharmacy of the University, and its technical responsibility lies with the university.

Number of Persian medicine specialists: 3

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 3

Number of active visiting rooms: 3

Number of rooms for manual interventions: 2

Average of daily/monthly visits: -/500

Number of pharmaceuticals: 54

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3.14. Shariati Persian Medicine Health Center, Affiliated with Fasa University of Medical Sciences

Address: Shariati Persian Medicine Health Center, Dr. Shariati Hospital, Fayazbakhsh St., Fasa.

Tel.: (+98 71) 53350116-7

Website: http://sh.fums.ac.ir/

Shariati Persian Medicine Health Center is the first of its kind in the south of Fars, Iran. From January 2015, it has been providing services through the equipment of specialized medical units of Persian medicine (P.M.) with the help of trained personnel and a P.M. academic specialist. Since then, the number of personnel have increased to 4 trained nurses and 3 specialists.

Active units of this center include: physician visiting room, conference room, two manipulating procedure rooms ((cupping (wet and dry), massage (dalk and qamz) and biotherapy (leech and maggot)), one herbal (natural product) pharmacy and one insectarium.

The technical staff members of the health center are:

1. Dr. Mohammad Hashem Hashempur (MD-PhD, Assistant Professor of FUMS)

2. Dr. Massih Sedigh Rahimabadi (MD-PhD, Assistant Professor of FUMS)

3. Dr. Mahsa Rostami Chijan (MD-PhD, Assistant Professor of FUMS)

4. Mrs. Samaneh Jafari (BS, nurse)

5. Mrs. Azam Amirnejhad (BS, nurse)

6. Mr. Khosronejad (BS, trained technician)

7. Mrs. Jamileh Ghasemzadeh (Diploma, trained office personnel)

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Number of Persian medicine specialists: 3

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: -

Number of active visiting rooms: 5

Number of rooms for manual interventions: -

Average of daily/monthly visits: 40/1000

Number of pharmaceuticals: 223

3. Health Clinics

A total number of 30 university affiliated health clinics all over Iran deliver Persian medicine services as follows:

3.1. Health Clinics of Iran University of Medical Sciences

3.1.1. Persian Medicine Clinic in Educational, Research and Clinical Rasoul-e Akram Complex

Address: Mansouri St., Niayesh St., Shahrara St., Sattarkhan Ave., Tehran

Tel.: (+98 21) 6435 2502

E-mail: stm.iums.ac.ir

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The Persian Medicine Clinic of Educational, Research and Clinical Rasoul-e Akram Complex has been in operation since September 2016.

3.1.2. Persian Medicine Clinic located in the Office of Vice-President for Student and Cultural Affairs Clinic

Address: Clinic of the Office of Vice-President for Student and Cultural Affairs, Iran University of Medical Sciences, Milad Tower, Hemmat Hwy., Tehran

Tel.: (+98 21) 86701

E-mail: stm.iums.ac.ir

Website address: stm.iums.ac.ir

3.1.3. Persian Medicine Clinic at Firoozabadi Hospital

Address: Fadaiyan-e Eslam St., Tehran

Tel.: (+98 21) 51048

E-mail: stm.iums.ac.ir

Website address: stm.iums.ac.ir

3.3. Health Clinics of Tabriz University of Medical Sciences

3.2.1. Traditional Medicine Clinic at Sina Hospital

Address: 2nd Floor, (Traditional Medicine Clinic), Sina Educational-Clinic Center, Azadi St., Tabriz

Tel.: (+98 41) 3549 8262

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The Traditional Medicine Clinic affiliated to Tabriz School of Traditional Persian Medicine has been established since 2013 at Sina Hospital’s in specialty and sub-specialty clinics. The clinic consists of two rooms for visiting patients, one special room for hand techniques and actions, and one lounge. At this clinic, on almost every day of the week, specialist practitioners of traditional medicine are actively working along with interns and assistants of tradition medicine. Hand techniques and actions are also provided consistent with the facilities of the hospital.

Number of Persian medicine specialists: 2

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 0

Number of active visiting rooms: 1

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 10/240

Number of pharmaceuticals: 0

3.2.2. Traditional Medicine Clinic at Asadabadi Hospital

Address: East Azerbaijan Province, Tabriz, Bahar St.

Tel.: (+98 41) 3280 4401

Number of Persian medicine specialists: 2

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 0

Number of active visiting rooms: 1

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Number of rooms for manual interventions: 1

Average of daily/monthly visits: 10/240

Number of pharmaceuticals: 0

3.2.3. Traditional Medicine Clinic at Imam Khomeini Medical Center

Address: East Azerbaijan Province, Tabriz, Elgoli, Baharestan St.

Tel.: (+98 41) 33893336

Number of Persian medicine specialists: 2

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 0

Number of active visiting rooms: 1

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 10/240

Number of pharmaceuticals: 0

3.3. Health Clinics of Tehran University of Medical Sciences

3.3.1. Integrative Oncology Clinic

Address: Imam Khomeini Hospital Complex, Dr. Gharib St., Tehran, Iran.

Located at Imam Khomeini Hospital Complex

3.3.2. Clinic of Pain and Spinal Cord Injury

Address: Imam Khomeini Hospital Complex, Dr. Gharib St., Tehran, Iran.

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Located at Reyhan Clinic in Imam Khomeini Hospital Complex.

3.3.3. Integrative Skin Disorders Clinic and Research Unit

Address: No. 4, Maryam Alley, S Kamranieh St., Sadr Hwy., Tehran

Located at the Dermatology and Stem Cell Research Center of Tehran University of Medical Sciences

3.4. Traditional Medicine Clinic of Integrative Oncology at Tajrish Martyrs Hospital affiliated with Shahid Beheshti University of Medical Sciences

Address: Tajrish Martyr’s Hospital, Tajrish Sq.

Tel.: (+98 21) 2271 8001, Ext.: 288

The clinic has begun work at the Educational and Clinical Radiotherapy- Oncology of Tajrish Martyrs Hospital (Daheshpour Hospita), alongside other oncologic clinics since April 2016. It offers consultation to cancer patients regarding lifestyle methods and dietary suggestions in an integrative way (traditional medicine with common medicine).

Reception of patients is conducted with a referral letter from Oncology Specialists.

3.5. Health Clinics of Shahid Sadoughi University of Medical Sciences

3.5.1. Clinic of Shahid Sadoughi Hospital of Yazd

Address: Shahid Sadoughi Hospital, Avicenna Street, Safadi, Yazd

Tel.: (+98 35) 3822 9007-9

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The Traditional Persian Medicine Clinic in Shahid Sadoughi Hospital was opened in Yazd in the presence of the Minister of Health in September 2007. This specialized clinic has been used in Shahid Sadoughi Hospital with about 2,000 square meters of infrastructure in three floors. All health doctors are traditional Persian medicine specialists and all services are provided at governmental expense rates for clients. Different types of bloodletting, cupping, leech therapy, massage therapy, water therapy, diet and counseling services are provided to patients.

3.5.2. Baghayi Pour Clinic

Address: Adjacent to Shahid Sadoughi Hospital, Riazi Sq., Safayieh, Yazd

Tel.: (+98 35) 3822 9105

3.5.3. Diabetes Clinic

Address: Talar Honar Alley, Shahid Sadoughi Blvd., Bahonar Sq., Yazd

Tel.: (+98 35) 3728 0228

3.5.4. Mehrab Martyrs Clinic

Address: Shahid Paknejad St., Yazd

Tel.: (+98 35) 3724 7074

3.5.5. Khatam ol-Anbia Clinic

Address: Adjacent to the Central Laboratoy, Taleghani Blvd., Yazd

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Tel.: (+98 35) 3733 0122

3.5.6. Ziayi Ardekan Hospital Clinic

Address: Moalem Blvd., Azadi Sq., Ardekan

Tel.: (+98 35) 3152 2070

3.5.7. Mehriz’s Fatemeh Zahra Hospital Clinic

Address: Motahadi Blvd., Mehriz

Tel.: (+98 35) 3724 7074

3.6. Health Clinics of Mashhad University of Medical Sciences

3.6.1. Central Clinic of Persian Medicine in Imam Reza Hospital

Address: Imam Reza Hospital, Daneshgah St., Taghiabad Sq., Mashhad

Tel.: (+98 51) 3852 5008

Technical Director: Dr. Marjan Mahjur Moghadam

Number of Persian medicine specialists: 5

Number of Persian medicine students who visit the patients: 3

Number of trained personnel: 1

Number of active visiting rooms: 4

Number of rooms for manual interventions: 2

Average of daily/monthly visits: 5/39

Number of pharmaceuticals: 130

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3.6.2. Chinese and Complementary Medicine Clinic in Imam Reza Hospital

Address: Imam Reza Hospital, Daneshgah St., Taghiabad Sq., Mashhad

Tel.: (+98 51) 3852 3031

Technical Director: Dr. Hamid Reza Bahrami

3.6.3. Persian Medicine Clinic of Ghaem Hospital

Address: Ghaem Central Hospital, Parastar St., Ahmadabad Street, Mashhad

Tel.: (+98 51) 3840 0000

Technical Director: Dr. Sadegh Shokri

Number of Persian medicine specialists: 1

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 0

Number of active visiting rooms: 1

Number of rooms for manual interventions: 0

Average of daily/monthly visits: 7/30

Number of pharmaceuticals: 0

3.7. Health Clinics of Arak University of Medical Sciences

3.7.1 Kowsar Traditional Medicine Clinic

Address: Seyedha Mosque, Imam Khomeini St., Arak

Tel.: (+98 86) 32216799

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Number of Persian medicine specialists: 3

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 2

Number of active visiting rooms: 2

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 40/-

Number of pharmaceuticals: 30

3.7.2. Amir Al-Momenin Hospital Traditional Medicine Clinic

Address: Al-Momenin Hospital, Basij Sq., Arak

Tel.: (+98 86) 3417 3601-10

Email: [email protected]

3.8. Imam Reza Hospital (PBUH) Specialty and Sub-Specialty Clinic (501st Army) affiliated with AJA University of Medical Sciences

Address: Imam Reza Hospital, Etemadzadeh St., W Fatemi St., Tehran

Tel.: (+98 21) 8609 6350

Website: http://imamreza.ajaums.ac.ir

3.9. Amin Hospital Traditional Medicine Clinic affiliated with Isfahan University of Medical Sciences

Address: Amin Hospital, Ebn-e-Sina St., Isfahan

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Tel.: (+98 31) 3445 5051

Number of Persian medicine specialists: 2

Number of Persian medicine students who visit the patients: 2

Number of trained personnel: 0

Number of active visiting rooms: 2

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 10/200

Number of pharmaceuticals: 0

3.10. Traditional Persian Medicine Specialty Clinic affiliated with Shahed University of Medical Sciences

Address: Traditional Persian Medicine Specialty Clinic, Shahed University’s Specialty Clinic, Italia St., Felestin Sq., Tehran

Tel.: (+98 21) 8896 6130-9

3.11. Imam Reza Specialized Integrative Clinic affiliated with Shiraz University of Medical Sciences

Address: Imam Reza Specialty and Sub-Specialty Clinic, Namazi Sq., Shiraz

Tel.: (+98 71) 32127001-5

E-mail: [email protected]

In the course of quantitative and qualitative educational development for students, the Traditional Persian Medicine Educational Clinic was opened in Imam Reza Specialized Clinic in October 2018. This specialty and sub-specialty

122 clinic is one of the most important educational clinics in Shiraz University of Medical Sciences. The clinic has three rooms suitable for visiting patients and training students. It has provided the conditions for increased educational cooperation with other medical departments. In this clinic, with the emphasis on complementary and comprehensive (integrative) medicine, in addition to the three traditional medicine specialists, other specialists, including an internal medicine specialist, a gastroenterologist, and a dietitian, are available.

3.12. Health Clinics of Zanjan University of Medical Sciences

3.12.1. Vali-e Asr Hospital Specialized Clinic

Address: Vali-e Asr Sq., Sheikh Fazlollah Noori Hwy, Zanjan

Tel.: (+98 24) 3302 3324

Pharmacy: 5th of Shahrivar Pharmacy

Technical Officer of Pharmacy: Dr. Ayatollahi

The Traditional Persian Medicine Clinic has two patient examination rooms, a library, a pharmacy, and a hand treatment room. Traditional medicine specialists visit patients five days a week (mornings and evenings). Several different treatments in this department are performed by the doctors and qualified individuals (on the order of the physician), including the following: Dry cupping, wet cupping, massage therapy, and leech therapy. Herbal remedies (in the form of pills, capsules, syrups, potions, powders, etc.) are located in separate shelters in the 5th of Shahrivar Pharmacy.

Number of Persian medicine specialists: 3

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 0

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Number of active visiting rooms: 2

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 6/120

Number of pharmaceuticals: 50

3.12.2. Shafieie Specialized Clinic

Address: Safa St., Old Shafieie hospital, Zanjan

Tel.: (+98 24) 33244001

Number of Persian medicine specialists: 3

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 0

Number of active visiting rooms: 2

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 6/120

Number of pharmaceuticals: 50

3.13. Traditional Medicine Clinic at Dazyani Specialty and Sub-Specialty Clinic of Gorgan affiliated with Golestan University of Medical Sciences

Address: Molaghati St., Shahid Beheshti St., Gorgan

Tel.: (+98 11) 32263060

In February 2012, the Traditional Medicine Clinic was opened at Dazyani Specialty and Sub-Specialty Clinic of Gorgan. In the beginning, work days were

124 two days a week, which, with the increase in the number of graduated students in this field in June 2017, was increased to four days per week in the morning shift in November 2018. At Dazyani Specialty and Sub-Specialty Clinic of Gorgan, there exists a doctor's room, a specially appointed room for hand treatment (massages, phlebotomy, bloodletting, cupping, etc.) with three beds, and a nursing room.

Number of Persian medicine specialists: 2

Number of Persian medicine students who visit the patients: 0

Number of trained personnel: 1

Number of active visiting rooms: 1

Number of rooms for manual interventions: 1

Average of daily/monthly visits: 10/-

Number of pharmaceuticals: 30

3.14. Bu-Ali Hospital Specialized Clinic affiliated with Mazandaran University of Medical Sciences

Address: Ibn Sina Hospital, Valiasr Highway, Sari

Tel.: (+98 11) 3334 3011

In 2013, the Traditional Persian Medicine Clinic was established at the specialized Bu-Ali Hospital. Visits and follow-up of patients will be held on Sundays and Tuesdays in the center, and the clinic is fully educational and students will benefit from this space for clinical education.

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Appendix 2. Trained health houses for traditional medicine as a pilot project

University City Population Number of Service Delivery Units Number

Rural Urban Health Comprehensive Health Comprehensive Behvarz Social Physician House Rural Health Base Urban Health worker Rural Urban Services Center Services Center

Mashhad Chenaran 54055 74872 53 4 7 4 80 34 17 8

Hamedan Asadabad 46207 74497 48 8 2 5 87 31 7 5

Golestan Gorgan 121847 346349 84 17 26 10 199 139 37 15

Shahid Damavand 19646 83170 26 1 6 4 38 39 2 12 Beheshti

Kashan Kashan 19425 355257 31 9 23 21 57 219 24 31

Kerman Kerman 92230 719082 57 4 29 22 124 247 34 41

Fasa Fasa 100958 119475 52 13 13 6 111 86 30 54

Mazandaran Babolsar 62186 69521 46 9 6 5 53 41 18 21

Babol Babol 229346 287918 178 27 24 9 351 144 64 109

Total 745718 2130141 575 92 136 86 1100 980 233 296

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Appendix 3. The list of faculty members in Departments of Traditional medicine and traditional pharmacy departments in Iran

University Faculty members (N)

Traditional Traditional pharmacy medicine

Fasa University of 0 2 Medical Sciences

Babol University of 1 4 Medical Sciences

Iran University of 1 5 Medical Sciences

Kashan University 0 1 of Medical Sciences

Tehran University 4 11 of Medical Sciences

Golestan University 0 2 of Medical Sciences

Shahed University 0 5 of Medical Sciences

Mashhad University 1 7 of Medical Sciences

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Kermanshah 1 1 University of Medical Sciences

Yazd University of 0 3 Medical Sciences

Shahid Beheshti 5 7 University of Medical Sciences

Arak University of 0 1 Medical Sciences

Hamedan 0 2 University of Medical Sciences

Shiraz University of 4 7 Medical Sciences

Zanjan University 0 1 of Medical Sciences

Kerman University 1 4 of Medical Sciences

Ahvaz University of 0 0 Medical Sciences

Alborz University of 1 0 Medical Sciences

Isfahan University 0 2 of Medical Sciences

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Qom University of 1 3 Medical Sciences

Mazandaran 0 3

University of

Medical Sciences

Tabriz University of 1 1 Medical Sciences

Sabzevar University 0 2 of Medical Sciences

Aja University of 1 2

Medical Sciences

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Appendix 4. The National Document of Medicinal Plants and Traditional Medicine

Introduction

Iran is a privileged and high-ranking country in terms of plant richness and biodiversity, with 11 of the world's 13 known climates. According to botanists and researchers, the number of plant species in Iran is about 8,000 species, which is at least twice as high as the European continent. Research has shown that more than 2,300 species of plants in the country have medicinal, perfume, spice and cosmetic properties. In addition, 1,728 species of these plants are endemic plants of Iran, exclusively cultivated in Iran and considered as a monopoly capacity in the country.

The volume of global trade in herbal medicine has increased from $60 billion in 1996 to $100 billion in 2010, and according to the World Bank's forecast in 2050, global trade and global focus on plant and medicinal plants and herbal medicines will amount to about $5 billion.

In most developed countries, traditional medicine has been supported by governments in various aspects and has taken on a good portion of responsibility in securing people's health within the health system of the country. Traditional Chinese medicine is responsible for 40% of health services in the country; insurance coverage for treatment, medicines, and traditional medicine services in Japan, China, Korea and Vietnam is complete and in Germany, Australia, Norway, the United Kingdom, Canada, and the United States, part of the costs are paid by the insurance company.

Considering the increase in the volume of world trade regarding medicinal plants and their products; the rich history of Iran in traditional medicine; and the

130 fact that, in the Comprehensive Scientific Map of the Country, medicinal plants are in priority A, and the field of basic and applied sciences as well as traditional medicine are in priority B of the health sector, it is obvious that in order to guide the revitalization and development of medicinal plants and traditional medicine in Iran via using the best of all national resources, having a scientific document that takes into account all the necessary points is crucial and inevitable.

Article 1: Specific Definitions

1. Medicinal Plants and Traditional Medicine Sector

Medicinal plants and traditional medicine sector includes all the institutions and agents involved in the use of medicinal and essential plants, and the technologies of production of plant-based medicinal-food-health products, as well as all services and stakeholders in the academic services in the Persian school of medicine (traditional medicine). This sector consists of two parts: “Medicinal plants and herbal products” and “traditional medicine”.

2. Medicinal Plant

Any plant that is directly or indirectly all or in part, fresh or dried, or its effective extracts are used in the health, prevention, and treatment of human, animal and other plants

3. Herbal Medicine

Any medicinal product that exclusively, in terms of active ingredients, includes one or more unprocessed plant material, one or more processed plant compound, or a combination of both, with different formulations for supply in the pharmaceutical market for the purpose of diagnosis, prevention, assistance to physiological functions, treatment, and health preservation of humans, animals, and other plants

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4. Traditional medicine

The collection of all theoretical and practical sciences and experience, including all health measures, approaches, information and beliefs, that are used in various forms of medicine for the preservation of health, as well as the prevention, diagnosis and treatment of diseases, passed on, either spoken or written, from generation to generation in a geographic region, that can be updated with the preservation of the basic frameworks

Intrinsic traits of traditional medicine are a universal attitude toward the human subject, attention to spirituality and ethics, result-driven orientation in treatment, reliance on natural methods with minimum side effects, patient-based approach, and consistence with the general culture due to its long history.

5. Herbal Products

Herbal material, raw or processed, for use in medical, veterinary and plant health, as well as commercial, industrial, food and health uses, including herbal medicines, natural or supplement herbal products, additives and flavors, food coloring, distillates, extracts and essences, cosmetic products, and pesticides and products for controlling plant diseases

6. Natural products

Products acquired from natural materials derived from plants, animals, microorganisms and mines, such as natural drugs (solid, semi-solid and liquid), natural raw materials (extracts and essential oils), medicinal herbal products, unprocessed products, traditional medicine products, homeopathy drugs, and allergy diagnosis products

Article 2: Fundamental Values

Considering the value foundations of the science and technology system of the country's Comprehensive Scientific Map and emphasizing the sovereignty of

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Islamic monotheism, the paradigm of justice, morality, wealth creation, environmental co-ordination, and the importance of human dignity, the value foundations of the National Document of Medicinal Plants and Traditional Medicine are:

1. Belief in the monopoly of healing for the Lord and the instrumental role of medicine for the fulfillment of the divine will in healing the patients;

2. Combination of traditional Persian medicine with ethical teachings and religious commitment and the necessity of strict observance of ethical standards at all stages of education, research and medical services at the highest level;

3. Justice-based orientation in the development of medicinal plants and traditional medicine and its achievements;

4. Firm belief in safeguarding the health of the body and soul in religious teachings; and,

5. Centrality of ethics, priority of public benefits over individual and group interests, strengthening a cooperative spirit, and the participation and accountability of the scientific community and its related institutions.

Article 3: Vision

By trusting in the Lord and relying on him, and in order to realize the 20-Year Vision of the Islamic Republic of Iran in the 1404 AH Horizons, the Medicinal Plants and Traditional Medicine Sector will have the following characteristics:

- Benefitting from the internal material and spiritual capital and resources, and the native and advanced facilities and advantage, with a superior share of human resources in the country and the region;

- Producing economic added value, with the ability to compete globally and having the first place in the region regarding the export of medicinal plants and herbal products;

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- Pioneering along the borders of knowledge and technology of medicinal plants and traditional medicine and gaining the first scientific rank in the region;

- Reliable and a source of pride for the community in Iran and the world;

- Prosperous, innovative and influential and prominent in the health system of the country through well-founded and evidence-based methods, safe, high- quality, effective and accessible to the community;

- Having the scientific authority in the world based on Iran's native and exclusive medicinal plants and Iran's rich written medical heritage.

Article 4: Macro Policies

1. Focusing on knowledge management in medicinal plants and traditional medicine;

2. Self-efficacy, employability and maximum use of internal resources in the medicinal plants and traditional medicine sectors;

3. Maximum participation of the private sector, cooperatives, non-governmental organizations, and foreign investors, and the emphasis on the coordination and coherence of the institutions;

4. Observance of the principles of bio-safety in the framework of accepted international protocols;

5. Maximum use of nature and natural products in line with human health and social welfare while maintaining the ecosystem cycles of nature;

6. Reducing government ownership, strengthening the private sector, and supporting the creation and development of quantitative and qualitative aid schemes for knowledge-based companies;

7. Considering the philosophical foundations of traditional medicine with the priority of prevention compared to treatment;

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8. Expert orientation and avoidance of folkloric propaganda as well as superstitions and superstitious tendencies in traditional medicine and medicinal plants;

9. Preservation of the genetic reserves of native and exclusive medicinal plants of the country;

10. Applied traditional medicine training in different categories of medicine and veterinary medicine;

11. Use of methods in medicinal plants and traditional medicine with minimum side complications;

Article 5: Objectives, Strategies and Measures

With regard to the unique features of the two areas of medicinal plants and herbal products, as well as traditional medicine, the objectives, strategies and measures of these areas are presented separately as follows:

5-1 Field of Medicinal Plants Herbal Products

A) Objectives (in the 1404 AH Horizon)

1. Acquisition of 20% of the country’s drug market value by certified products based on herbal medicines and natural products;

2. Acquisition of 20% of the country’s veterinary drug market value by certified products based on herbal medicines and natural products;

3. Increased exports of medicinal plants, herbal medicinal products, herbal products to gain a rank among the first top 10 countries of the world;

4. Acquisition of 3% of the science production share of medicinal plants and herbal medicines in the world;

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5. Acquisition of 1% of the global patent share in the field of herbs and its products;

6. Registration and coverage of all exclusive and indigenous species or extinct medicinal plants of the country in the national protection systems;

7. Reducing the formal and informal harvest from natural lands to 200,000 hectares in the 1404 horizons; and,

8. Increasing the cultivation of medicinal and essential herbs to 500,000 hectares in the 1404 horizon.

B. Strategies

1. Review, modify, simplify and update the relevant laws, regulations and standards in the field of medicinal plants and herbal products;

2. Organize the education system, research, and development of technology and innovation in the field of medicinal plants and herbal products;

3. Promoting, informing and acculturalization in the field of medicinal plants and herbal products;

4. Creating continuous and effective co-operation between institutions, partnerships and organizations related to the field of medicinal plants, whether public or private;

5. Expand international partnerships in the fields of science and technology of medicinal plants;

6. Organize processes and structures for monitoring and evaluation of all activists and activities in the field of medicinal herbs;

7. Organize production and distribution, the market, and the export of products and services in this field and commercialization of scientific and technological achievements;

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8. Organizing resource management and conservation of basic resources, with emphasis on the development of cultivation, breeding, gathering and processing of medicinal plants;

9. Protecting the country's exclusive plant species and preventing the departure of the specimen or information about these species from the country; and,

10. Optimal use of Islamic guidelines in the field of botany, nutrition and health.

C) Measures

1. Preparation of guidelines, plans and bills to amend and simplify the laws and submit them to competent authorities for approval (1)

2. Preparation and compilation of national standards for medicinal plants as well as their export and import, and submitting those to competent authorities for approval (1)

3. Launch of a national research institute and the international center for research and development on medicinal plants and herbal products until 1404 AH (2)

4. Organizing scientific documents and the heritage of Islamic scholars (2)

5. Accelerating, facilitating and substantiating procedures for the registration and conduct of clinical trials and tests for herbal medicines (2)

6. Creation and development of the fields, phases, and disciplines of the field of medicinal plants and herbal products according to the needs of the country and based on the combination of higher education and research in the country (2)

7. Using the national media capacity and supporting the distribution of information in public and specialized media, as well as holding national and international exhibitions and festivals in the field of medicinal plants (3)

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8. Use of educational capacity to promote the importance of medicinal herbs at primary to secondary education levels (3)

9. Organize and create legal arrangements for effective and rational communication between producers and consumers or pharmaceutical partners, as well as developing exports in the field of medicinal plants and herbal products (4)

10. Acquisition, transfer and localizing advanced sciences and technologies of other countries in the field of medicinal plants and herbal products (5)

11. Creating a national brand as well as joint trademarks with other countries for export of field products (5)

12. Observations on the development of the pharmaceutical industry (5)

13. The organization and development of authorized economic activities in this area based on valid certificates and the prevention of unauthorized activities (6)

14. Establishing a surveillance system on the market and centers for supplying products and services in the field of medicinal plants, especially traditional herbal remedies (6)

15. Supporting commercialization and industrial production of the achievements of medicinal herbs and herbal products in accordance with the approved indexes (7)

16. Supporting pilot commercialization of products, processes, or high technology processes and innovations related to the medicinal herbs and herbal products industry (7)

17. Planning for full insurance coverage of registered herbal medicines (7)

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18. Observation, identification and introduction of markets and products of medicinal herbs and herbal and natural products at the national and international level (7)

19. Supporting the establishment and organization of procurement, supply and distribution centers for medicinal plants and herbal medicines and exchange of medicinal herbs (7)

20. Supporting the establishment of centers for the production of mother plants including seeds, transplant, and sapling (7)

21. Supporting the renovation and updating of the pharmaceutical processing industries (7)

22. Establishment of an international center for commerce, commodity and brand studies in the field of medicinal herbs and herbal products (7)

23. Supporting the quantitative and qualitative development of mass cultivation and the cultivation of medicinal plants whose uncontrolled harvesting affects the fields of the country's forest and rangelands (8)

24. Supporting the cultivation of medicinal plants of other climates in the country (8)

of important اهلی کردن Planning for the development of cultivation and .25 species of medicinal plants with economic value (8)

26. Creating a database of medicinal herbs and herbal products of the country (8)

27. Reinforcing and developing the gene bank of different species of exclusive or endangered medicinal herbs

28. Creating and announcing the list of priority medicinal herbs of the country

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29. Establishing a pharmaceutical and herbal products research center approved in the Quran and divine narratives (10)

Note 1: The Ministry of Health, Treatment, and Medical Education must approve the supply of human herbal medicines to the market.

Note 2: The country’s Organization of Veterinary must approve the supply of veterinary herbal medicines to the market.

5-2 Field of Traditional Medicine and Traditional Pharmacy

A) Objectives

1. Acquisition of 10% of the country’s health market value based on the principles of traditional medicine, including the Six Principles of Health;

2. Acquisition of 4% of the country’s treatment market value;

3. Acquisition of 2% of the country’s drug market value through approved products based on traditional medicine drugs;

4. Suitable insurance coverage in order to reach the 30% pocket payment in the field of traditional medicine;

5. Improving the society’s health level based on the development of traditional medicine and benefitting from the six principles of health and the comprehensive attitude;

6. Acquisition of the first rank in the region in terms of fulfilling health and medical needs in the field of traditional medicine and the provision of services, technical knowledge, and herbal products up to 20% of the exports from the medical services of the country; and,

7. Increasing the annual patent registration in this area and reaching the annual registration of 50 patents in 1404 in the field of traditional medicine products.

B. Strategies

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1. Review, modify, simplify and update the relevant laws, regulations and standards in this area;

2. Organization and determination of the territory of traditional medicine activities in the health system and the country's medical education and research system;

3. Developing and reforming the society's attitudes toward the status of traditional medicine and establishing and promoting a healthy lifestyle and nutrition based on the teachings of this area of medicine;

4. Modifying the processes and structures for the monitoring and evaluation of traditional medicine;

5. Organizing and promoting scientific-specialized capacities, professional skills, and the spiritual position of specialist staff, as well as textbooks and reference resources in the field of traditional medicine and traditional pharmacy;

6. Expanding scientific and technological collaborators on an international level in the field of traditional medicine

7. Expand, facilitate and organize the provision of services in the field of traditional medicine

8. Effective support of basic, developmental and applied research in the field of traditional medicine and traditional pharmacy

9. Development of traditional pharmacy to respond to domestic consumption and meet export needs

10. Establishing and organizing effective institutions in the field of traditional medicine and traditional pharmacy, and supporting reputable population-based institutions in this area.

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11. Deepen and expand epistemological and philosophical foundations of traditional medicine and provide practical opportunities for active interaction and synergy between traditional medicine and modern medicine.

C) Measures

1. Continuous coordination and communication with all policy-making and executive agencies in order to propose the terms and conditions required by this sector (1)

2. Review and determine the criteria for validation to facilitate the establishment of educational, research and service centers for traditional medicine (1)

3. Support the establishment of standard and accredited traditional medicine and traditional pharmaceutical services (1)

4. Creating the guideline regarding the provision of health services by the stakeholders of traditional medicine in Iran, especially physicians and pharmacists specializing in this field (1)

5. Supporting the use of traditional medicine services at all levels of the referral system and among family physicians (2)

6. The provision of " Traditional Persian Medicine Services Package” by all family medical personnel as the most important and most common element of the health system of the country to the community (2)

7. Preparation and compilation of appropriate educational content regarding the foundations, values, culture, traditions and heritage of traditional medicine and support for its addition to education textbooks (3)

8. Design, implementation and implementation of a program of empowerment of socially renowned groups in traditional medicine and traditional pharmaceutical fields, in order to play a role in general awareness and promotion (3)

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9. Promotion of Islamic teachings (Quran, Itrat) in the field of health and nutrition (3)

10. Promotion of a healthy lifestyle based on Islamic teachings consistent with traditional medicine in public education programs using national media channels, press, mosques and other religious sites, health centers and other public places, and other informational and general awareness raising methods (3)

11. Promotion of observation with regard to the six principles of health of the school of traditional medicine among the community (3)

12. Designing and promoting a model of maternal and child health based on instructions and Islamic teachings consistent with traditional medicine (3)

13. Establishing a database of traditional drugs available and creating a system for the registration of traditional and natural medicines and providing pharmaceutical information (3)

14. Establishment of a code of conduct for the supervision of traditional medicine activities in cooperation with governmental and non-governmental institutions (4)

15. Design and deployment of appropriate models for quality improvement, performance evaluation, standardization of all processes and services (4)

16. Needs analysis and determination of the work force required for admission through approved programs (5)

17. Training of expert human resources by creating orientations, courses, disciplines, and specialized fields in different fields of traditional medicine based on the need and according to the higher education level of the country (5)

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18. Identifying and supporting centers of excellence in the field of traditional medicine and traditional pharmacy and assigning national missions to these centers in order to meet the needs of the health system of the country (5)

19. Using Iranian-Islamic sources of traditional medicine and promoting them (5)

20. Identifying and maintaining the spiritual heritage and credible implicit and explicit scientific sources in traditional Persian-Islamic traditional medicine through inter-departmental coordination with the Cultural Heritage Organization (5)

21. Compilation of reference books, specialized resources, and practical guidelines for traditional medicine (5)

22. Extracting traditional therapies (in two fields of medicine and veterinary medicine) and collecting oral resources of folk medicine based on the medical sources of different types cultures of the Iranian plateau (5)

23. Developing and strengthening short-term training courses and retraining traditional medicine (5)

24. Identifying, promoting and institutionalizing the teachings based on traditional Persian-Islamic medicine in the medical education system of the country (5)

25. Creating a suitable context for sharing the resources of traditional therapists and transferring them to later generations (5)

26. The ratification and publication of the global charter on the Theoretical Foundations of Traditional Persian-Islamic Medicine, in order to insert the name of traditional Persian-Islamic medicine as a well-known school, in line with other valid medical schools, in major international texts (6)

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27. Establishing stable relationships and international collaborative partnerships with reputable centers of traditional medicine, especially the Muslim world (6)

28. Comparative studies between the Persian-Islamic traditional medicine system with the traditional medicine of other nations and the classic medicine (6)

29. Planning for the effective promotion of the capacities, experiences, teachings and resources of traditional medicine of other nations, as well as classical medicine capacities (6)

30. Extending the insurance coverage of traditional medicine services with an emphasis on the principle of social justice (7)

31. Determining tariffs for services and matching of fees (public and private) with other health services and the support of difference insurances of these services (7)

32. Prioritizing the purchase of products and byproducts of traditional medicine by government departments and the insurance of these products (7)

33. Supporting private sector investment in the production and commercialization and export of traditional medicine products (7)

34. Encouraging insurance companies toward investment in traditional medicine as a prevention medicine in order to reduce treatment costs (7)

35. Creating the health identification document within the regulations of the Ministry of Health, together with temperament mixture for the society’s population (8)

36. Establishing and reinforcing growth centers of technology units in the field of traditional medicine and traditional pharmacy (at least 20 centers in the horizon year) (8)

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37. Establishing at least 5 scientific-research journals in Persian and other international languages in the field of scientific-research achievements of traditional medicine and their applications in modern and classic medicine (8)

38. Allocation of at least 5% of research budgets of universities of medical sciences to traditional medicine research and its applications in modern and classic medicine (8)

39. Establishment of a traditional medicine research network and the development of its activities (8)

40. Designing and providing constant, short-term, and in-service education to pharmacists of the traditional medicine system (9)

41. Designing, supporting, and providing the resources for the establishment and development of facilities for the technology, production, and export of traditional medicine, cosmetic byproducts, supplements, and food products based on traditional medicine teachings (9)

42. Establishment of a museum for the revitalization and protection of traditional medicine heritage (10)

43. Supporting the establishment, development and empowerment of valid population-based centers and institutes related to patient rights and improving their level of participation in decision creation (10)

44. Creating, approving and implementing the method guidelines of integrating traditional medicine and traditional pharmacy in the health services system (11)

45. Establishment and support of a theorizing desk on traditional Persian- Islamic medicine (11)

46. Creating interdisciplinary orientations in the field of traditional medicine and traditional pharmacy, humanities, Islamic sciences, social sciences (11)

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47. Establishing a research center for epistemological studies based on theoretical-philosophical foundations of Persian-Islamic traditional medicine (11)

Article 6: Mechanism for the implementation and monitoring of the implementation of the Document of Medicinal Plants and Traditional Medicine

The Supreme Council for Cultural Revolution is responsible for massive macro- policy coordination, macro-level coordination and macro-supervision for the implementation of this document. The “Headquarters of the Comprehensive Scientific Plan of the Country” is responsible for monitoring the implementation of this document, and it will submit the necessary reviews and reports at specified intervals as stated in the relevant document to the Supreme Council for Cultural Revolution. The “Headquarters for the Development of Science and Technology of Medicinal Plants and Traditional Medicine", hereinafter referred to as headquarters, has the task of policy-making, guidance, coordination, monitoring of indices, and the establishment of necessary inter-institutional communication, both public and private, for the development of technology and knowledge-based industries on medicinal herbs and traditional medicine in the framework of this document.

This headquarter has a council and a secretariat.

A. Members of the Headquarters’ Council

1. Vice-President of Science and Technology (Chief of Staff)

2. Minister of Health, Treatment, and Medical Education (Deputy Chief of Staff)

3. Minister of Science, Research and Technology or relevant Deputy Minister

4. Minister of Agricultural or relevant Deputy Minister

5. Minister of Industry, Mines and Trade or relevant Deputy Minister

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6. Minister of Labor and Social Welfare or relevant Deputy Minister

7. Head of University Academic Jihad Organization

8. Head of the Center for Presidential Technology and Innovation Cooperation

9. Chair of the Specialized Council of the Seminary

10. Deputy of Traditional Medicine, Ministry of Health, Treatment and Medical Education

11. Deputy of Research and Technology, Ministry of Health, Treatment and Medical Education

12. Representative of the Headquarters for implementing the Comprehensive Scientific Plan of the Country

13. Four experts associated with the decree of the Chief of Staff

Note 3: Professionals are appointed for a period of four years, and their re- appointment is permitted. Two experts are appointed by suggestion of the Minister of Health, Treatment and Medical Education by the decree of the Chief of Staff.

14. Head Secretary of the Headquarters

Note 4: The head secretary is elected by the Chief of Staff for a period of four years, and his re-appointment is permitted.

Note 5: The secretariat of the headquarters is based in the Vice-Presidency of Science and Technology.

B. Headquarters’ Responsibilities

1. Implementation policy, coordination, monitoring, and follow-up of inter- organizational communication to expand and monitor activities in the areas defined in this document;

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2. Preparation and development of an operational plan for the implementation of the document's actions each year;

3. Guidance and follow-up of public-private interactions to achieve the objectives of this document; and,

4. Material and spiritual scientific and informational support, and facilitation for knowledge-based companies as well as for plans with technological and commercialization capacities.

5. Encouraging support for scientific, technologic, and knowledge-based economic activities in the field of medicinal plants and herbal products based on approved guidelines in the headquarters’ council

6. Reviewing internal and international developments of this field, in order to achieve the objectives of this document and providing the Headquarters for Implementing the Country’s Comprehensive Scientific Plan with necessary revision suggestions for review and update purposes

7. Continuous evaluation and monitoring the suitability of implementation regarding the assigned plans to different organizations and bodies, as well as reviewing and revising the indexes and providing annual reports to the Headquarters for Implementing the Country’s Comprehensive Scientific Plan

Note 6: This report will include the achievement rate of the objectives in the two fields of “Medicinal Plants and Herbal Products” and “Traditional Medicine” as well as the quantities of the document’s indexes, together with their extraction process.

Note 7: After six months of the approval of this document, the headquarters is responsible for creating the titles of the indexes of this document under five chapters, namely research and technology, education and human capital, economic, health, and facilities. The headquarters is also responsible for gaining

149 the approval of the Headquarters for Implementing the Country’s Comprehensive Scientific Plan.

Note 8: The government is responsible for predicting the necessary budgets of this document in the form of an independent resource in the annual budget bills and five-year development plans.

Note 9: Structural organization and role description of the headquarters secretariat will be created in the headquarters and receive the approval of qualified authorities.

The National Document of Medicinal Plants and Traditional Medicine, devised in 6 Articles and 9 comments, has been approved by the Supreme Council for Cultural Revolution at the Council’s 735th meeting, dated July 16, 2013, with the execution of its contents being obligatory from the date of approval, rendering void any and all previous contradictory approvals and policies.

Signed by

Mahmoud Ahmadinejad

President and the Head of the Supreme Council for Cultural Revolution

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