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Public health improvement in Iran—lessons from the last 20 years
Public Health (2004) 118, 395–402
Public health improvement in Iran—lessons from the last 20 years M. Asadi-Laria,*, A.A. Sayyarib, M.E. Akbaric, D. Graya a
Division of Cardiovascular Medicine, Queens Medical Centre, University Hospital, Nottingham NG7 2UH, UK b Under-Secretary for Co-ordination, Ministry of Health and Medical Education, Iran c Under-Secretary for Health, Ministry of Health and Medical Education, Iran Received 9 September 2003; received in revised form 10 May 2004; accepted 26 May 2004
KEYWORDS Primary health care; Health needs assessment; Health reform; Iranian healthcare system
Summary Introduction. Health services are historically based on providers’s and policy makers’s understanding of population health status. This does not necessarily reflect the real needs of a population. Health needs assessment (HNA) should improve individual or population health and optimize the way that limited resources are utilized. Objectives. To review health needs literature and to describe Iranian primary healthcare (PHC) achievements in developing a needs-driven health system. Findings. The Iranian PHC system was established to meet healthcare needs identified through population health status surveys. Since 1984, the PHC system has become highly organized and efficient, resulting in a dramatic decrease in infant, maternal and neonatal mortality rates, population growth, increasing life span and a marked shift towards non-communicable diseases. Through an organized partnership of the general population, volunteers, health workers and health professionals, a needs-oriented healthcare system became central to health policy in Iran. Several information sources were utilized to establish need. Improving death certification was an immediate and important part of this process. Comment. Improved knowledge about personal rights, community and environmental health policies, and involvement of the media led to an increased range and depth of needs. Moving towards quality improvement and a needs-driven healthcare system requires continuous needs assessment. Novel methods of HNA, such as postal and telephone surveys, group discussions, surrogates for need such as quality-of-life measurement (commonly used in developed countries) or other locally designed methods such as the basic development needs approach, may be relevant to the Iranian PHC network. Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: C44-115-9249924; fax: C44-115-9709384 E-mail address: [email protected] (M. Asadi-Lari). 0033-3506/$ - see front matter Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2004.05.011
396
Introduction Historically, health services in the Western world are based on providers and policy makers understanding of the population health status. This has led to the introduction and widespread use of technological solutions to health problems. In developing countries such as Iran, however, public health issues such as rapid population growth, appalling infant and maternal mortality rates, and low vaccination rates against common infectious diseases predominated until recently, and increasing urbanization has seen the emergence of chronic illnesses including coronary heart disease. Is the Western approach to medical care, which is biased towards curative and technological solutions, appropriate for developing nations or is there an alternative? The ideal model of care dictates that services meet the genuine health needs of the general population. ‘Need’ is difficult to define,1 yet in modern healthcare systems, fulfilling health needs has a central role. Health needs refers to a wide range of issues related to people’s health, including deprivation indices, literacy, housing and even social facilities such as a bus service to reach the health services.2 Health needs assessment (HNA) recognizes the importance of people’s genuine needs, and aims to ensure that health service resources are spent in the most efficient way to improve the population’s health. This paper provides an overview of the primary healthcare (PHC) system in Iran and its advantages, assesses the impact of the health needs approach on health care in Iran, and describes novel approaches to ongoing HNA.
Identifying health needs ‘Health’ is an all-inclusive concept, not just lack of illness3, so it is not surprising that numerous definitions have been presented for health need;1 geographic variations, socio-economic status, and knowledge and attitude of the population may influence demand for health care, while guidelines and effectiveness of procedures may affect availability. Ideally, the provision of healthcare services should meet most of the population’s needs. As these may not be constant, HNA surveys are necessary both locally and nationwide to establish what services are required to match these needs; HNA may involve the public and professionals in the decision-making process and influence on service utilization rate, and has potential impact on
M. Asadi-Lari et al. priority setting and primary care planning.4 On the other hand, application of a comprehensive approach to HNA may lead to more cost-effective health service provision.5
Approaches to HNA Several methods have been used to assess a population’s healthcare needs including utilization, deprivation and mortality.6 Recently, however, four practical methods have gained more attention.
The epidemiological approach Data on community incidence, prevalence of disease and the effectiveness of interventions7 form the basis of this rather traditional method of determining need.8,9 The most common or most severe conditions are targeted, which is not strictly consistent with a comprehensive definition of health.
The comparative approach The comparative approach contrasts the services provided for a defined population with those elsewhere or within the same population over time, and therefore may accelerate the achievement of equity in health planning.10 Without comparative data, routine data collection in the context of epidemiological HNA is of limited use in planning health services.11
The corporate approach This is based on demand, needs and perspectives of interested parties including professionals, policy makers, patients and the public, which emphasizes the culture of partnership. Professionals (especially in primary care) are influential, particularly at individual level, because of day-to-day patient contact and their assessment of the impact of illness, and its treatment, on quality of life,12 despite their questionable perception of a population’s needs as disagreement between professionals’s and patients’s perception of needs is not just an exception.13,14
Outcome assessment This concentrates on the effectiveness of health care, which should not hinge exclusively on clinical assessment but also on health-related quality of life or other qualitative measurements. Although
Infant mortality trends in the Iran health-related quality of life is already widely employed as an outcome, ‘need’ has only gained attention recently. The combination of outcome and need could be useful.15–17 The purpose of HNA is to collate essential information from various sources into a common framework to improve the health of the population, thus avoiding failure in service development and inappropriate deployment of resources.18,19 HNA should identify both medical and non-medical factors that impact on an individual’s, and even carers’s,20 healthcare needs. Data collection is at the core of HNA, as Iranian officials have observed.
Iranian primary health care The Alma Ata declaration21 highlighted the importance of primary care, and many countries, including Iran, revised their healthcare system to meet the global aim of ‘Health for All’ by 2000. This declaration, endorsed by the Iranian Cabinet and Parliament in 1984, led to the development of a PHC network to: † improve existing public health indices, including population growth rate, infant and maternal mortality rate, and vaccination coverage; † provide community health care in rural areas; † prioritize preventive rather than curative care; † integrate public health activities, including malaria control, family planning, school health and environmental health; † encourage community participation in all stages of planning, implementation and evaluation of health care; and † create an appropriate environment for community oriented human resource training. To achieve these goals, sample networks were set up in a single city in each of Iran’s 24 provinces. Despite financial constraints imposed by war (1980– 1988), the PHC network expanded rapidly with somewhat different models in rural and urban areas. As such, improvements in the provision of community health care became obvious.
397 each with a population of approximately 1000, and retain family health records. In addition to the HHs, Iran has 2300 rural health centres (RHCs), each staffed by a medically qualified general physician and a team of up to 10 health workers to provide health services to about 7500 people. RHCs are technically and administratively superior to HHs. In rural areas, monitoring systems operated by health workers mean that rural inhabitants receive healthcare services that are superior to urban dwellers; the immunization programme is one example.22 Every child is followed-up by health workers to make sure that vaccination occurs on schedule; otherwise, a Behvarz will make a home visit to provide the vaccine. This system is exclusive to rural areas, so reproductive and child healthcare indices are at least comparable and in many cases better than those in urban areas (Table 1). For example, all immunization rates, with the exception of hepatitis B vaccine, are higher in rural areas than urban areas due to this active follow-up. The lower hepatitis B rate is attributable to the newly introduced vaccine in the ‘Expanded Programme for Immunization’ that was deployed extensively by the private sector in urban areas. However, the vigilance system has more advantages in terms of breastfeeding advocacy, health promotion and higher consumption of iodine salt, which had a great impact in controlling goitre in Iran.23
The urban healthcare model Over 2300 urban health centres (UHCs), each with at least three general physicians and 15 health workers, cover a population of approximately 15 000 people. In larger cities, 600 health posts (HP), each manned by five health workers, provide public health services to nearly 10 000 people, mainly in slum areas. HPs provide PHC but not curative care. About 50 000 female volunteers assist health workers in public health education, family planning, child growth control, child immunization and environmental health.
The role of hospitals The rural healthcare model Basic health care is provided by over 16 000 health houses (HH) staffed by at least one auxiliary health worker (or Behvarz). Behvarzes are selected by and resident in the main village, and undergo 2 years of training in specific health duties. HHs cover most of Iran’s 65 000 villages,
Patients whose basic health care cannot be met at a local level may be referred to a general hospital for specialist opinion. Larger cities have designated referral hospitals where specialists and subspecialists provide curative services. In a recent reform, in three pilot provinces, patients’s information is fed back from the specialists in referral hospitals to
398 Table 1
M. Asadi-Lari et al. Major health indices in rural and urban areas in Iran.
Health indicator
Rural area
Urban area
Total
Population!1000 (2001) Immunization BCG (1997) Hepatitis B (1997) DTP3 (1997) Measles (1997) Poliomyelitis3 (1997) Crude birth rate per 1000 (2001) Infant mortality rate per 1000 live births (2001) Child mortality rate % (2001) Exclusive breastfeeding (under 4 months) (2000) Maternal mortality rate (per 100k) (1996) Modern contraceptive prevalence rate in married women aged 15–45 years % (2001) Literacy rate in males O6 years of age % (2000) Literacy rate in females O6 years of age % (2000) Deliveries carried out by trained personnel %
22 275 98.8 82.2 97.1 96.3 97.1 18.4 30.2 35 57.2 54.5 57.3
43 265 98.5 90.6 96.7 95.4 96.8 15.2 27.7 37 51.1 24.3 55.2
65 540 98.6 89.9 96.9 95.9 96.9 16.3 28.6 36 53.3 37.4 55.9
79 65 75
91 82 95
87 76
local health centres for continuing care or retention in medical records.
perspective of demography and health status in rural communities.
Infectious disease notification
Health information flow in Iran Routine data collection An exclusive data sheet or ‘vital horoscope’ (VH) forms the basis of data collection for every member of a community in rural areas. The VH is held as a spreadsheet in each HH and comprises several concentric circles in 12 equal slices (representing 1 year) to record vital events including births and deaths in the main and adjacent (satellite) villages. Data on inter-alia age-stratified demographics, environmental health, family planning, vaccine-preventable disease, amount of iodized salt consumed, maternal mortality including aetiology, cause of death in children under 5 years of age and, ultimately, ageand sex-stratified mortality are also recorded. A specific spreadsheet records birth by weight, sex, maternal age, and delivery location and conditions. These data help to track underweight children for extra care by the Behvarzes and referral for examination by a physician. Data quality is checked regularly by supervisors in the health centres and district authorities, and HHs are provided with appropriate feedback. Data are accumulated in district health centres, entered into a software program specifically designed for this purpose, analysed locally and eventually conveyed to the PHC centre to the Deputy for Public Health. This provides an observatory
Sixteen infectious diseases must be reported promptly (by telephone or fax, 24 h/day) and in writing in line with the World Health Organization’s (WHO) guidelines. This approach has proved so efficient that formal reports, approved by the WHO, have confirmed the eradication of diseases such as poliomyelitis and the control of infectious diseases such as measles. Appropriate feedback is provided for healthcare delivery centres at district level to improve the overall health status.
National census surveys Maternal mortality rate as an index of development has been considered to be a matter of public health concern in developing countries; before the establishment of the PHC system in Iran, this was high at 150 per 100 000 live births. There are certain limitations to conducting surveys to estimate the rate among the whole population, but the national census may have potential for this purpose.24 The last census in 1996 included a question to establish the maternal mortality rate prior to introducing a national programme. This revealed a rate of 39 per 100 000 which dropped to 37.4 in 2002. More importantly, areas of high prevalence were identified; further enquiries conducted and specific programmes were designed to reduce maternal mortality. The next census will discover the efficiency of interventions.
Infant mortality trends in the Iran
399
Routine surveys Routine surveys deal with issues such as family planning, children’s health and nutrition. For example, the second National Health Survey revealed that almost one-third of pre-school children in rural areas were growth retarded, significantly more than their urban counterparts, and that girls were affected more than boys.25 Hundreds of healthcare services surveys are carried out by the medical universities and health authorities across the country, and results are the subject of public policy review; for example, when a local epidemiological study on coronary artery disease in central Iran was brought to the attention of health decision makers, a specific surveillance system was set up to document coronary disease mortality.26
In an attempt to overcome the disadvantages of traditional death certification, a death registry was set up using data from hospitals and cemeteries in accordance with standardized tracing methods. This registry was scheduled to extend nationwide by the end of 2003 to provide a reliable basis for calculating the burden of disease regionally and nationally, and of life years lost.27 Death registration is considered to be a surrogate for population health needs.28,29 Table 2 shows the 10 major
Disorders
Cardiovascular Accidents Cancer Perinatal Respiratory Gastroentrological Urological Infectious Metabolic and nutritional Congenital Suicide
Other sources of information There is a broad spectrum of data sources, each with advantages and disadvantages. These include information from city and village councils, and nongovernment organizations (Table 3).
Applying HNA to solve health problems in Iran
Death registry
Table 2
causes of death in 2001. The main advantage of the death registry is disease mapping countrywide, to the extent that after publication of the first draft in 2001, health authorities in the 10 provinces studied were aware of local epidemiological features to design projects against specific diseases; a case for comparative HNA. This led to comprehensive planning for controlling cardiovascular diseases, the major cause of death in three provinces.
In 1979, neonatal and maternal mortality rates in Iran were among the worst in the world (Fig. 1), and population growth rate exceeded 3.2%. Other major health problems identified in surveys included low vaccination uptake, high death rates from childhood infectious disease, high maternal mortality rate, limited access to clean drinking water in rural areas, and poor access to healthcare facilities in indigent localities (Table 3).
The 10 major causes of death for all age groups (2001) in 10 provinces (25% of the Iranian population). % Of total deaths
Rate in total population
Rate in sex
M
F
15.1
13
Rate in rural areas
Rate in urban areas
Median age of death
% YLL
13.11
14.42
68
22.8
34.79
13.89
12.03 10.66 4.4 4.33
4.8 4.26 1.76 1.73
7.13 5.09 1.89 1.95
2.4 3.4 1.4 1.5
4.82 4.54 1.75 1.64
4.79 4.07 1.76 1.79
35.3 59.7 0.1 58.8
21.6 9.9 10 3.8
2.04
0.81
0.98
0.6
0.81
0.82
59.2
1.9
1.69 1.68 1.66
0.67 0.67 0.66
0.74 0.73 0.59
0.6 0.6 0.7
0.69 0.62 0.54
0.67 0.7 0.74
61.8 41.8 62.3
1.5 2.3 1.4
1.55
0.62
0.62
0.6
0.74
0.54
3.1
3.5
1.55
0.62
0.6
0.6
0.73
0.54
YLL, years of life lost.
29
3.3
400 Table 3 Iran.
M. Asadi-Lari et al. Source of healthcare needs information in
Urban areas
Rural areas
Health workers General physician Specialist Census Registration (family file records at HPs and UHCs) Health surveys Notification Health volunteers Death registry Hospital records Insurance records Private sector Health workers in other sectors Regular health check of factory workers
Vital health records (VH) Behvarz and other health General physician workers Census Family file records at HHs Health surveys Notification Death registry Hospital records Insurance records
HP, health post; UHC, urban health centre; HH, health house.
A contemporary review of the health status of the Iranian population reported: “While developed nations of the world were expecting a 20% increase in their population over the period of 1975–2000, and the total population increase in the developing world was to be 65%, Iran would have to prepare for a 92% increase in its population over the same period of time (25 years)".30 Faced with unacceptable levels of mortality and morbidity, Iran’s leaders elected to introduce health policies that would address the genuine healthcare needs of its population, so the PHC system was
Figure 1
introduced as the focus of Iran’s health needs. In this regard, the epidemiological approach was the only method to assess health needs and impetus for establishing PHC services; now it is necessary to consider other methods of HNA to achieve a sustainable framework for health improvement. For example, the population boom and vaccine-preventable diseases were the principal findings of the first HNA, 20 years ago, so the majority of effort was devoted to control these major problems; the Iranian population are now experiencing the benefits. As new data were obtained (for example, data from the death registry), the system was flexible enough to accommodate new changes to respond to noncommunicable diseases such as coronary artery disease, diabetes and asthma, and also emerging diseases such as hepatitis C or human immunodeficiency virus infection. Every new programme was integrated in the PHC system after a formal process encompassing a scientific appraisal, endorsement of several executive committees, training of auxiliary health workers, preparing referral hospitals, and also health insurance back-up where indicated (Fig. 2).
The future The PHC system in Iran was established in response to healthcare needs identified in surveys, but needs will change over time due to, for example, urbanization, increasing congestion and pollution, and chronic diseases in an ageing population. The application of the epidemiological approach to HNA methodology was central at the beginning of the PHC network. However, as health needs have a dynamic nature and change over time, it must become the combined responsibility of all health
Infant mortality trends in the Iranian population between 1974 and 1996.
Infant mortality trends in the Iran
Figure 2
401
Demographic trend in the Iranian population over 40 years.
workers, trained professionals and the population. The range of techniques used to monitor health needs should increase to cover new methods: faceto-face interviews, professional panels, prescribing data, rapid appraisal by postal or telephone surveys, or focus group discussions. Health-related, quality of life assessment can be used as a preliminary ‘screening test’17 in the normal population and within specific areas of ill health, reserving detailed HNA for those with poor quality of life. The concept of health-related quality of life is new among Iranian health professionals and decision makers, but its introduction could enhance the ability of the Iranian PHC system to meet its population needs. Inevitably, HNA will remain central to health care and resource allocation in Iran, ensuring improvement in the quality of care and a reasonable level of equity.
Key messages † health needs should have a central role in modern healthcare systems † other methods to assess health needs, rather than an epidemiological approach, should be considered to ensure a thorough appraisal † novel methods of assessing health needs are emerging † health services based on the expressed needs of the general population rather than providers’s and policy makers’s assumptions would be more effective and would maximize health gain † Iran’s primary healthcare system was based upon a needs-driven approach concurrent with health
system reform in accordance with the Alma Ata declaration † major improvements in health followed health system reform † the health needs model of care is relevant to other developing, and developed, countries
References 1. Asadi-Lari M, Packham CJ, Gray D. Need for redefining needs. Health Qual Life Outcomes 2003;1:34. 2. Wright J, Williams R, Wilkinson JR. Development and importance of health needs assessment. BMJ 1998; 316:1310–3. 3. WHO, Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. 4. Ruta DA, Duffy MC, Farquharson A, Young AM, Gilmour FB, McElduff SP. Determining priorities for change in primary care: the value of practice-based needs assessment. Br J Gen Pract 1997;47:353–7. 5. Kroll L, Woodham A, Rothwell J, Bailey S, Tobias C, Harrington R, Marshall M. Reliability of the Salford needs assessment schedule for adolescents. Psychol Med 1999; 29:891–902. 6. Newbold KB, Eyles J, Birch S, Spencer A. Allocating resources in health care: alternative approaches to measuring needs in resource allocation formula in Ontario. Health Place 1998; 4:79–89. 7. Stevens A, Sadler M. Epidemiologically based needs assessment. In: Harris A, editor. Needs to know: a guide to needs assessment for primary care. Glasgow: Churchill Livingstone; 1997. 8. Pickin C, St Leger S. Assessing health need using the life cycle framework. Buckingham: Open University Press; 1993. 9. Stewart GT. Epidemiological approach to assessment of health. Lancet 1970;2:115–9.
402 10. Martin M, Pehrson J, Orrell M. A survey of social services needs assessments for elderly mentally ill people in England and Wales. Age Ageing 1999;28:575–7. 11. Wright J, Walley J. Assessing health needs in developing countries. BMJ 1998;316:1819–23. 12. Shanks J, Kheraj S, Fish S. Better ways of assessing health needs in primary care. BMJ 1995;310:480–1. 13. Lasalvia A, Ruggeri M, Mazzi MA, Dall’Agnola RB. The perception of needs for care in staff and patients in community-based mental health services. The South-Verona Outcome Project 3. Acta Psychiatr Scand 2000;102:366–75. 14. Rothwell PM, McDowell Z, Wong CK, Dorman PJ. Doctors and patients don’t agree: cross sectional study of patients’ and doctors’ perceptions and assessments of disability in multiple sclerosis. BMJ 1997;314:1580–3. 15. van de Bos GA, Triemstra AH. Quality of life as an instrument for need assessment and outcome assessment of health care in chronic patients. Qual Health Care 1999; 8:247–52. 16. Asadi-Lari M, Gray D. Comparison of generic and diseasespecific quality of life instruments in patients with suspected myocardial infarction as a means of detecting health care needs. Circulation 2002;106(Suppl.):2. 17. Asadi-Lari M, Gray D. Is quality of life measurement likely to be a proxy for health needs assessment in patients with coronary artery disease?. Health Qual Life Outcomes 2003;1:5. 18. McEwen J, Russell EM, Stewart S. Needs assessment in Scotland: collaboration in public health. Public Health 1995; 109:179–85. 19. Smith H. Needs assessment in mental health services: the DISC framework. J Public Health Med 1998;20:154–60. 20. Ward H, Cavanagh J. A descriptive study of the selfperceived needs of carers for dependents with a range of long-term problems. J Public Health Med 1997;19:281–7.
M. Asadi-Lari et al. 21. WHO and UNICEF. International Conference on Primary Health Care: Report of the International Conference on Primary Health Care, Alma Ata, USSR. Geneva: World Health Organization; 1978 p. 79. 22. Nasseri K, Sadrizadeh B, Malek-Afzali H, Chamsa M, Cheraghchi Bashi MT, Haghgoo M, Azmoodeh M. Primary health care and immunisation in Iran. Public Health 1991; 105:229–38. 23. Azizi F, Sheikholeslam R, Hedayati M, Mirmiran P, Malekafzali H, Kimiager M, Pajoui M. Sustainable control of iodine deficiency in Iran: beneficial results of the implementation of the mandatory law on salt iodization. J Endocrinol Invest 2002;25:409–13. 24. Stanton C, Hobcraft J, Hill K, Kodjogbe N, Mapeta WT, Munene F, Naghavi M, Rabeza V, Sisouphanthong B, Campbell O. Every death counts: measurement of maternal mortality via a census. Bull World Health Organ 2001; 79:657–64. 25. Ghassemi H, Harrison G, Mohammad K. An accelerated nutrition transition in Iran. Public Health Nutr 2002; 5:149–55. 26. Sarraf-Zadegan N, Boshtam M, Malekafzali H, Bashardoost N, Sayed Tabatabaei FA, Rafiel M, Khalili A, Mostafavi S, Khami M, Hassanvand R. Secular trends in cardiovascular mortality in Iran, with special reference to Isfahan. Acta Cardiol 1999;54:327–33. 27. Michaud CM, Murray CJ, Bloom BR. Burden of disease— implications for future research. JAMA 2001;285:535–9. 28. Webb R, Esmail A. An analysis of practice-level mortality data to inform a health needs assessment. Br J Gen Pract 2002;52:296–9. 29. Wurthwein R, Gbangou A, Sauerborn R, Schmidt CM. Measuring the local burden of disease. A study of years of life lost in sub-Saharan Africa. Int J Epidemiol 2001;30:501–8. 30. Shadpour K. The PHC experience in Iran. Ministry of Health and Medical Education. Tehran: UNICEF; 1994.
Public health improvement in Iran—lessons from the last 20 years M. Asadi-Laria,*, A.A. Sayyarib, M.E. Akbaric, D. Graya a
Division of Cardiovascular Medicine, Queens Medical Centre, University Hospital, Nottingham NG7 2UH, UK b Under-Secretary for Co-ordination, Ministry of Health and Medical Education, Iran c Under-Secretary for Health, Ministry of Health and Medical Education, Iran Received 9 September 2003; received in revised form 10 May 2004; accepted 26 May 2004
KEYWORDS Primary health care; Health needs assessment; Health reform; Iranian healthcare system
Summary Introduction. Health services are historically based on providers’s and policy makers’s understanding of population health status. This does not necessarily reflect the real needs of a population. Health needs assessment (HNA) should improve individual or population health and optimize the way that limited resources are utilized. Objectives. To review health needs literature and to describe Iranian primary healthcare (PHC) achievements in developing a needs-driven health system. Findings. The Iranian PHC system was established to meet healthcare needs identified through population health status surveys. Since 1984, the PHC system has become highly organized and efficient, resulting in a dramatic decrease in infant, maternal and neonatal mortality rates, population growth, increasing life span and a marked shift towards non-communicable diseases. Through an organized partnership of the general population, volunteers, health workers and health professionals, a needs-oriented healthcare system became central to health policy in Iran. Several information sources were utilized to establish need. Improving death certification was an immediate and important part of this process. Comment. Improved knowledge about personal rights, community and environmental health policies, and involvement of the media led to an increased range and depth of needs. Moving towards quality improvement and a needs-driven healthcare system requires continuous needs assessment. Novel methods of HNA, such as postal and telephone surveys, group discussions, surrogates for need such as quality-of-life measurement (commonly used in developed countries) or other locally designed methods such as the basic development needs approach, may be relevant to the Iranian PHC network. Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: C44-115-9249924; fax: C44-115-9709384 E-mail address: [email protected] (M. Asadi-Lari). 0033-3506/$ - see front matter Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2004.05.011
396
Introduction Historically, health services in the Western world are based on providers and policy makers understanding of the population health status. This has led to the introduction and widespread use of technological solutions to health problems. In developing countries such as Iran, however, public health issues such as rapid population growth, appalling infant and maternal mortality rates, and low vaccination rates against common infectious diseases predominated until recently, and increasing urbanization has seen the emergence of chronic illnesses including coronary heart disease. Is the Western approach to medical care, which is biased towards curative and technological solutions, appropriate for developing nations or is there an alternative? The ideal model of care dictates that services meet the genuine health needs of the general population. ‘Need’ is difficult to define,1 yet in modern healthcare systems, fulfilling health needs has a central role. Health needs refers to a wide range of issues related to people’s health, including deprivation indices, literacy, housing and even social facilities such as a bus service to reach the health services.2 Health needs assessment (HNA) recognizes the importance of people’s genuine needs, and aims to ensure that health service resources are spent in the most efficient way to improve the population’s health. This paper provides an overview of the primary healthcare (PHC) system in Iran and its advantages, assesses the impact of the health needs approach on health care in Iran, and describes novel approaches to ongoing HNA.
Identifying health needs ‘Health’ is an all-inclusive concept, not just lack of illness3, so it is not surprising that numerous definitions have been presented for health need;1 geographic variations, socio-economic status, and knowledge and attitude of the population may influence demand for health care, while guidelines and effectiveness of procedures may affect availability. Ideally, the provision of healthcare services should meet most of the population’s needs. As these may not be constant, HNA surveys are necessary both locally and nationwide to establish what services are required to match these needs; HNA may involve the public and professionals in the decision-making process and influence on service utilization rate, and has potential impact on
M. Asadi-Lari et al. priority setting and primary care planning.4 On the other hand, application of a comprehensive approach to HNA may lead to more cost-effective health service provision.5
Approaches to HNA Several methods have been used to assess a population’s healthcare needs including utilization, deprivation and mortality.6 Recently, however, four practical methods have gained more attention.
The epidemiological approach Data on community incidence, prevalence of disease and the effectiveness of interventions7 form the basis of this rather traditional method of determining need.8,9 The most common or most severe conditions are targeted, which is not strictly consistent with a comprehensive definition of health.
The comparative approach The comparative approach contrasts the services provided for a defined population with those elsewhere or within the same population over time, and therefore may accelerate the achievement of equity in health planning.10 Without comparative data, routine data collection in the context of epidemiological HNA is of limited use in planning health services.11
The corporate approach This is based on demand, needs and perspectives of interested parties including professionals, policy makers, patients and the public, which emphasizes the culture of partnership. Professionals (especially in primary care) are influential, particularly at individual level, because of day-to-day patient contact and their assessment of the impact of illness, and its treatment, on quality of life,12 despite their questionable perception of a population’s needs as disagreement between professionals’s and patients’s perception of needs is not just an exception.13,14
Outcome assessment This concentrates on the effectiveness of health care, which should not hinge exclusively on clinical assessment but also on health-related quality of life or other qualitative measurements. Although
Infant mortality trends in the Iran health-related quality of life is already widely employed as an outcome, ‘need’ has only gained attention recently. The combination of outcome and need could be useful.15–17 The purpose of HNA is to collate essential information from various sources into a common framework to improve the health of the population, thus avoiding failure in service development and inappropriate deployment of resources.18,19 HNA should identify both medical and non-medical factors that impact on an individual’s, and even carers’s,20 healthcare needs. Data collection is at the core of HNA, as Iranian officials have observed.
Iranian primary health care The Alma Ata declaration21 highlighted the importance of primary care, and many countries, including Iran, revised their healthcare system to meet the global aim of ‘Health for All’ by 2000. This declaration, endorsed by the Iranian Cabinet and Parliament in 1984, led to the development of a PHC network to: † improve existing public health indices, including population growth rate, infant and maternal mortality rate, and vaccination coverage; † provide community health care in rural areas; † prioritize preventive rather than curative care; † integrate public health activities, including malaria control, family planning, school health and environmental health; † encourage community participation in all stages of planning, implementation and evaluation of health care; and † create an appropriate environment for community oriented human resource training. To achieve these goals, sample networks were set up in a single city in each of Iran’s 24 provinces. Despite financial constraints imposed by war (1980– 1988), the PHC network expanded rapidly with somewhat different models in rural and urban areas. As such, improvements in the provision of community health care became obvious.
397 each with a population of approximately 1000, and retain family health records. In addition to the HHs, Iran has 2300 rural health centres (RHCs), each staffed by a medically qualified general physician and a team of up to 10 health workers to provide health services to about 7500 people. RHCs are technically and administratively superior to HHs. In rural areas, monitoring systems operated by health workers mean that rural inhabitants receive healthcare services that are superior to urban dwellers; the immunization programme is one example.22 Every child is followed-up by health workers to make sure that vaccination occurs on schedule; otherwise, a Behvarz will make a home visit to provide the vaccine. This system is exclusive to rural areas, so reproductive and child healthcare indices are at least comparable and in many cases better than those in urban areas (Table 1). For example, all immunization rates, with the exception of hepatitis B vaccine, are higher in rural areas than urban areas due to this active follow-up. The lower hepatitis B rate is attributable to the newly introduced vaccine in the ‘Expanded Programme for Immunization’ that was deployed extensively by the private sector in urban areas. However, the vigilance system has more advantages in terms of breastfeeding advocacy, health promotion and higher consumption of iodine salt, which had a great impact in controlling goitre in Iran.23
The urban healthcare model Over 2300 urban health centres (UHCs), each with at least three general physicians and 15 health workers, cover a population of approximately 15 000 people. In larger cities, 600 health posts (HP), each manned by five health workers, provide public health services to nearly 10 000 people, mainly in slum areas. HPs provide PHC but not curative care. About 50 000 female volunteers assist health workers in public health education, family planning, child growth control, child immunization and environmental health.
The role of hospitals The rural healthcare model Basic health care is provided by over 16 000 health houses (HH) staffed by at least one auxiliary health worker (or Behvarz). Behvarzes are selected by and resident in the main village, and undergo 2 years of training in specific health duties. HHs cover most of Iran’s 65 000 villages,
Patients whose basic health care cannot be met at a local level may be referred to a general hospital for specialist opinion. Larger cities have designated referral hospitals where specialists and subspecialists provide curative services. In a recent reform, in three pilot provinces, patients’s information is fed back from the specialists in referral hospitals to
398 Table 1
M. Asadi-Lari et al. Major health indices in rural and urban areas in Iran.
Health indicator
Rural area
Urban area
Total
Population!1000 (2001) Immunization BCG (1997) Hepatitis B (1997) DTP3 (1997) Measles (1997) Poliomyelitis3 (1997) Crude birth rate per 1000 (2001) Infant mortality rate per 1000 live births (2001) Child mortality rate % (2001) Exclusive breastfeeding (under 4 months) (2000) Maternal mortality rate (per 100k) (1996) Modern contraceptive prevalence rate in married women aged 15–45 years % (2001) Literacy rate in males O6 years of age % (2000) Literacy rate in females O6 years of age % (2000) Deliveries carried out by trained personnel %
22 275 98.8 82.2 97.1 96.3 97.1 18.4 30.2 35 57.2 54.5 57.3
43 265 98.5 90.6 96.7 95.4 96.8 15.2 27.7 37 51.1 24.3 55.2
65 540 98.6 89.9 96.9 95.9 96.9 16.3 28.6 36 53.3 37.4 55.9
79 65 75
91 82 95
87 76
local health centres for continuing care or retention in medical records.
perspective of demography and health status in rural communities.
Infectious disease notification
Health information flow in Iran Routine data collection An exclusive data sheet or ‘vital horoscope’ (VH) forms the basis of data collection for every member of a community in rural areas. The VH is held as a spreadsheet in each HH and comprises several concentric circles in 12 equal slices (representing 1 year) to record vital events including births and deaths in the main and adjacent (satellite) villages. Data on inter-alia age-stratified demographics, environmental health, family planning, vaccine-preventable disease, amount of iodized salt consumed, maternal mortality including aetiology, cause of death in children under 5 years of age and, ultimately, ageand sex-stratified mortality are also recorded. A specific spreadsheet records birth by weight, sex, maternal age, and delivery location and conditions. These data help to track underweight children for extra care by the Behvarzes and referral for examination by a physician. Data quality is checked regularly by supervisors in the health centres and district authorities, and HHs are provided with appropriate feedback. Data are accumulated in district health centres, entered into a software program specifically designed for this purpose, analysed locally and eventually conveyed to the PHC centre to the Deputy for Public Health. This provides an observatory
Sixteen infectious diseases must be reported promptly (by telephone or fax, 24 h/day) and in writing in line with the World Health Organization’s (WHO) guidelines. This approach has proved so efficient that formal reports, approved by the WHO, have confirmed the eradication of diseases such as poliomyelitis and the control of infectious diseases such as measles. Appropriate feedback is provided for healthcare delivery centres at district level to improve the overall health status.
National census surveys Maternal mortality rate as an index of development has been considered to be a matter of public health concern in developing countries; before the establishment of the PHC system in Iran, this was high at 150 per 100 000 live births. There are certain limitations to conducting surveys to estimate the rate among the whole population, but the national census may have potential for this purpose.24 The last census in 1996 included a question to establish the maternal mortality rate prior to introducing a national programme. This revealed a rate of 39 per 100 000 which dropped to 37.4 in 2002. More importantly, areas of high prevalence were identified; further enquiries conducted and specific programmes were designed to reduce maternal mortality. The next census will discover the efficiency of interventions.
Infant mortality trends in the Iran
399
Routine surveys Routine surveys deal with issues such as family planning, children’s health and nutrition. For example, the second National Health Survey revealed that almost one-third of pre-school children in rural areas were growth retarded, significantly more than their urban counterparts, and that girls were affected more than boys.25 Hundreds of healthcare services surveys are carried out by the medical universities and health authorities across the country, and results are the subject of public policy review; for example, when a local epidemiological study on coronary artery disease in central Iran was brought to the attention of health decision makers, a specific surveillance system was set up to document coronary disease mortality.26
In an attempt to overcome the disadvantages of traditional death certification, a death registry was set up using data from hospitals and cemeteries in accordance with standardized tracing methods. This registry was scheduled to extend nationwide by the end of 2003 to provide a reliable basis for calculating the burden of disease regionally and nationally, and of life years lost.27 Death registration is considered to be a surrogate for population health needs.28,29 Table 2 shows the 10 major
Disorders
Cardiovascular Accidents Cancer Perinatal Respiratory Gastroentrological Urological Infectious Metabolic and nutritional Congenital Suicide
Other sources of information There is a broad spectrum of data sources, each with advantages and disadvantages. These include information from city and village councils, and nongovernment organizations (Table 3).
Applying HNA to solve health problems in Iran
Death registry
Table 2
causes of death in 2001. The main advantage of the death registry is disease mapping countrywide, to the extent that after publication of the first draft in 2001, health authorities in the 10 provinces studied were aware of local epidemiological features to design projects against specific diseases; a case for comparative HNA. This led to comprehensive planning for controlling cardiovascular diseases, the major cause of death in three provinces.
In 1979, neonatal and maternal mortality rates in Iran were among the worst in the world (Fig. 1), and population growth rate exceeded 3.2%. Other major health problems identified in surveys included low vaccination uptake, high death rates from childhood infectious disease, high maternal mortality rate, limited access to clean drinking water in rural areas, and poor access to healthcare facilities in indigent localities (Table 3).
The 10 major causes of death for all age groups (2001) in 10 provinces (25% of the Iranian population). % Of total deaths
Rate in total population
Rate in sex
M
F
15.1
13
Rate in rural areas
Rate in urban areas
Median age of death
% YLL
13.11
14.42
68
22.8
34.79
13.89
12.03 10.66 4.4 4.33
4.8 4.26 1.76 1.73
7.13 5.09 1.89 1.95
2.4 3.4 1.4 1.5
4.82 4.54 1.75 1.64
4.79 4.07 1.76 1.79
35.3 59.7 0.1 58.8
21.6 9.9 10 3.8
2.04
0.81
0.98
0.6
0.81
0.82
59.2
1.9
1.69 1.68 1.66
0.67 0.67 0.66
0.74 0.73 0.59
0.6 0.6 0.7
0.69 0.62 0.54
0.67 0.7 0.74
61.8 41.8 62.3
1.5 2.3 1.4
1.55
0.62
0.62
0.6
0.74
0.54
3.1
3.5
1.55
0.62
0.6
0.6
0.73
0.54
YLL, years of life lost.
29
3.3
400 Table 3 Iran.
M. Asadi-Lari et al. Source of healthcare needs information in
Urban areas
Rural areas
Health workers General physician Specialist Census Registration (family file records at HPs and UHCs) Health surveys Notification Health volunteers Death registry Hospital records Insurance records Private sector Health workers in other sectors Regular health check of factory workers
Vital health records (VH) Behvarz and other health General physician workers Census Family file records at HHs Health surveys Notification Death registry Hospital records Insurance records
HP, health post; UHC, urban health centre; HH, health house.
A contemporary review of the health status of the Iranian population reported: “While developed nations of the world were expecting a 20% increase in their population over the period of 1975–2000, and the total population increase in the developing world was to be 65%, Iran would have to prepare for a 92% increase in its population over the same period of time (25 years)".30 Faced with unacceptable levels of mortality and morbidity, Iran’s leaders elected to introduce health policies that would address the genuine healthcare needs of its population, so the PHC system was
Figure 1
introduced as the focus of Iran’s health needs. In this regard, the epidemiological approach was the only method to assess health needs and impetus for establishing PHC services; now it is necessary to consider other methods of HNA to achieve a sustainable framework for health improvement. For example, the population boom and vaccine-preventable diseases were the principal findings of the first HNA, 20 years ago, so the majority of effort was devoted to control these major problems; the Iranian population are now experiencing the benefits. As new data were obtained (for example, data from the death registry), the system was flexible enough to accommodate new changes to respond to noncommunicable diseases such as coronary artery disease, diabetes and asthma, and also emerging diseases such as hepatitis C or human immunodeficiency virus infection. Every new programme was integrated in the PHC system after a formal process encompassing a scientific appraisal, endorsement of several executive committees, training of auxiliary health workers, preparing referral hospitals, and also health insurance back-up where indicated (Fig. 2).
The future The PHC system in Iran was established in response to healthcare needs identified in surveys, but needs will change over time due to, for example, urbanization, increasing congestion and pollution, and chronic diseases in an ageing population. The application of the epidemiological approach to HNA methodology was central at the beginning of the PHC network. However, as health needs have a dynamic nature and change over time, it must become the combined responsibility of all health
Infant mortality trends in the Iranian population between 1974 and 1996.
Infant mortality trends in the Iran
Figure 2
401
Demographic trend in the Iranian population over 40 years.
workers, trained professionals and the population. The range of techniques used to monitor health needs should increase to cover new methods: faceto-face interviews, professional panels, prescribing data, rapid appraisal by postal or telephone surveys, or focus group discussions. Health-related, quality of life assessment can be used as a preliminary ‘screening test’17 in the normal population and within specific areas of ill health, reserving detailed HNA for those with poor quality of life. The concept of health-related quality of life is new among Iranian health professionals and decision makers, but its introduction could enhance the ability of the Iranian PHC system to meet its population needs. Inevitably, HNA will remain central to health care and resource allocation in Iran, ensuring improvement in the quality of care and a reasonable level of equity.
Key messages † health needs should have a central role in modern healthcare systems † other methods to assess health needs, rather than an epidemiological approach, should be considered to ensure a thorough appraisal † novel methods of assessing health needs are emerging † health services based on the expressed needs of the general population rather than providers’s and policy makers’s assumptions would be more effective and would maximize health gain † Iran’s primary healthcare system was based upon a needs-driven approach concurrent with health
system reform in accordance with the Alma Ata declaration † major improvements in health followed health system reform † the health needs model of care is relevant to other developing, and developed, countries
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