Introduction
The appreciable human, social, and financial impacts of COVID-19 have demonstrated a world lack of well being system resilience, highlighting gaps in well being system capacities as a result of fragmented approaches to well being system funding, planning, and implementation. Widespread and extended disruptions to important well being companies have been seen in nearly all nations, no matter their earnings standing or their degree of growth (1). It has been demonstrated that lowering each particular person and inhabitants vulnerability to well being threats is a key consider guaranteeing sustainable financial growth (2). There is international recognition of the necessity to strengthen well being methods to help common well being protection (UHC) and well being safety with a view to construct resilience towards future public well being emergencies (PHEs) (3). One of the important thing actions for guaranteeing equitable important well being companies in all nations in regular conditions in addition to emergencies is thru strengthening the first healthcare (PHC) system. This requires governance, advocacy, planning, and financing at nationwide, regional, and international ranges. The Islamic Republic of Iran (IR Iran) has pursued the PHC method since 1979, shortly after the Alma-Ata Declaration was adopted in 1978 (4). The nation has conceptualized its method to strengthening major healthcare by way of the WHO well being system framework and its six constructing blocks, i.e., management, financing, well being workforce, medical merchandise, vaccines, and applied sciences, service supply, and well being data system (5).
In the context of the unfolding pandemic, the Ministry of Health and Medical Education (MoHME) undertook a wide range of strategic actions to reply to the pandemic, to make sure the sustainability of well being companies throughout the present well being emergency, and to advertise well being system resilience towards future shocks.
Context
Iran is the seventeenth largest nation on this planet with an space of 1.648 million sq. kilometers (6), with various weather conditions, vegetation, and animal species, and a wide range of ethnicities, languages, cultural practices, and ranges of socioeconomic development. Consequently, totally different provinces within the nation are going through various environmental and socioeconomic situations. The nation’s inhabitants is ~86 million individuals (7) of which about 61 million dwell in city areas.
Overview of Iran’s well being system previous to the pandemic
The well being system falls below the mandates of the MoHME in Iran which is answerable for the availability of well being companies in addition to medical schooling, analysis, and well being coverage (8). Iran has a protracted historical past of funding in PHC, which started instantly after the Alma-Ata declaration in 1979. Since its institution, there was a gradual enchancment in well being indicators (9). The system has expanded countrywide with greater than 500 district well being facilities and 4,600 rural and concrete well being facilities titled “complete well being care facilities (CHC),” that are current even in distant rural areas. There are ~18,000 community-based “well being homes” in rural areas the place neighborhood well being staff (Behvarz) present important well being companies in addition to referral for prognosis and therapy of public well being points to increased ranges, i.e., CHCs the place required (seek advice from Figure 1). There are ~5,000 well being posts in city areas countrywide. Each city CHC covers a inhabitants of 37,500 and every well being submit, which is affiliated to an city CHC, covers 12,500 individuals, whereas a rural CHC covers a inhabitants of 8,000 and each affiliated well being home covers 1,000 individuals. Service supply intends to offer high quality interventions by way of the PHC system. As of 2005, MoHME established the “Family Physician Program” in rural areas, which launched the position of the household doctor, with the latter offering public well being, prognosis, and therapy companies. This has been useful in lowering the burden on hospitals by treating sufferers on the early levels of sickness. There are ongoing efforts to develop this system in city areas (10).
Figure 1. The construction of Iran’s well being system in every province. *Each rural CHC covers virtually 8,000 individuals, whereas an Urban CHC covers ~37,500 individuals. **Each Health House serves virtually 1,000 rural individuals, whereas every Health Post gives companies for 12,500 metropolis dwellers.
There are greater than 5 million non-Iranian nationals (asylum seekers, refugees, and migrants) at the moment residing in Iran. This is a gigantic problem for the nation’s well being system and one, which Iran has taken severely and systematically. The nation has a longtime refugee well being extension program by way of which refugee-specific CHCs (Behdasht-Sara) are constructed inside refugee camps. Peer physicians and neighborhood well being staff (Behbakhsh) from the refugee inhabitants, who’ve obtained coaching in Iran, are recruited to offer companies within the camps. The United Nations High Commissioner for Refugees (UNHCR) helps the development of particular CHCs and the recruitment of these in response to the well being extension program. Each refugee-specific CHC is affiliated with the closest CHC. In addition, if a refugee attends any city or rural CHC, they’re entitled to obtain the identical degree of public well being companies for free of charge as Iranian residents. Peer well being staff chosen from the migrant inhabitants are recruited in well being homes in refugee/migrant camps and function assistants of well being workers within the PHC system. Some of those well being homes are established and recruited by way of UNHCR help as a world associate; nonetheless, given the increasing refugee inhabitants, demand is larger than the present capability.
As of 2017, there have been 981 hospitals with 129,604 bizarre beds and eight,264 grownup Intensive Care Unit (ICU) beds within the nation. The hospital bed-population ratio was decrease in contrast with developed nations, and their distribution diversified by geographical space.
While there are two sectors for the supply of scientific companies inside Iran, i.e., private and non-private, all public well being companies comparable to immunization, youngsters and maternal well being, psychological well being, and so forth., are offered freed from cost. In the general public sector, 70% of therapy service charges are coated by the nationwide medical insurance system. The MoHME operates public hospitals, each basic and particular ones, all through Iran. Public hospitals are sometimes below the direct administration of universities, whereas personal hospitals are regulated and supervised by MoHME.
The nationwide digital well being file (EHR) system has been working since 2007 following the Open-EHR reference mannequin. For every affected person or household who involves CHCs, well being posts and homes in city and rural areas an EHR is filed. Each member of the family/or affected person has their very own EHR. For roughly 65% of individuals, their EHRs are linked to the EHRs of their first diploma family members. After the COVID-19 vaccination marketing campaign, the share of Iran’s inhabitants has been registered within the nationwide EHR system reached over 90%. There are 4 totally different EHR methods countrywide. More than 800 public hospitals switch inpatient information to the EHR infrastructure on daily basis.
The Iranian built-in illness surveillance and response system (IDSR) was established in 2016. Although known as a “syndromic surveillance system” (Triple S or SSS) with its authentic early warning (EWAR) element based mostly on a syndromic method, Triple S is a broad-based four-module system together with modules on early warning, case-based epidemiological surveillance, lab-based surveillance, and automatic stories (11). It was developed with WHO help. The research part was began in 2011 and concluded with the primary model of the digital platform in 2016. Currently, a wide range of IT options are supplied to include SSS within the EHR system as a built-in module, which is an effort to combine SSS with evolving EHR platforms. The SSS early warning element relies on 17 syndromes and their minimal datasets, which is the nation’s EWAR mechanism for well being emergencies. Currently, the system has built-in ~40 communicable illnesses of acute respiratory and food-and-water-borne nature below acute respiratory and acute diarrhea syndromes.
The COVID-19 pandemic interval
Iran was one of many first nations to expertise the fast development of the COVID-19 pandemic. The first peak occurred on the finish of March 2020, with round 3,200 day by day circumstances, which created a really difficult scenario for the individuals and officers (4).
Iran confronted constraints in relation to private protecting gear in addition to hospital and laboratory gear because of the worldwide provide scarcity because of the fast and excessive demand exacerbated by delayed supply timeframes firstly of the pandemic. Restrictions on the worldwide switch of funds from Iran’s banking system to worldwide banks added to this problem.
Key interventions in Iran’s response to the COVID-19 pandemic
In response to the evolving pandemic, Iran put in place a number of interventions to make sure the upkeep of important well being companies along with the availability of response. Some interventions have been new, knowledgeable by international expertise with COVID-19 whereas others leveraged present strengths throughout the present well being system.
Whole-of-government method
Box 1. Illustrative instance of ministries and sectors represented within the National Steering Committee.
Another whole-of-government mechanism known as the National Committee for COVID-19 administration has been established by the Ministry of Interior, which is in command of the implementation of insurance policies set by the NSC. All the manager officers of the counterpart ministries of the NSC are members of this committee.
Leveraging the PHC capability
Before COVID-19, Iran had invested closely in PHC with the present flagship program. “Each house acts like one well being submit” being rolled out, with a give attention to systematically strengthening PHC by way of illness prevention and well being promotion (7). From the very starting of the COVID-19 pandemic, this present PHC capability was leveraged with the MoHME designating some CHCs as chosen 16-h COVID-19 facilities in every district. Routine well being companies continued to be supplied within the different CHCs as a mechanism to realize a extra resilient PHC system. This mechanism helped to take care of important companies (UHC) whereas needed care was given to delicate circumstances of COVID-19 in chosen facilities as a part of the response to a well being emergency. This technique additionally follows the precept of an infection and prevention management in well being amenities. MoHME designated ~1,050 COVID-19-selected well being facilities amongst 4,600 CHCs countrywide. Those designated facilities have been working throughout successive pandemic waves and have had a major impression in lowering the burden on hospitals as a load of sufferers presenting for a session to these PHC facilities was virtually 10 instances greater than these presenting to hospitals. This distinction demonstrates the potential of the PHC system to safeguard secondary and tertiary care and has made the hospitals extra resilient to this burdensome pandemic. All chosen COVID-19 facilities and CHCs have been energetic involved tracing with the help of navy forces and volunteers.
Community-based nursing care facilities have been expanded throughout COVID-19 to ship companies at house to help the early discharge of sufferers from hospitals and to safe the continuity of care in the neighborhood. Standard packages of nursing companies at house have been developed for a number of precedence situations to standardize and systematize high quality and harness cost-effective nursing companies at house. While the enlargement of community-based nursing care was welcome, it was additionally needed to make sure the availability of different occupational classes together with midwives, physiotherapists, scientific psychologists, and social staff in such facilities. Thus, MoHME has made an effort to attach the facilities for counseling and nursing care at house with CHCs with the intention of accelerating entry to those companies whereas lowering the visits to emergency rooms, in addition to lowering the well being system’s prices and hospital mattress occupancy fee.
In order to guard elective and routine operations and therapy companies, MoHME designated some hospitals for COVID-19 inpatients firstly of the pandemic. In addition, within the final 12 months, the ministry has elevated acute hospital mattress capability by 10,000 hospital beds, bringing the present whole to 155,000 (12). During the restoration part, these current developments be a part of the routine service capacities for the traditional scenario.
Supporting the workforce
The Iranian well being system has a mixture of healthcare workers together with medical doctors, nurses, midwives, nutritionists, psychological well being specialists, dentists, environmental and occupational well being staff, communicable illness specialists, lab technicians, and scientists, which is well-distributed within the nation. On common, there are ~1.6 physicians for each 1,000 inhabitants (13). According to the World Bank, the doctor per inhabitants fee has been 1.4, 1.7, 2.6, and 4.9 within the Middle East and North Africa, the globe, North America, and European Union, respectively, in 2017.
The nation’s well being system undertook a number of modern approaches to develop the capability of the workforce in response to COVID-19 together with the usage of navy workers and volunteers in COVID-19 facilities and CHCs, particularly for energetic case discovering and get in touch with tracing of COVID-19 circumstances. Many post-graduate college students (scientific residents) from different scientific disciplines obtained short-course coaching and have been redeployed throughout the pandemic to offer help to infectious illness specialists, pulmonologists, internists, pediatricians, and ICU specialists who have been on the frontline of offering care to sufferers with COVID-19. During the height of the pandemic, a nationwide database of nurses was established to allow the recruitment and redeployment of nurses throughout provinces.
Regarding surge capability, the workforce has been strengthened by hiring by way of 90-day contracts and by extending the time of the contract. In addition to this, one of many measures taken by MoHME has been the periodic evaluation of well being system capability in every province, particularly throughout the peak of pandemic waves to help the redeployment of workers. For instance, when the delta wave hit the nation from July until the top of September 2021, the scientific sector of some provinces was overwhelmed, utilizing the periodic evaluation to determine workforce capability. The Ministry was in a position to mobilize reserve physicians and nurses to the hospitals of severely affected provinces (surge capability) to take care of scientific companies for hospitalized sufferers.
Recognizing the intense threat of burnout amongst frontline healthcare staff (HCWs), Iran has adopted a wide range of actions to help and empower HCWs within the scientific sector together with the event of a program for bettering their psychosocial wellbeing, to handle psychological well being points and stop burnout throughout COVID-19.
Looking to make sure future capability, capacity-building for on-line instructing was addressed in colleges of Medicine and Nursing since 2020, by equipping these with the mandatory infrastructure, planning, and conducting coaching of trainers (TOTs) programs for school workers. Thus, it was doable to carry on-line courses for the scholars. In addition, many webinars have been held throughout the pandemic to help the coaching of the healthcare workforce and trade experiences and studying.
Strengthening preparedness and response by way of multisectoral and multidisciplinary working and partnerships with worldwide companies
In late June 2022, we carried out a multisectorial multidisciplinary workshop in Tabriz metropolis, Iran, attended by 175 stakeholders of all related MoHME departments, ministries, and organizations to succeed in a consensus and consolidate an built-in Pandemic Influenza, COVID-19, preparedness, response, and restoration plan (IPICPRP), which has additionally built-in acute respiratory infections with epidemic potential. The attendance fee was excessive (simply two invitees have been absent). The three back-to-back multidisciplinary workshops helped collect views and suggestions on the draft plan, which adopted WHO suggestions (14, 15).
The up to date pandemic plan was developed in mild of the COVID-19 response. In the plan, strategic actions are categorized in response to 4 phases (inter-pandemic, alert, pandemic, and restoration phases), and respective actions for every motion with timelines, accountable company, companions, and price range are included with the help of in depth multidisciplinary and multisectoral deliberations.
New methods taken by the Global Fund and Gavi to enhance service protection and handle inequities in Iran reveal how the partnership of worldwide companies can enhance some constructing blocks of the well being system and safe well being system features together with higher entry to well being commodities and built-in communicable illness surveillance. Recent reclassification as a lower-middle earnings nation (LMIC) by the World Bank will allow Iran to profit from Gavi help as a beneficiary of COVID-19 and different vaccines. Gavi helps Advance Market Commitment (AMC) nations, that are largely LMIC ones. This is necessary to fight pandemics and epidemics and might empower the well being system of many nations towards well being emergencies. Iran obtained greater than 10 million doses of COVID-19 vaccines from Gavi by way of the COVAX mechanism as a non-AMC nation. However, as of 18 December 2022, the whole vaccine photographs obtained by the Iranian inhabitants reached roughly 155 million doses, which MoHME provided largely by way of bilateral contracts and home manufacturing.
During the pandemic, the Global Fund supported the COVID-19 response by offering private protecting equipments (PPEs), RT-PCR machines, and cold-chain gear in help of COVID-19 vaccine deployment. After the pandemic, such gear can proceed to be leveraged to help well being system infrastructures and enhance service supply, particularly surveillance and response features. Therefore, these partnerships are necessary in attaining a extra resilient well being system (16). Also, the Global Fund and Gavi have constructed efficient mechanisms for market shaping, procurement, and provide chains of vaccines and well being commodities, with the help of the UNICEF provide division to deploy COVID-19 vaccines to many nations together with Iran. This mechanism can leverage to acquire reasonably priced high quality well being commodities for the subsequent well being emergencies.
Improving entry to medicines, vaccines, and well being merchandise
COVID-19 drugs and vaccines have been distributed all around the nation based mostly on inhabitants dimension and provincial wants. The MoHME leveraged the already present provide chain of the PHC system as proven in Figure 1. The first batch of COVID-19 vaccines grew to become obtainable in Iran in March 2021 and was distributed following a prioritization system that within the preliminary part focused frontline HCWs combating COVID-19, high-risk individuals in long-term care together with the disabled and the aged in addition to veterans who had been affected by chemical weapons throughout the Iran–Iraq conflict within the Nineteen Eighties and highly-disabled veterans residing at house.
As enough vaccines grew to become obtainable in the summertime of 2021, vaccination was expanded to incorporate all individuals no matter nationality, faith, or ethnicity. Leveraging the prevailing countrywide PHC together with its vaccine-distribution capability, the Iranian MoHME established roughly 1,200 mass vaccination facilities in stadiums, museums, colleges, and so forth as an adjunct to PHC. This enabled Iran to realize a COVID-19 major vaccination protection fee of round 75% up till January 2022.
In addition, Iran has developed an area manufacturing capability for seven home COVID-19 vaccines, which will be thought to be one of many key classes from the pandemic and has established the nation’s capability for the manufacturing of medical countermeasures for epidemic-prone illnesses. These embrace vaccines throughout totally different expertise platforms comparable to protein-based, inactivated, and adenoviral vector vaccines. Local manufacturing of an mRNA-based vaccine is at the moment below investigation (December 2022). Efforts are ongoing to obtain the WHO emergency use itemizing (EUL) of the domestically produced vaccines with the help of Iran’s Food and Drug Administration (FDA). Many scientific trials have been designed and carried out in numerous phases on domestically produced vaccines (17, 18) by Iranian analysis institutes and Clinical Research Organizations (CROs) throughout COVID-19 below the supervision and help of Iran’s FDA, National Committee for COVID-19 Vaccine, and the Undersecretary for Research and Technology of MoHME.
The present capability will be leveraged to provide different vaccines, enhance response capacities for different communicable illnesses, and obtain a extra resilient well being system towards the subsequent well being emergency. However, extra help from WHO and WHO/EMRO is required for expertise switch and aiding native producers in receiving WHO/EULs and prequalification with a view to leverage at the moment present capacities.
Some drugs for treating COVID-19 have been additionally produced domestically, and Iran produced PPE domestically to beat the shortages, which have been obvious firstly of the pandemic.
Health data system
The Electronic Health Record (EHR), which was in place a number of years earlier than the pandemic, was tailored to register suspected circumstances of COVID-19 and their contacts and to file delivered companies together with testing and coverings. Leveraging the prevailing EHR capability, an digital registry was added to help the nationwide vaccination marketing campaign towards COVID-19.
The syndromic surveillance system (SSS) platform was tailored by including COVID-19 below respiratory syndromes, i.e., ILI (influenza-like sickness), SARI (Severe Acute Respiratory an infection), and ARI (acute respiratory an infection) along with the differentials of acute respiratory sickness beforehand included comparable to Influenza varieties and subtypes.
Discussion
Health system strengthening that promotes resilience is crucial for governments as resilient well being methods are elementary to bettering, attaining, and sustaining fairness in populations’ well being and wellbeing; responding to public well being emergencies, and enabling sustainable socioeconomic growth. In recognition of this, the 69th regional committee of WHO/EMRO revealed a technical article in September 2022 outlining regional priorities for advancing UHC and guaranteeing well being safety (stopping and controlling future well being emergencies within the Eastern Mediterranean Region) by constructing well being system resilience. These priorities embrace:
• Establishing major healthcare-oriented fashions of care.
• Enhancing fit-for-purpose, fit-to-practice well being workforce.
• Promoting fairness and enhancing monetary safety.
• Enabling an setting for analysis, innovation, and studying.
• Improving entry to medicines, vaccines, and well being merchandise.
• Fostering an built-in method in coverage, planning, and investments for long-term well being system resilience.
Iran’s method each previous to and throughout the pandemic is strongly aligned with these regional priorities. For instance, the IPICPRP promotes an built-in method in preparedness, response, and restoration planning for long-term resilience whereas strengthening well being and emergency and catastrophe threat administration by creating platforms to deal with multi-hazards. The multisectoral nationwide committees established to help the COVID-19 response characterize a whole-of-government method to well being that strengthens emergency administration. Such buildings will be maintained throughout the restoration part to offer a holistic authorities method to well being, not simply throughout emergencies. This multisectoralism was additionally obvious within the growth of native capacities for the supply of PPE, medicines, and vaccines and is aligned with bettering entry to medicines and applied sciences and securing provide chains in help of emergency preparedness and response. The a number of modern approaches utilized to make sure workforce capacities together with redeployment and extra coaching are aligned with a fit-for-practice workforce.
The MoHME is at the moment planning to additional construct on this in help of well being methods resilience by making use of the method to weak populations pursued with COVID-19 vaccination to routine immunization. This will contain integrating routine immunization of refugee populations to fill the gaps in TB detection fee and COVID-19 vaccination.
Existing capacities in PHC and HIS have been additionally leveraged to help the upkeep of companies and to advertise excessive uptake of COVID-19 vaccination. Disruptions to important companies have been seen globally in response to the third report of pulse surveys, with a mean lower of 36% and 49% in communicable illness companies and immunization protection worldwide, respectively (1). In Iran, there was a 28% lower within the TB detection fee throughout the COVID-19 pandemic and no drop in routine vaccination protection in 2020–2021 (22).
During the COVID-19 peak, a tenet issued by the MoHME states that in case of a daily mattress occupancy fee past 50% and ICU mattress occupancy past 60%, the admission of sufferers for elective operations could possibly be canceled by the chancellor board of the college. In the restoration part of the pandemic, these beds have returned to routine healthcare companies, e.g., devotion to elective procedures and operations (23).
According to World Bank information, Iran’s GDP per capita stood at 2,756.7 in 2020 far under that recorded for Germany, France, and the USA which reached 50,801.8, 43,518.5, and 69,287.5 respectively (24). When positioned within the context of the financial realities going through Iran, the method taken demonstrates that it isn’t absolutely the availability of assets however political will and the leveraging of all investments, together with these targeted on response efforts to strengthen well being system foundations with PHC that builds resilient well being methods. This method ensures that investments yield long-term dividends and gives an instance of the worth of investing in PHC in routine instances in help of well being safety throughout emergencies.
In spite of efforts made to combine between totally different well being data methods comparable to totally different EHR methods and surveillance platforms, e.g., SSS, the COVID-19 pandemic demonstrated that additional work is required within the space of built-in and interoperable well being data methods to handle the difficulty of knowledge fragmentation.
Regarding expertise switch and native vaccine manufacturing, it is a cumbersome space that wants way more help from WHO and funding from international companions. Challenges within the digital wiring between Iranian and worldwide banking methods to provide medical countermeasures and help expertise switch is one other constraint, which negatively impacts well being system resilience, and people have to be addressed earlier than the hit of the subsequent well being emergency or pandemic.
Strengths and limitations
Data availability assertion
Author contributions
Acknowledgments
Conflict of curiosity
Publisher’s observe
Footnotes
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