مجله فرهنگ و ارتقای سلامت (فرهنگستان علوم پزشکی جمهوری اسلامی ایران)
پیاپی 4 (زمستان 1397)

Health equity and the use of generic drugs is an important tool in the field of financial resource efficiency and one of the crucial factors in the field of health economics in the world. In Iran, the approach to the development of the Iranian drug system, which occurred after the victory of the Islamic Revolution in the field of health and Its strategies for reducing drug costs were an important step in this manner.

The main factors of lack of productivity in health equity in the field of pharmaceutical products, is less using generic drugs and using expensive drugs ( brand)  and using non-standard drugs and counterfeit drugs and inappropriate usage of drugs. Over Last 40 years, the growing trend of prescribing generic drugs instead of branded or branded medicines has increased increase productivity and saving billions of pounds in the world and in the health system. In a study, generic drugs in the United States, Southeast Asia, and the Eastern Mediterranean are by public sector near international reference prices, but in the African, European, and Pacific regions, governments are paid average 34 to 44 percent more Which is required.In Australia, mandatory price reductions and price disclosure have led to a drugs price reduction  and ensuring that the costs will be repaid. In addition, price differences were a decisive factor for patients to accept generic drugs, since patients reject a generic successor when the cost is saved or the price difference is minimal.In Iran, in order to increase productivity and reduce costs in the "modern pharmaceutical system of the country", the following five principles were specifically addressed 1- Use of the generic name 2- Centralized importation of drugs by government-controlled companies 3- Distribution of drugs across the whole country 4- ownership of Multinational drug factories and companies by goverment 5. Scientific introduction of generic drugs.

Several countries around the world have been using and encouraging generic drugs to lower costs and having more productivity in government and health insurance budgets. Iran's new drug system, a generic based design which was started gradually from 1980 and improved and progressed year by year, has had a significant impact on productivity, cost reductions and the availability of medicines for patients with a fully acceptable quality of care with paid costs and less out of pocket of patients. Therefore, it should be acknowledged that the implementation of the Iranian Drug Administration (generic based design) has a completely positive effect on the health system.

This article presents 40 years of experience in the process of developing primary healthcare. It also addresses the opportunities and challenges ahead and outlines the roadmap for the future.

A literature review was undertaken, recording, documenting and using available scientific resources.

Positive points and opportunities at the onset, and especially in the first decade after the revolution were noted. Training medical technicians, evidence based policymaking, need-based education, simple statistical system, international organization support, formulation of a roadmap for quantitative and qualitative development of the program considering  ecological conditions of each region, use of the quantitative scientific capacity of medical universities to exploit human resources and improve services rendered, proper guidance and supervision were undertaken. This led to a significant improvement in health indicators, particularly in reducing maternal and child mortality rate, eradication and elimination or control of communicable diseases, decreasing total fertility rate and increasing life expectancy.
Shortcomings and challenges included failure to implement family medicine planning , failure to organize the whole referral system, lack of timely change in structure and implementing programs based on community needs. Lack of full use of information technology in the statistical system, change in approaches and management with changing governments and managers, lack of public participation programs and weakness in cross-sectoral partnerships necessitate further planning .In this regard, suggestions are presented as a roadmap for future development of the healthcare system.

Primary healthcare was established through research in the Islamic Republic of Iran and it grew by commitment and planning, especially in rural villages; however, it needs serious reconstruction in order to preserve what has been achieved.

After the Islamic Revolution of Iran in 1979, two main changes were made in the health system namely the establishment of the Ministry of Health and Medical Education and the formation of the Health Network of Iran. The Ministry of Health and Medical Education is responsible for policymaking, planning, leadership, stewardship, monitoring and evaluation of health services and also training and educating the healthcare workforce in a community-based health system, which comprises the country's healthcare structure.

Library documents were reviewed and information and relevant data were collected.

From 1979 to 2015, the number of medical, dental and pharmacy schools in Iran increased from 7 to 72, 3 to 19 and 3 to 21, respectively; the number of admissions to medical school increased from 1357 to 44040 during the aforementioned time period. Training courses , PhD and clinical sub-specialties were established after the revolution. Nowadays, admission to these disciplines  are 268 and 350 students, respectively. This quantitative increase has been accompanied by a significant improvement in the educational quality of clinical services rendered and increased research.

Integration of medical education into the health system in Iran has proved to be an appropriate and economical strategy for promotion of healthcare and is considered a turning point in improving medical education in the Islamic Republic of Iran.

The United Nations has an extensive and diverse structure;  thus, it is involved in numerous activities worldwide. This article briefly describes some of them.

The data and documents were collected   using library studies and the UN website.

The active institutions of the United Nations can be divided into two sections: 1- Institutions directly related to health and 2- Institutions indirectly related to healthcare. Organizations and funds officially providing services in the first section include: The World Health Organization (WHO), United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA) and United Nations Educational National and Cultural Organization (UNESCO). In addition to these agencies, two other newly established international agencies are of  mention namely  the Global Fund to Fight AIDS, Tuberculosis and Malaria and Joint the United Nations Program on HIV and AIDS (UNAIDS). The second section assesses  organizations such as the United Nations Development Program (UNDP), UN Refugee Agency (UNHCR), United Nations Environment Program (UNEP), International Labor Organization (ILO), World Trade Organization (WOT), Organization for the Prohibition of Chemical Weapons (OPCW), the Food and Agriculture Organization (FAO), and World Food Program (WFP).

In this brief review, the structure and some of the more important activities of UN agencies involved in Development of Primary Health Care In Iran are discussed.

"Women's health" comprises a state of complete physical, mental, social and spiritual well-being in women. This includes health promotion and disease prevention. In addition to biological factors, healthcare services and well-being, women are also influenced by social determinants such as education, culture, economics, spiritual and ethical factors. One of the great achievements of the health system in the Islamic Republic of Iran after the revolution has been the comprehensive promotion of women's healthcare thus improving health indicators, reducing health inequity and increasing women's access to healthcare services during this period of time.

The present study was mainly conducted by reviewing library documents and collecting data and information from the electronic literature.

The important transformative points worthy of mention in the field of women's health in the Islamic Republic of Iran now 40 years after the victory of the Islamic Revolution relate to progress made in four main areas namely relating to legal issues , improvement in Indicators, transformational programs and discussion forums.

According to the indicators and documented studies, women's health in the first 40 years after the victory of the Islamic Revolution has been constantly and rapidly improving and is in good condition compared to other neighboring and regional Islamic countries.

Social capital is cornerstone of success and growth facilitator in society. Promoting community participation and trust indicate higher social capital in that community. This study was designed to review the social capital status in Iran and suggest recommendations for its improvement.

In this study, manuscripts and scientific documents published in Persian and English reviewed and data extracted. Then, experts' opinions were taken in group discussion and content analysis was performed.

The study of social capital in the country and comparing different provinces shows that country’s social capital is low and has downward trend. Based on the People's Participation Model, strategies for promoting social capital are defined in three steps. The first step is informing, the second step is consultation and cooperation, and the third is monitoring and partnership.

Iran's society, especially in the provinces that are on the path to modernity, is a situation in which traditional social capital has been diminished and new social capital has not been completed. In order to avoid sharp decline in social capital, we should consider promoting interventions in action plans

The Islamic Revolution sought the implementation of justice, eradication of  poverty, and provision of the healthcare needs of the community and this led to the establishment of the "National Health Network System". The goals of  health equity and equitable access to basic and universal healthcare services, for all people, materialized relatively quickly. The main goal was to provide healthcare to all regardless of  socio-economic status and locale, so that basic healthcare services may be rendered without difficulty.

The relevant publications on  healthcare equity and social determinants of health were identified through a literature review of major local and international databases assessed and documented.

The important policies rendered  in the line of healthcare equity included the establishment of the  primary national healthcare network, the integration of medical education into the healthcare delivery system, the generic drug project. and  the health insurance system. Further strengthening and development of these projects ensured equitable, accessible and essential healthcare services for all, especially those in remote areas of the country.

Maintaining, promoting and restoring health, establishing equity in healthcare and minimizing avoidable differences in rendering healthcare are among the most important goals of the healthcare system of Iran. The achievements now four decades  onward , were in line with the most fundamental goals of the healthcare system. Attaining ideal goals and seeking justice in all aspects of the healthcare system, is in line with  future efforts to be pursued in this regard.

The goal of the pharmaceutical system in all countries centers around increasing patient access to affordable drugs. The ideological basis of the Islamic republic of Iran emphasizes justice and self-sufficiency. This was one of the main vectors of activity in the health system including the pharmaceutical system. At the 40th anniversary of this important event the résumé of activities and challenges in this field including success and failures are summarized.

The related data were gathered through searching electronic databases in both Farsi and English. The published articles as well as the reports from Ministry of Health and Medical Education were used.

In the early years after the Islamic revolution there was a trend towards self-sufficiency; most of the pharmaceutical industries were nationalized and imports were restricted while generic production was encouraged. Over time more private factories were launched; generic production was transformed to generic brand and brand production. This transformation was criticized recently with more emphasis on generic production again. Currently over 100 drug manufacturing companies, 200 drug importing companies, 70 drug distribution companies and over 11,000 drugstores are active in the nation. The quantitative share of domestic production was more than 97%. The total cost of drugs in Iran was about 4 Billion US dollars in recent years corresponding to the annual per capita drug usage of about $ 57 which is lower than the world average. The highest export figures of drugs from Iran has been around 200 million US dollars. Many products are manufactured domestically at a lower price than the world market. Drug subsidies have also kept prices artificially low for some imported items. Establishment of the Food and Drug Organization was one of the most important developments in the country's pharmaceutical field that could underpin transparency and efficiency in drug policy making.

The pharmaceutical system in Iran has transformed from a system mainly based on drug importation to a system with self-sufficiency and autonomy. But there are still many challenges in equitable drug access especially for more sophisticated drugs.

Respect for ethics and spirituality, inspired by the ideals of the Islamic revolution and the teachings of the late Imam Khomeini are still highly regarded now 40 years onward, Medical ethics and spirituality in health has been acknowledged to be growing and improving rapidly now 40 years after the Islamic revolution. Healthcare workers in addition to following beliefs and fundamentals of the ethical and spiritual determinants of health, are strict in their beliefs. Developments in the field of ethics and spirituality during the four decades after the revolution, have been reviewed and are presented herein.

A literature review study approach was undertaken and historical documentation was assessed and the data were collected and assessed.

All valid aspects of ethics and spirituality, including theoretical fundamentals, practical aspects of professionalism, human resource, morality, cultural and social considerations, have all been shown to have improved in the Islamic Iranian society.

Medical errors, faults or failures made by a doctor or medical team, which can cause bodily harm or injure patients constitutes malpractice; this may occur in the diagnostic phase, upon medical treatment or upon surgery or after. Inaccuracies or improper use of technology or equipment, as well as erroneous interpretation of paraclinical tests are important issues inherent to malpractice. In this article, we discuss the status of malpractice in developing countries, its classification and types of medical injuries considered to be malpractice.

This article is a review compiled from scientific sources, including texts, and existing documentation in the electronic literature.

Essential aspects of malpractice may relate to ethical or legal aspects, physician-patient relationship, physician irresponsibility, patient dissatisfaction or breaching medical ethics in practice.

By abiding by the law, complying to medical ethics, pursuing patience in their practice, attention to the patient’s mental and socio-economic status as well as his or her general condition may decrease or prevent malpractice and litigation.

The Holy Defense now constitutes a cross-section of the history of the great Iranian nation. It is the essence of spirituality, religion, idealism, self-sacrifice, resistance, and perseverance. It symbolizes the dignity and honor of the Iranian nation. The voluntary presence  of the  healthcare community, reflected the moral sense of  responsiblity, spirituality, and self-sacrifice. The dimensions of this all-encompassing, voluntary, historical and cultural-based presence, are briefly reviewed herein.

A review of authentic library resources, history interviews, and focus group discussions of the two-volume booklets "Getting to Know the Culture and Values of the Holy Defense" were the basis of the present study conducted from 1978-97.

At the onset and during  the war, the Healthcare Sector, participated and played a lasting epic self-sacrificing role. The dimensions of this presence are summarized in the twenty-chapter arranged 
first edition of the book "Introduction to the Culture and Values of the Holy Defense”, especially targeted mainly medical students.

The dignified and powerful presence of health professionals in the holy defense reflects the altruistic services rendered to the Iranian nation thus inspiring future generations.

Forty years now after the Islamic revolution, Iran has witnessed important achievements, especially in the healthcare sector: however, important challenges are still pending.

This review article presents the views of the author on the challenges overcome by the healthcare system in Iran; the author’s view is based on the relevant literature reviews presented in published articles, as well as healthcare policies slated to be pursued by the Ministry of Health.

Compared to other regional countries as well as in the global trend, one of the most important milestones reached by the Iranian healthcare system now 40 years after the Islamic Revolution relates to equity regarding provision of healthcare as well as elimination of gaps in provision for and utilization of universal healthcare. However, a master plan is lacking; especially in the era of dynamic healthcare requirements; the rapid transition from the burden of communicable diseases to non-communicable diseases is a major challenge facing health policy makers. The economic aspect of the healthcare system has been overwhelmed by the need for extending universal health coverage, improving , promoting and implementing healthcare policies nationwide without discrimination.

With the Islamic Revolution now entering its fifth decade, it is imperative that the current healthcare system be updated with emphasis on accountability to conform to the dynamic needs of the evolving Iranian society. This can only be achieved by changing the policy making strategies and planning for provision of a contemporary healthcare system.