Background

According to the World Health Organization (WHO), the primary goals of a health system are to enhance community health, ensure accountability, and promote equitable financial engagement, and health system reforms are fundamentally aimed at realizing these goals (1). In the years following the Islamic Revolution, the education of specialized healthcare professionals in Iran underwent significant transformations. The Medical Education Curriculum Review Committee was established in the early years of the Cultural Revolution Headquarters to conduct a comprehensive quantitative and qualitative assessment of medical education, highlighting the existing challenges in its final report. Following the publication of the aforementioned research report and subsequent approval by the Islamic Consultative Assembly, in 1985, all authorities, duties, and responsibilities of the Ministry of Culture and Higher Education pertaining to medical education were transferred to the newly established ministry. With the separation of medical education from the Ministry of Culture and Higher Education and its integration into the then Ministry of Health and Welfare, the Ministry of Health, Treatment, and Medical Education was formed (Table 1) (2).

The vision for the health system is specified through macro-level policies and programs (3, 4). These general policies determine the main guidelines and decisions that are implemented to safeguard the public interest and ensure the coherence and harmony of societal goals (5). The development of upstream documents, development policies, and budgetary plans are all types of macro-level and national policies (6).

The ultimate goal of any health organization is to meet the needs of individuals and the community. As these needs are constantly evolving, service-providing organizations must remain flexible and adaptable. Therefore, reforming the health system or sector should be viewed as an ongoing and continuous process (7).

Table 1. The historical trend of medical higher education in Iran over the recent 150 years: From the establishment of Darolfonoun to the establishment of the Ministry of Health, Treatment, and Medical Education (1849-1985)

Given the importance and position of integration of medical education and research into healthcare services, this study focuses on the integration of education and research into healthcare services in health upstream documents in the Islamic Republic of Iran. These documents include:

• Constitution of the Islamic Republic of Iran (1989)
• Vision Document 2025 (2003)
• Statement on the Second Phase of the Islamic Revolution (2018)
• General Policies on Science and Technology (2014)
• National Development Plans (1989-2023)
• General Policies on Health (2014)
• Population Policies (2014)
• Comprehensive National Scientific Plan (2010)
• Health System Transformation Plan (2011)
• The Law on the Formation of the Ministry of Health and Medical Education (1985)

1- Constitution of the Islamic Republic of Iran

In order to realize Clauses 4, 12, and 13 of Article 3 of this law, the Government of the Islamic Republic of Iran is obliged to strengthen the spirit of inquiry, research, and innovation across all scientific, technical, cultural, and Islamic fields by establishing research centers and encouraging researchers. It must also establish a sound and just economy based on Islamic principles to create welfare, eradicate poverty, eliminate all forms of deprivation in terms of nutrition, housing, employment, and health, generalize insurance, and promote self-sufficiency in science, technology, industry, agriculture, military affairs, etc. Article 29 of this law emphasizes the optimal and coordinated use of health facilities to achieve these objectives.

2- Vision Document 2025

A society that is committed to human flourishing, supported by an efficient, equitable, and innovative health system, has attained the leading position in the Southwest Asia region regarding health indicators and scientific authority in science and technology. It has emerged as a medical hub for both Southwest Asia and the global health community.

3- Statement on the Second Phase of the Islamic Revolution

A comprehensive list of mandatory statements related to medical education has been identified within the 12 domains: “Governance, knowledge, corruption deterrence, economy, cultural development, social development, self-confidence and hope, international interactions, youth-orientation, national resistance, enemy deterrence, and justice” (8).

Instead of relying on individual, discretionary decisions by senior health managers, a comprehensive framework for an optimal health system must be designed, aligned with established policies, program-orientation, and organization-orientation (9).

4- The Law on the Formation of the Ministry of Health and Medical Education

Article 1 of this law signifies the optimal and coordinated use of health sector resources for all members of society in the realization of Clauses 4, 12, and 13 of Article 3 and that portion of the objectives of Article 29 of the Constitution of the Islamic Republic of Iran that has been formed by the Ministry of Health, Treatment, and Medical Education since the adoption of this law. Articles 3, 5, and 10 address the cultivation of a workforce committed to ethics and possessing adequate skills and competencies, the establishment of educational equity, the expansion of medical research and science, the presence of diverse research institutes alongside universities of medical sciences, and the coordination and trusteeship of charitable healthcare centers. Article 7 explicitly addresses the primary role of the Ministry of Health, Treatment, and Medical Education in policymaking, policy determination, and medical education planning.

5- General Policies on Health

The general policies on health promulgated by the Supreme Leader, which were announced in 14 clauses in 2014 in enforcement of Article 110, Clause 1 of the Constitution of the Islamic Republic of Iran.

The core axes of these policies encompass human and Islamic values, public awareness, and the enhancement of community members’ responsibilities and capabilities. They prioritize prevention over treatment, promote evidence-based decision-making, and strengthen infrastructure. Additionally, they focus on demand management, food security, the separation of regulatory functions, and the quality and safety of services. Achieving equity in health promotion, particularly in underserved areas and among populations in need, is also a key objective. The policies aim to expand the quantity and quality of health insurance, ensure sustainable financial sources, and transform Iran into a medical hub in Southwest Asia and the Islamic world (10).

Part 1 of Clause 7 of the general policies on health, promulgated by the Supreme Leader on April 07, 2014, stipulates that “the Ministry of Health, Treatment, and Medical Education is responsible for the health system trusteeship, including executive policymaking, strategic planning, evaluation, and trusteeship.” Trusteeship, as one of the most critical functions of a health system, is a primary responsibility of the government that cannot be delegated, and the government must be accountable for it by prioritizing the public interest (11).

Clause 7 emphasizes the separation of roles in healthcare, specifically the responsibilities for trusteeship, financing, and service provision, aiming at ensuring accountability, equity, and optimal healthcare service provision to the people (12).

Furthermore, Part 2, Clause 7 of the general policies on health emphasizes “management of health resources through an insurance system, centered on the Ministry of Health, Treatment, and Medical Education, in collaboration with other centers and institutions.” Additionally, Part 1, Clause 8 of these policies focuses on “promoting decision-making and taking actions based on solid and scientific findings in health care, education, and services, through the development of standards and guidelines, and the evaluation of health technologies.” Hence, when considering trusteeship and assigning all its responsibilities to the Ministry of Health, Treatment, and Medical Education, it implies a mandatory requirement for the ministry’s involvement in all these areas (13, 14).

A review of Clauses 7 and 9 of the general policies on health reveals that the Supreme Leader’s primary emphasis lies on the core aspects of trusteeship, including legislation, strategic policymaking, and supervision and enforcement of laws and regulations. According to this national document, the Ministry of Health has been designated for the primary trusteeship role, and all other institutions and organizations are expected to operate under its authority. The direct and indirect impacts of trusteeship and its functions on health system goals and outcomes, such as accountability, effectiveness, quality, accessibility, coverage, and safety are worthy of consideration (15).

Although the general policies on health (promulgated by the Supreme Leader) lack a separate chapter or clause explicitly dedicated to ethical principles or “ethical appendix,” every clause of this document is imbued with ethical and moral concepts (11).

The importance of sustainable and equitable financing is explicitly emphasized in several clauses
(7 and 9) of the promulgated document, particularly in Clause 10, as the financing system can be likened to the beating heart of the health system. Financing is considered equitable when individuals benefit from services according to their ability to pay and their specific needs (16).

Another important function is health service provision. The Islamic Republic of Iran does not limit health service provision to the government sector, but highlights the use of both public and private sectors alongside the government sector in Clause 9 (17). Similar to other upstream documents, such as the Sixth Development Plan, the focus of health services is on the family physician (18).

Over the past decade, Iran has made significant strides in medical research, elevating its international standing. These achievements have coincided with a surge in the number of research centers and researchers working at these centers, increased research funding, and a growth in the number of Iranian journals indexed in international databases, such as Scopus, PubMed, and ISI (19, 20).

Clause 14 not only emphasizes the enhancement of Iran’s position in research but also highlights the issue of scientific leadership and transforming Iran into a research and scientific hub in medical fields in the among regional and Islamic countries, with a focus on Islamic and humanitarian principles and values (11).

In Clauses 1 and 13 of the document, besides quantitative and qualitative development, emphasis is placed on a health-centered, community-needs-based, accountable, and equitable approach to medical education (21).

Following the Islamic Revolution, the country’s pharmaceutical system was renamed the “Modern Iranian Pharmaceutical System” and later the “Generic Pharmaceutical System,” as mentioned in Clauses
4 and 5 of the general policies on health (22).

6- Comprehensive National Scientific Plan

The “comprehensive national scientific plan” has incorporated the theme of universalizing science in values and strategies. In line with the presented visions in the field of health, the mission of the “Health Science, Technology, and Innovation System” is to identify and address challenges in the following key areas: (1) Trusteeship and provision of healthcare services, (2) capacity building of the human resources required by the health system, (3) equitable provision, production, and distribution of financial resources, (4) excellence in production, and (5) utilization of knowledge in areas where the country has relative and competitive advantages to achieve a leading position in the region.

7- Policies on Science and Technology

One of the areas where the impacts of science and technology advancements are most evident is healthcare. Science and technology have the potential to revolutionize our understanding of diseases and enhance the effectiveness of healthcare provision. The vision for science and technology in healthcare is “to achieve the highest level of public health in the region by 2025 by leveraging existing knowledge and generating new scientific and technological advancements.”

8- Health System Transformation Plan

This plan is, in fact, a comprehensive collection of activities within the health sector of the country, including health, treatment, education, research, and technology. By designing this plan, the original and transformative health policies are specified, and it is hoped that by gaining legitimacy from the main pillars of the Islamic Republic of Iran, it will culminate in stability in policies, which will undoubtedly lead to the improvement of the health system.

9- The Five-Year Development Plan Act

Our country has formulated and implemented seven five-year national development plans since the Islamic Revolution. The first through sixth development plans have focused on expanding the service provision network and improving health standards to ensure universal access to public services. These plan have aimed to promote public health, expand universal insurance, control population growth, create structural and institutional changes to facilitate privatization, ensure equitable financing, reform the policymaking and financing systems for developing insurance, reduce the public’s share of health costs, and implement various initiatives, such as healthcare network reform, the integration of medical education into hospitals, hospital autonomy, the establishment of a family physician system, health transformation, etc. (23, 24).

Chapter 14 of the Seventh Development Plan draft focuses on enhancing the health system and consists of 6 articles. The topics include improving the quality of services, governance of the health system, drugs, medical equipment, and health insurance, reducing costs, and increasing patient satisfaction. It is explicitly stated that the Ministry of Health, Treatment, and Medical Education is solely responsible for executive policymaking, strategic planning, evaluation, and supervision (25).

Conclusion

Based on the WHO conceptual framework, healthcare systems have three primary objectives: Improving population health, ensuring equitable financing, and being accountable to people’s expectations regarding issues beyond health concerns. Four core functions must be performed to achieve these objectives: Trusteeship, financing, resource provision (human resource, physical resource, equipment, drugs, and information), and service provision (17).

In the years following the Islamic Revolution, various reforms were planned and implemented within the Iranian health system, including the integration of health system and medical education plan in the 1980s, the expansion of healthcare networks in the 1990s, the hospital self-governance plan and the establishment of a payment system in the 2000s, the implementation of the family physician plan in the 2010s, and the health system reform plan in 2014 (26, 27).

Some of the initial strengths and opportunities encompass the localization of staff, particularly health workers, scientific evidence-based policymaking, and needs-based training, leading to remarkable improvements in health indicators (28). One area that facilitates Iran’s progress toward becoming a global health leader is the health system transformation (29). The Iranian health system offers a unique model that integrates healthcare services and education and research, aiming to enhance public health (30).