The organization and effectiveness of the rural primary health care reforms in Iran, focusing on the behvarz health workers and health homes, are reviewed and the potential for implementation in the Mississippi delta is analyzed. The analysis indicates that Iranian health houses are effective and clinically relevant to the health challenges faced by communities in Mississippi. These strategies however are not immediately replicable due to political barriers. Recommendation are to develop health worker training curricula in preparation for a political event that removes these barriers.
In 1979 the Islamic Republic of Iran inherited from the Shah regime a dysfunctional rural health care system created by years of neglect. The rural maternal mortality ratio was 370 per 100,000 live births and the rural infant mortality rate was 120 per 1000 live birthsi. In addition, the rural physician to population ratio was only 1:18000.ii The new government, however, was determined to fulfill the promises of the revolution to its rural supporters, and as part of the Reconstruction Jihad decided on the creation of a network of health houses staffed by minimally trained local health workers. Physicians criticized this as a collapse in the quality of care,iii but the government arrested hundreds of them in response and moved forward with their plans.
Thirty years after the revolution, these plans have grown into a network of 17,000 rural health houses staffed by 30,000 salaried behvarz (community health workers) that provide primary care services to 23 million Iranians, or 95% of the rural population.iv Each health house is generally staffed by 1 male and 1 female behvarz, who are responsible on average for 1500 people in their village and surrounding communities.v The behvarz is required to have 11 years of education and be elected by their community before receiving 2 years of community health worker education at a district training center. The community selection is an intentional policy design meant to increase community engagement, ensure cultural competence and decrease personnel turnover. Behvarz duties include collecting census information, maintaining family health records, maternal and child care, family planning, immunization, home visits, simple curative care, administration of medicines, and sanitation.vivii As the first point of contact, they are also responsible for basic triage and referring cases to one of 2300 primary care clinics at the district level, who provide ambulatory care for approximately 10,000 people.viii In addition to treating patients sent directly to them at the clinics by the behvarz, primary care physicians make intermittent rounds through the villages their clinic is responsible for. Any cases that can’t be handled at the district primary care clinics are referred to secondary care at district hospitals or tertiary care at provincial hospitals.
Access to primary care services in public facilities is free and is financed through federal budget transfers.ix In 1995 the Medical Services Insurance Organization funded by a general tax was created to provide insurance to civil servants, self-employed and special groups. In 2005 the Rural Health Insurance Program (RHIP) expanded this coverage to all rural citizens, which resulted in 95% rural insurance coverage.x Notably, RHIP also formalized the family practice (FP) specialty in an attempt to improve quality of rural care. This has resulted in friction with the behvarz system, as there is some evidence that FPs don’t always provide superior care.xi
Twenty years of primary care reform in Iran resulted in significant advancements, including reduction of the fertility rate from 6.5 to 1.92, reduction of the rural infant mortality rate from 71 per 1000 live births to 30.2 per 1000 live births, reduction of rural maternal mortality ratio from 370 per 100,000 live births to 35 per 100,000 live births, and achievement of over 96% immunization coverage for DPT, MMR and Polio vaccinesxii. Most importantly, there was significant convergence with the urban infant mortality rate and maternal mortality ratio, which during this period had improved to 27.7 per 1000 live births and 22.0 per 100,000 live births respectively. By 2015 the expansion of the family practice specialty under RHIP further reduced the overall infant mortality rate to 13 per 1000 live births and the maternal mortality ratio to 25 per 100,000 live birthsxiii xiv. Avoidable death rates for rural and urban areas have also converged (37.40% and 36% respectively.xv In some critical measures the reforms have even enabled rural communities to surpass urban ones. Rural hypertension and diabetes prevalence, 17.2% and 5.6% respectively, are lower than in urban communities, where they are 18.4% and 8.5% respectively.xvi
Comparison to Mississppi
Mississippi is chosen for comparison with Iran because the state was rated as the worst health system in the U.S. eight years in a rowxvii and a pilot program at Jackson State University is experimenting with Iranian-style health homes.xviii In 2012 the maternal mortality rate in Mississippi was 39.7 per 100,000xix, and in 2014 the infant mortality rate was 8.2 per 1,000 live births, ranking last in the U.S.xx Full immunization at age 2 was only 80.5% in 2007. Also, 67.8% of Mississippi adults were obesexxi, 11.6% were diagnosed with diabetesxxii and 22.7% smoked in 2009.xxiii Prevention and treatment is complicated by the greatest physician shortage in the U.S.xxiv (159 physicians per 100,000) and only 82% of the population having insurance coverage.xxv
Lessons for U.S. Policy
Mississippi’s challenges are similar to those faced by Iran and make the behvarz model a valuable source of lessons in healthcare system design due to Iran’s superior performance on many of these metrics when compared to Mississippi. The success of the behvarz reveals two key lessons for future primary care reforms in the state. The first is that dedicating funding to primary care and public health results in significant health gains for the population. However, this is not a new idea and has been argued for decades by public health officials. The population health successes of the Family Health Program in Brazil are another current example of this policy. The most important lesson, and the point where the Iranian behvarz differentiate themselves from the Family Health Program, is that the program is primarily administrated by non-physicians. Iran reveals that it is possible to create significant improvements in basic primary care access and corresponding health outcomes with limited physician involvement. This has important implications for health system capacity building in rural areas and developing countries, a key U.N. goal after the recent ebola outbreak. Delegating basic and routine primary care tasks to minimally trained behvarz allows for highly trained physicians’ time to be allocated to more serious cases. In addition to the efficiency gains, physicians are likely to have improved job satisfaction due to decreased stress on their time and more meaningful utilization of their unique skills. The more efficient skill mix in the healthcare system could also allow for lower total healthcare expenditures.
However, the political environment in the U.S. is currently poorly aligned to implement this model. The behvarz reforms were a conscious top-down commitment by the Iranian government to a primary care based health care system. In the U.S., on the other hand, Congress only committed $1billion per year to the Prevention and Public Health Fund – far short of the $12 billion per year level recommended by the Institute of Medicinexxvi. In addition, only 30% of Iranian government revenue is from taxation and 70% is derived from the sale of natural resources.xxvii This makes Iran’s generous primary health care transfers difficult to replicate. Finally, Iran was able to bypass the protests of the medical community against the behvarz through authoritarian oppression. This is not an option in the U.S. and the physician community is likely to lobby against behvarz as they do against nurse practitioners.xxviii In general the separation of powers in the American political system is designed to empower such opposition. In fact, this may even be happening in Iran, where the 2015 reform expanded FP and specialist financing, but did little for the behvarz.xxix
Facing these realities, the recommendation for policymakers in the U.S. is to prepare for a future political crisis that could be used as an opportunity to implement health homes by developing health worker certification curricula that could be quickly adopted.
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[xxi] Kaiser Family Foundation, statehealthfacts.org. Data source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System Survey Data, 2009, unpublished data, at http://www.statehealthfacts. org/profileind.jsp?ind=91&cat=2&rgn=26.
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[xvi] “Issue Brief: The Prevention and Public Health Fund.” APHA, June 2012. Web. 14 Apr. 2016. <https://www.apha.org/~/media/files/pdf/factsheets/apha_prevfundbrief_june2012.ashx>.
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