Global Learning Process for Scaling Up Poverty Reduction: Shanghai Conference May 25-27, 2004

1. Global Learning Process for Scaling Up Poverty Reduction: Shanghai Conference May 25-27, 2004

2. Primary Health Care and the Rural Poor in the Islamic Republic of IranAmir Mehryar & Shirin Ahmad-niaCenter for Population Studies & ResearchMinistry of Science, Research & Technology, Tehran, IranApril 22, 2004

3. Outline and Objectives of Presentation • Brief description of Iranian Primary Health Care System • Evidence of Improvements in Health Status of Rural Population • The Role of Primary Health Care System • Factors Underlying the Success of Iranian PHC • Lessons Learned

4. Rural Population of Iran • Iran has experienced a high rate of urbanization over the past 50 years. • Currently about one-third of Iran’s population, around 24 million, live in rural settlements. • Rural settlements are defined by population size (less than 5000) and/or absence of an officially recognized municipal administration. • In 1996 about 64000 rural settlements were identified.

5. Relative Deprivation of Rural Population in Terms of: • Government investment, including most of the subsidized goods • Private income/expenditure • Access to social services: • Education • Health • Social Insurance • Poverty levels

6. Organization & Structure of Iranian Health Network & the PHC System • Nationally • In Urban Areas • In Rural Areas

7. Components of PHC System in Rural Areas • Rural Health House • Based in a village • Staffed by 2 or more Behvarz • Covering a population of 1,500 individuals • Rural Health Center • Based in a large village • Supervising/supporting 5 health houses • Staffed by at least one GP & several health workers • Offering outpatient care,oral health, basic environmental sanitation, maternity facilities • District Health Center • Supervising and supporting several Health Centers • Medical trained personnel, laboratories, Behvarz Training Centers • Referral to District Hospitals & higher levels of care

8. Basic Features of Iran’s Rural PHC System • Community participation • Recruitment of locally acceptable providers (Behvarz) • Careful training/retraining of health workers • Continuous monitoring/supervision/motivation • Emphasis on appropriate technologies • Simple but well integrated health information system

9. The Behvarz • Criteria for Selection • Responsibilities • Training

10. The Health Information System • Household file • Vital horoscope • Statistical wheel • Monthly report forms

11. Impact on Health Outcomes • Impressive improvements in health indicators of rural population since 1980s in terms of: • Health of children • Infant and child mortality • Preventive health/medical care • Health of mothers • Mortality • Antenatal care • Postnatal care • Reproductive health & family planning • Environmental hygiene • Considerable narrowing of urban-rural disparities in health outcomes

12. Changes in Maternal Mortality Ratios of Urban and Rural Areas, 1974-1996.

13. Changes in Infant Mortality Rates of Urban and Rural Areas, 1974-1996.

14. Changes in Under 5 Mortality Rates (per 1000) of Urban & Rural Areas, 1988-2000.

15. Urban-Rural Differences in Antenatal Care Visits, 2000.

16. Urban-Rural Difference in Using Different Contraceptives, 2000.

17. Factors Underlying the Success of Iranian PHC System • Learning and Experimentation Concept of Behvarz tried in two pilot projects: • Kavar rural district (Shiraz University) • West Azarbijan (World Health Organization) • Leadership Commitment to Change • Political commitment to provide basic health care services to poor population • Reallocation of government health budget towards preventive and public health care • Institutional Innovation • Decentralization • Selection and training of Behvarz