District health network policy in Iran: the role of ideas, interests, and institutions (3i framework) in a nutshell

Abstract

Background District Health Network (DHN), one of Iran’s most successful health reforms, was launched in 1985 to provide primary health care (PHC), in response to health inequities in Iran. The present study aims to use interrelated elements of the 3i framework: ideas (e.g., beliefs and values, culture, knowledge, research evidence and solutions), interests (e.g., civil servants, pressure groups, elected parties, academians and researchers, and policy entrepreneurs), and institutions (e.g., rules, precedents, and organizational, government structures, policy network, and policy legacies) to explain retrospectively how (DHN) policy in Iran, as a developing country, was initiated and formed. Methods A historical narrative approach with a case study perspective was employed to focus on the formation and framing process of DHN. For this purpose, the 3i framework was used as a guideline for data analysis. This study mainly searched and extracted secondary sources, including online news, reports, books, dissertations, and published articles in the scientific databases. Primary interviews as a supplementary source were also carried out to meet cross-validation of the data. Data were analyzed using a deductive and inductive approach. Results According to the 3i framework, the following factors contributed to the formation of DHN policy in Iran: previous national efforts (for instance Rezaieh plan) and international events aiming to provide public health services for peripheral regions; dominant social discourses and values at the beginning of the Iranian revolution such as addressing the needs of disadvantaged and marginalized groups, which were embedded in the goals of DHN policy aiming to provide basic health services for deprived people especially living in rural and remote areas. Besides, the remarkable social cohesion and solidarity among people reinforced by the Iran-Iraq war were among other factors which contributed to the formation of participatory plans such as DHN (ideas). Main policy entrepreneurs including Minister of Health, his public health deputy and two planners of DHN with similar and rich background in the public health field and sharing the same beliefs (interests) which subsequently led to creation of tight-knit policy community network between them (institutions) also accelerated the creation of DHN in Iran to great extent. Political support of parliamentary representatives (interests), and formal laws such as principles of Iran Constitution (institutions) were also influential in passing the DHN in Iran. Conclusions The 3i framework constituents would be insightful in explaining the creation of public health policies. This framework showed that the alignment of laws, structures, and interests of the main actors of the policy with the dominant ideas and beliefs in the society, opened the opportunity to form DHN in Iran.

Evaluating primary care networks in low-income and lower middle-income countries: a scoping review

“…Quality improvement, reducing health inequity and responsiveness were some of the goals identified in network implementation in Honduras and Iran 17 18. Networks in DRC and Iran also aimed to improve accessibility of healthcare services19 20 and in the former to also achieve socioeconomic sustainability 20.…”

“…The degree of change sought varied between networks. While PCNs in Iran were described as bridging the gap of healthcare access between the rural and urban areas and bringing healthcare to ‘where people live’,18 28 the Lesotho network sought to improve the community’s trust in local healthcare services 22. The networks in Honduras sought to move from a fragmented healthcare system to one with integrated networks17 and the Bolivia network aimed to change the referral structure and thus strengthen primary care 21…”

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“…At the network level in Iran, the district health network team, with Ministry of Health and Medical Education representatives, was responsible for network administration. Networks consisted of primary healthcare delivery facilities networked with provincial medical schools and training units for community health workers 18. Iran’s PCN achieved some intended goals in the early stages of the policy, but, more recently, these have stalled due to various factors including epidemiological shifts in disease patterns and rural–urban migration 32.…”

Preferences of people in choosing a family physician in rural areas: a qualitative inquiry from Iran

“…RHCs monitor and guide the health houses' activities, provide outpatient care, and refer more complicated cases to the upper level, which is the district hospital. In 2020, there were 6973 FPs, 5669 midwiferies, 1899 dentists, 138 dentistry technicians, 806 nurses, 1503 laboratory technicians, 98 radiology technicians, and 4661 health technicians in the RHCs (Doshmangir et al, 2019;Khedmati et al, 2019;Yazdi-Feyzabadi, Bazyar and Ghasemi, 2021).…”