Cleaning up after the men

Marzieh Vahid Dastjerdi pictured above with Fatemeh Ajorlou

Iran's first woman health minister faces many challenges ahead -- segregating health care facilities for men and women is not one of them.

Reporting from Iran | 5 Sept 2009

Dr. Marzieh Vahid Dastjerdi, Iran's new Minister of Health, represents a breakthrough for women inside the Islamic Republic. She is the first female minister in Iran since the revolution and her appointment has broken a great taboo in Iranian politics. Despite her conservative background and appointment by Mahmoud Ahmadinejad, she faced fierce opposition by hard-line clerics. In doing so, it appears that the government has started to bow to the Iranian feminist movement -- although the result is far from desirable as Dastjerdi is a conservative anti-feminist. Nevertheless, this is a step in a direction from which the government can never retreat.

Despite this symbolic victory for women, the appointment of Dastjerdi will not change the reality of the Iranian government nor the Ministry of Health and Medical Education, MOHME. The reality is that women in Iran are still highly discriminated against. In MOHME, almost half of the employees are women, but only a few hold ranking managerial posts at the university level and no woman has held even a middle ranking managerial post before Dastjerdi.

She will now inherit one of the most entangled and complex health care systems in the world, entwined as it is in Islamic revolutionary concepts and rhetoric while still trying to provide basic medical services to its people. The Iranian health system is succeeding in some areas while still quite dysfunctional in others. According to UN health expert, Dr. George Schieber, the Iranian health care system succeeds by ensuring population growth is under control; providing 90 percent of the population with some sort of formal health care coverage; and generally ensuring that health care outcomes are good. However, malnutrition is still a serious problem with 19 percent of children; there is still a vast gap between urban and rural health care outcomes; and hospitals are operating at over capacity. Financing for the health care system -- typical for Iran -- is complex, opaque, not actuarially sound and likely inefficient and inequitable.

In her statement to the parliament, Dastjerdi failed to mention any of these challenges facing MOHME, and instead spoke of her desire to sexually segregate health care provisions as much as possible. And yet, she is no stranger to the MOHME. She has long been involved in different committees in the ministry as well as serving as a member of the health committee in the parliament. It can be said that she has more experience than the previous health minister and her supporters in the parliament including Dr. Alireza Marandi, the veteran of the Iranian health system and a former health minister himself, insisted on this as her strength. Marandi's strong endorsement was likely the deciding factor in winning the parliament over in her favor.

The Islamic Republic has been successful in improving health-related indicators such as the Infant Mortality Rate (IMR), the Maternal Mortality Rate (MMR), the Under 5 Mortality Rate and life expectancy, but there is still much room for improvement. In 1998, life expectancy in Iran was 61 years, which increased to 69.3 years by 2004 -- an improvement but still far short of the 78-year life expectancy of the developed world in countries that are members of the Organization for Economic Co-operation and Development, including the United States and western Europe. Throughout the past three decades, a 10-year gap in life expectancy between Iran and OECD states has remained constant.

Iran's infant mortality rate was 35 deaths per 1000 live births in 2004, a statistic which Iran has managed to more than halve since the revolution. But in comparison with OECD states -- six deaths per 1000 live births -- Iran still needs to do much better. The data on the maternity mortality rate, the under 5 mortality rate and other indicators reveal similar findings. Digging into these numbers reveals something else about Iran's health statistics -- a wide variance between different socioeconomic groups, which illustrates that Iran has not been able to ensure equity in health care between rich and poor. For instance, 16 percent of Iranian children suffer from malnourishment while a similar percentage suffer from obesity.

Another major goal of a health system is the degree of financial risk protection, meaning that each person should bear an equal and reasonable financial risk for receiving health care, which is highly dependent on the financing structure and insurance system of a country. Countries with nationalized health systems like the NHS of Great Britain enjoy high degrees of financial risk protection, but countries with market-based health systems like the American health system suffer greatly in terms of this metric. Iran, unfortunately, is not faring too well in this field either. Despite the law that states that at most 15 percent of health care costs should be paid out-of-pocket by the patient, in many cases patients have to pay as much as 60 percent of costs, and this doesn't include unofficial and indirect payments, which are a common feature in Iran's health system.

The Iranian health system is financed from its budget allocated from oil and tax revenue; from money that insurance companies pay; and out-of-pocket payments by patients. Iran has a number of state-owned insurance schemes alongside a few insignificant private insurance companies. Such multiplicity has resulted in fractioning of insurance risk pools as well a complex insurance system. Furthermore, the insistence of the government on attaining universal insurance coverage without providing the necessary funding has resulted in considerable reduction in effectiveness. A considerable part of the Iranian health system's funds are provided by the users through out-of-pocket payments. This has imposed a huge burden on the average Iranian.

On service delivery, Iran has long been one of the leading countries in providing universal primary care. However, the primary care provision has been focused in the rural areas. Iran was one of the premier countries in establishing an effective primary care system; the system depended on semi-professional health care workers alongside physicians to provide an essential package of primary health care in every Iranian village. However, the trend after the end of the eight-year war with Iraq focused on hospitals and secondary care; primary care was neglected. Only recently the damage caused by such negligence has been realized and costs have skyrocketed while primary care has stubbornly refused to enter the urban areas.

During the Khatami administration, MOHME tried to correct the situation by deploying family physicians. However, years later the system is still suffering from lack of funds, inadequate coverage and still the primary care system has not been established inside the cities. Iranian physicians have traditionally been paid through fee-for-service methods based on a universal fee scheme that is determined annually through much quarreling between MOHME, the Ministry of Welfare and the Medical Association. This method of payment has been blamed for rising costs, but the fact is that Iranian physicians are grossly underpaid in comparison with their counterparts elsewhere in the world.

MOHME has not exerted its oversight and influence in health system in a positive manner. Its history is marred with periodic and often contradictory strategies and there is no existing long-term and system-wide plan in MOHME despite the fact that an overall strategy is set every five years for all ministries.

In trying to manage MOHME, Dr. Marzieh Vahid Dastjerdi faces considerable challenges. To some, her appointment is a testament to the will of women rights activists in Iran who have made an ultra-conservative government like that of Mahmoud Ahmadinejad bow to their pressures, but how effective can any person be -- male or female -- in managing a system with such wide-ranging institutional problems?

Copyright (c) 2009 Tehran Bureau