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

2. 2 Primary Health Care and the Rural Poor in the Islamic Republic of Iran Amir Mehryar & Shirin Ahmad-nia Center for Population Studies & Research Ministry of Science, Research & Technology, Tehran, Iran April 22, 2004

3. 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. 4 Rural Population of Iran 1.Iran has experienced a high rate of urbanization over the past 50 years. 2.Currently about one-third of Iran’s population, around 24 million, live in rural settlements. 3.Rural settlements are defined by population size (less than 5000) and/or absence of an officially recognized municipal administration. 4.In 1996 about 64000 rural settlements were identified.

5. 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. 6 Organization & Structure of Iranian Health Network & the PHC System  Nationally  In Urban Areas  In Rural Areas

7. 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. 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. 9 The Behvarz  Criteria for Selection  Responsibilities  Training

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

11. 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. 12 Changes in Maternal Mortality Ratios of Urban and Rural Areas, 1974-1996.

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

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

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

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

17. 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