Barriers of health equity in the Iranian health system from the medical ethics viewpoint

Journal of Medical Ethics and History of Medicine · 7 authors, 7 centres

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TL;DR

This qualitative study identifies barriers to health equity in Iran's healthcare system through semi-structured interviews with 30 experts. The barriers fall into five categories: cultural, financial, geographical, social, and religious factors, organized under micro and macro themes. The findings highlight that achieving equitable healthcare access requires addressing these multidimensional barriers through comprehensive policy reforms aligned with bioethical principles.

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**Background:** Health equity is a foundational goal of healthcare systems, yet barriers to equitable access persist, particularly in middle- and low-income countries. In Iran, despite health system reforms such as the Health Transformation Plan (HTP) implemented in 2014, catastrophic healthcare expenditures have ranged from 1.3% to 42.6% across studies. This study aimed to investigate barriers to accessing healthcare services in Iran from a medical ethics perspective, examining geographical, financial, cultural, social, and religious dimensions.

**Methods:** This qualitative study employed semi-structured interviews conducted between June 22, 2018, and March 6, 2019. Purposive sampling was used to recruit 30 participants including general practitioners (n=7), specialists in medical sciences (n=14), and PhDs in public health (n=9) involved in health management and/or provision. Participants had a mean age of 47.8 years (SD 7.3, range 32–60), mean work experience of 24.4 years (SD 5.9, range 10–35), and 83.3% were male. Interviews lasted a mean of 45 minutes (SD 12, range 25–84 minutes). A multi-triangulation approach was adopted for data collection. Content analysis was performed using MAXQDA 10 software with inductive-deductive coding. The study protocol was approved by the research ethics committee of the School of Medicine, Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1401.110).

**Key Results:** Content analysis identified two themes—micro factors and macro factors—five sub-themes, and 44 codes. Micro factors included: (1) Cultural barriers (11 codes): differences in individuals' perceptions of health interventions, induced demand through advertising, social stigmas, religious and ethnic beliefs, and conflicts of interest among physician-managers. (2) Financial barriers (12 codes): direct payments, financial connections between physicians and patients, inadequate insurance coverage, segmentation of insurance systems, inflation and sanctions affecting financial ability, and deductibles that remain prohibitive for at least 30% of the population. (3) Religious barriers (4 codes): non-acceptance of modern technologies (e.g., fertility treatments), religious attitudes of providers affecting diagnosis and treatment of conditions like HIV and alcohol abuse, and preference of certain religions. Macro factors included: (4) Geographical barriers (11 codes): inequality in regional development, concentration of services in provincial capitals, marginalization, urbanization disparities, natural disasters, managerial biases in resource distribution, lack of infrastructure in deprived areas, and restrictions imposed by service leveling and referral systems. (5) Social barriers (6 codes): direct relationship between income level and access, effect of occupation type, literacy level, tendency of low-income individuals to avoid services, and social class as a significant barrier. Participants noted that 7–9% of individuals lack any insurance coverage, and government employees receive supplementary insurance while unemployed and rural residents are partially or completely deprived.

**Clinical Implications:** The study demonstrates that achieving health equity in Iran requires addressing barriers across all five identified domains simultaneously. Cultural barriers necessitate improved health literacy and management of induced demand. Financial barriers require equitable insurance premium setting, comprehensive coverage across all five service levels (health promotion, prevention, treatment, rehabilitation, and palliative care), and protection against catastrophic costs. Geographical barriers demand equitable resource distribution, service leveling, and compensation for travel costs in underserved areas. Social barriers call for policies addressing income inequality, education, and occupational disparities. Religious barriers require culturally sensitive service delivery that respects diverse beliefs while maintaining access. The authors recommend developing innovative strategies emphasizing equity and social equality, establishing comprehensive longitudinal data systems for equity-oriented research, and reforming policymaking and legislative structures to align with the four principles of bioethics: justice, autonomy, beneficence, and non-maleficence.

STUDY TYPE

other

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medical_ethics

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ORIGINAL PAPER

PMC10151731

Barriers of health equity in the Iranian health system from the medical ethics viewpoint

Journal of Medical Ethics and History of Medicine

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ABSTRACT

In order to lessen health inequalities, the obstacles to health equity will need to be identified. This study aimed at investigating the barriers to access to health-care services from the medical ethics point of view. Data were collected through a qualitative study by performing semi-structured interviews. Purposive sampling was used to recruit participants involved in health provision and/or management. Content analysis was done using MAXQDA software. Overall, 30 interviews were conducted. The content analysis of the interviews identified two themes including “micro factors” and “macro factors”, five sub-themes including “cultural, financial, geographical, social and religious barriers”, and 44 codes. Based on our findings, differences in individuals’ perceptions, cultural control, religious beliefs and social stigmas create cultural barriers. Financial barriers consist of the financial connection between service recipients and service providers, insurance premiums, and inadequate coverage of health-care services. The most important geographical barriers identified in our study were differences in urbanization, inequality in various geographical areas, marginalization, and inequality in resource distribution. Finally, differences in the level of income, education and occupational diversity were among the social barriers. Given the wide range of barriers to access to health-care services, a comprehensive plan covering various dimensions of health equity should be implemented. To this end, innovative and progressive strategies emphasizing the principles of equity and social equality should be developed.

CITATION EXPORT

Davoud Nezamoleslami, Efat Mohamadi, Bagher Larijani et al.. Barriers of health equity in the Iranian health system from the medical ethics viewpoint. Journal of Medical Ethics and History of Medicine. (2022). https://doi.org/10.18502/jmehm.v15i14.11570

AUTHORS

7 · 7 CENTRES

Davoud Nezamoleslami, Efat Mohamadi, Bagher Larijani, Alireza Olyaeemanesh, Masoumeh Ebrahimi Tavani, Roya Rashidpouraie, Fataneh Sadat Bathaei

1 PhD Candidate in Medical Ethics, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
2 Assistant Professor, Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran.
3 Professor, Institute of Endocrinology and Metabolism, Tehran University of Medical Sciences, Tehran, Iran.
4 Professor, Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran; National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran.
5 Assistant Professor, Group of Quality Improvement, Monitoring and Evaluation, Center for Health Network Management, Deputy for Public Health, Ministry of Health & Medical Education, Tehran, Iran.
6 Researcher, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
7 Researcher, Department of Medical Ethics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.