Country profiles

Islamic Republic of Iran

Overview

The Islamic Republic of Iran, with a surface area of 1 648 000 km², is a highly diverse country from every point of view, not only in its ethnic variety, but also in topography and climate. The population in 1994 was officially estimated at 59.6 million and is now estimated at around 65 000 000. The population is relatively young, with 39.5% below the age of 15 years (1996). In 1996, 4.3% of the population was aged above 65 years. In 1994, 58% of the population resided in urban areas. Life expectancy at birth, in 1995, was 69 years. The literacy rate for the population 10 years of age and above was 80% in 1996, and the female literacy rate for the population 10 years of age and   above was 74.2% in 1996. 27% above the age of ten are economically active. The per capita income in 1997 was US$ 2118. The majority of the population is Muslim. Although the reduction of the population growth rate was ratified as official policy of the government in 1988, the crude birth rate still remains high at 18.7 per 1000 population, the crude death rate was estimated at 4.2 per 1000 population, the infant mortality rate was estimated at 23 per 1000 live births(1998) and the under-5 mortality rate was 33 per 1000 live births. Life expectancy at birth was calculated to be 69 years in 1995. Maternal mortality was estimated at 3.7 per 10 000 live births in 1997

During the 1960s and 1970s, the country experienced the expansion of health services through "Health Corps and Pilot Projects of Primary Health Care." However, it is since the Islamic Revolution in 1979 that the country’s health policy has been based on primary health care, with particular emphasis on expansion of health networks and programmes in rural areas and with priority allotted to preventive over curative services.

Recently, more attention has been given to the following: reduction of population growth by use of family planning; control of diarrhoeal, respiratory and iodine deficiency diseases; integration of mental health, tuberculosis, leprosy, diabetes, and malaria programmes into the primary health network system; community-oriented medical education; considerable increase of immunization coverage; reduction of maternal and infant mortality; increase of community participation; increase of basic environmental sanitation and adequate safe water in rural communities; and expansion of health networks, including the construction of district hospitals where needed. There is also the new policy of vaccination of women, which requires that all women of childbearing age, not only pregnant women, be immunized against tetanus.

All of the above activities were supported by allocation of the required budget in the respective five-year development plans. The health budget doubled in 1991 compared with 1982-87. The declared policies have been made known to the different levels of government and nongovernmental sectors through the mass media as well as through publications and brochures.

Many laws and regulations have recently been decreed which support the health for all policy. These include the law of economics, social and cultural development; this states that deprived areas should receive equal services with other areas so that, within eight years’ time, there should be no deprived areas in the country.

Since April 1985, the expansion of health networks based on primary health care has been rapid. In both towns and villages, the first point of contact between the public and the health system is the health centre. However, in the villages, the health centre performs its functions with the help of a large number of health houses, which effectively become the first point of contact. The responsibility of the rural health centre is to supervise, support and accept referrals from the health houses.

District hospitals in towns offer services to referred cases from rural as well as urban health centres. District hospitals are responsible for specialized, hospitalized and outpatient curative services. The activities of the district health centres, as well as those of the district hospitals, are coordinated by the manager of the health network. Although, formally, this referral follow-up chain exists, it is somewhat weak, especially at the level of the rural health centre upwards.

In addition, a shortage of doctors and to a lesser extent, the flight from the country of health professionals, including doctors, at the time of the revolution, has led to many rural health centres’ being staffed by expatriates, which affects the feedback and referral mechanisms and has decreased support for the health houses. This is being solved through a dramatic increase in the number of medical graduates and the formation of the Ministry of Health and Medical Education, which puts many medical facilities in service of training. Low literacy rates, especially in some rural areas and among girls, has made it difficult to find suitable candidates to be trained as community health workers and is affecting the expansion of the primary health care network in some parts of the country. Moreover, a shortage of funds and suitable facilities for health centres is also among the major obstacles impeding expansion of the primary health care network.

National health policies are decided at meetings of the Council of the Undersecretary of the Ministry of Health and Medical Education, headed by the Minister of Health and Medical Education. However, the initial information on needs for planning purposes is collected from the bottom up. In each district, there is a district planning council, to which each sector submits its planning needs in priority order. The plans approved by this council are referred for formal consideration to the provincial council, which, with due consideration of provincial priorities, coordinates the plans and ultimately sends them to the planning councils at the national level. The planning process is thus a two-way one: both top-down and bottom-up.

The health network has been decentralized to district level so that implementation of programmes is independent of central administrative and financial control. Entrusting full administrative and financial powers to provincial and district health centres has greatly facilitated the implementation of health for all strategies.

As it was just mentioned, an important development is the establishment of the Ministry of Health and Medical Education, which combines responsibility for provision of health services and medical training. In each province of the country, there is at least one university of medical sciences and health services. The chancellor of this university is in charge of all health affairs in the province, executing his duties through deputies for health, treatment, and so on. He also works with the deans of different health-related schools.

The communities are actively involved in the planning and implementation of health services, mainly through the health councils in rural areas. The decentralization of administrative and financial management of health services has also increased community participation; this is in addition to the fact that all personnel working in rural health centres and health houses are locally recruited. Community involvement in large cities is not as impressive.

In 1990, the Ministry of Health and Medical Education’s budget represented 12.9% of the total government regular budget while in 1998, expenditure of the social sectors, education, health and social security constituted 32.8% of total government expenditure. Approximately 40% of the Ministry of Health and Medical Education’s budget is spent on the primary health care system. The per capita national health expenditure in 1998 was US$ 32.1, which is lower than the 1987 figure of US$ 107 due to a change in the exchange rate, but the per capita expenditure in Iranian rials has increased substantially.

Public health and primary health care now account for 13% of the medical curriculum. In 1991, per 10 000 population, there were 4.7 government-employed physicians, 0.91 dentists and 7.4 nursing/midwifery personnel. However, despite government incentives to attract physicians to rural, deprived areas, the distribution of physicians to these areas is very inequitable, with urban areas having rates of physicians 23 times higher than those in the deprived areas.

As regards physical resources, there were 14.6 hospital beds per 10 000 population in 1988, rising to 16.4 in 1996. Available health facilities in 1988 included 8000 health houses, 3015 health centres and 140 district health centres. Available health facilities by January 1999 comprised 14 936 health houses, , 2332 rural health centres, 2007 urban health centres and 271 district health centres and 422 health posts.

It is quite evident that implementation of health for all strategies has improved the health status of the population, as indicated by the decreased mortality indicators and increase in life expectancy. More than two-thirds of the population are currently covered by health care due to the expansion of the health centre network. Moreover, the expansion of water networks in towns and villages has resulted in 100% coverage of the urban population with safe water by 1988 (96.5% covered with piped water in the home) and hygienic sanitary facilities. In the same year, 75% of the rural population had access to safe water.

There is more efficient use of human resources through the policy of local recruitment of staff for health centres. Although resources allocated to the health sector have doubled in recent years, the fact that the district health centres have become completely autonomous units, both administratively and financially, has also resulted in more efficient use of resources.

MENTAL HEALTH

The Islamic Republic of Iran has been in the forefront of the primary health care and mental health movements. Some of the earliest general population psychiatric epidemiological studies were carried out in the 1960s. . The eight-year-long Iran-Iraq war also provided impetus for the understanding of mental health issues of the general population and war victims along with the expansion of the primary health care infrastructure. The shift is not only dramatic, but also path-breaking as it has generated new technology and approaches relevant to other countries of the Eastern Mediterranean Region.

The history of development of mental health services in the country can be divided into four periods.

The period of asylum care, covering most of the early decades of this century. Asylums of different sizes existed in Teheran, Hamadan, Shiraz and Isfahan. The condition of these facilities were very poor and most of them were either connected to or extensions of collection areas for beggars. Teheran’s municipality opened the first government-supported asylum in the 1930s.

The introduction of psychiatry as a part of medical education and the formation of new university hospitals. This period started in the late 1940s, developed during the 1950s and was established from the 1960s onward. Residency training in psychiatry started during the early 1960s in Teheran University’s Roozbeh Hospital. It was than followed by similar programmes in Shiraz, Isfahan, Tabriz and Mashhad universities.

Community mental health programmes were begun in the 1970s. The society for rehabilitation of the disabled and planning for community mental health headed by a first deputy of the Ministry of Health and Welfare introduced the concept of comprehensive mental health care, initiated the building of new hospitals and centres in different provinces, started a wide range of epidemiological research, and established specialized level training programmes for psychiatry and psychiatric nursing. After the revolution of 1979, training and research programmes were integrated to form the Teheran Psychiatric Institute.

The period of integration of mental health services into the primary health care system started in the mid 1980s. The first pilot projects were started in 1987 at Shahr-e-Kord and Shahreza and since then, integration has continued throughout the country with a large nationwide coverage through the general health system described above. This programme was evaluated by an independent expert group in 1995. The evaluation was organized by the WHO Regional Office for the Eastern Mediterranean in collaboration with the national government and the Division of Mental Health and Prevention of Substance Abuse, WHO headquarters, Geneva, Switzerland.

Facilities

• Number of psychiatric beds: public 6575; private 310; welfare 2000; other (military, etc.) 571. Total: 8252

• Number of public sector psychiatric wards in general hospitals: 38 with 796 beds

• Number of psychiatric hospitals: 23

• Number of private psychiatric offices: 485

• Number of private clinical psychology offices: 255.

Mental health human resources

• Number of psychiatrists: 590

• Number of psychiatry residents (under training) every year: 55-63

• Number of PhD psychologists: 60

• Number of MSc psychologists: 400

• Number of BSc psychologists in health services: 600

• Number of MSc psychiatric nurses: 35.

There are 39 medical schools in the country. Most are part of the Universities of Medical Sciences and function directly under the Ministry of Health and Medical Education. The rest belong to the Islamic Azad University, which is a tuition-dependent, semi-governmental higher education system with schools throughout the country. Only one or two schools belong to other sectors, such as the military. All these medical schools have undergraduate training in behavioural sciences and psychiatry on both theoretical and practical bases. Ten medical schools, all belonging to the government sector, offer psychiatry residency programmes. The number of graduates is between 40 and 50 a year. They get board certified through a national board made up of representatives from the medical schools. The certification examination includes written, oral and clinical parts. Only the ones who get certified by the board can become faculty members of medical schools; the rest can work in service delivery and small towns. It is estimated that the number of graduate psychiatrists will increase by 50-60 a year in the next five years. In 1997, board certification in child psychiatry with a two-year additional training period was started.

One centre in the country offers postgraduate psychiatric nursing training towards an MSc degree. Three centres offer the same degree in clinical psychology. There are 6-10 psychiatric nursing graduates a year, but many of them do not continue in mental health services. There are about 25 clinical psychology graduates a year, and almost all of them continue to work in mental-health-related areas.

Epidemiological studies carried out in the Islamic Republic of Iran by different authors represent different prevalence rates for psychiatric disorders. The discrepancies are largely due to the different methodologies and sampling frames . The prevalence rate obtained in these studies range from 9% in a population sample with a lower age limit of 6 years, to over 36% in another sample whose lower age limit was 15 years. In the later study, 3% of the psychiatric cases aged 15 or above were seriously ill, warranting intensive psychiatric care and treatment. In the same study, 15.3% had minor psychiatric problems and 26.6% had other emotional problems. The commonest diagnostic category in this study was depressive disorder, amounting to 24.3% of all cases. Schizophrenia was 0.6%, grand mal epilepsy 0.4%, and lastly, the rate of opium addiction was about 1%.

In a study carried out in a general medical outpatient clinic, 34.5% of patients were assessed by general physicians as having psychiatric problems, 25.1% of whom were diagnosed as suffering from both physical and psychiatric problems. The largest diagnostic group identified was depression, diagnosed in 27.2% of all cases referred to the clinic.

In an another study carried out in a general medical ward, only 36% of all persons admitted were diagnosed as having no psychiatric problems. The rest were suffering from emotional reactions (41%), psychiatric disorders (10%), or a combination of physical and psychiatric problems (13%). Depressive disorders represented the largest diagnostic category amounting to 43% of all psychiatric cases. Interestingly enough, there were also schizophrenic patients (1%), and drug-dependent individuals (2%) among the admitted patients.

In another study, the first contact of 80% of psychiatric cases was to general practitioners; 16% went to the specialists other than psychiatrists; and only 4% called on a psychiatrist from the outset. It has also been shown that the shortage of psychiatrists, especially in the provinces, is not the major reason for preference of general practitioners. More than two-thirds of these patients complained predominantly of physical symptoms.

The following figures are taken from Roozbeh Hospital (the main teaching centre for psychiatry in Teheran University of Medical Sciences), which has one of the busiest psychiatric clinics in the country. In this clinic, about 43 000 cases are seen annually, of which 20% are new cases; 40% of all cases are referred from other provinces. Of all cases, 45.3% were diagnosed as having depressive disorders, 39.1% were suffering from "neuroses" of different kinds, and 7.8% were diagnosed as having schizophrenia.

There has been no major study on the prevalence of mental health and psychiatric problems of children. A very important recent development is a drastic fall in the infant mortality rate, which is the result of reduction of prevalence of infectious diseases due to immunization, the nutritional programme and other public health measures. The infant mortality rate dropped from 104 per 1000 live births in 1982 to 23 in 1998. It would be quite interesting to check the effect of these changes on the prevalence of psychiatric problems of childhood.

In terms of residential mobility, the population of the Islamic Republic of Iran can be divided into a sedentary population and unsettled or nomadic groups whose movements and residence follow seasonal or occupational changes. The latter groups include the properly nomadic (about 15 per 1000 of the total population) and people who move constantly between villages and towns, such as gypsies and vendors (8 per 1000 of the total population) .Within-country migration rate is high-about 23%. The main reasons for migration are changes of employment or seeking better jobs, military or civil service duties, marriage and study. About 60% of the migrants move with their families. In a controlled study of a group of migrants to Teheran, there were no major differences between the groups of migrants and non-migrants. Of migrants, 34% were identified as having psychiatric problems; 46.6% of whom being in need of psychiatric help and treatment.

Opium and heroin are the substances most abused in the country. Although the common routes of taking these drugs are smoking and inhaling, there is an increasing concern over injection abuse, which seems to be on the rise. Alcohol and psychotropic substances do not represent a significant problem. The cultivation of opium has been banned since 1979, and since then, the law deals with addicts with criminal and social problems by putting them in reorientation centres; others can receive care in open facilities. At present, 16 such facilities exist. However, this number is not adequate and more facilities need to be set up. Recently, there has been a new initiative for a comprehensive demand reduction programme by the Welfare Organization. Hopefully, this will result in a new approach to treatment and rehabilitation of drug dependent individuals.

The national programme of mental health was formulated in October 1986 by a multidisciplinary team of professionals and was consequently adopted by the Ministry of Health and Medical Education. The implementation of this programme started in 1987.

The objectives of this programme are:

• To make essential mental health care available and accessible for all in the Islamic Republic of Iran in the near future, with special emphasis on the most vulnerable, unserved and underserved rural population as well as the unprivileged, inappropriately served population in deprived urban areas and in remote parts of the country.

• To develop mental health care models in keeping with the culture and social structure of Iranian society and to encourage community participation in the development of mental health care services.

• To enhance mental health knowledge and skills in general health care and to encourage the wider application of mental health principles to promote social health, socioeconomic development as well as improving the quality of life.

• To develop suitable programmes for the mental health care of those affected by the imposed war (such as immigrants, homeless, disabled, bereaved, mentally ill) as well as to have a long-term plan for post-war mental health problems.

The strategies identified include service strategies, training strategies, administrative strategies and promotion of mental health and war-related services. The national mental health programme document also identifies clear objectives for implementation.

The period 1987-97 can be divided into two periods namely, the period of pilot programmes (1987-90) and the period of expansion (1990-99). A notable feature of the national mental health programme was the independent evaluation of the progress in November 1995.

The first two pilot programmes were implemented in 1987 in Shahr-e-Kord district in Chahar Mahal-e-Bakhtiari province and Shahreza district in Isfahan province in the central part of the country. The aim of the Shahr-e-Kord study was to integrate mental health activities into primary health care. The population of Shahr-e-Kord covered was 28 903, in 22 villages. In this area, all the health personnel (27 behvarz [footnote: Village level worker], 5 doctors) were trained. A control area was also kept for comparison. The results of the training showed a significant increase in knowledge both immediately after the training, as well as after one period. In the experimental area, prior to the training, there were 121 cases identified with 46% misdiagnosis. At the end of one year, it was 266 with only 14% misdiagnosis. In the control area, there were 124 cases with 45% misdiagnosis. Similar positive results were seen in the general practitioners, who were able to identify, diagnose and treat the cases.

One of the striking findings of the study was that at the point of identification, the duration of illness in 70% of persons with epilepsy was more than 10 years and most of them were not on regular treatment. In a small sample, a total population survey was made at the end of one year. This survey showed that the health personnel had identified 63% of the mentally ill patients. The care pattern showed that only a very small proportion of cases needed specialist help and this need decreased as the programme progressed. In 83% of the patients, the acceptance of the care programme by the patients and families was satisfactory. A community attitude survey showed a difference between control and experimental areas, with more positive attitudes in the experimental population.

The other pilot programmes were in Hastegerd, Teheran province, and Shahreza.

These pilot projects provided both the experience as well as the practical details of integration of mental health in primary health care.

Following the pilot projects, a number of developments occurred in the country that led to the expansion of the programme rapidly in the rural areas. These were:

• creation of a mental health unit within the Ministry of Health and Medical Education

• formation of a national mental health advisory group

• involvement of the medical universities in the national mental health programme

• declaration of mental health as the ninth component of primary health care

• preparation of a manual for behvarz, a manual for doctors and an information system, and training for all health personnel

• celebration of a mental health week every year in October

• review workshops on national programme (1991) and research methodology (1993)

• international independent evaluation (1995)

• seminars and conferences

• public mental health education through the mass media and other sectors

• establishment of general hospital psychiatric wards

• urban mental health and school mental health programmes.

As a result of all these efforts, there was a rapid expansion of the mental health programme. As of January 2000, about 15.6 million (23%) of the total population were covered. Of this, 12 million are in the rural areas, which forms 49% of the rural population. The programme covers 8494 health houses, 1554 health centres and 199 districts. Total number of patients seen is 128 425, of which 13 900 are psychotic, 23 500 epileptics, 28 800 mentally retarded, 47 900 neurotic and 14 200 miscellaneous.

As it can be seen, beginning with pilot projects, a system of mental health care from the health house level to the specialist level has been developed. The current nationwide coverage is about 23%. The development of manuals, records and mental health education materials has been adequate. The mental health unit has played a central role in training, supplies, support and supervision. Due to some administrative changes (see below), the expansion of the programme since 1994 has not kept pace with that during 1990-94.

New areas for consideration are urban mental health, quality assurance at all levels of care and intersectoral coordination of services. There is also need for greater emphasis on common mental disorders seen at the primary health care facilities and improved training for general practitioners. The annual mental health week has been a major initiative in the Islamic Republic of Iran with positive effects. This has brought the support of community resources for mental health as well as increased community awareness. The use of the mass media has also been satisfactory. Initial efforts have been made to identify and use religious and moral values and schools for healthy lifestyles and promotion of mental health. There is need for expansion of the school mental health programme. In this area of work, there is need for evaluation of the initiatives in a prospective manner.

Special programmes for the war-affected population have been developed in the country. The mental health needs have been given importance. In addition, mental health professionals have contributed to the overall development of rehabilitation services.

The involvement and leadership role of the medical universities have been an important part of the national mental health programme of the Islamic Republic of Iran. This has not only addressed the objectives of technical support, but also resulted in greater support to the programme from professionals; training has focused on the national mental health programme. The support materials (manuals, health education materials, and so on) have been developed by a process of sharing and collaboration of centres around the country.. A new cadre of psychologists has emerged in place of social workers. The psychologists are playing a vital role at the level of primary health care and supervision of the health houses. They carry potential for greater contribution to the national mental health programme.

This area has two phases. During the first phase, 1990-94, the mental health unit in the Ministry of Health and Medical Education was fully staffed and very active in implementing the programme. An advisory committee met on a number of occasions and guided the programme. Since 1994, there has been lack of such an active mechanism and this has been reflected in levelling of the expansion of the programme. The formation of a multisectoral national coordinating group has not been possible. Administrative mechanisms have a vital role, and a revised system has to be developed for the future development of the programme.

During the past 10 years, an impressive amount and wide range of research has been undertaken by the professionals. The most important of these is the evaluation of the community mental health programmes at Shahr-e-Kord, Shahreza and Hasteger. The other change of note is the shift in the areas chosen for MD or MSc thesis by postgraduates in psychiatry and psychology. There is a move toward studies on epidemiology and treatment evaluations as future of the national mental health programme depends on continuous research input.

In November 1995, an independent evaluation was undertaken of the national mental health programme by an international group of five consultants. This evaluation included special studies, field visits and a national workshop.

The special studies provided information about mental health care and the way the programme is perceived by the personnel. The salient findings are as follows:

• Behvarz. A total of 266 behvarz were studied. The results show that more than half of the behvarz scored above 50% in the total knowledge and attitude scores. On average, about 15 patients were identified by each behvarz at health houses covering an average population of 1500. A majority of the patients were provided care at the health houses by the visiting general practitioner and the behvarz of the area.

• Rural health centre. The rural health centre is the health care level where diagnosis and treatment are provided by general practitioners. Of the psychiatric patients seen at rural health centres, most were referred from health houses. There were more direct referrals of persons with "neurosis" as compared to other diagnostic groups. The doctors provided care for a number of psychiatric emergencies. The most common difficulties reported by the doctors in providing mental health care were: follow-up of cases, diagnosis, duration of treatment, and side effects and dosage of medicine. A one-day census showed that, Rapid turnover of doctors at the primary health care level with an average stay of only 3-6 months, often led to many of them not having specific mental health training and becoming fully involved in the programme.

• District health centre. These centres are staffed by psychiatrists or general practitioners trained in psychiatry and one psychologist. About 25% of patients seen at the district health centre are patients with psychoses and about 20% each with neuroses, mental retardation and epilepsy. There is a regular process of referrals and back referrals at different levels of health care. The need for referrals to specialized psychiatric centres is relatively small.

• Pathways study. The total number of patients included in the evaluation was 980 at the level of general hospital psychiatric outpatient department, private psychiatric clinics and psychiatric inpatients. For the total group, first contact was with a traditional healer in 13% and the health centre in 87% of cases. Thirty-four per cent gave a positive response to having ever visited a faith healer or used an herbal medicine for the psychiatric problem. It was noted that the proportion seeking help within three months of onset of symptoms was 41% at the general hospital outpatient department, 31% in private clinics and 25% in the inpatient units.

• Families study. Of the 738 families who were not covered by the mental health programme, there was significant use of psychotropic medicine. Diazepam, chlordiazepoxide, and oxazepam were found in 20%, 13% and 9% of families, respectively. Antidepressants were found in 10% of families while antipsychotic drugs were in use in only 1% of the families. This indicated the unmet mental health need in the community.

• National workshop. The workshop was attended by more than 40 professionals and planners from different disciplines and departments and reviewed the evaluation findings and outlined the programme for the next phase of the national mental health programme for the period 1996-2001.

• Conclusions of the evaluation and main recommendations. The national mental health programme of the Islamic Republic of Iran, formulated in October 1986, has been actively implemented and has achieved significant progress and results. The most striking is the integration of mental health care with primary health care at all levels. The coverage of about 41.5% of the rural population, amounting to about 10 million rural people and over 107 000 patients, is noteworthy, especially as the majority of these persons were without care prior to the programme. This has been the result of systematic efforts to develop an administrative system and support mechanisms by the Ministry of Health and Medical Education and mental health professionals. It is very creditable that all of this has been achieved within a decade and with national resources. The involvement and active commitment of universities is unique.

In the period covered by this evaluation, the national mental health programme of the Islamic Republic of Iran has demonstrated the feasibility of providing care to the mentally ill living in rural areas of the country, and shown that activities necessary to ensure care of the mentally ill, the prevention of mental disorders and the promotion of mental health can be integrated into primary health care.

The evaluation of the achievements of the programme was extensive and sufficient to make specific recommendations concerning the future development of the programme. Nevertheless, several components of the programme have been examined only partially and it will be necessary to carry out further evaluative work (for example on the functioning of mental hospitals) in the immediate future, and adjust the national health information system so as to be able to monitor the development of the programme on the basis of routine statistics.

The findings of the evaluation and the experience gathered over the past eight years provide a solid basis for the formulation of the programme covering the forthcoming period in which the activities already started should continue. In addition, it is now possible to make recommendations about new areas of activity which will render the programme comprehensive and make it even more useful to the overall health programme of the country.

The successful development of the national mental health programme requires the continued commitment of the government of the Islamic Republic, expressed explicitly:

• in the government’s health and development policies and legal provisions for their implementation

• in the specific allocation of human and material resources allocated to the programme at a level defined by the activities accepted as part of the programme

• in arrangements which will allow the regular monitoring of the programme’s progress.

The successful development of the national health programme, in general, the high level of commitment and capacity of the participants in the mental health programme as well as the demand for action and readiness of communities to support the mental health programme are major assets which make its further success highly probable. The benefits of such a development will not only be significant for the improvement of the health of the population of the Islamic Republic of Iran, but also serve as an inspiration and source of vitally important practical knowledge for the other countries in the Eastern Mediterranean Region and elsewhere.

Four foundations are responsible for the care of different aspects related to post-war conditions. Mental health care is an important aspect, which is the point of attention concerning the affected individuals in war-related psychiatric conditions, as well as primary health care for their families.

• Janbazan Foundation. The Janbazan Foundation is responsible for taking care of disabled individuals at all three levels of mental health services.

• Primary health care. Consulting centres in Teheran and the larger provinces offer consulting services to families of war-disabled individuals. Clinical psychologists and social workers are the service givers to referred family members, especially for enhancing coping mechanisms in the affected individuals and their families. Some minor psychiatric disorders are also dealt by them (in term of using cognitive, behavioural and psychotherapeutic methods).

• Secondary level. Emergency and outpatient clinics are available in Teheran, Isfahan, Shiraz, Mashhad, Ahwaz and Tabriz. Those patients who require hospital admission are admitted in the hospitals belonging to or having contract with the Janbazan Foundation. Treatment facilities, such as occupational therapy and different medical care needs are available in the hospitals.

• Tertiary level. Rehabilitation centres in Teheran, Mashhad, Ahwaz and Isfahan admit those war-related psychiatric-affected individuals who are referred to as chronic patients, in that their families claim that they are not able to take care of the patients. Patients receive services such as occupational therapy, short and long trips, and recreation, along with medical and psychiatric treatments. These centres sometimes work as day centres. Another programme is the community and home-based rehabilitation programme run by social workers, physicians and psychologists.

• Martyr Foundation. The Martyr Foundation has consulting centres in all provinces working primarily with clinical psychologists and social workers. Guidance and counselling, psychotherapy for minor psychiatric conditions, advice for more necessary treatments, social work and follow-up of the cases are the most important functions of the centres giving mental health services to the families of the affected. All clinics and hospitals admit the family members of the affected according to the recommendations of the Foundation or automatically. They also support the families of the affected in many ways including income generation by the clinics by providing high quality medical care. This income is shared with the families of the affected.

• Prisoners of War Foundation and War Refugees Foundation. The Prisoners of War Foundation and War Refugees Foundation are two institutions that are losing their activities gradually and refer their clients to other service givers by recommendation, or the patients get absorbed automatically by the other foundations mentioned above. Patients who are employed by or otherwise connected to the Army with Sepah (including Baseej) take special services from their own mental health facilities in terms of outpatient and inpatient clinics as well as availability of social workers and consulting services located in many cities.

In the decade,of the 90’s more than 80 counselling centres have been developed and established in medical and other universities and 20 by welfare organizations; 10 are private. Twenty centres offer telephone counselling and a hotline for clients.

Many activities have been done to use religious resources in the field of mental health. Establishing some research units in this area in the Iran, Tabriz, Isfahan, Kerman and Mashhad universities of medical sciences is an important activity and many studies, conferences and researches have been done.

Ranking of life events to quantify the stress of general population of Zahedan with relation to psychiatric problems was studied. Results showed: comparing of life event stressors to similar projects in the Islamic Republic of Iran and other countries revealed that life events, in interaction with regional, cultural and psychological factors, can cause distress; financial problems, unemployment, high rate of mortality and high rate of birth were the most stressful events in population of Zahedan; there is a positive correlation between the level of stress and psychiatric symptoms; stress is a significant risk factor for psychiatric problems.

This study focused on tertiary prevention in the area of rehabilitation and adjustment of chronic mental patients, as practised at Zahedan Psychiatric Centre. A follow-up unit was established at this centre, providing services for hospitalized and discharged chronic mental patients. Services include regular visits; enhancement of drug compliance; controlling drug side-effects; family, social and occupational counselling and intervention, as well as referring to Imam Khomeini Committee, and provision of financial support. There were 121 patients (20 female and 101 male), mostly schizophrenic, included in this programme. Results showed that the number of rehospitalizations decreased, and drug compliance and social and occupational functions improved. It appears that such tertiary prevention units could promote mental health.

The study investigated the effects of continuous care teams on rehabilitation of chronic schizophrenic patients, as practised at Shahid Ismaili Psychiatric Centre. The continuous care team provided extensive services such as family education (about illness, treatment, drugs, side-effects, management of the illness), counselling, crisis intervention, regular home visits and providing social support for patients and their families. Sample size was 55 chronic schizophrenic patients, mean age 37.9 ± 7.16 years. Of these, 71% were men, 44% single and 36% high school graduates. Data on the number of relapses, days of hospitalization, costs of treatment and social functioning, three years preceding and following treatment were collected and analysed. Results showed significant decrease in number of relapses (11.5 times), days of hospitalization (12 times) and costs of treatment (7.5 times) after intervention. Social functioning improved after treatment (1.6 times). Before the intervention, 40% of patients had a job but after treatment, 60% had a job.

This t study envisages to look at the nature of occupational stressors and mental health problems in a group of hospital employees at Zahedan University of Medical Sciences. The study was carried out on 130 employees chosen from various hospitals in Zahedan. Results reveal that there is a significant relationship between occupational stress, depression and anxiety. No sex differences were observed with regard to psychological problems and level of stress. Furthermore, the level of stress, depression, as well as anxiety, is higher in the medical staff than the office staff. On the whole, the most stressful factors were: fear of failure at the job, inadequate understanding of employee problems by the management, and low opinion of the assigned job by the employees.

The focus of the Iranian national mental health programme has been mainly on rural mental health, but the demographic realities of the countries are that the population is shifting to urban areas. The need for provision of services in urban areas has been felt for a long time, and some innovative activities have been initiated in urban areas. One such activity has been the introduction of a mental health component to "healthy city" projects. The main objective of the programme is to provide the necessary mental health services to urban, suburban and slum dwellers by using the vehicle of healthy city projects, including neighbourhood health volunteers. Attitudes and knowledge tests of the community and volunteers were done along with a prevalence study for case findings for the initiation of this project. At present, the project is active in prevention activities and the promotion of mental health. Patients are referred to general practitioners or, when need exists, specialists.

This project is the cornerstone of innovative activities in the city of Teheran. The experience was presented to a major meeting in London in October 1997. Teheran was selected as one of 11 cities of the world for presentation at this meeting (a video of each cities experiences was also produced). The proceedings of this meeting are published [footnote: Mohit A. Mental health in Tehran in the context of the national mental health programme of Islamic Republic of Iran. In: Goldberg D, Thornicroft G, eds. Mental health in our future cities. London, Psychology Press, 1998: 217-38)].

In Tehran there are three universities that are involved with child psychiatric mental health services. Teheran, Iran, and Shahid Beheshti medical universities.

Child mental health facilities include 30 beds in Iman Hossein Hospital, with an outpatient clinic three days every week, an inpatient and outpatient family therapy unit, and a speech therapy unit. There are 20 beds in Navab Hospital, with an outpatient clinic two days every week. There are also outpatient clinic services and a family therapy unit in the Teheran Medical Centre.

Child mental health human resources. There are three child psychiatrists in Imam Hossein Hospital, one in Navab Centre and three in Teheran University.

Child mental health training programmes consist of routine medical school education for medical students, and internship, specialized child psychiatry courses (about three months), therapeutic intervention at outpatient clinics, two-year child psychiatry fellowships course for in Shahid Beheshti Medical University.

One of the programmes in child psychiatry that is proceeding is the pilot special project in school mental health in the Dammavan area. With regard to preparatory steps, they are working in the intervention stage in the levels of children, parents and families. After 1 year, they will be evaluated.

Mental health week has been celebrated in the third week of October since 1985. Mental health week seminars are held in nearly all district and provincial health centres. The programme was initiated after a three-day seminar on the prevention of mental diseases in Mashhad in 1983.

The goal of this programme to increase people’s information, to changing and correct popular attitudes, and to attract popular attention and support for mental health promotion in the Islamic Republic of Iran. In addition, the mental health week celebration is a reminder of the significance of mental health and need to provide material and human resources and facilities..

Mental health seminars usually cover subjects such as the family, school, childhood, adolescence, the relationship between mental health and other aspects of health, stress, primary prevention, addiction, and so on. Educational instruments such as pamphlets, booklets and posters are provided by Ministry of Health and Medical Education and by mental health and health education experts in the universities with supervision of scientific consultants.

The experience of the Islamic Republic of Iran in the integration of mental health care within the primary health care system, and the degree it has been implemented is a fine achievement. The degree of coverage, particularly in rural areas shows that:

• given the necessary infrastructure and political will, it is possible to integrate mental health within primary health care

• general health personnel are capable of providing certain level of mental health care, provided they are trained and supervised and are backed by a proper referral system

• once the system is established, mental health professionals cooperate with it, and with their cooperation, continuation of quality of care is guaranteed

• the presence of a well structured health system is necessary for integration of mental health.

Rapid urbanization and population realities point to a need to shift the attention towards urban areas and problems of youth. Therefore, development of urban and school mental health services is necessary. After more than 10 years of experience, now is the time to review and update the national mental health programme. It is hoped that the revised programme will include new areas for expansion. More attention to promotion of mental health and prevention of mental illness in the new programme would further assure the comprehensive nature of the programme.

The success of the programme in the Islamic Republic of Iran has become possible because of the commitment of key personnel such as politicians, administrators, professionals, religious authorities and the general public. Continuation of the initiatives could lead to not only a better quality of life for the ill individuals, but also provide opportunities for other countries to benefit from these innovations.