Based on the results of document review and semi-structured interviews, five main themes were identified (i.e., actors and stakeholders, policy structure and process, financial support, services delivery structure, and community and culture building). We used these themes to report our results.
Actors and stakeholders
Respondents believed that the Iranian Ministry of Health and Medical Education (MoHME) is the main custodian of community health in policy-making, particularly concerning older people's health. The most important stakeholders in this field are organisations and groups such as State Welfare Organisation (SWO) and Ministry of Cooperatives Labour and Social Welfare(MCLS), non-governmental organisations, charities, health service providers, international organisations, and medical professionals. Most of the interviewees believed that stakeholders' role and power and their support in implementing older people health policies would help achieve the goals of the designed policies. However, MoHME could not manage this issue alone. MoHME does not have the needed facilities to provide necessary support and rehabilitation services to older people, and the welfare organisations were deemed most suited for their provision. Others, based on legal documents, consider the National Council of the Older People to have a more colourful role in this regard and consider this organisation as the main policy-maker in the affairs of older people.
“In the Fifth Plan and the new policies of the integrated health system, the Ministry of Health is in charge of health. However, the important thing is that health is a social issue, and many of its dimensions, such as the environment, social welfare and livelihood and retirement, are not subdivided by the Ministry of Health, and these challenges unfortunately exist.” (Senior MoHME policy maker)
Interviewees also noted conflicting roles and existing overlaps between the MoHME and the MCLS and SWO, which are the subset of MoHME. Following the existing legislature, the responsibility of the disabled persons is with the SWO, and the responsibility of public health is with the MoHME, which causes conflicts.
“The main responsibility has not been determined - the legislator has given the responsibility of disabled people to the State Welfare Organization and the responsibility for people’s health to the Ministry of Health and Medical Education. Therefore, when we say that the health policies of the older people are partly related to the Ministry of Health and Medical Education and partly related to the state Welfare Organization, which is itself a problem.” (SWO policy maker)
Respondents believed that older people have no representation or power to influence decision-making and policy development, and people from other age groups prepared policies concerning older people. There is also no specific forum or channel for older people to participate in policy-making. Ageing health policies are mostly made by political and technical elites, politicians, specialists and physicians.
“Older people are a group that, for various reasons, do not have a tribune and cannot defend their rights.” (older people). “But really, one of the problems for the older people in many countries is that they do not have a voice, which causes their social isolation, and it is almost the same in the world, and it causes the rights of the older people to be violated.” (older people)
According to the interviewees, only a small number of charities are active in older people's health, and they have a very limited role in the development of policies related to older people. However, they have the potential to play a mediating role between the policy-makers and older people. For example, one of the oldest charitable associations is the Kahrizak Older People Complex, which provides services to the poor older people for a very long time. Another example is the non-governmental organisation, the Dementia and Alzheimer’s Association of Iran, that also works in older people's health. The private sector's role is mainly summarised in the establishment and management of nursing homes and residential complexes for older people, and they do not play role or influence policy-making. Overall, non-governmental organisations' capacity to intervene in health policy-making is insufficient, and even the existing capacity is underutilised, and these organisations must be trained to work better.
According to the interviewees, the media in Iran can play an important role in health policy-making and bringing issues to the policy agenda. However, this capacity has not been used, and even the media itself is not aware of the importance of older people's issues.
“The media is more focused on specific issues and issues where the money is involved, and the voices of older people are not being heard.” (MoHME officer)
Policy structure and process
Despite some specific policies in some areas of health of older people, the Iranian MoHME does not have a specific action plan for this large group of population and have neglected related policies. Particularly, the policies related to the prevention and treatment of chronic diseases are missing, and older people are usually provided care by relatives at home, and there is no dedicated (health) insurance that would cover associated risks and costs. The current insurance coverage does not include social health services and home health services, so it is quite difficult to appoint a home nurse and pay for it. According to the interviewees, the MoHME has not paid enough attention to ageing and does not have a long-term strategy or vision. Inadequate coherence between upstream and downstream policies and a lack of communication between existing policies have also resulted in a lack of specific interventions or specific service packages for older people. Existing policies and programs are often passive, short-term and cross-cutting, and lack a holistic and macro perspective.
“The policy of forming the National Council of the Older People, which was formulated and approved in 2004, had an appropriate and coherent content and for this reason was accepted by the parliament in its time. However, this policy, for some reasons, was not implemented properly.” (Senior policy maker)
Interviewees stated that to maintain the health of older people and achieve healthy ageing, policies that address youth and working-age people's health are needed. Another problem that was mentioned is the lack of intersectoral policies.
“We have not done anything about the mental health problems and depression of the older people. Families of older people should be educated about the specific characteristics of older people and their needs.” (SWO officer)
Interviewees noted that indicators and tools for evaluating these policies and existing programs are not found in the existing policies' content.
“So far, not only we have not evaluated the policy; we do not even have a way to measure the scale of a problem in this field.” (Senior MoHME officer)
However, participants also noted some positive aspects in the field of health of older people. Such aspects include the sensitisation between the state officials and academic institutions on the ageing population, training of medical students in various fields of ageing, the establishment of a geriatric office in the MoHME, and the existence of clinical expertise to cover services for older people. At the same time, interviewees scored the health status of the older people in the structure of the MoHME as weak. Extensive structural changes, separation of the SWO from the MoHME and the health policy-making process related to older people have had a significant impact on past policies in this regard and how they were implemented. The SWO and the MoHME often confront each other in matters related to the health of older people.
“Unfortunately, with the very heterogeneous integration that has taken place in previous governments and the merging of three heterogeneous areas such as cooperation, labour and social welfare, and the formation of a ministry, the current situation of the welfare organisation and social activities has worsened.” (Faculty member)
Respondents believed that the social security system does not provide adequate protection for older people and that the views are usually unidimensional, and there is no adequate insurance for older people.
“The older people are retiring, but their pensions are not enough. It is very important to link older people health policies to welfare policies. Do our policies respond to access to affordable food and fruit?The cost of fruit and preparing proper food are high. When we plan, we usually look and move one dimension forward. Only one dimension usually dominates our minds” (Health insurance officer)
Most interviewees stated that the existing insurance programs do not have a specific plan for older people, geriatric services and common diseases of older age. The insurance mainly covers older people the same as other age groups in society. Supplementary insurance for older people is available only in a very limited number of business structures.
“...Insurance companies remove deceased people from the list and invalidate their insurance books so that no one can deceive them. The older people must go to the insurance office and prove that they are still alive. What does it mean for older people if they are disabled?” (older person)
Experts say that most of older people health issues are outside the scope of the MoHME and there is a need for strong inter-sectoral leadership and intra-sectoral governance, while there are very few capable people in the MoHME and there is serious concern about governance and leadership. Also, the implementation of policies in the country follows the top-down approach, and policy-makers formulate and announce policies that must be implemented in any way possible, and this top-down attitude prevents the formation of social participation.
“We usually formulate and approve a policy and then force it to be implemented.” (Health policy maker)
Other inhibiting factors considered by the participants in the study included intra-sectoral and inter-sectoral inconsistencies, the inability of the MoHME to externally influence other sectors involved in the health of older people, lack of consideration to the issues of ageing and insufficient attention of policy-makers and politicians to the ageing society, lack of the multiplicity programs in the health sector, the inability and inefficiency of the structure of the health network and family physician to implement the announced policies and programs.
“The most important difficulty in the health of older people is that the Ministry of Health and the health system has the least role in the health of older people.Everything we want to do about the health of older people is faced with the external sector, and we do not have the tools to manage and examine the external health sector, which is our biggest problem.” (MoHME officer)
Financial support
Interviewees believe that the high cost of health care for older people has attracted politicians and policy-makers' attention, and they have developed and implemented programs and policies in this area. Other interviewees cited the economic hardships of older people as a source of influence on older people's policies and health. Inadequate pensions and the majority of older people's poor economic situation were among the issues raised by the vast majority of interviewees, who acknowledged that more than one-third of the country’s older people were covered by aid from support organisations such as the Imam Khomeini Relief Committee and the SWO.
“8% of the population are older peopleand 27% of health care costs are being spent on them.” (MoHME, Health policy document). “One-third of older peoplepopulation will have difficulty surviving if no one pays them. Economic problems contribute to many of the problems of older people .” (SWO, Health policy document)
According to the interviewees, chronic diseases and associated high costs of treatment are also among factors that strongly affect older people's economic situation and the insurance organisations. Moreover, Iran's current economic situation, international sanctions, and high inflation also have adverse effects on policies.
“Out of every four older people, three have chronic diseases, which are very costly and economic factors can have a huge impact on policies.” (Family physician)
Interviewees consider the annual budget, expenditure of the health sector and financing to be potentially effective in the formulation and implementation of programs and policies for older people's health. They believe that the budgets allocated to these issues are insufficient, and the lack of financial resources does not usually allow for any long-term policy-making. The MoHME spends all its efforts on solving urgent problems and matters.
“Budgets allocated to the health of older people are very limited and are distributed among different organisations.”Unfortunately, the allocation of budgets, neither at the national level nor especially within the Ministry of Health, does not correspond to the older people needs at all.” ( NGO for the Welfare of Older People)
The independence of the SWO causes the country’s budgets related to the health of older people to be divided. A large amount of the budget is given to the SWO, while the MoHME has no role in policy-making.
“The budget of the State Welfare Organization and its independence in practice on the one hand, and the very small share of the Ministry of Health in the budget for the older people on the other hand, actually reduces the leadership role of the Ministry of Health in policy-making, management, implementation, monitoring and evaluation of older people.” (SWO officer)
In the past and now, priority is still given to other age groups. Resources and budgets are mostly devoted to children and youth health programs.
“In terms of resources and budget in society, more attention is paid to young people and children. There is no more positive view of older people and older age in society. Moreover, some say that they have lived their lives, and it is not rational for them to spend resources on them(Older person)
Community and culture building
Several interviewees believed that due to Iran’s religious context, religious and cultural factors play an important role in policy-making for older people by emphasising respect for them. However, they acknowledged that attention to these factors was more rhetorical, and one of the main problems in the issue of older people is the cultural problem in society.
“In our culture, there is more emphasis on respect for older people, which is done in words, but in practice, it seems there is no practical action.” (older person) “We have to use religious factors. Clergy and mosques are places that I think are influential in social and behavioural leadership.” (older person)
Interviewees believe that social factors have been less influential in older people health policy-making in the past, but today more attention has been paid to this issue. It has also been stated that in Iranian society, there is ageism, and this is an influential social factor. However, some of the interviewees mentioned that the adoption of a legal article in the law of the Third Development Plan and awareness of the issue of ageing in the country and public opinion had been an appropriate way in attention to older people by policy-makers and government officials.
Service delivery system
Experts said no comprehensive system for providing proactive health services for older people, especially in the cities. This issue has been abandoned, and all services are inactive. Our primary health care system is incomplete in this area, and the prevention, treatment and rehabilitation services for older people are not included. In the current framework, it is not possible to provide appropriate services to older people. There is a need to create new templates and capacities for such services. Experts participating in the study expressed different views on the problems of providing health services to older people. Some emphasised the different abilities of the SWO and the MoHME in providing services to older people and believed that the SWO is active and capable in providing support and rehabilitation services but cannot provide acute medical services. The MoHME is active in acute treatment of patients, but a follow-up treatment of older people has been practically abandoned.
“The State welfare organisation does not have the capacity and facilities to cover all aspects. The work was suspended and was not completed. However, in my opinion, the Ministry of Health, which has a very good capacity but does not have a sanatorium, is also weak in the field of rehabilitation, and these areas have not been developed in the Ministry of Health. The Ministry of Health pays full attention to acute care and does not pay attention to the individual after treatment and discharge from the hospital. After-hospital care is very important for older people.” (Health researcher)
The interviewees acknowledged that the country’s health care networks had not received the necessary training in the field of prevention and provision of primary health services to older people, especially related to chronic diseases and mental illnesses. Most importantly, there are no facilities to provide the desired service to older people in the country's health network. Because the country’s health care network has been designed and implemented to maintain and promote the health of mother and child, therefore, introducing the provision of older people services to health centres is associated with resistance and, together with the lack of necessary facilities and workforce, has caused the inefficiency of these services in the network.
“The system and structure we have to provide services is a very old system and is designed to provide limited services to mother and child, and if we want to put the heavy task of providing basic health services to older people in this system, this structure will not be able to do it, and we need to change the structure of health centres.” (related document)
The nature of the problems of older people is different from other age groups. It was stated that a package of treatment and prevention services provided by the MoHME should take into account other sectors.
“The nature of ageing problems is different from other age groups. With increasing age, physical strength decreases. We try to maintain other dimensions of health in older people, which is possible.” (National Doc for older people)
The lack of special structures to provide services to older people in the country, such as specialised hospitals or medical wards or clinics, was one of the interviewees' points of interest, which greatly affects the implementation of the older people health policies.
“Why shouldn’t ageing people, which make up a large part of the countries population, do not have its special hospital? Unfortunately, we do not have a geriatric hospital in our health system.” (health care provider)
Another important problem in the structure of providing health services to MoHME is their access to services. Many older people are unable to leave their homes and are denied access to health care.
“.... Some older people have no job and do not have the physical ability to leave home. Now, what are our plans for these people who cannot leave home, so if we want to talk about health needs and medical needs? We think there are many problems with physical access”. (public health officer )