Table 3 Iran’s health system challenges in responding to COVID-19

Monitor health status to identify health problems

 1. The weakness of the country’s surveillance system in the screening and diagnosis of cases in the country

 2. The weakness in on-time detection of the virus in the country and lack of a foresight for it. Weakness in capacity-building for epidemiological crisis management in the country, lack of modelling about health system's exposure to an infectious disease in advance considering the high probability of the occurrence of such a problem based on the symptoms and target groups and complications of the disease, medication and equipment and the duration of COVID-19 treatment

 3. Non-institutionalization of International Health Regulations (IHR) in the country

 4. Weakness in patient detection and identifying travellers entering the country from infected countries (interventions related to detecting high-risk cases, training them, quarantining and tracking their contacts)

 5. Weakness in benchmarking the similar experiences of other countries

Diagnose and investigate health problems and health hazards

 1. Weakness in capacity-building and preparation of comprehensive health centres to deal with the epidemic

 2. Weakness in support capacities and diagnostic, care and treatment facilities

Inform, educate and empower people about health issues

 1. Weaknesses and limitations in communicating with society and the exchange of information, lack of planning to carry out activities to gain the trust of the people and lack of specific programmes based on community participation

 2. Weakness in planning and preparing society for the health and socioeconomic consequences of the disease

 3. Weakness in the management of information related to the disease and the lack of a registration system for the disease in both preventive sector and treatment sector and hospitals, as well as governmental and nongovernmental sectors

 4. Weakness and slowness in notification, education and media for people (different groups) and different classes

 5. Unreal cyberspace with false news, therapeutic rumours, self-treatment and herbal drugs

 6. Public concerns because of various reasons, including the concern of different trades over getting sick during work, concern over the lack of knowledge about the disease and concern over the inadequate notification about at-risk people

 7. People not paying attention to protection against the disease and considering instructions, and teleworking

 8. Emergence of a range of feelings of hopelessness, learned despair and changing attitudes towards the meaning of life in society

 9. Increase in methanol poisoning for preventing COVID-19

 10. Many people attending medical centres and people flocking to buy masks, sanitizers and gloves and its shortage and the existence of a black market

Mobilize community partnerships to identify and solve health problems

 1. Lack of appropriate and on-time advocacy in the country’s policy-makers for preparedness of the country at the beginning of the epidemic and weakness in multisectoral cooperation

 2. Lack of comprehensive planning to use the capacity and potential of the private sector and social institutions

Develop policies and plans that support individual and state-wide health efforts

 1. Weakness in crisis management and designing a comprehensive plan to combat and control the epidemic and formulate it so that the interventions are known separately for each stage of the epidemic and the necessary predictions for different scenarios

 2. Delay in involvement of the health and prevention sector in the management of COVID-19 and the lack of attention to the contact tracking system and more attention to the treatment sector at the beginning of the epidemic

 3. Delay in all necessary actions such as quarantine and social distancing

 4. Insufficient use of scientific evidence (economic calculations, disease burden, etc.) in policy-making to develop intervention to cut the chain of transmission

 5. Lack of a unified and specific approach to hospital management in terms of crisis management (the problem was financing in service-providing facilities due to lack of elective operations and income-generating services) and the disorientation of other patients both in hospitals and in offices and clinics

 6. Lack of updating diagnostic guidelines (sensitivity and specificity of tests) and treatment based on new information and disagreement

 7. Weakness in digital employment and the lack of a telemedicine system

 8. Lack of attention and planning for spending the patient’s recovery period after discharge

 9. Lack of appropriate policy-making for hospitals in order to divide the admission of COVID-19- and non-COVID-19infected patients

 10. Relative shortage of hospital equipment, protective equipment, medicine, diagnostic kits and the existence of a medicine and laboratory black market

 11. The impossibility of allocating subsidized masks and sanitizers to the community and various social and industrial groups

 12. Public transportation problems due to restrictions and congestion in them

 13. Problems of waste disposal, especially hospital waste, the problem of keeping corpses in hospitals

 14. Weakness in the implementation of protocols such as disinfection of schools, public centres, prisons, rehabilitation centres, public health services, bakeries, banks, welfare centres, etc.

Enforce laws

 1. Not using the capacity of legislative bodies for the approval of effective measures

 2. Weakness in the accountability structures of the Iranian health system (structural, legal, executive) that was more apparent during the crisis

Link people to needed personal health services and assure the provision of healthcare when otherwise unavailable

 1. Weak laboratory facilities, delays in receiving test kits and preparation of laboratories

 2. Lack of attention to determining the norms and per capita of protective equipment and sanitizers required per person in each of the preventive and treatment sectors due to the existing shortcomings and also the economic situation

 3. People’s unwillingness to donate blood during an epidemic

 4. Failure in routine vaccination of children due to fear of attending health centres

Assure a competent public and personal healthcare workforce

 1. Shortage of treatment staff

 2. Burnout, job stress, physical and mental fatigue and lack of motivation of the health workforce which dealt with COVID-19

 3. Relative shortage of personal protective equipment for health workforce and lack of a single protocol on personnel protection in all hospitals

 4. Lack of knowledge and empowering of health staff in identifying and dealing with COVID-19, especially at the beginning of the epidemic at the different levels of the health system

 5. Lack of an integrated view toward the health workforce as a team facing the risk and the dissatisfaction among lower-level workers (such as supportive services personnel), especially in the treatment sector

 6. The high level of infection and death among medical staff

Evaluate effectiveness, accessibility and quality of personal and population-based health services

 1. Weakness in the implementation of waste disposal protocols

 2. Weakness in providing psychological support to patients infected by COVID-19 and their families, the incomplete mourning of the bereaved families and lack of physical sympathy with mourners and consoling them

Contextual and general challenges

 1. The lack of clarity in professional boundaries and at the same time lack of teamwork in Iran, which was more apparent better during the crisis

 2. Weakness in the proper management of ongoing studies for COVID-19

 3. The unavailability of COVID-19related data for researchers

 4. The direct and indirect high economic burden of the disease in the face of international sanctions

 5. Socioeconomic harms include:

   a. Economic consequences: reduction of the country's foreign exchange earnings, economic consequences for various guilds and on exports and imports, as well as cancellation of flights from other countries to Iran

   b. Reduction of social capital and the negative effects of stress on families and children

 6. An increase in water consumption in the country and the reduction of water quality in some cities