The Impact of Economic Sanctions on Health and Strategies for Mitigation: A Glance at the Case of Iran

Abstract

Background:

Sanctions can affect humanitarian, GDP growth, the value of the national currency, income inequality, poverty, food security, and health. This study aims to represent the relationship between sanctions and public health and the strategies to deal with it.

Methods:

The study used a mixed-methods approach. We used data and information from two sources: a scoping literature review and a survey on experts' opinions (10 participants from health policymakers, managers, and researchers). Inductive thematic analysis was adopted to analyze the qualitative data with the MAXQDA software version 10.

Results:

The international economic sanctions affect directly and indirectly on targeted population's right to access social welfare and health. The literature review about Iran showed that the sanction had affected public health in four general respects: Economic, Sociocultural, political, and direct health factors. The strategies to deal with sanctions categorized into two themes are the health sector and the health-related extra-sector.

Conclusions:

The devastating effects of economic sanctions directly and indirectly on health have significantly reduced financial and physical access to drugs and medical equipment in Iran, leading to a substantial decline in public health, The UN and the international community should anticipate these side-effects of sanctions to prevent further humanitarian catastrophes in the future.

Introduction

The United Nations General Assembly declared the right to health as a universal standard in 1948, embedding this concept in international law.[1,2] Human rights, including the right to health, are norms that dictate how governments and non-state actors interact with individuals and groups based on ethical principles grounded in national and international legal systems. Human rights’ origin must be sought in the process of norm formation in national and international legal systems that provide formal validity of normative positions. These norms originate from ethical reasoning in moral philosophy, religious faith, or political claims driven by social mobilizations.[3] Like other social and economic rights, the right to health is now recognized as an inalienable international human right.[4] The inclusion of health-related goals in the sustainable development agenda reflects global commitment to realizing this right.[5] Despite these commitments, conflicts, and wars continue to have devastating direct and indirect effects on health worldwide.[6]

In ancient times, if an army could not conquer a city surrounded by defensive walls, it would besiege the city and prevent it from providing the necessary equipment for its inhabitants. This strategy, now known as economic sanctions, has not changed significantly since then.[7] Today, economic sanctions, dating back to at least 432 BC, are increasingly being used by some powerful nations. In the modern era, the United States was the first country to use economic sanctions in 1812. After the German invasion of Norway in 1940, the United States used sanctions to prevent the Nazis from using the occupied countries’ assets. Then it expanded the sanctions by blocking Axis power’s assets and prohibiting foreign trade and financial transactions with these countries. During the Cold War, sanctions were consistently used to destabilize governments, especially in Latin America. The use of economic sanctions leverage as a foreign policy tool, although not unknown, has become increasingly popular in recent years.[8] By the 1950s, only five countries had been affected by economic sanctions, but that rose to 47 in the 1990s.[9] The scope of sanctions varies from country to country and can even include policies to completely isolate a country and completely cut off economic and trade relations with that country. There are rare cases where a sanction has been imposed to sever all trade and economic interactions with a particular country.[10]

In recent decades, Iran has been one of the countries that have always struggled with sanctions. Sanctions against the Islamic Republic of Iran have a long history dating back to 1979 to 1981.[11] After the arrest of US embassy staff in Tehran in 1979, Carter imposed a growing set of sanctions against Iran by banning oil imports from Iran and then blocking all Iranian government assets in the United States (approximately $ 12 billion). These initial sanctions were lifted following the release of the hostages following the 1981 Algerian agreement. Nevertheless, in the following years, sanctions were increasingly re-imposed under the pretext of Iran’s activities.[8] The goals of US sanctions against Iran have expanded over time. Economic sanctions were imposed in the mid-1980s to limit Iran’s strategic power in the Middle East. Since the 1990s, US sanctions have also targeted Iran’s oil sector and nuclear program to weaken Iran’s economy. At the time, European countries avoided pursuing the US policy of imposing economic sanctions on Iran.[12] However, in the 2000s, after uranium enrichment in Iran, the United Nations and the European Union joined the campaign to impose economic sanctions on Iran. As a result, the severity of the sanctions increased significantly. The international sanctions’ primary purpose was to prevent Iran from gaining access to nuclear materials and pressure the Iranian government to end its uranium enrichment program and other nuclear weapons-related efforts.[10] Finally, after almost 20 months of negotiations with the six richest countries globally (Germany, France, Britain, Russia, China, and the United States), in July 2015, a comprehensive joint plan of action (JCPOA) was reached to resolve Iran’s nuclear dispute. Accurate assurances ensured that Iran’s nuclear program would not be directed toward weapons targets. The highest level of transparency and inspection standards was agreed upon, leading to the lifting of sanctions on Iran’s nuclear program by the United States and the United Nations. The agreement was welcomed by the international community and approved by the UN Security Council.[13] A review of the history of sanctions shows that the initial US sanctions against Iran were not related to the recent nuclear weapons concerns, so the country announced its withdrawal from the JCPOA in May 2018 and again Imposed economic sanctions with the strategy of exerting maximum pressure on Iran.[14] Economic sanctions inflict significant socioeconomic and political damage on target countries. In other words, economic sanctions can be a destructive tool in foreign policy because of the many destabilizing effects they have on the target countries.[2]

Various studies indicate the impact of sanctions on various macroeconomic variables in Iran. EU and Japanese sanctions have hampered 57 percent of Iran’s oil exports and negatively affected other macroeconomic indicators. Thus, total imports decreased by 20%, total exports by 16.5%, private consumption by 3.9%, capital income by 3.8%, and GDP by 3.2%.[12] Sanctions imposed on Iran from 2012 to 2014 have significantly impacted Iran’s exports to its trading partners. During these years, the value of Iran’s exports has decreased by an average of 33% per year, and the resulting loss during these three years has been $ 104 billion.[15] The 2012 sanctions have had a direct and more robust impact on the exchange rate by imposing adverse shocks on foreign exchange receipts from oil exports and government budgets.[16] Heavy economic sanctions destabilize the market exchange rate and widen the gap between the official exchange rate and the market exchange rate. It also increases the expected inflation rate among the people, which is the stimulus for rising inflation.[17] International sanctions reduced the total welfare of Iranians by 14 to 15 percent. The rate of welfare losses due to sanctions in rural households was twice that of urban households. The most impoverished urban and rural households have experienced the most welfare losses.[18]

The economic pressures created by sanctions can be one of the main drivers for changing the political behavior of the target states,[12] but in addition to the mentioned economic effects, by reducing access to education and public health care, reducing their quality and deteriorating economic conditions also hurt the citizens of countries affected by sanctions.[18]

Since the beginning of 2020, the world’s population has been plagued by the Covid 19 respiratory pandemic, a disease that has infected 107,423,526 people and killed 2,360,280, according to the World Health Organization (Feb 2021).[19] This disease becomes a socioeconomic crisis more than a health crisis, the economic impacts of COVID-19 lead the world economy to experience a recession.[20] The Iranians faced the COVID-19 crisis in a situation plagued by tough US sanctions’ economic and social consequences.[21] In this context, the present study aims to represent the relationship between sanctions and public health and the strategies to deal with it.

Methods

Study Design

The study used a mixed-methods approach. drawing data from two sources: a scoping literature review and a qualitative survey of experts’ opinions. The methodology for both is detailed below:

Scoping review

We conducted a scoping review to identify the various dimensions of how sanctions impact Iran’s health system and public health, as reported in scientific literature. The scoping review approach has a five-step framework[22] that we have used in this phase. we followed the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA)[22] Statement. The eight-person study team performed five steps in order.

Identifying the initial research questions

The dimensions that formed our study questions were: how will the relationship between sanctions and public health and the health system appear? So, we put the following items on the agenda

• What aspects of public health have been affected by sanctions?

• What aspects of the national health system have been affected by sanctions?

• What are the crucial challenges around sanctions and health?

• Which diseases are most affected?

• What are the potential solutions?

• What organizations can play vital roles in controlling the situation?

• What is the potential of health diplomacy to fix the situation associated with sanctions?

Identifying relevant studies

We performed comprehensive literature searching in the major databases, including Scopus, PubMed, Web of Science, and Embase databases from January 1, 2012, to January 1, 2019, for English and Persian language articles in all types of research. a search strategy appropriated to each database regarding MeSH guidelines was developed and used, main keywords include: “economic sanction,” “oil sanction,” “sanction,” “impact,” “public health,” “macroeconomics”، “household welfare,” “medicine,” “Iran. “We also searched for data in grey literature.

Study selection

After searching the specified databases, we identified 135 articles. In the first level of screening) titles and abstract) irrelevant articles were excluded. After applying the inclusion and exclusion criteria, 70 studies were selected for final synthesis [Figure 1].

Figure 1.

Flow diagram of study (PRISMA)

Data charting and collation

At this point (charting of selected articles), the data is extracted from the articles and prepared for interpretation. The study team developed a framework for this step based on the questions and the studies’ dimensions. We summarized all selected articles in the developed Excel form. This form includes general details such as publication date, country, authors, types of sanctions’ impacts, outcome, and proposed solution. [Details of the final selected studies are available in Supplementary File 1 ^{(278.8KB, pdf)} ].

Summarizing and reporting findings

The fifth and final step of the scoping review is summarizing the sum of the obtained data and reporting them, which we have dealt with in the findings section.

Qualitative phase

We used a set of interviews to explore the opinions of national health experts, policymakers, and managers about the impact of sanctions on the healthcare system of Iran and strategies to deal with them. We followed the Consolidated criteria for reporting qualitative research (COREQ)[23] in this phase.

Study participants and setting

For the qualitative phase, the study team was formed, all of which had experience in qualitative research, for all qualitative phase stages, and they had university degrees in health policy, health economics, and health management. All study team members were PhD students or university professors, and there was no conflict of interest. We collected data through in-depth and face-to-face semi-structured interviews. Using purposive sampling (The interviewees were among the health-related sections most influenced by the sanctions, based on the scoping review) and snowballing recruitment, ten stakeholders, i.e. policymakers, health business owners, experts, and health professionals, were selected to be interviewed. The interviews were done between January and April 2020 at the interviewees’ workplace, and 50 minutes was the median time for most interviews. During the interview, more details were asked for clarification whenever necessary. All interviews were recorded and transcribed verbatim.

Interview’s guide, validity, and reliability

Before the interviews, the study team developed an interview guide based on a literature review that included specific cores, such as (economic and monetary, program implementation, access to medicine and facilities, general social health, and c); these cores obtained data more valid. Before conducting the interviews, we provided the interviewees with the information sheet and consent form. The interviewees’ feedback regarding the interview results and their statements were officially received. Each verbatim transcript was indexed and coded by at least two authors. Illustrative quotations are presented within the results section to validate the findings.

Data analysis

Inductive thematic analysis was adopted to analyze the data by using the MAXQDA software version 10. Themes and their respective sub-themes were revised several times to reduce the risk of bias and eventually determined through discussion between the research team. All data used to recognize the initial codes, through a scoping review, we deductively generated the initial themes regarding the effects of sanctions, and all obtained codes were used to evolve themes and sub-themes. During five group sessions, the research team members examined their understanding of the primary codes, and the disagreements were discussed until solidarity was obtained.

Results

Scoping review

Although the international economic sanctions have affected the government’s micro policies, they, directly and indirectly, affect the targeted population’s right to access social welfare and good health, contrary to universal human rights principles and values. The results of the present literature indicated that the sanction had affected public health directly and indirectly (through economic, political, and social-cultural factors) [Figure 2]. Finally, the potential strategies in two general groups including the health sector-related and macro environment were extracted according to the literature review.

Figure 2.

The sanction impacts on health

In the following, the details of the impact of sanctions on the 4 mentioned dimensions will be explained [Table 1].

Table 1.

Various dimensions of the impact of sanctions on health

Dimension	Sub-dimensions	Description
Political	National policies	The adverse effects of sanctions on Iran’s national cancer program in prevention, treatment, and equipment have led to increased cancer deaths. On the other hand, reduced resources allocated to public government responsibilities such as health and education have short-term and long-term impacts on population welfare and quality of life. Besides, If the government fails to meet its social responsibilities, such as providing essential goods or controlling the prices of goods and services, the likelihood of rebellion in society increases.[24,25]
economic factors	Export and Import	Economic sanction increases the prices of imported goods since the exchange rate was increased. Besides, the countries that imported oil and its derivatives from Iran reduced their oil import significantly. On the other hand, after the US left the JCPOA, the number of foreign investment companies that are leaving Iran is increasing[12,26,27,28]
	Financial transportation	Since the imposition of economic sanctions against Iran, the financial turnover and industry cycle have been disrupted, the medical equipment companies have difficulty in their financial interactions, and the amount of dollars and euros available for import goals has declined. The swift banking network suspended its banking services to several Iranian banks.[29,30]
	Physical and financial access	Since much of the Iranian government’s budget was dependent on oil export, due to the unpredictable and uncontrollable effects of global economic sanctions, the public budget was declined; therefore, the allocated budget to all parts of the government, especially the Ministry of Health, was reduced and, the supply chains were damaged.[30-33]
	Transportation	US unilateral sanctions against Iran’s economy, besides banking and various industries, also target the transportation industry. The sanctions were imposed on Iranian shipping and shipbuilding departments. Further, these sanctions have affected customs clearance, and many goods were deposited.[34-36]
	Economic Policy	The negative economic strategies have affected the unemployment rate and led to a shrinking economy.
Sociocultural factors	Education and Research	The pressure on Iran is not limited to economic issues and is trying to limit its leverage, So the access to reliable articles was limited; on the other hand, the number of submitted articles with invalid profiles was reduced, and the number of admitted graduate students decreased because of budgetary constraints.[37-41]
	human resources	Economic sanctions against Iran resulted in increasing the unemployment rate and incomparable welfare and earnings of counterparts in foreign countries have dissatisfied the elites and caused them to despair, complain, and finally migrate.[35,42,43]
	Depravity	Financial sanctions have short-term and long-term consequences on the lives of all segments of society, especially female-headed households, as the unemployment rate will increase among them; therefore the reduction in their incomes can increase the possibility of depravity.[35,36]
	Corruption	Some beneficiary people have taken advantage of the sanction’s space and destroyed billions of dollars of the country’s currency under the pretext of circumventing sanctions.[35,36]
Health factors	Medicines and Medical Equipment	Sanctions effectively hampered the import of medicines and medical equipment by boycotting communication channels and placing Iranian banks on the blacklist. Although nearly 95% of medicines are produced domestically, about 50% of their raw materials are imported, so access to medicines has become a challenge, incredibly, the lack of medicines for specific diseases (hemophilia, Thalassemia, cancers, &c.).[24,25,26,27,30,33-36,38,41,44-63]
	Nuclear medicine	Delayed problems in the supply of raw materials used in the preparation of nuclear medicines are very problematic because they usually have a very short lifespan and must be transported very quickly.[30,34,64]
	Mental illness	In addition to the stress that patients and their families endure, they also have to worry about the future. On the other hand, decreasing incomes and increasing the price of goods and services put people under psychological pressure and increase the incidence of depression and suicide.[35,62]
	Women Health	As mentioned, women’s health is one of the most important factors affected by the US sanctions, as the economic problems have led to a reduction in human resources in the manufacturing sector, mainly the female workforce, so the probability of depravity among them have increased.[27,35,39,60,65]
	Infants and Children Health	Children are the most vulnerable people in human society. Under economic sanction, the rate of infants and children’s infectious diseases and, as a consequence, the mortality rate of them have increased. Another problem is the increasing number of working children to help their families’ incomes.[36,65-67]
	Public Health	By imposing sanctions, food security, access to preventive care, and health care were reduced as the sanctions affected inflation, affordability, access to health care, air pollution, &c..[35,37,52,66,68,69]
	Environment	One of the most critical issues that Iran has faced is severe air pollution in large cities because of low-quality gasoline; controlling and resolving such a considerable problem requires financial resources and scientific and technical assistance, which are limited due to sanctions.[25,26,27,36,70]
	Nutrition	From a welfare economy perspective, the impact of sanctions shock on household welfare, such as food security, poverty, and inequality, is usually significant. Evidence showed that sanctions reduce household calories and increase malnutrition. Another effect is reducing drinking water access due to chlorine deficiency.[35,39,42,52,66-68,71]

Economic factors

Although the United States announced exemptions for medicines and medical equipment amid unilateral international sanctions on Iran, it did not guarantee Iranians’ access to critical goods like food, medicine, and medical equipment for Iranians.

Sociocultural factors

The social issues of poverty, unemployment, discrimination, social inequality, addiction, prostitution, and violence are particularly concerning in Iran compared to other countries.

In addition to many adverse effects on government policies and programs, sanctions, directly and indirectly, affect Iranian citizens and their right to health, contrary to the universal principles and values of human rights.

Political factors

The success or failure of a policy-making system depends on political, economic, social, and cultural factors. Disruption in any of these factors can undermine the entire policy cycle and lead to the interruption or non-implementation of many national policies, especially under ongoing economic sanctions.

Expert’s opinions

Three key themes and five subthemes were identified to deal with the crisis caused by sanctions, which are:

Theme one: Contribution of the service consumers

Education

The common theme among all interviewees was education. Education can help to increase the health system’s resilience by changing behavior, reducing unnecessary hospital care utilization, rational use of medicines, avoiding self-medication, and purchasing domestically produced medical products.

Theme two: Contribution of government

Financial considerations:

To implement the health transformation plan, the government allocated 10% of the resources collected from the subsidy targeting program and 1% of the collected value-added tax revenue to the health leading to an increase in resources allocated to the health sector.

Medicines and medical equipment

The shortage of medicines and their high prices are the major problems caused by sanctions. Health policymakers should undertake all appropriate legislative, administrative, and other measures to implement health services and medication’s rational use.

“Eliminate many expensive drugs that are ineffective and produce similar drugs that are cheaper… Moreover, Drug list restraining can play a successful role in a control policy.” (p: 3).

Theme three: Contribution of health insurance organizations: Two subthemes

Financial considerations

Participants have stated that economic sanctions have forced insurance companies to adopt a budget ceiling policy so that they are not allowed to spend more than the budget limit. With the implementation of the Means test law, people were obliged to pay insurance premiums according to their financial ability to cross-subsidize the poor. Interviewees believe that insurance organizations should also use international sources for financing in addition to domestic financing strategies.

Strategic purchasing

Compiling and implementing guidelines and reimbursement for providers according to guidelines are critical strategies. Participants confirmed that with these limited resources, the control of induced demand, consumption management, and rational drug prescribing should be considered.

Theme four: Legislative solutions

According to interviewees, an essential solution for decreasing the effects of sanctions is developing the appropriate national rules and laws.

Adapting financial policies

It is necessary to develop a clear plan for providing medicine and equipment through Nimai and government-subsidized currency. Moreover, special cash flow should be developed to act as a catalyzer between key organizations like the Ministry of Health and Medical Education and the Program and Budget Organization to provide the resources as soon as possible.

Another essential solution is to facilitate the coordination between financial institutions and the Ministry of Health and Medical Education to support drug production.

According to interviewees, generating extra financial resources is a way to decrease the deficiencies. It is recommended to increase the consumption and sale tax on cigarettes and other tobacco and soft drinks and increase customs duties on cosmetics and other harmful goods. Increasing the allocation of VAT revenue to the health system from 1 percent of the whole country to 2–5 percent is another solution that will make more than 3000 million dollars for every one percent increase in the health system.

Developing appropriate rules

According to interviewees, removing or modifying the rules that are barriers to sanctions could have positive effects.

“Unfortunately, half the time, our health professionals generate unnecessary costs for health organizations. This behavior can waste limited resources!” (P: 9)

Furthermore, formulating the rules for health workers’ compulsory training about resource management and rational prescribing of diagnostic and therapeutic services can be effective. Finally, developing the guidelines for integrating the databases, and validating and establishing them as a basis for continuous monitoring and correction will facilitate evidence-based decision-making.

Using the potentials of human resources

According to interviewees, separating the policy-making body and the executive body in health clearly and operationally might improve the quality of decisions in the long term. Besides, establishing a team of skilled and experienced people to monitor unmet needs and resolve import and export challenges can be helpful.

Evaluation of developing strategies to deal with sanctions (in the health sector and the health-related Extra-Sector).

Health sector

The health sector activity is divided into stewardship/governance, research, and health education.

Stewardship/governance of the health system

Establishing a drug information center to address drug needs through regular meetings between manufacturers, importers, and the Food and Drug Administration. Some practical and beneficial actions include:

• Policymakers’ support for patients and insurance companies.

• The private sector’s participation in the supply of medical goods and equipment: In this regard, Logically Choosing and using drugs can promote the use of generic medicines and design and utilize clinical guidelines to address the effects of sanctions.

• Reform in the payment strategies for performance to providers using a cost-effective drug.

• Hold workshops to raise public awareness that generic drugs and brands are similar except in their price.

• Increasing the ability to pay for medicines through drug pricing mechanisms, using financial protection from the poor such as subsidies, registering patients and infants to receive medicine.[72]

• Ensure a reliable supply system for the drug and medicines.

• Prepare the single drug with the primary goal of reducing or preventing drug waste.

• Sustainable finance for medicines by the mobilization of resources for the pharmaceutical sector, the efficient allocation of pharmaceutical resources, and the use of economic assessments to include drugs in the country’s pharmaceutical list.[43]

• Efficient allocation of pharmaceutical resources. To this end, encourage and support the use of domestically produced drugs instead of imported drugs, import of generic drugs instead of branded drugs, and provide positive lists for repayment through insurance coverage or other financing models.[55]

• Consumer financial protection on the financial consequences of drug use by improving insurance repayments

• Make policies on the level of payment and independence of drug suppliers, actual drug prices, reasonable drug prices, competitive drug prices, and c.[61]

Health Research and Education

Examining possible ways to support low-income and vulnerable groups in using health services, evaluating and developing effective strategies and programs to improve the supply chain, and finding Sustainable ways to avoid sanctions and reduce their effects can be done through in-depth research.

Health-related extra-sector

The health-related extra-sector includes two areas: international politics, and national politics.

International politics

These policies require the cooperation of other countries and international bodies. Adopting new policies to protect civilians from violating their rights through the development of constructive engagement with other countries, especially neighboring countries, has been accepted as an international strategy to counter-sanctions.[48]

Alternative measures include interaction with international economic networks, blacklisting of economic agents, reciprocal economic sanctions, reciprocal measures, a ranking of goods and trade, the prohibition of transactions, blocking of assets, and Demonstrating power to counter international threats is an alternative mechanism.

National policy

Fight against economic corruption, production of domestic goods, protection of national products, consumption management, and prevention of consumerism by creating a culture of resistance economy, optimizing renewable energy sources was suggested as policies require national decisions. Other suggested policies moved towards the non-oil economy by using participatory economic mechanisms such as multinational corporations investing in production instead of oil revenue in production, employing knowledge-based economies and creating infrastructure, and developing entrepreneurial and third-generation universities.[28,29,44,48,49,52,73]

Discussion

This study investigated the impact of sanctions on Iran’s public health and health system. The findings reveal those economic sanctions have both direct and indirect effects on the health of Iranians. These impacts are categorized into four main groups: economic, socio-cultural, health, and political factors. The results of this study, in line with past and subsequent studies, have pointed out the harmful and multidimensional effects of sanctions on health.[74,75,76,77,78] Chaufan and his colleagues have concluded in a systematic review that due to the intertwining of the global economy, it is impossible to design sanctions that will provide the objectives of the sanctions but do not cause significant harm to civilians. Therefore, using sanctions as a tool threatens global health.[75] Yazdi-Feyzabadi and colleagues have also divided the effects of sanctions on health into two categories: direct (access to essential medicine, medical products, vaccines, and technologies, financing, and financial risk protection, health workforce, service delivery, research and health information systems and health outcomes) and indirect (socioeconomic status; food and agricultural products; stress; early life conditions; high-risk behaviors and addiction; and transport).[77]

Health is a universal right encompassing primary care, medical care, education, and other underlying socioeconomic determinants.[79] While medical care can extend survival after illness, it is not the sole determinant of a population’s health, socioeconomic factors play a more critical role.[80] Over 70% of health outcomes are influenced by factors beyond healthcare.[81]

Recessions and economic crises have many direct and indirect destructive effects on health.[82,83,84,85] Sanctions affect main macroeconomic variables such as export and import, foreign exchange rate, fiscal status, access to global financial markets, and economic growth widely). Economic sanctions have a significant negative impact on the countries’ GDP; for example, UN sanctions from 1976 to 2012 led to a 25% reduction in the nation’s per capita GDP.[86]

The history of past political sanctions imposed against Iran shows a significant negative impact of these sanctions on Iran’s exports.[15] Also, Sanctions reduce the import of capital goods and significantly affect GDP for years after the sanctions. A 1% decrease in imports of capital goods in a given year causes a reduction of 0.68% of GDP over eight years.[87] Economic sanctions are causing inflation in the country by creating instability in the exchange rate and increasing the people’s expected inflation rate.[16,17] Contraction of 15% to 20% of Iran’s economy (2015), loss of $ 160 billion in oil revenues (2012), reduction of total imports by up to 20% (2015), reduction of total exports by up to 16.5% (2015), reduction of capital income up to 3.8% (2015) and reduction of GDP up to 3.2% (2015) show the negative impact of sanctions on macroeconomic indicators in Iran.[12,88]

Although various sanctions have been imposed over the past four decades, since May 2019, unilateral US sanctions against Iran have increased dramatically to almost a complete economic lockdown.[21] So, Iran could not bear a proportionate share of financial capacity to health shocks like the recent outbreak of the coronavirus epidemic, leading to an inability to contain it.[89] Many health sector activities that require financial exchanges and transactions are often not possible due to the government’s limited ability to raise funds or import essential goods due to sanctions.[90] Meanwhile, the US unilateral economic sanctions against Iran restricted imports of essential goods, and Iran is unable to import medical supplies from any other country,[91] so lack of medical, pharmaceutical, and laboratory equipment such as protective clothing and medicines can increase the epidemic burden and the number of casualties.

In the economic crisis, most countries face the double challenges of fighting unemployment while limiting social spending. Decreased expenditure and unemployment have a direct and indirect impact on health-related decisions. This effect heterogeneously distributed among different social groups, and therefore, not only the level of health is endangered, but its distribution is jeopardized.[92] government revenues fell from 40% to 50% Due to the negative impact of sanctions on the country’s oil sector, and international sanctions reduced the total welfare of Iranians by 14% to 15%. The most impoverished urban and rural households have experienced the most welfare losses due to sanctions; likewise, the rate of welfare losses in rural households was twice that of urban households.[18]

An economic crisis like sanctions does not affect everyone and every part equally; the extent to which it affects each individual depends on the interaction between social class, age, ethnicity, gender, and the type of work lost. There is sound evidence that people with low socioeconomic status are more likely to lose their jobs during a recession than those with high socioeconomic status.[93] Through affecting the individual and society’s employment status, macroeconomic phenomena can have significant psychological effects on individuals and increase psychological injuries. Economic instability is one of the main factors affecting the hospitalization rate due to psychological problems, and there is a significant relationship between economic crises and psychological conditions such as suicide.[85] the study of Veisani et al. Shows a positive relationship between income inequality and suicide in Iran.[94] Moreover, the survey of Mohamadnejad shows a negative relationship between poverty and mental health in all age groups and both sexes.[95]

In the current situation, many people have lost their incomes due to the COVID-19 pandemic in Iran, but due to the severely restricted financial resources, the government is unable to compensate them. Hence, the US unilateral economic sanctions are one of the critical factors that contributed to the premature lifting of Iran’s lockdown.[96]

The evolution of health systems is closely linked to governments’ economic performance, which supports a large percentage of healthcare spending. There is a direct relationship between the health system and the financial situation. In other words, in times of economic crisis, public health costs are usually reduced, and the recession has devastating effects on many health indicators.[85] In addition to the impact of unilateral economic sanctions on the country’s revenues and reducing the share of health budgets, economic sanctions lead to reduced access to health services, drugs, and medical equipment. The results of Aloush study are also consistent with the current study.[62]

Sanctions have affected all sectors of the economy. However, they increasingly affect vulnerable patients by blocking the delivery of drugs and raw materials to Iranian pharmaceutical companies and medical equipment for hospitals. Although drugs and medical supplies are not included in the sanctions, there are shortages of certain medicines and medical equipment, which lead to a sudden 50% increase in the price of medicine. Problems with drug export licenses, financial transactions, currency transfers, transportation, pharmaceutical companies, and international banks’ fears of possible US penalties are some of the reasons for this impact.[28,48,97]

With the decrease in access to medicine, Iranian healthcare professionals determine resource allocations based on needs. Nevertheless, resources are limited even for the neediest patients like lethal diseases and emergency surgery.[33,41,49,98] That is to say, sanctions weaken Health infrastructure, which causes the health system to be disabled to provide services and respond to health crises.[48] Strategies to address this challenge include: strengthening domestic and local production of healthcare services, medicines, and health equipment. This work can be done by mobilization of resources and their efficient allocation. Besides consumer protection from the financial consequences of receiving health care services by improving insurance repayments, increasing repayment can help. Providing documents and objections to the secondary effects of sanctions on the Iranian people’s fundamental rights to present for international organizations and pursuing the authorization of banking transactions in areas related to health, can take guarantees for compensation due to contradictory sanctions on Iran.

Conclusion

This study has comprehensively examined the profound impact of economic sanctions on Iran’s public health and healthcare system. The findings indicate that these sanctions have led to significant challenges, including reduced access to essential medicines and medical equipment, heightened economic and social inequalities, and deteriorating health outcomes. The sanctions’ effects are multifaceted, impacting economic, sociocultural, political, and health factors, which collectively contribute to a substantial decline in public health.

The strategies identified to mitigate these adverse effects underscore the importance of both national and international efforts. At the national level, strengthening domestic healthcare infrastructure, enhancing health-related policies, and improving resource allocation are critical steps. Internationally, there is a pressing need for the UN and the global community to recognize and address the humanitarian consequences of sanctions, ensuring that essential health services and supplies remain accessible even under restrictive measures.

In conclusion, while economic sanctions are intended as tools of political leverage, their unintended consequences on public health can be severe and far-reaching. Both policymakers and international organizations must anticipate and mitigate these effects to prevent further deterioration of public health in sanctioned nations like Iran. Future strategies should prioritize the protection of health as a fundamental human right, ensuring that political actions do not come at the cost of human lives and well-being.

Authors’ contributions

All authors have contributed to this study.

• Substantial contributions to the conception or design of the work (MM, STR, SN, SD, MA, HM, TN, MG, LS, NJ), acquisition, analysis, or interpretation of data for the work (MM, STR, SN, SD, MA, HM, TN, MG, LS, NJ).

• Drafting the work or revising it critically for important intellectual content (MM, STR, SN, SD, MA, HM, TN, MG, LS, NJ)

• Final approval of the version to be published (NJ, SD)

• Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved (NJ).

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.