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Iran's health houses provide model to improve rural health in the Mississippi Delta

November - December, 2009 | Volume 8, Issue 6

Iranian male doctor in lab coat shares a fist bump with Dr. Aaron Shirley, another Iranian male doctor observes
Photo by Dr. Mohammad Shahbazi/
Jackson State University

Mississippi health care pioneer Dr. Aaron
Shirley visited Iran to learn how he could
adapt the successful health house concept
of primary care delivery for use in the
Mississippi Delta.

By Ann Puderbaugh

A rocky, remote region of southern Iran may not seem the most likely place to look for a health care delivery model that would work in the U.S. But the remarkable success of Iran's health house concept - in which small primary care centers are located in each community - is providing hope and inspiration to officials in the Mississippi Delta.

After decades of frustration and millions of dollars invested with dismal results, Mississippi health care pioneer Dr. Aaron Shirley knew he needed a fresh approach. In some parts of his state, the infant death rate for nonwhites is on a par with Libya and Thailand. Mississippi's health consistently ranks dead last among states in annual tallies produced by the United Health Foundation. It has the highest rates of obesity, hypertension and teen pregnancy in the country, with about 20 percent of its population lacking health insurance.

"We've been attacking this problem over and over again with just heartbreaking results," said Shirley, chairman of the Jackson Medical Mall Foundation, a one-stop health care facility for Mississippi's underserved. "Instead of bragging about the number of buildings that get put up, I'd like to focus our efforts on improving health outcomes by providing primary care to people right in their communities."

Turning to Iran for advice

Together with James Miller of the Oxford International Development Group, Shirley reached out to Iranian health care experts for advice. He knew WHO and World Bank evaluations indicate positive outcomes from Iran's novel health house concept and thought it might provide the solution for his own population.

He discovered his Iranian counterparts are dealing with many of the same issues he faces: lack of funding and trained personnel. And yet they are having stunning successes, reducing child mortality rates by about 70 percent since 1980 and increasing contraception rates to 90 percent, even in rural areas.

Shirley and Miller began conversations with officials from the Shiraz University of Medical Sciences (SUMS), which manages more than a thousand urban and rural public health facilities in Iran's Fars province, in addition to training health care workers and conducting research projects. Over time, they built a relationship based on mutual respect and a desire to share information.

Two women, both in black headscarves, sit across from each other. One, facing the camera, speaks while gesturing with her hands
Photo by WHO/Mojgan Tavassoli

The U.S.-Iranian partnership project is planning
joint research projects with counterparts at
Shiraz University, using its health houses as
research nodes.

"There are many significant areas of collaboration open to us, both in areas of research, academic exchanges and healthcare delivery, all of which will increase understanding and friendship between our two nations and its peoples," according to Dr. Hassan Joulaei, health deputy at SUMS.

Health house concept achieves results

Their ongoing dialogue led to an invitation to examine Iran's system in person. During a visit to Shiraz in May 2009, Shirley and his team discovered some fundamental differences between Iran's approach and the one used in the Delta.

In Iran, preventive care is a priority and special attention is paid to high-risk groups such as mothers and children. Health care workers are chosen and trained within each community. Preventive and curative programs are integrated seamlessly. The system is decentralized, which encourages regional facilities to become self-sufficient and empowers local communities.

In contrast, Mississippi has a fragmented ad-hoc system of hospitals, health clinics and individual medical practices, says Miller. "Our public health programs and services aren't integrated and are anything but user friendly. Our health research is often too narrowly focused on specific risk factors and, like the rest of the U.S., we place the emphasis on curing existing conditions rather than preventing them in the first place."

Introduced in Iran in 1980, health houses are the basic unit of the rural health care structure, with responsibility for family health and wellness, census taking, public education, disease monitoring and control, environmental health, and the collection and reporting of health data. The health house staff - usually local residents who've been specially trained - refer patients to the area's health center or district hospital if they need more sophisticated services.

A woman with a headscarf on holds and looks at a baby, the baby looks at the camera, both are in front of a bulletin board
Photo by Dr. Mohammad Shahbazi/
Jackson State University

Iran's child mortality rate has dropped by
70 percent since 1980, when the health house
concept was first implemented.

Iran, US partnership forms

While in Shiraz, Shirley and his partners at Oxford International Development Group and Jackson State University signed a formal agreement with their SUMS counterparts to work together to adopt Iran's model to suit the Delta's unique needs, in addition to establishing educational exchange programs and joint research projects.

Last fall, in consultation with Fogarty's Middle East officer, Judy Levin, it was Mississippi's turn to host its Iranian partners for a conversation on how to reduce health disparities in both the U.S. and Iran. Participants explored the possibility of jointly designing an information system to track health factors among rural populations in the two countries and developing "sister" research projects examining the social determinants of health - or the causes of illness and disease.

Mississippi develops health house plan

Shirley and his team have developed a pilot community health house plan and are looking for funding to implement it. So far, more than 15 Delta communities have expressed interest in participating. "I believe this will provide a cost-effective way for us to provide quality primary care, engage local communities and empower individuals to take responsibility for improving their health," he said.

The project sites are intended to become permanent research nodes to generate health disparities data over time and the overall model is designed so that it is scalable and can be widely adapted.

"This is a wonderful example of how science can provide the basis for meaningful exchanges," according to Fogarty's Levin. "It also shows that great ideas can come from unexpected places and when we look outside our borders we discover how much we can learn from others."

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