In the past weeks, a very shocking news has affected the community; a short but very emotional news: Emergency personnel at one of the country’s hospitals had to stitch up a young child due to their parents’ financial hardship!

Although various sources later reported the news in different ways, the difference was drawn from the lack of need for stitches, the removal of stitches in another location, and the hospital’s directive not to pay staff fees if the patients or their companions do not pay the bill, and the impact of this directive on the performance of employees. Until the news was completely confirmed, it was discussed in various media outlets and many criticisms were made about the decline of morality in society, which is truly a very thought-provoking issue and requires fundamental and foundational actions to be taken.

But the point that seemed to be completely overlooked was what is the duty of the government in preventing such incidents? And has the government fulfilled its duties adequately in this regard? Condemning guilty individuals based on a scientific and precise investigation, although it can be a suitable step in pursuing the issue, will certainly have a significant and temporary impact on preventing similar incidents in the future. It seems that statesmen, including the Minister of Health and other executive officials of the country, judicial officials, and representatives of the parliament, should not only pursue this issue, but also take scientific and purposeful steps in preventing similar incidents. If these steps are not taken or are lacking in sufficient knowledge or appropriate executive ability, or unfortunately, the purpose of their actions and interviews is only to deceive the community. But what are the responsibilities of governments towards the health system and society?

Undoubtedly, the individuals of every society need education and training, communication infrastructure, transportation infrastructure, clean water and access to energy, employment, housing, security, health, and social security, along with freedom. It is the responsibility of governments and administrations that consider themselves servants of society to plan and create suitable structures to achieve these goals.

A very important point in relation to the concept of social welfare is that social factors have a significant impact on health and the improvement of the health system, and perhaps looking at each of these dimensions alone cannot bring society’s policymakers closer to their social goals in the health sector. If we do not pay attention to the fact that external factors can have a serious impact on health, ignoring these factors can seriously affect the policies outlined in the health sector. Similarly, if we look at social factors without considering health indicators, we have not had a comprehensive view of this issue, and ultimately, in order to create a system based on social welfare, all of these factors must be considered together and their indicators must be adjusted and implemented in a targeted manner so that the health and social welfare system can be presented in a comprehensive and universal model. For example, the education level of a mother certainly has an impact on the health of a newborn, and the more a mother has learned in her studies about how to improve her

The concept of social security and its supports, whether in the form of social insurance for healthcare or in the form of unemployment insurance and even retirement, can be effective in promoting community health through different mechanisms. On one end of the spectrum, it provides suitable healthcare coverage and protects the society from crippling medical expenses, preventing individuals and families (who spend more than 50% of their non-food expenses on healthcare) from falling into poverty. On the other end of the spectrum, it falls under the umbrella of social supports aimed at preventing poverty or other social abnormalities.

Integrated planning of social welfare programs and creating a suitable structure for coordinated movement of different sectors can, on one hand, provide appropriate access for individuals in need of services, and on the other hand, reduce accidents and promote the health of individuals, resulting in a decrease in medical needs. For example, access to energy can improve the level of hygiene and reduce diseases, while proper roads and standard vehicles can prevent accidents, disabilities, and deaths.

However, an important and unfortunately overlooked point is that government officials in every sector should have the necessary familiarity with social welfare indicators, how to regulate and coordinate the activities of different sectors to improve these indicators, as well as the social factors that affect other sectors of social welfare. With a comprehensive and process-oriented perspective, they should be able to present a comprehensive approach to improving the level of welfare and subsequently the improvement of indicators and measures in the sector.

Although the discussion on this topic cannot be fully covered in this speech, mentioning this introduction is necessary for identifying the importance and impact of various aspects of social welfare on the health sector.

With an emphasis on the fact that it is certainly not possible to outline all the goals of the health system in this brief, it can be pointed out that all experts, with different perspectives, agree that health is a fundamental right of all individuals regardless of gender, race, nationality, religion, etc. It is the responsibility of statesmen to pay special attention to this sector and design the necessary structure for people of all income levels, genders, etc. to have access to necessary health services in a way that their vital medical needs are not affected by their financial situation. But what characteristics should this structure have? To better understand the subject, I briefly refer to the goals and structure of the health system.

Undoubtedly, the overall goal of the healthcare system is to promote the physical, mental, emotional, spiritual, and social well-being of all members of society (ensuring, preserving, and promoting physical and mental health, etc.). However, in order to achieve this overall goal, specific objectives must be pursued, such as increasing life expectancy, reducing disease and disability, improving the quality of life for people, improving social justice in the field of health, improving access for all people to comprehensive and quality health services, and promoting environmental health (in the workplace, schools, homes, cities and villages, public places, etc.).

To achieve these goals, attention must be paid to the components of the health system, including service recipients (who are the people), service providers (such as doctors, nurses, and healthcare institutions), and health system management (which is the policy maker in many countries). However, the management of the health system, which is the subject of this article, should have a customer-oriented and customer-centric approach, with the participation of service recipients and providers, be responsive, have a strategic and dynamic management approach, be process and data-driven, and have an educational focus in order to create a coherent structure between service providers (both public and private sectors) and be based on meeting the needs and well-being of the people, with cost-effectiveness in addition to the use of appropriate and modern technology, effective and coordinated management, and in line with other sectors of social welfare development, and most importantly, provide services fairly and equitably to service recipients.

But alongside designing a proper structure, statesmen are obligated to design programs for the healthcare system that, with appropriate scientific support and sufficient dynamism and consideration of cost-effectiveness, take the priorities of this sector seriously and, while considering all dimensions of health, are in line with the needs and demands of the people.

In one sentence, it can be said that health services should have the following characteristics: appropriate service, adequate coverage and access, proper management, and suitable structure.

Next to these issues, and perhaps more precisely within the core of these issues, the principle of justice in health is demonstrated. A principle that neglecting it can lead to the emergence of such problems in society. But what is justice in health? The concept of justice in health takes on different definitions with different approaches governing the systems of government. This definition is drawn differently in countries with a free market and capitalist approach compared to countries with a socialist approach. In Iran, based on top-down laws such as health outlook and development plans, the approach of the World Health Organization has been considered for health matters. Justice in health has three dimensions:

Justice in providing financial support for healthcare services

B- Justice in Providing Health Services

Justice in the consequences of health.

In each of these axes, justice is examined from three aspects: horizontal justice, vertical justice, and intergenerational justice, which cannot be fully described in this discussion.

In the issue of justice in providing health care services and the defined framework for health justice in Iran, two principles are emphasized:

Equal treatment for equal needs regardless of individuals’ income.

B- Equal access to healthcare services

In the incident at Khomeini Hospital, the first issue is the lack of justice in providing health services, according to section A.

In this section, we must answer the question of how to distribute the financial burden of healthcare costs among different social classes in a fair manner (emphasizing that the proposed solutions are based on higher-level laws and the development plan and vision). In the financial system of the healthcare sector, resource distribution must be based on three principles; resources should be directed from healthier individuals to less healthy individuals, from the wealthy to the poor, and from the productive stage of life to the non-productive stage of life.

The second major problem in the Khomeini city hospital incident has occurred here. Governments usually use different tools to create justice in financing health resources for different layers of society. In this regard, individuals who are severely impoverished or, in other words, living in extreme poverty, are covered by full government support and are provided with very comprehensive and suitable health insurance from public resources (such as taxes). Although this coverage is usually structured and often in the form of a referral system, the individual does not pay any fees for the services received or only pays very minimal fees. In fact, this mechanism prevents further problems for this group of individuals in society due to lack of treatment for diseases caused by financial problems.

Other layers of society that are employed or organized in social groups are supported through employment and social security mechanisms, and the insurance coverage for individuals living near or below the poverty line should be designed in a way that they do not fall into a catastrophic financial situation due to medical expenses.

Alongside these mechanisms, by creating a mandatory health insurance system, all members of society are practically protected against serious health risks; in addition, with this mechanism, it is possible to achieve successes in redistributing resources from wealthier individuals to those who are poorer. A notable point in the Khomeini Shahr hospital incident is that individuals who needed medical services and were either in extreme poverty or relative poverty did not receive the necessary support. Unfortunately, the resources that could have been used for individuals in extreme poverty have been diverted since the previous government, under deceptive slogans such as a 50% discount on health insurance costs, to places that do not require such expenses; this is because individuals in extreme poverty cannot even afford to pay half of their health insurance costs, while those who are eligible for the discount benefit from it, and in reality, a portion of these resources is used to insure those who are eligible for the discount, which is in clear contradiction with the principles of justice in healthcare.

Justice in its consequences also indicates that everyone, regardless of income, position, race, and other factors, should have access to an equal level of health. This means that the justice or injustice of a system should be judged based on the level of disability/death among different groups of individuals (region, income, occupation, race, etc.), not just access to care. The goal of this justice is to create equal capabilities and, in fact, equal opportunities for different individuals, although this section cannot be fully described in this article.

However, alongside the issues that we discussed within the framework of justice in healthcare, in other mentioned areas in this discussion, such as appropriate service, coverage and access, proper management, and suitable structure, should also be considered; for example, the necessity of severing the relationship between the doctor and the patient, reviewing medical tariffs and, if necessary, increasing them with the condition of reforming healthcare insurance structures and making insurance mandatory in a way that medical expenses do not cause financial hardship for patients, identifying and allocating resources to the healthcare sector that have been collected in other areas such as motor vehicle accident insurance, student accident insurance, etc. (in addition to the ten percent allocated to the healthcare sector), identifying and creating new resources for the healthcare sector, such as taxing factors that endanger people’s health and using these resources to provide appropriate coverage for the needs of the community, reviewing the required standards for hospital staff, such as the nurse-to-patient ratio and improving the salaries of nurses and medical staff

It is hoped that the country’s officials, free from populist slogans and with a scientific approach, will join forces to solve the problems of the people in the healthcare sector.