Stage one

We identified 7437 studies, out of which 13 met the inclusion criteria (refer to Additional file 1: Appendix 2). The PRISMA diagram outlines the screening process (Fig. 2). Most studies were conducted in Iran and published after 2010. They included eight reviews and five original studies. The review output was a list of 62 proposed or implemented mitigating measures to improve the health system performance in response to sanctions. Table 2 presents an overview of the measures.

Fig. 2

PRISMA flow chart of search, inclusion, and exclusion screening, and accepted studies of the review on measures or interventions implemented or proposed to make the health system resilient regarding sanctions

Table 2 Summary of mitigating measures to improve the performance of the health system in terms of sanctions identified via reviewStage two

Ten respondents completed the interview. The details of participants can be found in Additional file 1: Appendix 3. According to many participants, Iran has always faced sanctions, except for a limited time.

“Iran is a country that is actually under sanctions, and many of these sanctions are related to the foreign policy, and the first place that is affected by the sanctions is usually the health sector, and the first place that benefits from the lifting of the sanctions is the health sector, too.” P1.Although efforts to delegitimize sanctions should not be overlooked, the health system must prepare for sanctions to operate better and minimize the damage caused by sanctions.

“At least a series of measures should be taken to delegitimize the system of sanctions in the health sector and show the effects of sanctions on the health sector as well as the violation of human rights and basic rights of Iranian citizens.” P1.

They highlighted several measures required to make the health system more resilient to the effects of sanctions. In fact, 380 meaningful codes were extracted, and 18 subcategories were identified (mitigating measures proposed by participants to improve the health system performance in response to sanctions). They were then classified as five main categories (i.e., health system functions) (Table 3).

Table 3 Mitigating measures to make a health system resilient to sanctions identified via interviews and gray literatureSustained financingUsing sustained health financial resources

Nearly all participants viewed the availability of resources as a key enabler in making a health system resilient. They said that the health system could overcome disruption when available resources were used strategically. Financial resources are necessary to mobilize other essential resources during sanctions and crises. The sustained protection of healthcare funding was identified as a key ingredient to its resilience. Given the economic status of Iran which mainly depends on oil, it was strongly recommended that diverse and stable financial resources, e.g., taxation or further efficiency, should be employed to minimize the risk of an underfunded response.

“You know that national income depends on the sales of oil in Iran. Whenever there is a disturbance in the sales of oil, almost all sectors suffer. The health sector is no exception. We know this, and its effects are also obvious. Now we have to ensure that, as far as possible, the financial resources of the health sector have minimal dependence on oil revenues. We should think about finding more sustainable resources for the health system.” P2.

“Our health system should be able to withstand sanctions and make some changes to be less vulnerable during sanctions. For example, do you remember that after the JCPOA, Iran’s income improved a bit, and as a result, the financial resources of the health sector increased? The same health transformation plan was implemented at the same time. It would be better if the health system tried to use these funds to become efficient so that it would not be under pressure if the embargo happened again. For instance, more should be invested in the primary health than hospitals.” P7.

Institutionalizing fair and effective resource allocations

Participants stated that the sanctions strongly affected how government resources were allocated to health and how health resources were allocated to various programs. In the absence of priorities and resource allocations, the shares of health expenditures usually reduce, and many health plans fail to be implemented, both of which are considered constant threats. The participants pointed out some of the efforts made in Iran to use a scientific and fair approach for prioritization and allocation of resources in the health sector. However, they believed that these efforts did not lead to the institutionalization of a clear and accurate method for prioritization. Thus, an approach to institutionalized and effective setting priorities and financial resource allocation should be developed to make a health system more resilient.

“The embargo there has led to a decrease in our incomes, and economic austerity has been formed after that. These austerity attempts will affect the allocation of resources to our government departments. When the allocation of resources declines, the policies of the Ministry of Health will be revised. How? This revision should be based on the principles of prioritization. Still, because there is no systematic prioritization, priorities are formed based on preferences, which often causes a waste of resources. We need a system that determines how to spend this little money more effectively and efficiently.” P10.

Systematic costing of medicines and medical devices

According to the participants, the most direct effect of sanctions was left mainly on the prices of medicines, medical devices, and equipment. The increased prices of these items have limited access or resulted in the emergence the black market, leading to the poor quality of these items, all of which pose a serious health risk. Many participants highlighted the vulnerability of medicines and medical equipment during the embargo period and the importance of selling medicines and medical products at stable prices during sanctions.

“We now know the pricing of some medicines, which means it is clear how much this medicine should cost. The same is true for some medical equipment and devices, but this price list is not for all items and is sometimes not updated. If we could have an updated list of prices for drugs and medical equipment available to all Iranian people, in times of crisis like this embargo, traders could not sell drugs to people at any price.” P5.

Good GovernancePreparedness and planning for sanction

Some participants stated that sanctions and their outcomes had not properly been analyzed in Iran’s national health planning and policies and that goals and strategies were not organized accordingly. In addition, although a resistant economy is an appropriate solution to counter the effects of sanctions, its implementation has not seriously been pursued. The participants emphasized that health planners should consider the scenario of continuing sanctions, and any targeting should be done in accordance with sanctions and their effects. The scenario exercises were reviewed, and pseudo-sanction situations were mentioned as a strategy to make preparations for crises or disasters.

“Sanctions will happen now, this round, or the next round. You must have a plan to confront sanctions, and until then, there will never be any discussions of sanctions. We did not look at any outlooks that sanctions might happen while we are forecasting. We did, but we did not consider the embargo. First, we did not look at it from this point of view. We never included these facts related to the embargo in our work, and this is a big problem that the country has.” P7.

Collateral collaborations for procurement of goods

Some participants said that during sanctions and the restrictions imposed on financial transactions and transfers, one of the most important factors that could be effective in maintaining the health system was the use of alternative ways of conducting exchanges and procurement resources. Ensuring that the health system has multiple alternative courses of action can lead to resilience. Collateral pathways refer to the availability of alternative routes to achieve the desired goal and enhance resilience by providing alternative courses of action. When a system experiences disruption or challenges on one pathway, an alternative pathway is utilized to achieve the same goal.

“There is a special bandage that the … company produces only in …, and they no longer sell these to Iran due to sanctions, and we saw what we did and the follow-up we did. We pressured the … ambassador, that is, the … government through … lawyers and in a way forced the … factory to sell, it was not their way, then they said we would not sell to the Ministry of Health, then we said there was no problem, sell it to … Iran, we will give it to the Ministry of Health. Then, because these issues of financial transfer and other things were difficult to solve, … made a donation and got a budget, and with the help of the ... government and the first party, we bought the first party.” P4.

Optimizing/shrinking organizational structure

Another governance practice affecting the resilience of a health system is an appropriate organizational structure to cope with sanctions. Participants believed that it was essential to establish a flexible and agile structure for deciding how to respond to sanctions and monitor the proper implementation of policies.

“After all, one of the emerging issues is the structure. Do the structures change because of this? Some things happened. For example, a deputy was removed. … Or, for example, assume that the Food and Drug Administration changed its organizational arrangement, and the issue of combating pharmaceutical problems and managing corruption was somehow brought up in the Ministry of Health.” P10.

Investing in domestic production

Another governance issue affecting the resilience of the health system is the formulation of simple rules and regulations away from bureaucracy to support domestic production. Some participants described the experience of eliminating cumbersome regulations in support of the domestic production of medicines and equipment, arguing that a transparent and law-abiding approach to supporting domestic production could reduce the dependence of the health system on foreign countries. As a result, they suffered less from sanctions.

“It can be said that one of the advantages of the embargo is that domestic production has been revived. We produce a lot of vaccines and medicines inside Iran. The more we can strengthen our internal capacities and potential to be producers, the less we will lose during sanctions. Of course, domestic production must be of high quality.” P2.

Strong leadership and management

The importance of managerial and leadership practices to the resilience of the health system is a recurrent concept emphasized by many participants. In a resilient health system, management and leadership are characterized by inclusive decision-making. Participants stated that managers and leaders should ensure that relevant stakeholders were included and contributed to decision-making. This could nurture the resilience of the system by building trust and empowering, motivating, and creating commitment among staff and other stakeholders.

“We have a lot of experience with this. For example, some ministers and deputies turned their words into actions during the war. Regarding sanctions, it is not possible for the minister not to speak or not to be heard. Look at the COVID-19 pandemic. Whenever they made a decision, they asked the Minister of Health because health is important. Even for sanctions, the words of those who know the bad outcomes for people's health cannot be heard. Health managers need to be charismatic and decisive.” P2.

Having constant collaboration and active social networks

Many participants stressed the importance of a government’s comprehensive efforts and people’s resistance to sanctions. They mentioned how well the health system established and leveraged its networks to determine its resilience to everyday challenges and acute shocks. Social networks offer useful avenues for the increased mobilization and transfer of knowledge and dissemination of innovations, thereby boosting the overall resilience of systems. Collaboration among organizations in a networked environment can also expand potential resources, the ability to learn, and the capacity to respond.

“If you remember the war, these jihadi groups and popular networks played an important role in helping soldiers and supporting the country in many places. Since they had a social base, they could coordinate resources well. The health system should also consider how it can create and improve these networks and communities in the community groups. It is a kind of social capital that can give morale in difficult situations and can do many things instead of the government.” P6.

Empowering the community and increasing their participation

According to the notes by participants, community empowerment is the strongest way to make the health system resilient. Community participation is a kind of investment in health, and it helps achieve huge capital.

“Undoubtedly, if the society is empowered, the health system can work more effectively, especially in crises. Do you know how much nongovernmental organizations can improve our drug shortages? The truth is that I think if we can work on this community participation, we can get through crises like embargo much better.” P10.

Strengthening health diplomacy

Some participants mentioned the benefits and advantages of health diplomacy, believing that it was a fundamental approach to resolving disputes between nations. Therefore, as a part of the plan to respond to sanctions and make the health system more resilient, public policymakers should consider their population and global health issues in their relationships with other countries. For success in health diplomacy, it is advisable to provide solid evidence to release the effects of sanctions on the human rights of target countries. The evidence can delegitimize sanctions in the international community and be used as the basis for international policies to improve global health.

“This all goes back to the field of diplomacy and health diplomacy or the same thing you are doing now. How do you challenge sanctions? This goes back to health diplomacy because the health field is an area that can easily interact. It means that even in the most difficult situations when countries are at war, it is easier to enter from the health sector, interact, and enter into the cooperation process. This field is the field of diplomacy and health.” P1.

Integrated and updated health information systemConstant monitoring and evaluation

According to the participants, the missing link of appropriate response to sanctions is the lack of a monitoring and evaluation system to analyze the effects of sanctions on health. Referring to data and studies currently available in Iran, they said that, unfortunately, due to the lack of a codified system, the data could not be used to judge the type and severity of impacts left by sanctions. Sometimes, the data required to perceive the impacts of sanctions does not exist. Another issue is the lack of scientific methodology to analyze the effects of sanctions on health. These all result in the wake of proactively monitoring what is happening in the health system. Equity was highlighted as an aspect that is often lost during sanctions. One participant stated that new strategies made hastily in need of a quick fix would often miss equity aspects. Hence, it is highly important to establish a monitoring and evaluation system in which different aspects of equity are routinely observed.

“The point was that we never came to see these indicators, how our access is to medicine, equipment, and procedures during the embargo, and the effect of the embargo on the public health was not there to see what their conditions would be. This makes us not have a complete judgment on this whole issue.” P7.

“Indicators of malnutrition in children, thinness, short stature, and even overweightness and obesity in children and adults were among of the important indicators that could be affected by sanctions. I did not see very documented statistics. One of the claims made by the Ministry of Health was that we kept it constant, and these indicators had not changed.” P8.

Enhancing surveillance system

The resilience of the health system is widely identified as dependent on how health data and information are managed and used. All participants believed that data and information including routine health or administrative data, valid and accurate research evidence, and survey data are the key to how timely and adequately the health system adapted to challenges caused by sanctions. Moreover, many participants highlighted the need for adequate information and epidemiological surveillance systems that monitor and report the status of the system and provide real-time early warning of impending health threats.

“When they create a surveillance system and want to control an epidemic, first of all, you have to see if the prevalence is high or if the economic burden is high, that is. I mean we have criteria for saying which should be the surveillance system. Now in Iran, many information systems are excessive. To be more resilient, we need a surveillance system as needed. For the same women's urine, it is possible to study whether this has changed during the embargo or their treatment and access to treatment have changed.” P7.

Strengthening evidence-informed policymaking

According to the participants, there are many obstacles in helping policymakers make evidence-informed decisions or sue for the illegitimacy of sanctions. The most important problems included not paying attention to monitoring the effects of sanctions on health and the health system; lack of registration and reporting systems; scattered, inaccurate or contradictory statistics, especially in the field of food status and access to health services; and low quality and the incompleteness of some of the evidence produced in Iran about the effects of sanctions. These obstacles must be solved to make the health system resilient. Adaptive and new strategies should be developed based on previous experiences, and lessons learned should efficiently be implemented.

“This is an area that I think you should document in this case, especially in international authorities, to put pressure on this, on this field, and in fact, the argument regarding the international legitimacy of the US sanctions system as a whole. A distinction was made between banking sanctions and sanctions in the health sector.” P1.

Qualified Health WorkforceProvision of adequate skilled health workforce

Participants recognized the important role that health workforces would play in the resilience of the health system. They pointed out that having an adequate number of health workforces and the requisite skills were critical contributors to resilience.

“It can be good. Sanctions affect the dollar exchange rate, which will harm the outflow of human resources, which means that they are more in demand. See, if we are looking to strengthen the health system, especially we, who are always at risk of sanctions, human resource policies should be changed a bit. We should learn what other societies are doing.” P9.

Motivating health workforce

It is essential to guarantee that the health staff is adequately motivated and fully committed to the predetermined goals. A way of ensuring that health workforces are motivated and committed is to prioritize their well-being. It was achieved by creating a positive social environment where the staff was free to express emotions and share information, providing adequate resources to match their work demand, actively listening, monitoring, and addressing changing staff stresses, and flexibility around staff needs.

“There are some factors that are more fundamental and not easily seen, attention to the incentive system, attention to the payment system, attention to the various human resource systems in the health system. These important issues are practically neglected. if they can be used for a strong health system, they can also create motivation, that which we feel in your presence, belonging to patriotism.” P9.

Efficient and equitable service deliveryGiving priority to public health intervention

Nearly all participants emphasized that establishing the primary health network was very helpful and supportive in providing essential health services for the population in recent decades. They strongly suggested focusing on preventive efforts such as public health interventions during stable times as one strategy for a health system to be well-prepared for sanctions. However, most sanctions and shocks were difficult to predict and prevent.

“The most serious damage caused by sanctions is for drugs and medical supplies mainly used for treatment. The conditions of the patients have worsened with every sanction. It is very simple, for the health system not to be harmed by this issue, for it should focus on prevention. As you said, prevention had priority over treatment at the beginning of the revolution.” P6.

Defining tailored health services package for vulnerable populations

Some participants stated that during sanctions, not only is it important to provide routine health services for the entire population, but it is also essential to ensure additional health services for vulnerable groups including women, children, low socioeconomic population, and refugees. However, maintaining everyday services should be put high on the agenda by a resilient health system. They assumed that defining and developing tailored health service packages might help ensure safe and premium care with minimum financial hardships.

“Experience has always shown that those with incurable diseases and those whose voices are less heard are more harmed during crises. For instance, if patients know some people in high places, their voices will be heard; otherwise, nobody listens to them. Now, suppose the Ministry of Health has the claim of trying to achieve equity in health. In that case, it should sit down and see where the vulnerable groups are in terms of health in society and what minimum services should be provided for them in crises to monitor them regularly.” P7.

Stage three

Thirteen experts were invited to join the panel. Finally, eleven responded. Additional file 1: Appendix 3 presents further details regarding the expert panel used in this study. In the first Delphi round, 28 mitigating measures were found once the suggestions and comments of experts were assessed. In the second Delphi round, all these measures were prioritized with regard to their effectiveness and feasibility. Table 4 presents the measures and their relationships with the functions of the health system.Fig. 3 A–B reports the ranking results, and Table 5 demonstrates the classification of resultant interventions based on the average scores of feasibility and effectiveness criteria in accordance with the time horizon of effects. For the sake of simplicity, any scores above the overall average score were considered effective or feasible, and the scores below average were considered ineffective or non-feasible.

Table 4 The mitigating measures for the resilience of Iran’s health systemFig. 3

Ranking mitigating measures for health system resilience against imposed sanction (based on expert opinions in Delphi rounds). The red dotted line shows the overall average score for each axis. Based on these areas are defined as: I. Effective and feasible. II. Effective but not feasible. III. Feasible but not effective. IV. Neither effective nor feasible

Table 5 Classification of interventions based on the average scores of feasibility and effectiveness criteria in accordance with the time horizon of effects

Comparing these two timeframes resulted in valuable findings, among which it is noteworthy to pay attention to three groups of mitigating measures.

Group 1: Effective and feasible measures in both short-term and long-term periods. Most of these measures focus on good governance and strengthening and improving supervision.

Group 2: Measures that are more effective in the short run than the long run.

Group 3: Measures that are more effective and feasible in the long run than the short run (e.g., funding for health through sustained sources, investing in domestic production, and strengthening global health diplomacy).

Apart from these measures, we identified some other measures that should be considered in the international community and agencies under sanctions (e.g., strengthening global health diplomacy, assigning some international intermediate organizations and specific companies and financial institutions to facilitate the implementation of exemptions, excluding vital medicine and medical supplies from sanctioned items, allocating a protected specific banking channel for humanitarian medicines trade, establishing specific cut-off thresholds for unintended consequences on civilians, establishing an international order for the protection of people before the imposition of sanctions, and monitoring and evaluation the effects of sanctions).