Dear Editor,
Health is fundamental to sustainable development across social, economic, political, and cultural domains, and a responsive health system that meets people’s needs is essential for inclusive growth (1-3). Launched in early 2014, Iran’s Health Transformation Plan (HTP) aimed to improve access to, the quality of, and satisfaction with health services (2). One objective of the HTP was to reduce health-equity gaps by integrating mental health and nutrition services into the primary health care (PHC) system. In Sistan and Baluchestan Province, where socioeconomic challenges and a wide geographic area affect service delivery, these services were intended to address the needs of underserved populations. This policy brief evaluates the performance of mental health and nutrition service delivery under the HTP from 2016 to 2021 and identifies implementation determinants affecting service sustainability and quality.
Under the HTP, mental health and nutrition experts were deployed in PHC centers. Mental health experts were responsible for mental health screening, psychological counseling, individual educational interventions, and follow-up of cases involving substance abuse, child maltreatment, and common mental disorders. Nutrition experts provided dietary counseling, monitored nutritional status, and implemented interventions intended to control risk factors for noncommunicable diseases (NCDs), including diabetes, hypertension, obesity, and hypercholesterolemia. Performance was assessed using routine service indicators extracted from the Integrated Health System (SIB) between 2016 and 2021, complemented by qualitative interviews exploring working conditions and service-delivery challenges. Performance measures included screening, counseling, and follow-up indicators for NCDs and common mental disorders.
Several implementation challenges were identified. First, mental health and nutrition experts were primarily recruited under temporary, short-term contracts in PHC centers. This employment arrangement resulted in low job security, frequent staff turnover, and limited professional continuity. Repeated replacement of trained experts disrupted service delivery, reduced accumulated experience at the facility level, and required recurrent retraining, ultimately affecting the consistency and effectiveness of mental health screening, counseling, and nutrition follow-up services.
Second, the scope of assigned tasks for both mental health and nutrition experts was extensive and often disproportionate to the available human resources. Mental health experts were responsible for population-level screening, including screening for substance abuse and child maltreatment, as well as individual counseling, documentation, and follow-up. Nutrition experts managed counseling, NCD risk-factor control, and monitoring of multiple clinical indicators. This high workload, combined with staff shortages in many centers, constrained the depth and quality of services provided.
Third, many health centers, particularly in rural and underserved areas, lacked essential infrastructure, including private counseling rooms, reliable internet connectivity, vehicles for outreach activities, and adequate equipment. These limitations affected the performance of both professional groups by restricting confidential mental health consultations, limiting community-based nutrition interventions, and causing incomplete or delayed data entry into the SIB system.
Fourth, the performance of mental health and nutrition experts was primarily assessed using quantitative indicators recorded in the SIB system, such as the number of screenings or consultations completed. This volume-based evaluation framework placed pressure on experts to prioritize numerical targets over the quality of counseling, follow-up, and patient-centered care. Consequently, meaningful clinical outcomes and service effectiveness were not fully captured in routine performance assessments.
Fifth, despite the availability of free mental health and nutrition services, utilization remained suboptimal. Qualitative findings indicated that limited public awareness of the role and availability of these experts, together with persistent social stigma, particularly related to mental health, reduced client engagement. This challenge limited the potential impact of expert-delivered services regardless of workforce presence or service capacity.
Sixth, mental health and nutrition experts reported difficulties in ensuring effective referral and follow-up for clients requiring higher-level care. Geographic distance, limited specialist availability, and incomplete referral feedback loops disrupted continuity of care. These constraints reduced the effectiveness of initial screening and counseling activities conducted at PHC centers (4, 5).
Despite these challenges, several achievements were observed. These findings were based on quantitative indicator data routinely collected between 2016 and 2021 and qualitative evidence obtained through semi-structured interviews conducted as part of a Master’s thesis at Zahedan University of Medical Sciences. Evaluations conducted during this period indicated that the deployment of mental health and nutrition experts in PHC centers contributed to measurable improvements in service delivery. Mental health experts expanded screening coverage for substance abuse, psychosocial problems, and high-risk behaviors while increasing psychological counseling and individual educational interventions. In parallel, nutrition experts strengthened dietary counseling and follow-up care for individuals at risk of NCDs.
Quantitative findings from university health records showed upward trends in several nutrition- and mental-health-related indicators. Nutrition experts achieved improvements in the control of diabetes, hypertension, obesity, and hypercholesterolemia across the medical universities of Zahedan, Zabol, and Iranshahr, with variability reflecting local capacity and resources. Similarly, mental health experts contributed to increased rates of counseling and follow-up interventions, despite fluctuations in initial screening coverage over time.
The HTP also introduced mental health and nutrition services to rural areas, informal settlements, and previously underserved urban populations. For the first time, residents of these areas gained direct access to trained experts within community health centers. This expansion reduced geographic barriers to care and enabled earlier identification and management of mental health- and nutrition-related risks at the primary care level.
Routine involvement of mental health and nutrition experts in service documentation strengthened use of the SIB system. Experts regularly recorded screening results, counseling sessions, and follow-up outcomes, improving the availability of standardized data for monitoring service outputs and population-level trends. This digital integration supported greater transparency and accountability in service delivery.
Qualitative findings further indicated that the continuous presence of mental health and nutrition experts in health centers improved trust and engagement between communities and the health system. Educational sessions and individualized counseling, particularly those delivered by nutrition experts, contributed to greater awareness of healthy behaviors and disease prevention, even in settings with persistent social and cultural barriers.
These findings support several policy recommendations. First, stable or permanent employment arrangements should be considered for contract staff to improve motivation, reduce turnover, and enhance service continuity and quality. Second, culturally sensitive public-awareness campaigns delivered through local media, schools, and community institutions could increase service utilization and reduce stigma. Third, resources should be allocated in proportion to population needs and deprivation levels to equip rural and underserved health centers with reliable internet connectivity, vehicles, appropriate facilities, and electronic health record capacity. Fourth, national health directives and service packages should be adapted to local epidemiologic and cultural conditions rather than applied uniformly without regard to provincial circumstances. Fifth, performance evaluation in the SIB system should incorporate quality- and outcome-based indicators, including patient satisfaction, follow-up rates, and clinical outcomes, to shift emphasis from service volume alone to meaningful impact.
Overall, implementation of mental health and nutrition services under Iran’s HTP in Sistan and Baluchestan Province illustrates both the potential and the limitations of expanding specialized services through PHC. Evidence from routine indicators and qualitative assessments suggests that trained experts can improve service coverage, early risk identification, and selected health outcomes, particularly in underserved settings. However, service expansion alone is insufficient to achieve sustained impact. Workforce instability, infrastructure gaps, performance monitoring focused on quantity rather than quality, limited public awareness, and weak referral mechanisms influence whether expanded services translate into meaningful health gains. These challenges reflect broader systemic issues relevant to national health policy. Aligning human-resource policies, service-delivery models, and evaluation frameworks with the goals of equity, quality, and sustainability is therefore essential. Integrating mental health and nutrition services into primary care requires not only technical guidelines but also supportive employment arrangements, context-sensitive implementation, and mechanisms that value service quality and continuity of care. Lessons from Sistan and Baluchestan may help strengthen the next phase of the HTP nationally and support durable improvements in population health, particularly in socioeconomically disadvantaged and hard-to-reach regions (5-8).
