In the wake of unprecedented global challenges, health systems around the world are being tested not only for their routine capabilities but for their resilience during crises, especially when confronted with sudden population displacements. The 2021 Afghan migration crisis posed such a challenge to Iran, a neighboring country that became an immediate refuge for hundreds of thousands fleeing conflict and instability. How Iran’s healthcare system responded to this influx sheds critical light on the intersection of health equity and system resilience in crisis settings. It reveals vital lessons on sustaining healthcare access for refugee populations, ensuring equitable service delivery, and maintaining the robustness of health infrastructures under pressure.
The dynamics of refugee influxes create unique and complex demands on host countries’ healthcare systems. Refugees often arrive with urgent health needs exacerbated by trauma, poor living conditions, and interrupted medical care. Iran’s experience provides a revealing case study of how a middle-income country can mobilize its health resources to accommodate such strains without compromising equity. Their approach underlines the importance of flexibility and adaptability in public health policy, expanding beyond traditional frameworks to meet emergent needs with both immediacy and empathy.
Central to Iran’s strategy was the alignment of national health policies with international humanitarian principles, emphasizing that refugees must have equitable access to healthcare services regardless of their legal or socioeconomic status. This objective required recalibration of existing health services to accommodate a dramatically increased patient load while maintaining quality and coverage for the resident population. The government’s proactive steps included the rapid extension of health insurance to undocumented migrants and the enhancement of community health outreach programs to bridge potential access gaps.
One of the technical pillars underpinning Iran’s success was its integration of primary healthcare networks into the refugee health response. The country’s established primary healthcare system, rooted in community health worker deployment and local health centers, was pivoted to register refugees and provide first-line medical services. This integration minimized barriers to entry, fostering trust through culturally sensitive care environments and community engagement. Such decentralized structures proved effective in scaling up health service provision without overwhelming tertiary hospitals.
Iran also capitalized on data-driven approaches to track health service utilization and epidemiological trends among refugee populations. Robust information systems allowed health authorities to monitor disease outbreaks, resource allocation, and treatment adherence in near real-time. These capabilities were vital in preempting public health emergencies, optimizing the distribution of medical supplies, and guiding vaccination campaigns—critical factors given the backdrop of the ongoing global COVID-19 pandemic.
Crucially, the Iranian experience highlights the interplay between health equity and system resilience as mutually reinforcing concepts. Equity-oriented policies ensure that no populations are marginalized during crises, fostering social cohesion and trust in public institutions. At the same time, resilient health systems that can dynamically reconfigure service delivery channels are better poised to absorb shocks without collapse. Iran’s multi-sectoral coordination across health, migration, security, and social welfare sectors exemplified such synergy and underscored the necessity for holistic governance frameworks.
The challenges Iran faced were multifaceted. Language barriers, cultural differences, and legal status issues complicated care provision. To address these, Iran invested in training health personnel in cultural competence and deployed interpreters and community health volunteers from refugee communities themselves. These measures improved communication and adherence to treatments, reducing disparities and strengthening the acceptability of services, which is a critical determinant of health outcomes.
Infrastructural strain was another prominent issue. Health facilities had to expand capacity, including maternity wards, chronic disease clinics, and mental health services. The surge in demand compelled innovative use of mobile health units and telemedicine to reach remote or underserved refugee settlements. These technological deployments not only extended reach but also aligned with broader global trends toward digital health, underscoring their applicability in crisis contexts.
Iran also faced fiscal concerns, managing limited budgets while absorbing increased health expenditures arising from the refugee influx. Partnerships with international organizations and donor agencies played a strategic role in augmenting resource availability. These collaborations enabled procurement of essential medicines, vaccines, and diagnostic tools, while knowledge exchange programs helped enhance local health workers’ skills in refugee health management, signaling the importance of global solidarity in humanitarian responses.
Mental health emerged as a critical domain requiring heightened attention. The refugees’ experiences of trauma, displacement, and uncertainty contributed to increased prevalence of depression, anxiety, and post-traumatic stress disorder. Iran’s health system responded by integrating psychosocial support within primary care settings and by developing referral pathways to specialized providers. Awareness campaigns destigmatized mental health issues, fostering a more inclusive health environment and reinforcing resilience at both individual and community levels.
The Iranian case underscores the necessity of viewing refugee health not as an isolated issue but as an intrinsic component of national health security. Protecting the health of displaced populations safeguards overall public health by mitigating disease transmission and promoting early intervention. Importantly, Iran’s approach illustrates that investing in inclusion and equity enhances system resilience, transforming vulnerabilities into strengths through adaptive capacity and social cohesion.
Furthermore, Iran’s response recognizably benefited from its prior investment in health infrastructure and emergency preparedness. The existence of comprehensive vaccination programs, disease surveillance systems, and emergency response protocols enabled swift mobilization when the crisis unfolded. This highlights a broader lesson for countries worldwide: consistent investment in foundational health system elements pays dividends during unforeseen shocks, enabling rapid and equitable responses.
The experience also brings to light the critical role of policy frameworks that explicitly recognize refugees’ rights to healthcare. In Iran, legal provisions and policy directives ensured that refugees were not excluded due to administrative hurdles. This legal underpinning is essential in preventing marginalization and ensuring sustainable access to care during protracted crises, which are increasingly common in today’s volatile geopolitical landscape.
Finally, as the global community anticipates continuing population displacements driven by conflicts, climate change, and pandemics, the insights gained from Iran’s 2021 Afghan migration response bear global significance. They present a replicable model for balancing the imperatives of health equity and system resilience, showing that achieving such balance is feasible even in resource-constrained settings. This bridging of humanitarian principles and practical health system management offers a blueprint for future crisis preparedness and response efforts.
In conclusion, Iran’s experience in managing healthcare during the Afghan migration crisis of 2021 exemplifies how health equity and system resilience can be harmonized to address complex humanitarian emergencies. Through innovative adaptations in service delivery, policy support, multisectoral coordination, and community engagement, Iran demonstrated the capacity to uphold the right to health for refugees without compromising its national healthcare delivery. The lessons arising from this case provide critical guidance for health systems worldwide seeking to prepare for and respond to the increasingly frequent and multifaceted crises of the 21st century.
Subject of Research: Health equity and system resilience in crisis settings, specifically focusing on healthcare provision for refugees during the 2021 Afghan migration to Iran.
Article Title: Health equity and system resilience during crises – ensuring healthcare for refugees based on lessons from Iran’s response to the 2021 Afghan migration.
Article References:
Karimian, Z., Hashjin, A.A., Bellizzi, S. et al. Health equity and system resilience during crises – ensuring healthcare for refugees based on lessons from Iran’s response to the 2021 Afghan migration.
Int J Equity Health 24, 191 (2025). https://doi.org/10.1186/s12939-025-02564-6
Image Credits: AI Generated
