Introduction
long-term development programs are a tool for drawing up future horizons. Therefore, by reviewing and analyzing development plans, the relevant experiences in the laws of development plans can be suggested; this could help to formulate health sector laws in future development plans or other comprehensive health services regulations [1].
One of the most important goals of the Islamic Republic of Iran is to preserve, provide, and promote the health status of all individuals in the society; this matter has been referred to in several constitutional principles in various forms [2]. Chapter 29 of the constitution of the Islamic Republic of Iran recognizes the right to health and medical care services for all. The second reflection of the right to health in Iran’s laws is the 20-Year vision plan document (2025 Vision). It describes the specifications of a healthy society in Iran and refers to the health sector items [3]. Health has been raised as a right in the upstream documents and laws. It also has a direct and indirect effect on increasing the country’s productivity and economic growth [4]. Economic, social, and cultural development plans in Iran from the pre-revolutionary years initiated with the aim of macro-management planning.
Preliminary plans were designed using a development approach (relying on the plan and project). From the planning point of view, the post-Islamic era can be divided into two parts; before and after the Iran–Iraq war. After the war and since 1981, planning activities were seriously on the agenda of the government. Despite the efforts made in the post-revolution years, the first medium-term development plan was launched with an 8-year delay in 1989. Since then, 6 development plans have been drafted and issued in Iran [5-7]. Many studies have evaluated the various dimensions of development plans [5-9]. 
A study investigated the status of Iran’s laws environment within the post-revolutionary years. They reported the upward trend and the development of environmental laws in the process of drafting and approval of planning laws regarding the regulations of 6 and 4 development plans before and after the Islamic revolution, respectively [5]. Another study addressed note 2, article 32 of the fifth national development plan regarding the phenomenon of physicians’ moonlighting from the health experts’ viewpoints. It also investigated the challenges of implementing this law. They concluded that establishing the necessary grounds in structural, managerial, regulatory, and monitoring dimensions, allocating adequate funds, reforming the tariff system, and payment mechanisms, having gradual and step-by-step implementation in the early stages, improving the quality of services in the public sector, and building trust between physicians and authorities are essential for the more effective implementation of this law [10]. 
In the field of health, Moghadam et al. reviewed the health status in the fifth development plan. They suggested that 11% of the policies in this plan are associated with the health sector, including the integration of policymaking, planning, evaluation, monitoring, and financing, the quantitative and qualitative development of health insurance system, and reduced out-of-pocket expenses for the health services by about 30% at the end of the plan [11]. Additionally, a study examined the right to health in various upstream documents, including the fourth and fifth development plans [3]. These studies have only addressed some development plans and disregarded a comprehensive look at all development plans.
Studies conducted in this field are incomprehensive and inadequate. In addition, each of the subsequent studies has investigated several aspects of the plans. Despite the limited attention to the health issues in development plans, no study has comprehensively addressed the health status in the national development plans. Thus, this study aimed to address and analyze the vital health promotion issues in the first (1989-1993) to the sixth (2018-2021) economic, social, and cultural development plans.
Methods
This review study used a documentary analysis method. Documentary analysis is a qualitative method in which the researcher strives to systematically use documentary data to discover, extract, and evaluate the content related to the research subject [12]. The current research explored purposefully-selected upstream documents. The data collection instrument was a researcher-made checklist. Using the checklist, some information, including the type of document, year, and place of publication, the purpose of publication, the timing of the document, and the health promotion notes and articles were extracted. Then, the time graph was plotted and the obtained information was analyzed. 
The face and content validity of the checklist was confirmed by 5 faculty members and PhD. students at Tabriz University of Medical Sciences. One faculty member and 4 PhD. students in health policy and health services management have expressed their views on the face and content validity of the checklist; the necessary changes were accordingly made and the checklist was finalized. The purpose of this work was to ensure that our collected information was aimed at studying. We investigated a set of documents approved in the first to sixth national development plans, which has been counted. 
Content analysis techniques were used for data analysis. Content analysis is subject-based, and the analysis unit is the content of the text [13]. The relevant representatives were searched in the form of these themes and were used to analyze the plans. The 6 national development plan documents were directly used in this article. This method facilitated examining health promotion issues in terms of quantity (frequency) and quality (importance and value) with maximum accuracy. The observation and recording units included the articles and notes of each approved law by the national development plans. Furthermore, the analysis unit was each specific development plan. 
Results
Health promotion concepts were reviewed and identified in the first to sixth development plans. There has been increasing attention to health issues throughout these 6 plans; a chapter on health has been added after the third development plan. Table 1 lists the provisions and notes of the first to sixth development plans referring to health promotion issues.

Different cases have been concerned according to the time conditions of the plans. Health promotion issues have been included in the plans since the first post-revolution development plan. Moreover, they have covered more topics, health insurance, and treatment for car accident injuries over time. Some decisions were also made in different plans concerning the time conditions. For example, with an increase in the prevalence of various diseases, some decisions were made to control them. In addition, the passage of time has had a visible impact on population-related issues; population control policies are discussed in the second development plan. Eventually, population expansion policies were of concern in the sixth plan.

In the first development plan of the Islamic Republic of Iran (1989-1993), the constitution and many upstream documents have recognized health as a fundamental right and identified it in their legal system. In this regard, the government is required to consider a comprehensive plan or national policy for its realization. It is also necessary to strive for creating suitable conditions to provide access to the highest health standards for all [3]. The first development plan was drafted after the end of the Iran-Iraq war in the absence of accurate data [7]. The plan mostly focused on the following objectives:
1. Restoring and strengthening national defense capabilities, reconstructing production centers, and damaged population during the Iran-Iraq war;
2. Promoting economic growth with an emphasis on the self-sufficiency of strategic agricultural products and inflation inhibition;
3. Meeting the basic needs of people and striving to provide Islamic social justice;
4. Specifying and modifying the consumption pattern;
5. Reforming the organization, executive, judicial administrations in Iran [14].
The second development plan of the Islamic Republic of Iran (1995-1999) with a single article and 101 notes was adopted in 1994 [5]. The quality objectives of healthcare in the second development plan are as follows: promoting healthcare services in the country, developing preventive measures in health care networks, organizing public health facilities and food centers, developing environmental operations and drinking water supply in villages, increasing access to treatment facilities, preventing the unnecessary consumption of drugs, establishing symmetry in the levels of general, specialized, and super-specialized health services, increasing the efficiency of inpatient treatment centers, optimizing the benefits of human resources and capacities, and providing the grounds for the participation of private sector in investments [15].
Health promotion plans mainly contain the public health sector, treatment, medicine, health insurance, and medical education. These aspects are not explicitly distinguished in the first development plan; however, they are entirely classified in the second and third plans. In general, the objectives are to some extent, seem to be determined based on unreachable political incentives [16].
The first and second economic, social, and cultural development plans aimed at achieving self-sufficiency and self-reliance; the third development plan was emerged to encourage structural reforms [7]. The third development plan of the Islamic Republic of Iran (2000-2004) was issued in 26 chapters, as well as 199 articles for two sectoral and supra-sectoral fields. One chapter of this plan was allocated to the health field for the first time. The main objectives of the third development plan were as follows: reduced government ownership, the expansion of the private sector, participation of the public in economic activities, social justice, decentralization, public access to information, environmental conservation, export promotion strategy, attention to cultural changes, providing free health and treatment services, and public access to food. The health and treatment promotion chapter in the third development plan contained issues, such as the free provision of all urban and rural health services by the government, ranking and regulating medicine market services, and food security.
The fourth development plan of the Islamic Republic of Iran (2005-2009) was complementary to the third development plan, and its main subjects of concern were interaction with the global economy, the expansion of privatization and economic competitiveness, knowledge-based development, the equality of educational opportunities, environmental conservation, food security and public health, universal access to health services, the establishment of justice and the reduction of social inequalities, the promotion of social capital, human and citizenship rights, the preservation and identification of Iran’s historical identity, detente with international relations, women’s affairs, national security, the development of judicial affairs, and state modernization [7].
The fifth development plan of the Islamic Republic of Iran (2011-2015) was adopted in 2010. It has been drafted to fulfill the 2025 vision document. Health and treatment issues were raised in its third chapter (social issues), the healthcare and health insurance section, and different chapters. In the Healthcare section of the fourth development plan, the implementation of the family physician project and the reduction of patients’ direct payments from 60% to 30% were concerned; however, they were not practically undertaken. Therefore, these issues were re-discussed in the fifth development plan [17]. A challenge of the health system is the simultaneous employment of physicians in the public and private sectors. In this regard, full-time physicians Law was considered in the fifth development plan. Furthermore, the Board of Trustees of Hospitals was also set as one of the priorities of the Ministry of Health and Medical Education [18].
The sixth development plan of the Islamic Republic of Iran (2017-2021) consists of 124 articles and 128 notes. Furthermore, it was approved by the Islamic Consultative Assembly on Saturday, March 14, 2016. Section-14 compromises with health, insurance and family-related issues. Considering that sustainable development and its indicators are subject to supra-sectoral field and include all socioeconomic, cultural, and environmental aspects of development, and the countries will be evaluated based on such indices shortly; therefore, the integration of these indicators into the policies and plans in different fields of the sixth development plan is inevitable and should be considered as target indicators in different fields [19]. Sustained and tax-based financing is the primary requirement of the health promotion plan. Thus, it should be well planned and implemented in the sixth development plan [20]. Figure 1 summarizes the health-relevant issues in the first to sixth development plans. 
Discussion
Health-related issues in the 6 development programs in Iran indicate that the approach of these programs was initially only the physical development of state-run healthcare facilities. From the beginning of the third development plan, there was a slight tendency toward service delivery. Moreover, the arguments of justice Distribution were introduced. In the fourth and fifth plans, concepts like equity in health have been developed. In addition, approaches to physical health and equity in access to health services and economic justice seem to have changed in health. In the sixth plan, the issue of financing through the tax on harmful goods has been considered.
In the fourth and fifth plans, concepts, like equity in health, have been developed. Besides, approaches to physical health and equity in access to health services and economic justice seem to have altered in health.
In the first development plan, more attention was paid to development and infrastructure health issues concerning the critical conditions of the country. The first development plan mostly focused on the following goals regarding health and treatment: the provision of health access for all by 2000, development of health education, the extension of social-medical perspective, decentralization, enhanced efficiency of different units and fair distribution of medical facilities, and regulation of medical conditions [15]. In the first development plan, the government’s focus was primarily on primary healthcare and public access to health care [4]. In 1978, the Declaration of Alma-Ata announced “Health for All by 2000” to all countries with the primary health care approach [21]. During the development process of this plan, the primary healthcare approach was of concern for all countries.
Furthermore, “Health for All by 2000” was mentioned as the general objective of the first development plan in Iran. Since the early 1990s, the self-governing hospital project has been implemented throughout the country. Accordingly, providing all costs of hospitals and educational centers other than the salary of personnel and staff should be provided from their specific revenues. According to the first development plan, the hospital is a self-governing body and (must) reimburse its revenues and the government pays only part of the development and personnel costs [22]. In the first and second development plans, issues such as public participation, inter-sectoral cooperation, the change of objectives, form of training, training medical personnel according to the increasing needs of the community, and changing the responsibilities of health centers and hospitals in the health system are not sufficiently concerned [15]. 
The healthcare network was established in 1985; it aimed to ensure the fair access of all individuals to primary healthcare and with prioritizing rural and deprived rural regions in the country [23]. The further expansion of the network services has been addressed in the second development plan.
In 1995, the instructions on the new hospital contained three objectives. Promoting the motivation of physicians and medical personnel, increasing the financial capacity of hospitals, and enhancing the authority of hospitals [24]. Article 192 of the third development plan also refers to the partial payment of revenues as a fee. The reformation of the budgeting system and the targeted linkage of resources to operational plans have been considered in formulating the strategic policies of the third development plan (Strategic Policy 15); consequently, it was mentioned in paragraph b of note 23 in budget act 2002, as well as in the paragraph m of note 1 in budget act 2003. Accordingly, Iran’s management and planning organization were obliged to implement the budget system reforms to operationalize budgeting and reform the revenue and expenses estimation system in all executive agencies, and to distribute cost credits based on the requirements of organizations and their performed activities [25]. 
In the third development plan, the quality of health services is among the government’s concerns in the field of health promotion. Governments and policymakers in the field of health promotion are inevitably in need of change and initiation of reforms, one of which is the initiation of active participation of the private sector in providing primary healthcare services. The healthcare cooperatives in East Azarbaijan Province is an example of private sector participation in health services [26].
Regarding controlling AIDS in 2001, there was proposed a five-year national strategic plan for the first time (2002-2006) by the Ministry of Health and Medical Education and with the partial collaboration of other organizations. This plan emphasizes the participation of other sectors and organizations, including both state and private ones [27, 28]. One of the policies of the third five-year plan for the development of the country in terms of the higher education sector is to improve the quality of education.
Additionally, education development centers and units are established at the universities of medical sciences for the same purpose; therefore, these centers are in charge of implementing this policy at universities [28, 29]. The concept of ‘quality of life’ was first included in the fifth plan before the revolution. In the third and fourth plans after the revolution, the concepts of citizenship, empowerment, and social capital were also included.
In the fourth plan, quality of life has been considered from three aspects; supporting needs, environmental needs, and basic needs [30]. In articles 138-88-49 and 144 of the fourth national development plan, rationalization of the government volume and size, gradual reduction of the funding costs, improvement of the service provision to the public, and attraction of the participation of the non-state sector and the development of employment and spending more budget and public revenues have been highlighted [25]. Based on articles 89, 90, and paragraphs B and C of article 91 in the fourth development plan and budget control act of 2005, the villagers’ insurance program with a focus on a family physician and a referral system began in all villages and towns with population less than 20000 individuals. This plan would increase the presence of physicians and healthcare members in health centers [31]. Furthermore, before the implementation of article 92 and the fourth national development plan, some of the patients injured in accidents could not financially afford the hospital bills after visiting the hospital and receiving treatment services.
The vehicles crashed with an injured person may not be covered by car insurance, or the driver might have left the accident scene. Thus, such patients had difficulties in post-treatment payment. After the law was implemented, many of these problems were fortunately resolved. According to this law, 10% of the amount paid for the car insurance will be deposited in the treasury’s special account. This has been mentioned in later development plans, and the implementation of this plan is currently effective [32].
One of the key slogans of the 11th national election campaign was a change and reform in health, making it one of its priorities. The government has been struggling to operationalize paragraph B of article 34 in the fifth development plan. In this regard, the health system reform was raised under 7 main fundamentals; establishing universal health insurance, controlling payment of sick leave in hospitals, extending vaginal and free delivery, motivating physicians’ stay in deprived areas, developing specialists’ stay in hospitals, and others. These were performed in the pursuit of the objectives of paragraph 19 of the general policy stated by the supreme leader and paragraph B of article 34 in the fifth development plan act, i.e. the reduction of the public health expenditure shares by 30% [33].
In the future, international decisions should be considered in drafting development plans. An explicit example of this issue is the Millennium Development Goals (MDGs) program, which was adopted at the largest gathering of heads of states in September 2000 in New York. The sustainable development indices were raised at Rio+20 Summit in Rio de Janeiro, Brazil, in 2012. It was agreed that these goals would be used as a benchmark to replace the MDGs to evaluate human activities in general and governments in particular regarding sustainable development over the next few decades. Moreover, the necessity of coordinating the provisions of this act with operational plans of the Ministry of Health and Medical Education and other related organizations should be considered. Furthermore, the monitoring and evaluation mechanism of the plans should be in line with the national development plans, which will increase coordination in this regard. The health promotion plan has begun with the goals, same as the fifth development plan, and general health policies have been stated by the supreme leader. The sixth development plan has also emphasized on the same goals, including increasing access and reducing from out-of-pocket payments for patients.
Furthermore, the screening plan for genetic diseases has been first mentioned in the sixth development plan. The timely and complete implementation of some plans proposed by the Ministry of Health and Medical Education, including the family physician, referral system, and service ranking, can meet many provisions of the recent development plans. Referring to some issues of the development plans in light of the binding nature of the law (e.g. the establishment of an electronic record system and the creation of health science settlements) can be beneficial.
A limitation of the present study was the lack of access to the preliminary drafts of development plans and considerations at the time of the compilation, changes made to the finalization of the development plans. Further comprehensive analysis of development programs is required.
Conclusion
Development plans are the overall reflection of the underlying and priority issues of the health system at a specific time. Failure to achieve the expected results in the plan and the repetition of the same article in the next plan reflects the government’s poor commitment to some of the provisions of the plan, especially at a certain time, as well as their insufficient attention to international trends and health promotion issues.
Furthermore, changes in general policies, like demographic policy alternations, affect repeating some cases in various development plans. Additionally, the change in the management team of the Ministry of Health and Medical Education significantly impacts the content of the development plans; changes in the content of development programs can be observed with the change of government and, consequently, the Ministry of Health and Medical Education. For example, the creation of the Council for Health and Food Security changed in different periods.
Ethical Considerations
Compliance with ethical guidelines
This research has been reviewed and approved by the Institutional Review Board (IRB) at Tabriz University of Medical Sciences (code:IR.TBZMED.REC.1397.908).
Funding
The authors received no financial support for this research.

Authors' contributions
Study design, data collection and analysis and manuscript preparation: All authors.
Conflict of interest
The authors declared no competing interests.


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