Forty Years of Primary Health Care (PHC) in Iran: Achievements, Lessons and Future Directions.

Iran's Primary Health Care (PHC) system was designed and structured in the post-revolution era and rooted in the principles of the Alma-Ata Declaration, over four decades (1985-2025), it has evolved into one of the most resilient and equity-driven primary care platforms in the Global South. Serving a population exceeding 85 million, it illustrates how sustained investment in community-based care can generate population-level impact despite geopolitical pressures, economic sanctions, and shifting epidemiological realities. This review, as a commemoration of 40 years of PHC establishment, expansion, and institutionalization, synthesizes the system's historical evolution, transformative achievements, persistent constraints, and strategic directions for the decades ahead. Iran's PHC network has achieved near-universal rural coverage, dramatic reductions in maternal, neonatal, and child mortality, and substantial gains in life expectancy. These achievements have been preserved despite war, prolonged sanctions, and the COVID-19 pandemic. The Health Transformation Plan (HTP, 2014) represented a major step toward universal health coverage (UHC), reducing out-of-pocket payments. Yet substantial challenges remain: structural under-resourcing, insufficient community participation in urban settings, limited PHC coverage in large metropolitan areas, the rising burden of noncommunicable diseases, fragmentation, and insufficient inter-sectoral collaboration. Looking toward 2050, Iran's strategic trajectory depends on modernizing PHC through digital innovation, data-informed decision-making, strengthening self-care capabilities, reinforcing continuity of care for all population groups, revitalizing community engagement, particularly in urban settings, and embedding stronger equity safeguards across the entire system. With deliberate reorganization and sustained political commitment, supported by intersectoral governance, Iran's PHC system can consolidate four decades of progress and offer a compelling, adaptable blueprint for health systems navigating resource constraints and geopolitical adversity.