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Table 1 Agents, their properties, role, power, and objectives

From: Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

Agents or subsystems Role Related components Importance/power Objectives/ incentives  
Supply-oriented Ministry of health and medical education (MOH) It is the main policy-making and stewardship agent that decides about macro health policies. It also regulates and finances all service provisions in healthcare Deputy of curative affairs, deputy of education and deputy for health. Some components like medical universities existing all provinces all around the country, are defined as a major and separate agent. The most important governmental agent that oversees all the actions and processes in health care system and is in charge of all things related to public health. Providing health and hygiene to all citizens.
Iran Food And Drug Administration (IFDA) Supervising and regulating all the processes of manufacturing, distributing, and use of antibiotics. It is authorized and financed by MOH The National Committee on Rational Use of Drugs (NCRUD), General directorate of Pharmaceutical and narcotic affairs It is the most substantial supervisory body that directly controls all the processes of supply and access to antibiotics. It makes policies related to access to antibiotics and compiles pharmaceutical guidelines through collaborating with other related bodies. It is also responsible for the rational use of all drugs, especially antibiotics. Enabling access to effective and safe medicines in a rational way.
Basic health Insurance companies They reimburse antibiotic drugs. There are three major basic public insurance companies in Iran. Besides National health Insurance called Iran Health Insurance Organization (IHIO) and Social Security Insurance (SSI), there is also Ministry of Defense Health Insurance Organization. There are also many private insurance companies, but they are not usually considered as major players They are the main enforcing levers of health policies in Iran. They can rationalize the use of antibiotics by developing limitations and special regulations for reimbursing antibiotics. Trying to minimize their cost.
Medical universities They are authorized by MOH. They educate and train physicians, pharmacists, specialists, and other healthcare professionals who can order or deliver antibiotics. Vice chancellor of Food and Drug administration in medical universities, Educational hospitals and pharmacies, professors, students and medical residents The power of medical universities is pretty high because MOH and IFDA enforce their supervision of prescribing and delivering antibiotics through Food and Drug Departments of different medical universities. All departments have a RUD committee. They periodically check upon physicians under their supervision to ensure their acceptable prescription practices and provide feedback to them. Additionally, they play a critical role in promoting physicians and pharmacists’ knowledge and practice of antibiotics by continuing medical education (CME) programs. They can also supervise all promotional activities of pharmaceutical companies in hospitals, pharmacies and clinics, etc. Training qualified and knowledgeable physicians, pharmacists and other health care professional. Helping health care professionals maintain competence and learn about new and developing areas of their field.
Research centers Conducting clinical and non-clinical researches related to the rational use of antibiotics. The outcome of their researches may influence two main processes: policy-making and antibiotic prescription. Communicating and collaborating with policy-makers and prescribers adequately. Carrying out feasible and practical researches.
Islamic Republic of Iran Medical Council (IRIMC) IRIMC is the largest national non-governmental organization in which all health care professionals (except nurses) have to register to be granted permission to practice in the country. It regulates health care professionals’ collaborations with other associations. It has developed many regulations and guidelines related to medical practice standards. It has more than 190 branches all over the country in different cities. It can play an important supervisory role in physicians and pharmacists’ practices. Additionally, it can affect the physicians’ prescription behaviors through their contribution to the development and enforcement of guidelines as well as educational programs. Improving and modifying medical affairs in Iran. Supporting patients’ and health care professionals’ rights. Promoting medical knowledge in Iran.
Scientific and guild NGOs Providing educational and research services. They support healthcare professionals’ rights. Many scientific and non-scientific NGOs are practicing in different fields of medical sciences. They play a significant role in other health care professionals’ behavior such as nurses, dentists, etc. They also enforce regulations, influence antibiotic prescription practices, and make connections between different groups of healthcare professionals. Improving education, training and research services. Protecting physicians and pharmacists’ monetary and non-monetary rights.
Pharmaceutical companies Producing or importing necessary pharmaceuticals of the country. Introducing, providing and promoting antibiotics to prescribers and pharmacies through diverse promotional activities. It includes many manufacturing and importing companies. They can highly affect both demand and especially supply sides of the antibiotic market. They promote their products through different ways such as giving free samples, discounts, gifts, etc. Making more profit through grabbing and maintaining more market share.
Prescribers They prescribe antibiotics to the patients. It includes physicians (General Practitioners or specialists), dentists and midwives. After MOH, they are the second important agent in both supply- and demand-oriented group agents. They determine the number and quality of antibiotic prescription. A wide range of interests from enhancing rational use of antibiotics and patients’ quality of life to monetary objectives and visiting more patients.
Hospitals Providing in-patient care service and also most of the time, out-patients’ services. Physicians, nurses, clinical pharmacists, Pharm-D, pharmacotherapy committee, and antibiotics stewardship committee Their practice highly affects the volume and the quality use of a wide spectrum of injectable antibiotics. Controlling antibiotic use, improving the rational use of antibiotics in order to prevent antimicrobial resistance at hospitals
pharmacists Delivering antibiotics to patients and to the general public. They also have to explain and give consultation to patients about the use of antibiotics in terms of how to use, interactions and side effects, etc. Irrespective of codes of action, they sometimes provide antibiotics to the public and patients over the counter. They occasionally collaborate with pharmaceutical companies to sell more antibiotics. They can also collaborate with physicians to prescribe more antibiotics. Providing good service delivery and maximizing their profit.
Demand-oriented mass media Improving public knowledge about antibiotics through educational programs and contents. TV, social networks like Instagram, telegram, Facebook, etc. They can highly affect public knowledge, attitudes about antibiotics. They also help to modify the general public’s life style and alter their perception of antibiotics, physicians and pharmacists. To attract and maintain more audiences.
Patients and public use antibiotics (final consumer) Patients, patients’ families and friends, public population They are the most important agent on the demand-side. Their health literacy, knowledge, perceptions, expectations and experiences highly affect antibiotic use. Living better and more comfortably. Having the best treatment in the world for their illnesses. Having the lowest cost services.