Abstract
Introduction
In recent decades, the nexus of public health, environmental governance, and economic development has emerged as a critical domain in public policymaking and political economy. In post-1989 Iran, national development trajectories have prioritized energy-intensive heavy industries (petrochemicals, steel, and cement), fossil-fuel-dependent transportation, and an entrenched reliance on hydrocarbon rents amid rapid urbanization. Consequently, systemic environmental hazardschiefly severe ambient air pollution, ecosystem degradation, and industrial emissionshave systematically eroded public health, precipitating an epidemiologic surge in non-communicable diseases (NCDs), including cardiovascular diseases, chronic respiratory illnesses, and malignancies. Despite the severity of this crisis, extant scholarship and policy frameworks predominantly analyze environmental degradation and healthcare provision as discrete, uncoupled domains. This sectoral fragmentation obscures the structural mechanisms through which a carbon-intensive accumulation regime externalizes health hazards, and how market-oriented, curative healthcare reforms transfer the resulting financial and epidemiological burdens directly onto private households.
Objective
This study elucidates the structural linkages among the fossil-fuel-based development paradigm, systemic public health degradation, and the commodification of healthcare in Iran spanning 1989 to 2021. Introducing Carbon-Based Biopolitics as an overarching analytical framework, this research interrogates how persistent hydrocarbon dependency structurally generates environmental morbidity while driving market-oriented institutional realignments within the healthcare system that commodify medical services and transfer financial risks to citizens.
Research Method
A qualitative-historical approach with a sequential-triangulated mixed-methods design was implemented across three distinct operational phases:
1.Documentary Analysis and Process Tracing: A rigorous review of 659 cabinet resolutions, five-year national development plans (First through Sixth), annual budget laws, constitutional provisions, upstream health policies, and statutory oversight evaluations (e.g., the Islamic Parliament Research Center’s audit of the Clean Air Law) was conducted to delineate causal mechanisms. Potential selection bias was mitigated by enforcing explicit inclusion criteria concerning statutory authority, fiscal/institutional relevance, and longitudinal coverage (1989–2021).
2.Thematic Analysis: Empirical data derived from regulatory archives and 11 in-depth, semi-structured interviews with senior health policymakers, welfare specialists, and political economists (selected via purposive sampling until theoretical saturation) were examined using Braun and Clarke’s six-phase thematic framework.
3.Econometric Modeling (GMM): To empirically assess the institutional persistence of out-of-pocket (OOP) health expenditures and evaluate administration-specific policy shifts, a dynamic Generalized Method of Moments (GMM) model was estimated using longitudinal time-series data (1989–2021) compiled from the Central Bank of Iran, the Statistical Center of Iran, National Health Accounts, and the Ministry of Health. Methodological rigor was substantiated through data triangulation, peer debriefing, member checking, and standard diagnostic tests (ADF unit root, Sargan over-identification, and Arellano–Bond autocorrelation tests).
Results and Discussion
The findings identify a persistent institutional architecture across governing administrations from 1989 to 2021, transcending alternating political doctrines and rhetoric.
1.Econometric Estimates (GMM): The dynamic GMM estimation confirms significant state dependence in health financing, as evidenced by a positive, statistically robust lagged OOP coefficient (β=0.62, p=0.001\beta = 0.62, p = 0.001β=0.62, p=0.001), denoting strong institutional inertia. Political administration dummies proved statistically insignificantbarring a transient, fragile contraction during the Health Transformation Plan (2014–2016) demonstrating that executive transitions failed to disrupt systemic reliance on private household outlays. Furthermore, private sector expansion (β=0.38, p=0.002\beta = 0.38, p = 0.002β=0.38, p=0.002) and environmental degradation metrics (β=0.24, p=0.008\beta = 0.24, p = 0.008β=0.24, p=0.008) exerted statistically significant positive pressures on household financial burdens.
2.Documentary and Empirical Evidence: Despite ubiquitous egalitarian rhetoric in state policy documents, a structural divergence between discursive equity and institutional practice was observed. Although consecutive development plans legally mandated capping OOP expenditures below 30%, empirical records indicate that household OOP payments consistently oscillated between 35% and 50%. National poverty monitoring data confirm that OOP expenditures push approximately 2.8% of the population (2.4 million individuals) below the absolute poverty threshold annually, with 2.88% of households incurring catastrophic health expenditures. Specific deregulatory measuresnotably hospital self-financing mandates (1993), public sector outsourcing under Article 192 of the Third Plan, and structural deregulation under Article 88fostered incomplete privatization, transferring financial liabilities to households in the absence of independent regulatory mechanisms to govern tariffs, supplier-induced demand, and physician-hospital conflicts of interest.
3.Thematic Taxonomy and Causal Pathways: Qualitative synthesis identified six primary themes: Ineffective Justice, Incomplete Privatization, Curative Primacy, Healthcare Marketization, Medicalization, and Health Financialization. Process tracing verified the structural causal chain of Carbon-Based Biopolitics:
Hydrocarbon Dependence →\rightarrow→ Environmental Degradation & Severe Pollution →\rightarrow→ Structural Production of Disease →\rightarrow→ Curative-Centric Policy Paradigms →\rightarrow→ Incomplete Privatization →\rightarrow→ Shifting Health Financing Burdens to Households (OOP).
Conclusion
This research concludes that public health trajectories in Iran cannot be analyzed in isolation from the political economy of carbon-intensive industrialization. The framework of Carbon-Based Biopolitics demonstrates that environmental degradation, structural morbidity, and healthcare commodification form a self-reinforcing institutional cycle. Rather than mitigating preventable illness at its structural source by curtailing environmental contamination, public governance has systematically treated morbidity as an extractive market frontier, shifting the economic liabilities of biological degradation onto citizens.
Overcoming this path-dependent trajectory demands moving beyond intra-systemic healthcare adjustments toward coordinated governance across three tiers:
I.Macro/Cross-Sectoral Level: Accelerating low-carbon industrial transitions, enforcing the polluter-pays principle through environmental taxation on heavy industrial polluters, and earmarking these fiscal revenues exclusively for an autonomous national preventive health trust fund.
II.Institutional Level: Establishing a High Council for Environmental Health Governance empowered to enforce mandatory health impact assessments on capital-intensive industrial developments, institutionalizing a strict separation between healthcare stewardship and market provision, and building autonomous state regulatory authority to extinguish systemic conflicts of interest.
III.Operational Level: Realigning public budgetary commitments away from tertiary hospital expansion toward Primary Health Care (PHC), while guaranteeing comprehensive insurance coverage for essential NCD therapies and preventive services across lower socioeconomic strata (income deciles 1 through 4) to ensure robust financial risk protection.