This study provided an overview of the impact of economic sanctions on health outcome and healthcare system indicators, as well as the perceived experiences of Iranian citizens during 2000–2020.

We identified significant changes in 11 indicators (39.2%) after the change point (Cp > 2009), while four indicators (14.2%) showed a significant increase after Cp (β_02-β_01 > 0). Findings revealed considerable increases in the out-of-pocket expenditure, household expenditure on food, COPD mortality rate, thalassemia mortality rate and hypertension mortality rate, during the study period. The increase in OOP reflects a significant additional financial burden on households. In practical terms, this means that under sanctions, a large number of families had to spend more of their disposable income on healthcare services, which could lead to difficult trade-offs between healthcare and other essential needs such as food, housing, and education. For the average citizen, particularly those in lower-income brackets, this increase in healthcare costs could result in delayed or avoided treatments, worsening health outcomes, and deepening health inequities. The effect is especially severe for patients with chronic illnesses, as continuous medical care becomes more unaffordable, potentially leading to poorer long-term health outcomes and higher mortality rates in vulnerable populations. A 6% rise in household expenditure on food during sanctions reflects the increasing cost of food, likely due to inflation and restricted imports. For the average citizen, this means that a larger portion of their income went towards basic necessities such as food, which might have exacerbated malnutrition and food insecurity, particularly among vulnerable populations, leading to long-term negative health effects, especially for children and the elderly. Increase in the mortality rate due to COPD, Thalassemia and Hypertension during sanctions signals that individuals suffering from these conditions faced worsened outcomes, likely due to restricted access to medication, healthcare services, and medical supplies. The impact of this increase is profound, as it implies that the sanctions contributed to the deterioration of health in those with such diseases, increasing premature deaths, and reducing quality of life, especially for older adults and those in lower socioeconomic groups.

The patterns observed in the heat map align with broader literature suggesting that sanctions exacerbate existing inequalities in healthcare access and economic resilience. Studies have shown that sanctions tend to disproportionately impact lower-income regions, where healthcare infrastructure is already limited [13]. The increased share of household expenditure on food in poorer provinces, coupled with rising out-of-pocket healthcare costs, indicates that sanctions further strained household budgets, forcing difficult trade-offs between healthcare, nutrition, and other necessities. Practically, these interactions highlight the need for targeted policy interventions to mitigate the compounded effects of sanctions on vulnerable populations. The increased inequality across provinces, as visualized in the heat map, suggests that regional disparities in healthcare access are likely to worsen under prolonged sanctions, with long-term health consequences, particularly for chronic disease management.

Despite identifying a significant increasing trend in some cancer mortality rates, i.e. stroke mortality rate and leukemia mortality rate, we did not find significant changes in such indicators. Our qualitative findings explored a wide range of negative effects of sanctions on citizens’ ability to access and receive quality medication and essential treatment interventions. Due to imposing financial hardship, sanctions led to catastrophic healthcare expenses, thereby deteriorating health indicators even further. Moreover, by shrinking healthcare resources, i.e., human and financial resources for health, medical equipment and medications, available healthcare services, as well as targeting the economic, social, and political infrastructures related to health, sanctions may affect the country’s healthcare system.

Despite our expectation, our finding did not present significant changes in the health outcome indicators. This might be partially related to the study period and type of selected indicators. For instance, health outcome indicators are influenced by environmental changes that occur over an extended period and have a lag time, therefore their effects may not be immediately apparent. Our research illustrated that investigating the effects of multidimensional and complex issues such as sanctions might need extended time periods. We propose considering longer time frames to allow an effective lag time of these indicators to elapse. Furthermore, the severity and intensity of sanctions were fluctuating, and potential instability means that the resulting complications may not have had a prolonged duration, preventing their effects from becoming significant when examined at a national level. In particular, indicators such as cancer mortality rates have low treatability and survival rate. Let al.one, local production of numerous medicines and medical equipment might have reduced the consequences of restricted imports. In addition, the extensive PHC network in practice over four decades, amalgamated with major healthcare reforms, i.e., the Family Physician and Universal Rural Health Insurance in 2004, and Health Transformation Plan to achive UHC in 2014, and domestic production of generic medicine have contributed to significant improvements of various health indicators, i.e., maternal and child mortality rates, control of chronic diseases (such as hypertension and diabetes), and access to healthcare services [10, 13, 26].

In line with previous studies, our qualitative findings revealed difficult international financial transactions that have hindered the importation of a significant number of necessary raw materials for medicine production. It was perceived that medicines were produced with lower quality, which might have led to ineffective and prolonged treatment periods, especially for complicated and chronic diseases, ever increasing cost, particularly for orphan drugs, scarcity of imported medicines, supply shortages of vaccines and other essential medical equipment, intensified patients’ dissatisfaction, and ultimately, increased mortality rates (notably among patients suffering from asthma, thalassemia, hemophilia, chronic diseases, blood disorders, multiple sclerosis, HIV/AIDS, and cancers) [3, 21, 27,28,29].

One study that examined the health-related effects of sanctions across four dimensions (health indicators, food security, medicine and treatment, and air pollution) demonstrated a relatively strong performance of Iran in health indicators for infants, children, and mothers compared to other middle-income countries. Improving medical care during pregnancy, childbirth, and postnatal care within the PHC platform, as well as the percentage of birth attendants in healthcare facilities, might be the main reasons, we envisage, behind infant mortality reduction in Iran [30,31,32]. We echo evidence form another study that in the absence of sanctions, the trends of infant and maternal mortality reduction might have been even more upward [32].

A comprehensive national and subnational breakdown of the burden of diseases, injuries, and risk factors presented the most substantial negative changes in mortality caused by NCDs - neoplasms in particular - associated with sanctions in Iran, with degrees of inter-provincial inequalities [10]. We found two out of 10 neoplasm mortality rate indicators, i.e. leukemia and prostate cancer showing an increasing trend after the imposition of sanctions, which were unequally distributed at the sub-national level.

There is an overwhelming evidence about the negative impact of sanctions on public food security, one of the main determinants of health [21]. The secondary effects of sanctions on banks, shipping, and insurance further hinder the import of food, raw materials and necessary machinery for food production. Consequently, the production index of certain food products was significantly impaired, with a cumulative effect exacerbating food insecurity in Iran [33]. Our findings revealed a correlation between sanctions and the share of household expenditure on food. This indicates that families are spending a higher percentage of their income on food products or, due to increased prices, are avoiding the purchase of certain products (such as animal-based proteins and dairy), which might result in reduced overall food security.

Studies in Iraq, Cuba, Libya, Venezuela, Iran and recently Russia consistently demonstrate the adverse effects of sanctions on access to public healthcare services [6, 7]. In Cuba, sanctions were associated with a marked escalation in malnutrition, especially among children. There was also an increase in mortality due to water pollution and increased vulnerability to other toxins. Additionally, sanctions caused severe increases in anemia among expecting mothers, typhoid fever, viral hepatitis, scabies, childhood diseases, and hospital infections [33]. The United Nations’ sanctions against former Yugoslavia, Serbia, and Montenegro (1992–2001) increased the incidence of tuberculosis, measles, and typhoid fever, along with higher hospital mortality rates and challenges in procuring food and basic commodities [33]. Similarly, sanctions negatively affected people’s health in North Korea and Venezuela [28, 34]. Although comparing the experiences of different countries is challenging and limited due to contextual variations and heterogeneity, such comparisons reveal common health trends despite differing geopolitical, economic, and social backgrounds. Sanctions can influence citizens’ health both directly and indirectly through various mechanisms [2, 9, 18, 27, 28, 35,36,37,38,39,40] The bureaucratic and economic barriers imposed by sanctions are likely to elevate challenges in production, import, and distribution of medicines, food, and related goods. Additionally, they result in elevated fuel costs, price surges for essential goods, reduced access to healthcare services and clean water [9, 33]. Moreover, factors such as insurance restrictions, reliance on self-insurance, restricted transportation and port access, decreased welfare, and disruptions in social stability and education, all may have deteriorating effects on public health. Reductions in welfare and disruption of social stability and education play fundamental roles as well. Worse still, shrunk financial resources and reduced human resources for health due to migration of workforce have led to less competent healthcare services, and the academic losses to less competent research activities. The impact of sanctions often intertwines with factors such as internal unrest, war, infrastructure collapse, breakdown of the rule of law, refugees’ movements, and environmental degradation, all of which can substantially affect the health status of the population. In addition, the impact of global challenges on the health of populations and the performance of the health care systems, such as migration movements, climate change effects and pandemics will have to be considered as competing risks, as well as demographic and epidemiologic transitions going on in respective countries [8, 13, 33, 41, 42].

Rigor and limitation of study

To the best of our knowledge, this is one of the few studies with quantitative measurement of the impact of sanctions on health indicators. Measuring the trend of 28 indicators over a 20-year period at both national and provincial levels, identification of the impact of sanctions on health from the perspectives of both the general public and policymakers and an innovative study design combining quantitative and qualitative components are some strengths of this study. Nevertheless, measuring the impact of sanctions on health indicators may require a longer period of observation and measurement. Should this study had primarily focused on the intermediate and process indicators instead of health outcome indicators, it could have provided a clearer illustration of the sanctions’ impact on the country’s population health and healthcare system.

This study had to deal with an intrinsic very high level of complexity due to the various dimensions and factors involved that affect health in addition to the specific pathways of sanctions. For instance, independent from sanctions, Iran has undergone several health policy reforms during the 20 years observation time of the study, which may have severely affected population health and the functioning of the health care system. In addition, similar to other LMICs, epidemiologic transition happening in Iran is associated with major changes, making it difficult to formally distinguish and dissect all these factors from another. Let alone, these factors and dimensions are not independent from each other and are strongly interconnected. Hence, exact identification of the role of international sanctions on health in a country like Iran (and others) remains hard. Also, the methodological constraints inherent in social research, rooted in the intricate fabric of society, pose significant challenges. Of paramount importance is the inherent limitation associated with the inability to fully control all confounding variables, thereby jeopardizing the transparency and validity of the observed effects pertaining to the variable under scrutiny. Unlike the controlled environment of experimental research, the dynamic and multifaceted nature of social studies renders it arduous to account for and manipulate all potential influencing factors, impeding the establishment of unequivocal causal relationships.

For indicators showing a decreasing trend, such as maternal and under-5 mortality rates, one can speculate that these rates might have declined more rapidly in the absence of sanctions.

Mortality rates chosen for investigation with respect to various types of cancers are known for potential lower survival rates and low treatability and might therefore have a low susceptibility to therapeutic interventions. Consequently, access to effective drugs and treatments may only slightly increase survival times, which could explain why mortality rates were not substantially affected by sanctions.

One potential limitation of the JPR model is its assumption of linearity within each segment. Nevertheless, we tested the robustness of our findings by conducting a sensitivity analysis with alternative change points. The consistency of the results across different points reinforces the significance of the detected changes around 2009, likely attributable to the sanctions. This strengthens the validity of our model and conclusions.

The credible intervals and p-values were computed using a Bayesian framework, with the credible intervals reflecting the uncertainty around the estimated coefficients. To further ensure the robustness of our model, we performed a residual analysis and used goodness-of-fit measures, such as AIC and BIC. These diagnostics indicated that the model provided a good fit for the data, with no significant patterns detected in residuals that would suggest model misfit. The consistency of these diagnostics strengthens the confidence in our findings.

The reliability of our dataset, which spans multiple indicators and dimensions, was supported by the use of sound statistical methods. The combination of JPR and GAMM allowed us to manage the complexity of the data while ensuring that the interactions between variables were accurately modeled. These approaches helped mitigate potential biases and provided a reliable framework for assessing the effects of sanctions on macroeconomic conditions and health outcomes.

While our models, including the JPR and GAMM, were designed to analyze the impact of sanctions on economic and health indicators, they face certain limitations. Attributing changes in health outcomes solely to sanctions is challenging, as other factors like healthcare reforms, regional conflicts, and global economic crises may have also played a role. Additionally, unobserved confounders, such as variations in healthcare infrastructure and population behaviors, could introduce bias. Our models, while effective at capturing complex relationships, may not fully account for interactions over time or external shocks (e.g. economic crises, potential impact of climate change) and delayed effects of sanctions. The assumption of linearity in the JPR model may overlook non-linear or lagged responses, suggesting that alternative approaches like time-series models could offer further insights.