For four decades, the rule of Iran’s Islamic Republic has rested on the pillars of redistributive social justice, foreign policy independence, Islam and a managed form of electoral legitimacy.  These pillars, each of equal importance, have served as guiding principles bolstering Iran’s domestic and foreign policy decisions.  Amid the latest round of protests to have gripped Iran, it is clear that these pillars are fracturing. 

On 15 November at midnight, the Iranian government, in a move supported by Supreme Leader Ali Khamenei, President Hassan Rouhani, Speaker of the Parliament Ali Larijani and Head of the Judiciary Ebrahim Raisi, announced a 200 per cent increase in fuel prices – a redistributive measure designed to provide cash transfers to the population.

In immediate reaction, Iranian citizens took to the streets to express their discontent with this policy move alongside mounting economic and political grievances.

What ensued over the subsequent days was an outbreak of protests through 100 Iranian cities, including at universities and bazaars, that was followed by a weeklong internet blackout and a brutal crackdown that has left at least 200 people dead and 7,000 arrested. Initially, public anger focused on the price increases but quickly targeted the political leadership, lack of government accountability, effective governance and corruption.

This wave of protests is the fourth in a two-decade period – 1999, 2009, 2017 and 2019 – for the Islamic Republic and comes at time when the Iranian government is under severe economic strain from Washington’s maximum pressure campaign. It is equally burdened by endemic factional politicking.

These protests are one of many reminders of the shattered social contract between state and society in Iran, which without repair will continue to resurface.

With internet connectivity resumed and news of the regime’s brutality spreading, conservatives and reformists are both trying to distance themselves from this internal crisis and reposition themselves in advance of the 2020 parliamentary elections.

Parliamentary elections for Iran’s 290-person legislature are expected to be held on 21 February. Amid concerns over public apathy and lower political participation, both reformists and conservatives are trying to develop strategies to maximize gains at their ballot box.

Even before these protests, voter turnout was anticipated to be lower than normal. Participation in the July 2019 Tehran municipality election was at a nadir of 9 per cent.  To prepare for this challenge, Iran’s parliament has lowered the vote threshold for a valid result from 25 to 20 per cent.

Elections in Iran, while by no means completely free and fair due to the vetting of candidates by the Guardian Council, have repeatedly been an important barometer of public support and participation. Electoral participation, which is traditionally higher than in most Western democracies, and compared to the lack of electoral opportunities in the Middle East, is heralded as a sign of public legitimacy. 

Voter participation is generally higher in presidential elections than in legislative ones.

For example, 73% voted in the 2017 presidential elections, 72% in 2013, 80% in the contested 2009 elections, and 59% in 2005 elections that brought Mahmood Ahmadinejad to office. Comparatively, in the 2016 parliamentary elections 62% voted, in 2012, 66%, in 2008, 47%, and in 2004, 51% participated.

Voter turnout in the 2008 parliamentary elections, reflective of public apathy, mounting international tensions over the nuclear programme, and Guardian Council vetting of reformist candidates, could be emblematic of what to expect next year. 

In the run up to the election, conservative groups are trying to capitalize on popular economic frustrations, disappointment with reformists, wider regional security concerns and tensions with the United States to rally voters. 

Reformists associated with the Rouhani government, who also supported the Iran nuclear agreement, have been severely weakened by the US maximum pressure campaign and the return of US sanctions.  They are also blamed for the current economic downturn and remain frustrated by their ability to affect change in a political system that affords more power to unelected figures.

Amidst this stalemate, Rouhani has continued to call for a national referendum to no avail, while reformist groups are debating how to position themselves – some even calling for greater accountability – so as not be tainted by the government crackdown. Leading reformist politicians such as Mohammad Khatami have called on reformists to stay united and avoid boycotting the elections. It remains to be seen how their strategy will develop after the protests.

Should the Guardian Council bar too many reformists from running, calls for a boycott could snowball and even incite new protests. Together with low turnout at the ballot box, the outcome of this election could further damage the regime’s already fragile electoral pillar and weaken its claims to legitimacy.

Universal Health Coverage (UHC) is driving the global health agenda and is embedded in the Sustainable Development Goals (SDGs). According to the World Health Organization, universal health coverage means that ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’.

Despite this comprehensive starting point, it has been observed that UHC efforts to date have focused more on provision of treatment services than promotion and prevention strategies. Not only is this a missed opportunity from a financing perspective (public health interventions often offer better value for money than curative services), without robust health promotion and prevention efforts, UHC may not fulfil its potential towards reducing health inequity.

Primary health care (PHC) is a whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and equitable distribution. PHC has been described as the cornerstone of UHC. As set out in the recent World Health Assembly report by the Director-General Primary health care towards universal health coverage: ‘..with its emphasis on promotion and prevention, addressing determinants and a people-centred approach, primary health care has proven to be a highly effective and efficient way to address the main causes of, and risk factors for, poor health...UHC and the health-related Sustainable Development Goals can only be sustainably achieved with a stronger emphasis on primary health care.’

The 2018 Declaration of Astana has sparked a renewed commitment to PHC. For NCD and mental health advocates there is an opportunity to now build on the foundations of PHC, to deliver more equitable, people-centred and sustainable UHC.

This event sets out why promotive and preventive health services for NCDs and mental health disorders are such an important part of UHC. It will focus on two key dimensions: the role of health promotion and preventative services within UHC in delivering health for all, and sustainable financing through innovative fiscal policy.

As one of the first high level events looking exclusively at prevention in the context of UHC, it will serve as an important reference for those going forward into the High Level Meeting on UHC as well as a unique opportunity for participants from a range of perspectives to discuss the barriers to progress.

The event is convened by Chatham House and the UK Working Group on NCDs – a coalition of over 20 UK-based NGOs with an interest in the inclusion of NCDs as an international development priority.

Objectives

• To understand how NCD prevention and mental health promotion are a key aspect of universal health coverage.
• To explore the case for investment in NCD prevention and mental health promotion, for both governments and donors/global health actors.
• To share experiences of financing and delivering prevention and promotion services, and to reflect on the potential of PHC to support NCD and mental health goals.

Attendance at this event is by invitation only.