# From policy to practice and vice versa: a cross-sectional study of healthcare workers’ perspectives on safeguarding public health service access for displaced populations in Iran

## TL;DR

This study explores how healthcare workers in Iran view public health service access for migrants and refugees, finding strong support for prioritizing citizens over non-citizens.

## Contribution

The study provides new insights into how frontline healthcare workers' attitudes may hinder or support equitable service delivery for displaced populations.

## Key findings

- 93.1% of healthcare workers supported prioritizing citizens during resource scarcity.
- Only 43.7% supported equal service provision for non-citizens.
- Younger and clinical staff showed stronger preferences for working with citizens.

## Abstract

Global progress toward the Sustainable Development Goals (SDGs) is severely off track. Iran hosts the world’s largest migrant and refugee population, but sanctions, inflation, and workforce migration have strained its capacity. Since the attitudes of service providers influence whether inclusive policies are translated into practice, this study explores frontline staff perspectives on access to public health services for non-citizens in one of Tehran’s largest public health networks.

We conducted a cross-sectional survey among staff in three public health centers that serve migrant and refugee populations. The questionnaire assessed five Likert scale outcomes: support for separate centers, shared user fees, prioritization of citizens under conditions of scarcity, equal service provision, and preference for working with citizens. Demographic variables included age, sex, years of experience, and role (clinical vs. non-clinical). Items were analyzed descriptively; subgroup comparisons were conducted using two-sided Mann–Whitney U tests.

Of approximately 150 eligible healthcare workers, 87 provided complete responses. Agreement with prioritizing citizens was highest at 93.1% (median 5). Support for equal service provision was lowest, with 56.3% of participants expressing disagreement (median 2). A preference for working with citizens was endorsed by 61.9% of the respondents (median 4) and differed by age, experience, and role, with younger, less-experienced, and clinical staff reporting stronger preferences (all p < 0.01).

Healthcare workers’ perspectives can serve as a rapid, low-burden proxy indicator for equitable service delivery. In this exploratory study, workers favored citizen prioritization and fee-based models under conditions of scarcity, with the lowest support expressed for equal access for non-citizens; these preferences were strongest among younger and clinical staff. Adapted service delivery models, targeted training, and clear operational guidance are needed to support equitable access in resource-constrained settings.