Background: Over the years, economic sanctions have contributed to violation of right to health in target countries. Iran has been under comprehensive unilateral economic sanctions by groups of countries (not United Nations [UN]) in recent years. They have been intensified from 2012 because of international community’s uncertainty about peaceful purpose of Iran’s nuclear program and inadequacy of trust-building actions of this country. This review aimed to identify the humanitarian effects of the sanctions on the right of Iranians to health and the obligations of Iran and international community about it.Methods: To assess economic sanction policies and identify violated rights and the obligations of states according to international human rights laws, in this study, Human Rights Impact Assessments (HRIA) tool is used. Applying this tool requires collection of evidences regarding the situation of rights. To provide such evidence, a systematic review of literature which involved 55 papers retrieved from the web-based databases and official webpages of Iran’s government and UN’ health and human rights committees and organizations was done. All articles about the consequences of economic sanctions related to nuclear activities of Iran on welfare and health of Iranians published from January 2012 till February 2017 in English and Persian languages were included. Search terms were economic sanctions, embargoes, Iran, welfare, health and medicine. Additional studies were identified by cross checking the reference lists of accessed articles. All selected papers were abstracted and entered into a matrix describing study design and findings, and categorized into a framework of themes reflecting the areas covered . According to HRIA framework, related obligations of Iran and other states about adverse effects of the sanctions on Iranians’ right to health were extracted.Results: The sanctions on Iran caused a fall of country’s revenues, devaluation of national currency, and increase of inflation and unemployment. These all resulted in deterioration of people’s overall welfare and lowering their ability to access the necessities of a standard life such as nutritious food, healthcare and medicine. Also, the sanctions on banking, financial system and shipment led to scarcity of quality lifesaving medicines. The impacts of sanctions were more immense on the lives of the poor, patients, women and children. Humanitarian exemptions did not protect Iranians from the adverse effects of sanctions.Conclusion: Countries which imposed economic sanctions against Iran have violated Iranians’ right to health. International community should have predicted any probable humanitarian effects of sanctions and used any necessary means to prevent it. Furthermore, Iran should have used any essential means to protect people from the adverse effects of sanctions. Now, they should work on alleviation of the negative effects of sanctions. Even though, some of the effects such as disability and death cannot be compensated. In future, before imposition of sanctions, decisions makers should advice an international order to prevent such impacts on targeted countries’ populations. However, multiple studies on Iraq, the former Yugoslavia, Nicaragua, Burundi, Cuba, and Haiti showed that due to their long term impacts on the lives and health of a large population, the adverse humanitarian effects of economic sanctions are comparable to, if not more immense than wars.7 Through exacerbating economic situation and functions of social systems of a target country, they decrease the access of people to necessities of life such as nutritious food and medical care.7 From practical point of view, there is no difference between dying due to being shot or being deprived from life-saving medicines. Islamic Republic of Iran  has been under economic sanctions for more than three decades. In this study, the effects of the sanctions on Iranians’ right to health, as well as international human rights obligations of Iran and international community regarding this issue are scrutinized.Since the World War I, sanctions have often been applied by international organizations and nations as a routine policy tool to react to any nation’s actions that they oppose.8 Right to health has been reflected in several international human rights treaties such as International Covenant on Economic social and Cultural Rights (ICESCR) Article 12. This right is a right to “the highest attainable standard of physical and mental health”  based on ICESCR.9 Achievement of this level of health is one of the most important universal social goals. In the Constitution of World Heath Organization (WHO), health of all human beings is defined as a necessary condition to the attainment of universal peace.10According to the UN Declaration of Human Rights 1948, everyone has a right to a standard of living adequate for his health and well-being including food, medical care and social security without any kinds of discrimination on any grounds such as gender, race and the political, jurisdictional or international status of the place to which a person belongs.11 The Committee on Economic, Social and Cultural Rights (ESCR) acknowledged resources limitations of states in realizing ESCRs in a limited time. Therefore, it required the states to realize minimum core obligations immediately after ratifying the covenant and progressively realize these rights by taking steps to pursue the goals of the Covenant and using the maximum of available resources.9 The core obligations of the right to health includes access to health facilities, products and services and minimum essential food, basic shelter, sanitation and safe water.12 While recognizing the right of the states (who lack recourses for provision of the minimum of rights) to international assistance, the Committee requires all the states parties to realize right to health and contribute to the improvement of international health.9According to ICESCR, the right to health includes a right to access timely and appropriate healthcare and underlying determinants of health, such as safe water, nutritious food, housing, and healthy environment. All the facilities, services and goods related to health and its determinants should be of good quality, acceptable, available and physically and financially accessible to all, without any kinds of discrimination. States are needed to provide health insurance and financial aids for the poor to enjoy this right.13 These measures are called countermeasures which are resorted against an international wrongdoer in the case that they are not decided by UN Security Council.14 They may be comprehensive which prohibit commercial activities entirely with a country, or targeted (or smart) which block transactions of and with certain businesses, groups, or individuals of a target country.15 According to the Articles 39-43 of the Charter of UN 1945, if the Security Council determines any threat to the peace, breach of the peace, or act of aggression, it can decide what measures shall be taken to maintain or restore international peace and security. These measures may include use of arm forces, complete or partial interruption of economic relations and of rail, sea, air, postal, telegraphic, radio, and other means of communication, and the severance of diplomatic relations. All members of the UN are required to collaborate on these issues with the Council.16Sanctions are “measures taken by a state to coerce another to conform to an international agreement or norms of conduct, typically in the form of restrictions on trade.”17 Therefore, the case of Iran was brought to UN Security Council. At first, Iran was needed to “build the confidence regarding to peaceful purpose of its nuclear program and to suspend all enrichment-related and reprocessing activities, including research and development.” However, Iran’s trust building attempts were not adequate according to the UN Security Council. In 2007, Iran confronted with the Council’s sanction resolution related to its nuclear activities.18 All the sanctions defined by Security Council against Iran have been about limitation on its nuclear and military industry. No economic sanctions against this country were initiated by the Council.19 However, some countries decided to use “coercive diplomacy” and unilaterally boycott Iran with economic sanctions in 2012. About the measures are to be taken by the member states of UN in order to maintain international peace and security, the Charter of UN clearly states that “the measures shall be concluded between the Security Council and Members or between the Security Council and groups of Members and shall be subject to ratification by the signatory states in accordance with their respective constitutional processes.”16 General comment no. 8 of ICESCRs about The relationship between economic sanctions and respect for economic, social and cultural rights indicates that:In 2003, because the International Atomic Energy Agency (IAEA) was uncertain about the scope and nature of Iran’s nuclear activities, it asked Iran to be transparent and build confidence and suspend all enrichment related and reprocessing activities including research and development. In 2006, IAEA declared that it is “unable to make progress in its efforts to provide assurances about the absence of undeclared nuclear material and activities in Iran.”20Whatever the circumstances, such sanctions should always take full account of the provisions of the International Covenant on Economic, Social and Cultural Rights. The Committee does not in any way call into question the necessity for the imposition of sanctions in appropriate cases in accordance with Chapter VII of the Charter of the UN or other applicable international law. But those provisions of the Charter that relate to human rights  must still be considered to be fully applicable in such cases.21 The Committee on the Rights of the Child also declared that economic sanctions can act as an obstacle to the implementation of the Convention on the Rights of the Child (CRC).22 Through humanitarian exemptions for food and medicine, the sanctions often do not aim to violate people’s right to health in target countries. But, still civilians of target countries suffer from deprivation; since, it is not possible to separate effects of economic sanctions on health and economy. UN Human Rights Council in 2013 declared that there are reliable evidences about serious consequences of sanctions on the rights of people particularly vulnerable groups such as women, children, the elderly, the poor, minorities, indigenous people and persons living with disabilities.23Sanctions are called “brutal instruments” by the UN Food Program; WHO has asked international community to ban them altogether.7 In sanctions period, decline of revenues, increase of poverty, unemployment, and inflation, as well as deterioration of health services’ functions, school attainment and society’s development were reported. Also, the sanctions have made essential goods more costly and difficult to produce and maintain.3 In these situations, people’s ability to afford health services and maintain a healthy life style has been reduced.5 Rise of maternal, infant and child mortality rates has been considerable during sanctions period in some countries under sanctions. In addition, poor nutrition and lack of access to health services and medical supplies brought severe public health problems such as epidemics of diseases particularly among the poorest groups of the society.24 Furthermore, shortage of medicines and medical equipment deteriorated the practices of health systems. For instance, in Syria, sanctions brought difficulty in the import of essential medicines which were not produced locally.25 Cuba also lost access to raw materials needed for manufacturing pharmaceuticals and lacked the currency to purchase medicines and medical equipment from international market in sanctions period.6 Moreover, sanctions on import of non-medical products and spare parts, and trade restriction on water and electrical supply systems affected effectiveness of health systems in Cuba, Iraq, and Haiti; trade embargoes on agricultural sector such as fertilizers and seeds caused food shortage.5 In another case, reduction of revenues of target countries has decreased governments’ ability to finance healthcare system or sanctions on opening LC (letter of credit) for Iranian banks and shipment of imported goods caused shortage of medicines in Iran. Therefore, to ensure access of people to food and healthcare, humanitarian exemptions and providing supplementary aid are not adequate.Economic sanctions on countries such as Iraq, the former Yugoslavia, Nicaragua, Burundi, Cuba, and Haiti were associated with the deterioration of health and welfare of the population.26 Also, for many years, Iran’s government provided subsidized essential food stuffs such as flour, rice, cooking oil, sugar and milk to all the population. In 2010, this country changed this policy to cash payment to everyone. Moreover, through establishing successful primary healthcare network around the country, health outcomes of the country have improved notably over recent decades. Life expectancy of Iranians increased from 63 to 73.3 during 1990-2012 and the rates of maternal, prenatal and child mortality have fallen considerably. Maternal mortality per 100 000 live birth decreased from 91 to 24.6 and infant mortality per 1000 live birth decreased from 44 to 15 in this period. Communicable diseases are controlled and are no longer the cause of mortality. Together, they cause less than 5% of deaths.27 UN Children Found (UNICEF) declared in 2011 that through a strong health and education network and infrastructure, Iran is on track to achieve most of the Millennium Development Goals’ targets including addressing poverty and hunger, primary education, child mortality and maternal health.28 However, regarding the reduction of poverty the country is facing major challenges such as increase of people in need of support because of conditions including inflation and unemployment.27Poverty alleviation and social and health equity are prioritized in the Constitution and development plans of Iran. After the Revolution 1979, a welfare state system which focuses on health, education and social aid has been established in Iran. As results of a vast system of subsidies, material poverty has fallen significantly in this country. By improving urban infrastructures such as providing electricity, safe water and sanitation and universal free education, Iran has improved the living conditions of Iranians to a great extent. In 2011, more than 95% of Iranians had access to improved drinking water sources and sanitation facilities. Total adult literacy rate was 85% in this year.30In recent decades, people of Iran, having an oil-dependent economy and inefficient industry continuously faced numerous challenges including the effects of Revolution 1979, eight-year-war with Iraq and several kinds of international sanctions from agriculture to the airline Industry. After the Revolution, the sanctions were mainly imposed by the United States. However,their effects were limited, since Iran could find ways to compensate for the loss partly through other countries or by some mediators despite these involving higher expenses. Sanctions imposed by UN Security Council which aimed at forceing Iran to stop its nuclear activates targeted the military and nuclear industry of Iran. However, without mandate of the UN, the United States, the European Union (EU) and some other countries decided to impose comprehensive multilateral restrictions on any cooperation with Iran in foreign trade. Embargos from the United States also included “secondary sanctions” on countries and companies doing business with Iran.31 Also, Iran had to accept payment in gold, local currencies and bartered goods from a few Asian countries that still bought Iran’s oil. Therefore, Iran’s access to the US dollar and the euro needed for import from most of countries became limited. Furthermore, sanctions cut off Iranian banks from global financial system; international banks which dealt with Iran faced severe restrictions by international community.32 It made the transferring of oil’s earning back to the country extremely difficult. As a result, Iran had to process the transactions by intermediary banks that was very difficult and expensive.31 These all diminished Iran’s industry and economy and deteriorated Iranians’ welfare to a great degree. Gross domestic product (GDP) per capita decreased by 35% during 2012 -2014 (33 The consumer price index increased from 100 to 178 (34 Minimum wage decreased from US$275.4 in 2010 to US$155 in 2012 (35 While the unemployment rate was 11.3 in 2016. This indicator was 10.5 in 2008.36When sanctions (imposed without the mandate of UN) were intensified in 2012 to target all sectors of Iran’s economy, the country’s ability to sell oil became limited. As an oil-dependent country, Iran’s revenues and financial ability to purchase needed supplies in the world market decreased considerably. It became worse after the freezing of properties of Iran’s Central Bank and other financial institutions in third countries. Sharp declines in oil revenues and industrial production, severe restrictions on the import of items, shipment and payment channels, and considerable devaluation of the national currency , caused high rate of inflation in every sectors of Iran’s economy.12 -2014 .33 The c0 to 178  and the 0 to 178 . GDP per0 to 178 .34 Minim in 2012 .35 WhileIn this article, after introducing the methods of study for assessing the humanitarian effects of sanctions and identifying materials that form the basis of the analysis, the adverse effects of economic sanctions on Iran’s economy, living conditions of Iranians and situation of right to health and medicine are reviewed. Next, the actions and legal obligations of Iran’s government and of the international community in the process of sanctions’ management are analyzed. Finally, some recommendations for future sanction regimes, in order to better respond to humanitarian effects of the sanctions are provided.37In this study, to assess the adverse effects of economic sanctions on people’s right to health and identify the related national and international obligations related to this violation, Human Rights Impact Assessments (HRIA) tool is used. To tackle with the adverse impacts of trade agreements on the right to health, policy-makers employed various impact assessment tools such as Sustainability Impact Assessment of EU Trade Agreements. However, traditionally these tools focus on economic and environmental and not social effects. HRIA is preferred because it uses a legally binding framework of International human rights law which is based on a strong normative consensus and universally agreed principles. Also, it evaluates a full range of internationally agreed human rights, while focuses on empowerment and improvement. HRIAs tools emerged in the late 1990s for anticipating and measuring impacts of policies and programs on different human rights. They are helpful in identifying various types of duty- and right-bearers and their responsibilities. HRIAs have been applied in a broad range of different fields such as in development (by the Norwegian Agency for Development Cooperation and Food and Agriculture Organization [FAO]), Health , trade  and multinational cooperations .38 The purpose of this tool is to identify any inconsistency between international human rights obligations and other national and international obligations. HRIA identifies human rights violations which can be challenged by judicial bodies and ignoring them might cause significant legal consequences for violating states and institutions. In this assessment, human rights obligations are extracted from main human rights laws such as Universal Declaration of Human Rights 1948, International Covenant on Economic, Social and Cultural Rights (ICESCR) 1966, General Comment no. 14 of ICESCR on right to health and General Comment no. 8 ICESCR on the relationship between sanctions and right to health. HRIA includes 8 steps for policy-makers and 6 steps (as below) for scholars:HRIAs are based on legal framework of human rights and promote accountability which is one of the key contributions of a human rights perspective.Screening: It requires selecting key human rights issues that are most likely to be affected. In this study, the screening is done through analyzing the effects of economic sanctions on Iran and other countries.1) Scoping: in this step, identifying the information needed and formulating concrete questions are necessary.2) Evidence Gathering: A quantitative as well as qualitative research techniques can be applied in this step. In this study, content analysis of relevant papers has been done.3) Consultation: interviewing affected populations and other potential right-holders or using secondary material, such as reports, studies and experiences which provide primary data is necessary. In this study, a literature review about the effects of the sanction policy on Iranians is applied.4) Analysis: in this step, deciding over the concrete human rights impact of the policy assessed by analyzing the results of the literature review should be done. In the case that sanctions affected availability, accessibility, acceptability and quality of health (and its determinants) services, products and facilities, violation of the right to health has been occurred.5) Conclusions and Recommendations: in this step, identifying specific duty-bearers and assigning them concrete responsibilities should be done .The question of this study is that what the implications of economic sanction policies of 2012 against Iran on Iranians’ right to health are. A qualitative case study design involving structured document review of relevant articles and policy documents were undertaken. Two sets of literature were studied; the first set aimed to obtain papers focusing on the situation of Iranians’ enjoyment of their right to health; while the second set aimed to understand legal human rights obligations of Iran and countries involved in implementing sanctions about Iranian’s right to health and a standard of life.In order to define keywords for search in databases, several articles about the subject were analyzed. Collected documents included original articles, reviews, editorials, letters to the editor, interviews, short reports and communications. The papers that described the effects of economic sanctions on Iranian’s right to health published between January 2012 and February 2017 were included. They were written in English and in the Persian languages. Articles related to sanction’s effects on other countries, sanctions which were not about Iran’s nuclear program and non-economic sanctions were excluded. The papers related to justification of sanctions against Iran were included in the study if they discuss the health effects of sanctions. Moreover, papers about sanctions relating to human right violations of the Iranian government were not considered.Data about the situation of Iranian’s enjoyment of their right to health in sanction period were collected from web-based databases including EBESCO, PubMed, Web of Science, Scopus, Emerald, Elsevier, Cochrane library, Hein online, J Store, Project Muse, Science Direct Springer, Wiley Online Library, Oxford Journals, Embase, SID, and Google Scholar by searching key words: “economic sanctions,” “right to health,” “embargoes,” “medicine,” and “Iran.” More data was found by cross checking the reference lists of accessed articles. Furthermore, official webpages of Iran’s government and UN’ health and human rights committees and organizations were studied to find the results of economic sanctions against Iran on people’s right to health. Selection of papers was exhaustive to locate every available one about the subject of the study. The collected papers were analyzed in-depth in order to collect evidences of humanitarian impacts of economic sanctions on Iranians’ lives and right to health. A total of 87 documents including papers (n = 76), books (n = 5), and reports (n = 6) on the humanitarian effects of economic sanctions were identified. The abstracts were reviewed and duplicated articles, or those that were not pertinent to the study  or did not adequately address the impacts of sanctions on Iranian’s livelihood  were put aside. 55 documents emerged to be related to the topic . The oth37Data gathering and analysis were organized according to the HRIA tool. All selected papers were abstracted and entered into a matrix describing study design and findings see . FindingEconomic sanctions have the potential to adversely affect the welfare and health of targeted populations. In the case of Iran, the results of the literature review indicated that the sanctions adversely affected affordability, accessibility and quality of health services and medicine and exacerbated the living standards of Iranians. In the next part, the effects of sanctions on Iranians’ health and its determinants are explained. This is followed by a discussion on the obligations of Iran and other countries about the humanitarian consequences of the sanctions.92 Also, through the Joint Plan of Action, a channel for humanitarian support was established between Iran and six other countries in November 2013.93 However, these exemptions of humanitarian trade, did not guarantee Iranians’ access to food, medicine and medical equipment. Since, limitations on trade, banking and financial system and shipment (mentioned before), made the transferring of any goods, including those exempted ones to Iran, extremely difficult and expensive. UNICEF describes Iran of 2012 as a country under tight unilateral economic sanctions which are adversely affecting the environment, public health and the socio-economic determinants of health of ordinary people, especially children.61 In the UN report on October 5, 2012, General Secretary, Ban Ki Moon stated that “The sanctions imposed on Iran have had significant effects on the general population, including an escalation in inflation, a rise in commodities and energy costs, an increase in the rate of unemployment and a shortage of necessary items, including medicine[…] The sanctions also appear to be affecting humanitarian operations in the country[…] Even companies that have obtained the requisite license to import food and medicine are facing difficulties in finding third-country banks to process transactions.”94After gauging the humanitarian impacts of sanctions on Iranians’ lives, particularly their access to food and medicine through extensive news reports and reports of UN General Secretory, the United States permitted its companies to sell selected medicines and medical supplies to Iran without requesting a license from the Treasury’s Office of Foreign Assets Control at the end of 2012.33 While the value of national currency declined by 80% during 2011-2013. In 2012, the overall inflation rate of consumer price index was 36% and 41.4% respectively in cities and rural areas.96 Sanctions influenced all aspects of Iran’s economy including public services that are necessary for welfare of the population.71 They also contributed to increase of the rates of inflation and unemployment  and had to fire many workers that deteriorated the living conditions of workers and their families considerably.31 As a result, purchasing power of population decreased  can have severe public health consequences which are very much similar to the effects of major military conflict.83 Sanctions on Iran had the potential to disrupt government’s subsidized healthcare.62 Economic sanctions decreased the revenues of Iran’s government and its ability to invest on health, education and social security of Iranians.85 Also, they forced the government to change the priorities of national investment from certain public responsibilities, such as supporting the poor.65 Therefore, the share of people of health services costs increased that adversely affected access to healthcare.70 Low income groups were more vulnerable to the effects of the sanctions. The poor paid bigger proportion of their income on healthcare.85 In 2013, Iran enacted a law to reform heath system; one part of this law requires the government to cover at least 90% of hospital services’ costs by public funds.115 But still every year 1% of the population fall below poverty line due to catastrophic health expenditures.116In 2012, with intensifying sanctions on Iran, inflation rate in health sector was 44.3% and 45.6% respectively in cities and rural areas.70 Economic sanctions have had other impacts on health of people in Iran. For example, due to ban on fuel trade and related production knowledge and technology, locally produced poorly refined fuel was substituted that had the main role in polluting the air all over the country.90 Economic sanctions influenced production models from clean production techniques to pollutant ones and led to more use of old technologies and air pollution.89 About 45 000 deaths in one year and increase of lung cancer cases among children were reported to be linked to air pollution in Iran.61 Another example is ban of selling air craft parts to Iran that resulted in unsafe flights and endangered lives of people. The same happened to automobile industry equipment. The sanctions also might endanger mental health of people because of continuous signals of threats and deteriorated living situation. Recently, the rates of mental diseases and drug addiction and cases of suicide among Iranians have increased considerably. According to the report of Iran’s Ministry of Health and Medical Education, the rate of mental diseases has increased 4% in recent four years. The suicide rate increased 7.6% during 2012-2013.118 Unemployment and financial distress are two main causes of mental conditions in Iran.119 A study in the province of Ghazvin showed that unemployment, inflation and welfare inequality had a meaningful relation with suicide rates.120 Another example is the impacts of economic decline on drug addicts and their families. While the price of medicines for treatment of drug addiction and drugs itself increased, having less financial means, drug users tend to decrease spending on their family’s life and use cheaper substances.121 New substances are associated with high risk methods of use such as injection and high risk sexual practices and more acts of violence and can have long term effects on body organs.122By limiting access to necessities of life, sanctions against Iran endangered public health particularly health of mothers, children and the poor.56 Sanctions can have more direct and immediate adverse effects on health by limiting the availability and accessibility of medicine. In theory, medicine exempted from sanctions against Iran, but in practice, access of patients to quality medicine became limited due to the sanctions of 2012. The report of UN Special Rapporteur on the situation of human rights in Iran 2013 indicated that “humanitarian safeguards in the form of exemptions for foodstuffs, medicines, chemicals for the production of medications and medical supplies are failing to meet their intended purpose. Reports indicate that financial sector sanctions effectively frustrate the purpose behind humanitarian exceptions. They also stress that the supply of advanced medicines, which treat the most serious illnesses, are particularly affected. Advanced medicines are produced primarily by firms based in Western countries and are subject to 20-year patents, rendering it impossible to substitute products from an alternative source.” The ineffectiveness of humanitarian safeguards is apparent in Iran.58The harms of economic sanctions to health indicators can remain hidden for several years and become evident in a longer period. As an example, unavailability of financial resources caused by sanctions is known as an obstacle to meet the goals of Prevention and Control of Non-communicable Diseases Program in Iran.123 By having a national generic policy, a network for provision and distribution of medicine and an overarching pricing system for medicine around the country, Iran had a satisfactory level of access to medicine and medical instruments before comprehensive sanctions.63 Depended to the type of services, insurance companies cover 70%-90% of retail price of medicines. Iran produces about 96% of all the medications of its pharmaceutical market in the terms of number and volume. But, the value of imported medicine is about 40% of whole market’s value.46Universal right to safe, effective and affordable medicine is a fundamental element of right to health; states should consider this right in their international agreements.80 Medicines were not subject to sanctions, but limitations on licensing, purchase and shipment of goods to Iran made the import of medicines difficult. Also, Iran is dependent to import of pharmaceutical’s raw materials, and production and quality control technologies which were not exempted from sanctions. Therefore, the sanctions crippled domestic pharmaceutical industry and disrupted the production and quality of generic medicine too.69 International pharmaceutical companies (and banks) were reluctant to deal with Iran because of the potential threat of secondary sanctions and difficulties of receiving payment.50 Being cut off from international banking network, Iranian government had to pay cash in advance that was very difficult, if not impossible, for mass imports of medicines. Moreover, the shortage of foreign currency and decline of country’s currency value made medicines expensive.69 In addition, a complex process of providing banking facilities to importers and extremely lengthy process of importation caused further shortages. Therefore, the cheapest medicines such as contraception pills and simple medical instruments such as vaccines, sutures and endoscopy instruments were not available by 2012.39 These all indicate that pharmaceutical system of Iran has been weak in provision of medicine in emergency and unusual situations such as economic sanctions.64With the tightening up of sanctions in 2012, the situation changed; government faced difficulties in provision of medicine; locally produced and imported medical equipment and medicines started to be scarce.58 and the average shortage of medicine from less than 30 in type reached to 144.52 Forty-four percent of scarce medicines were classified as essential medicines  by WHO. A vast majority of these medicines were supposed to be exempted from the sanctions.53 Access to nuclear medicines and radiotherapy pieces for diagnoses and treatment of cancer were completely cut off, since they were in the list of sanctions due to the possibility of military usage.47 Several studies showed that access of about 6 million patients with life-threatening diseases such as asthma, thalassemia, hemophilia, chronic diseases, blood disorders, multiple sclerosis and HIV/AIDS to their medicines was limited.44 In addition, anti-rejection transplant medicines, and kidney dialysis instruments were scarce by 2013.48 Domestically produced replacements were scarce and not effective enough. Unavailability and unaffordability of medicines resulted in poor drug adherence.66 A number of deaths due to a lack of access to medicines were reported in 2012.124 Furthermore, the shortage of medicines reduced the ability of health system to provide services even in emergencies; suspended operations were serious problems following sanctions 2012.48 Moreover, Iran does not produce drugs for eradicated diseases and raw material for antibiotics that can threaten universal public health. For example, Iran could not produce BCG vaccine till 2015. Moreover, shortages of medicines and medical equipment needed for diagnosis and treatment of some diseases might change the county’s overall disease burden; the number of deaths by non-communicable diseases  has increased in recent years in Iran.52Following multilateral sanction as of 2012, the import of medicines and raw medical materials fell by 30%-55%110 However, the alternative medicines usually had lower quality and limited effectiveness than equivalents from Europe or United States.69 Moreover, medicines have to be registered and their safety and effectiveness must be approved by Iran’s Medicine and Food Organization to be allowed to be produced, imported and distributed in Iran.125 This process takes several months. In response to the shortages, Iran allowed medicines which were approved by US Food and Drug Administration (FDA) or European countries to be imported without assessment and national approval. But this resulted in major side-effects including intolerance by the patients to a change in a long term treatment.32 On the other hand, due to the absence of official supplies in health facilities and pharmacies, smuggled medicines increased in the local market of Iran. They were often out of date, of poor quality, contaminated, or spoiled by climate extremes. They were also sold at a price several times higher than the official price. It was also difficult to know whether they were counterfeit or real.41 In 2013, following eye surgery, 22 patients got serious infection in their eyes and were in danger of losing their visions because of using a non-standard ampoule.126To compensate 30%-46% fall of medicines’ import from the United States and EU during 2011-2012, Iran increased its purchase of medicine and medical equipment from countries that did not ban oil trade with Iran. From 2012, the purchase of medicine from China and India increased respectively 2 and 5 times.44 The price of most medications has not been a problem until recent years in Iran. To guarantee access of people, Iran provides a subsidy for selected medicines. Usually, the amount of subsidy is determined at the end of each year based on the estimation of medicines’ price and country’s revenues in the coming year. The sharp fall of revenues and in the value of country’s currency was not predicted in 2012. After facing shortages, Iran allocated more financial resources and foreign currencies for the import of medicines and could establish companies in neighboring countries to use their banking system for purchasing medicine. As a result, many key medicines are now available; but still it is expensive for some diseases. The situation is more difficult for the poorest people who are not insured. In this condition, some health services such as dental care has become a privilege which is inaccessible to the working and middle classes of population.40Economic sanctions also made medicines financially inaccessible from 2012 to 2013. The increase in medicines’ price was 50%-75% during this period.The results of the literature review concur that economic sanctions against Iran have resulted in depriving Iran’s population of their economic and social rights, specifically the right to health and its determinants. About 80% of the studied papers indicated that sanctions adversely affected access to health services and related products. Sixty-three percent of papers confirmed the inaccessibility and affordability of medicine for the population. Moreover, 56% of the papers showed that sanctions affected the determinants of health such as environment health, employment and access to food. The sanctions on Iran caused a fall in the country’s revenues, devaluation of the national currency, and increased inflation and unemployment. These all resulted in a deterioration of people’s overall welfare and lowering their ability to access the necessities of a standard life such as nutritious food, healthcare and medicine. Also, sanctions on banking and financial system and shipment led to scarcity of quality lifesaving medicines. The impacts of sanctions were more immense on lives of the poor, patients, women and children. According to HRIA tool, the economic sanctions against Iran have had a significant humanitarian effect; therefore they should be reconsidered. To place pressure on Iran to limit its nuclear activities, other measures should be used instead that do not have such effects. While international peace should be respected, human rights obligations cannot be forgotten. Review of the obligations of Iran and international community about Iranians’ right to health is essential when considering compensation measures.To protect people in the sanctions period, imposing countries, international community and target country have human rights obligations. The fundamental part of these obligations is that everybody should enjoy his/her rights without discrimination of any kind.71 In the period between announcement and implementation of the sanctions, Iran should have provided a national policy with suitable measures to prevent suffering of people from the adverse effects of sanctions and to ensure everyone enjoys his/her basic rights including right to health. The failure to take appropriate steps towards progressively realization of right to health and to enforce related laws is in contrast with international human rights obligations. Moreover, Iran should have prevented third parties; black market dealers, pharmacies and health facilities that provided unsafe medicines, as well as smugglers who sent scarce medicine to neighboring countries from violation of people’s rights. Failure to regulate third parties’ activities is against the right to health.20Review of Iran’s response to the sanctions indicates that this country has not been prepared for the sanctions, delayed in responding to shortages and could not manage the situation appropriately. Also, bureaucratic constraints, corruption and inefficient resources management contributed to the deterioration of people’s enjoyment of their basic rights.127 In the sanctions period, the government of the target country has human rights obligations. People’s lack of access to nutritious food, primary healthcare, basic shelter and education indicates that the country has failed to discharge its obligations under ICESCR. The State is required to monitor human rights situation and utilize the maximum resources available to eliminate the suffering with low cost programs, international assistance and cooperation. Moreover, even in severe resource limitations, vulnerable groups of the population such as children and the poor must be protected. Non-compliance with the core obligations of right to health  cannot be justified under any circumstances.20 The CRC also states that children are entitled to human rights; parents without enough means should be supported to provide a standard of life for their children. Governments should prohibit child marriage, child trafficking, child work, violence against children and engagement of children in drug selling. The needs of immigrants’ and asylum seekers’ children should be taken into account too.128 Generally, states have the obligations to respect, protect and fulfill right to health. They must ensure that everyone, without any kinds of discrimination, enjoys this right. In all times, including the period of sanctions, states are required to provide available, accessible, acceptable and good quality facilities, goods and services related to health and its determinants to everyone. In addition, they are required to use all necessary means, the maximum of their available resources and to adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realization of right to health.20 There is the possibility to seek international assistance for realization of the right to health too.Countries targeted by sanctions should respect international peace, security and human rights obligations to alleviate a humanitarian crisis.129 Second, they should avoid violation of this right and prevent third parties such as international organizations and groups of countries also violating this right.20 According to the UN Charter 1945, Security Council may decide what measures including sanctions should be employed to maintain or restore international peace and security.16 Generally, economic sanctions which are imposed by some countries against the others are inconsistent with the Charter’s basic principles of equality and dignity of every human being. Resolution 39/210 of UN General Assembly 1984 states:The international community has two kinds of obligations in relation to the right to health. First, in cooperation with international organizations, all countries are required to provide conditions at international and regional levels to ensure everyone enjoys the right to the highest attainable standard of physical and mental health. They should help developing countries to progressively realize this right through the establishment of effective and integrated health systems with adequate, affordable and reliable and good quality supply of medicines.130Developed countries should refrain from threatening or applying trade and financial restrictions, blockades, embargoes, and other economic sanctions, incompatible with the provisions of the Charter of the UN and in violation of undertakings contracted, multilaterally and bilaterally, against developing countries as a form of political and economic coercion that affects their political, economic, and social development.131 Adoption of laws interfering with the enjoyment of right to health, failure to take into account the legal obligations related to this right in bilateral and multilateral agreements and also failure to regulate activities of third parties in order to prevent them from violating right to health are violations of the ICESCR obligations. Imposing embargos and other measures that restrict the supply of another state with adequate medicine and medical equipment should be refrained. The Committee on ESCR prohibits restriction on these goods as a tool for political and economic pressure. States must respect the enjoyment of right to health in other countries by refraining from denying or limiting the access of people to healthcare and medicine. They must ensure that their international agreements do not adversely impact upon this right. The states who are members of international and regional financial institutions should consider protection of the right to health in their credit agreements and lending policies.20The Vienna Declaration and Program of Action 1993 requires the states “to refrain from any unilateral measure not in accordance with international law and the Charter of the UN that creates obstacles to trade relations among States and impedes the full realization of the human rights set forth in the Universal Declaration of Human Rights and international human rights instruments, in particular the rights of everyone to a standard of living adequate for their health and well-being, including food and medical care, housing and the necessary social services.”11 Countries that impose, maintain or implement sanctions should take immediate steps to respond to the suffering experienced by people in targeted countries.20 This can be done by facilitating the delivery of necessary items for life and health such as medicine, food and medical equipment. The states imposing sanctions should carefully assess the effects of their policies and international agreements on the health of people in the target country. Subsequently, they must develop policies and laws to alleviate the negative impacts of their agreements on the human rights of population in the target country.132 A country’s population should not be deprived of their basic ESCRs due to any determination that their leaders have violated international peace and security norms.20 The international community must protect the core content of the ESCRs of targeted population. UN bodies should observe the situation of human rights and implement humanitarian and human rights laws. Otherwise, basic principles underpinning international law such as equality of all human beings will lose credibility. In addition, the Security Council should alleviate sanctions regimes in order to eliminate the humanitarian effects of sanctions on target population and ensure that they have access to food, medicines and other necessities of preserving health.127 It seems that regulations on humanitarian exemptions are formulated imprecisely and confusing; they lack standards and an impact monitoring system. Also, exempted goods and their distribution are poorly understood and interpreted, and often the urgent delivery of humanitarian supplies is blocked.133 These all have major implications on the basic rights of the population of target country.States are responsible legally for their policies that violate human rights of people beyond their borders and for the policies that support this action by third parties. According to paragraph 39 of General Comment no 14 ICESCR, “to comply with their international obligations in relation to article 12, States parties have to respect the enjoyment of the right to health in other countries, and to prevent third parties from violating the right in other countries, if they are able to influence these third parties by way of legal or political means, in accordance with the Charter of the UN and applicable international law.”According to the results of HRIA, economic sanctions against Iran have resulted in violation of Iranians’ right to health. There is incompatibility between obligations derived from economic sanction agreements and human rights. In this case, HRIA suggests several options: termination or amendment of the policy, insertion of safeguards, and adoption of compensation measures. The main principle of this assessment is that no policy at national and international level should breach international human rights laws. This tool, at first step, suggests that such policies should be stopped. However, it does not mean that countries should not face any limitation if they threaten international peace, rather it means such policies should protect people’s basic human rights too. The assumption behind economic sanctions is that economic pressure on the population of a country forces the government to reconsider its policies. The statement that economic sanctions do not target humanitarian goods seems incorrect when they aim to diminish the main source of a state’s revenue. The level of realization of human rights is dependent to the state’s income level. Therefore, economic sanctions endanger current level of people’s enjoyment of their right to health by decreasing available resources of a country to be spent on the health of population.Despite the international community’s statement that sanctions are directed at the government of Iran for its nuclear program, during the sanctions period, the enjoyment of Iranians of their fundamental rights has been dramatically decreased. The sanctions affected health of Iranians in two ways; first by deteriorating their living conditions through rise of inflation and unemployment, and decline of households’ income and access to adequate nutritious food and healthcare; then, by direct effect on the availability, accessibility and quality of lifesaving medicines. Humanitarian exemptions which were established after the call of shortage could not protect the population from adverse effects of sanctions. If the purpose of sanctions has been refraining Iran from developing nuclear weapons, sanctions should have been all about the materials and technology related to this program and targeted decision-making elites, not ordinary people. Although, it seems that the world overlooked countries that actively have nuclear weapons without ratification of Non-Proliferation of Nuclear Weapons Treaty.134 The countries imposing sanctions, UN treaty bodies and Iran itself are responsible for the humanitarian effects of sanctions on Iranians’ lives. Iran could not appropriately handle the humanitarian crisis caused by sanctions and still be able to maintain the level of its population’s enjoyment of their basic rights. The country should have predicted the impacts of sanctions and planned for the protection of its population. But some of the consequences of the sanctions such as the difficulty in access to medicines (which were in theory exempted from sanctions) were difficult to be predicted. It shows that laws on “humanitarian exemptions” solely do not protect the rights of the population of targeted countries. On the other hand, through joining UN and ratifying human rights treaties, almost all countries around the world are committed to respect human rights of everyone without any kinds of discrimination. No international human rights treaty questions the equality of human beings in their inherent dignity and fundamental rights. It is thus against all these treaties to assume that violation of people’s rights in one country, through pressure of sanctions is acceptable. Olivier De Schutter, UN Special Rapporteur of the right to food in his report of 2011 stated that a state who uses its means of influence, such as its economic leverage to induce policies in another state’s jurisdiction that undermines the targeted state’s human rights obligations, is responsible for violation of rights under international law.135 Iran has not been the first country that has faced sanctions; therefore the adverse impacts of sanctions on this country could be predictable by UN Security Council and by the countries which imposed them. In future, prior to the imposition of any economic sanctions, the international community must use effective measures to protect the human rights of target country’s population. Countries should also use every political and legal means to prevent violation of the rights of these people by other countries or international organizations. International laws related to economic sanctions also need improvement. All the UN organs’ resolutions on economic sanctions are similar in content and are not deterrent enough. These resolutions are soft laws advising targeting and targeted countries to respect human rights. However, no international accountability system is established for countries which impose economic sanctions and do not conform to these laws. According to General Comment no 14 ICESCR, effective judicial and appropriate remedies at national and international levels should be provided for people whose rights are violated.20 Even following dissemination of the report of the Special Rapporteur on Human Rights and UN General Secretary about humanitarian effects of sanctions on Iran, the imposing countries were not compelled to lift sanctions. The UN as a “center for harmonizing the actions of nations in the attainment of peace”16 should take a clear position about bilateral sanctions or “measures” such as these, imposed arbitrarily by countries or groups of countries against another one.According to international human rights laws, right to health is a justiciable right.Moreover, in the case of Iran, humanitarian exemptions were decided too late, while the process of implementation of the exemptions was not clear. Prior to the imposition of sanctions, an international order for the protection of people should be established and some international intermediate organizations and certain companies and financial institutions should be designated to facilitate the implementation of exemptions. Furthermore, the effects of sanctions should be continuously monitored; if basic human rights are affected, the sanctions should be reviewed. Economic sanctions in their current method of implementation are “collective punishment” and violation of all human rights treaties. By putting such great pressure on the population of a country, other countries will not also be safe. The prevalence of diseases and internal conflicts in a country, as results of economic sanctions, are threats to international health and peace. People who find their rights violated seek asylums in other countries. Considering human rights approach in foreign policies might be a better solution than economic sanctions for resolving international disputes.Recently, a proposal is suggested by imposing countries to lift sanctions on Iran due to a shift in Iran’s nuclear policies. However, the adverse consequences of economic sanctions have already taken place and will take a long time to be alleviated, if not impossible. The social impact of economic sanctions against Iran may extend beyond the sanction period because the costs of imposing sanctions exceed the benefits of lifting sanctions. Moreover, lifting sanctions necessarily will not lead to improving living standards and welfare of Iranians if this country does not invest more on the population. After improving access to medicine and allocating more funds to health system, now, Iran needs to make considerable efforts to improve the living conditions of the people, especially the poor and children by using all the necessary means and recourses available. In addition, this country must consider new policies to protect civilians from the violation of their rights in similar situations. Imposing countries and the international community are also responsible for the humanitarian consequences of their actions and should aid Iran by any appropriate or necessary means to alleviate the situation and to allow Iranians to enjoy their human rights which have been affected by the sanctions.Not applicable.Author declares that she has no competing interests.FK is the single author of the paper.


Globally, the threat of infectious diseases, particularly emerging infectious diseases, originating at the human-animal-environment interface, has caught health systems off guard. With forecasts that future pathogen emergence will be centred in hotspots in Asia, Africa, and Latin America, the need to prepare policy frameworks that can combat this threat is urgent.Emergence of diseases such as avian influenza and Ebola virus disease, which threatened social disruption, have established the need for intersectoral coordination/collaboration. These events led to the initiation of establishing institutionalised collaborative frameworks in India to adopt a One Health approach to disease prevention and control. However, the gains made in influenza control could not be adapted to other infectious diseases. Intersectoral coordination was briefly carried out, more as a reactive response to threats. The systemic failure to sustain such efforts have therefore, only undermined a coordinated response. The recent draft National Health Policy, 2015, has also failed to establish the need for intersectoral coordination in disease control approaches. Neglecting the need to endorse linkages between human health, animal health and husbandry, agriculture, and environmental sectors, has led to duplicative and weak response systems.The absence of health impact assessment with respect to the development agenda in policies, has cast negative effects on the health and wellbeing of man, animal, and the environment. Lack of attention to building core capacity in these critical sectors has further raised challenges in designing and deploying mitigation strategies. With developing countries like India being home to a major portion of the world’s poorest livestock farmers, the absence of a policy discourse that endorses the One Health approach in development and health policies is a major hurdle in eliminating poverty and poverty-related diseases.The adoption of One Health approaches in health and related sectoral policies is a critical policy requirement for India and other developing countries. The goal should be to not just establish preparedness plans, but also to encourage a policy environment where assessment and mitigation of downstream impacts of different agenda are incorporated.The online version of this article (doi:10.1186/s40249-016-0181-2) contains supplementary material, which is available to authorized users. Please see Additional file The belief that infectious diseases were conquered and the book on communicable diseases was about to be closed has amounted to nothing but hubris. Emerging infectious disease (EID) events of the recent past have seriously damaged these claims over and over again, mostly through diseases that have emerged at the human animal interface. This war between man and microbe might be the inescapable nemesis we have to deal with.On an average, a new disease has emerged or re-emerged each year since the Second World War; 75 % of these have been from an animal source;  between South Asia has been identified as one of the major hotspots for infectious diseases, with India contributing maximally to the burden of zoonoses, poverty, and reliance on livestock . The emeGiven the uncertainty surrounding EIDs and their potential to cause explosive outbreaks, the need for a cogent response, characterised by strong multisectoral linkages, and rooted in transdisciplinary approaches, has been felt for a while now –13.The emergence of the H5N1 influenza, and the resulting policy and public panic, led to the conceptualisation of multisectoral linkages in India, with human health, animal health, and wildlife sectors coming together to combat the problem. The collaboration was institutionalised in the form of an Inter-Ministerial Task Force and Joint Monitoring Group at the national level, with coordination mechanisms established all the way down till the district level . WrittenWhile the avian influenza preparedness and response have been success stories for India, the opportunity created could not be capitalised on. The scope of these coordination mechanisms remain limited and have not been extended to cover zoonoses and wider sets of issues emerging at the human-animal-wildlife interface. Several subsequent zoonotic disease events, occurring nationally and internationally, such as Crimean-Congo Hemorrhagic Fever (CCHF), Ebola Virus Disease (EVD), Middle East Respiratory Syndrome Coronavirus (MERS-CoV), brought the sectors together briefly, culminating into a national programme for intersectoral coordination. A proposal for the same was submitted by the National Centre for Disease Control (NCDC) to the Planning Commission Working Group on the disease burden of communicable diseases for the 12th 5 Year Plan .Central to this proposal was the recruitment of a veterinarian at the Integrated Disease Surveillance Project (IDSP) State Surveillance Unit (SSU) in each of the states. This functionary is proposed to serve as a bridge between the two sectors, though limited evidence has been produced to support this strategy.Around the same time, the National Standing Committee on Zoonoses (NSCZ) was activated . The StaSimilarly, the Indian Council of Medical Research (ICMR), the research arm of the Ministry of Health & Family Welfare (MoHFW), responded by announcing requests for proposals (RFPs) for collaborative research, though it is unclear as to how the disease/s and research priorities had been identified for this research funding. ICMR’s efforts to promote intersectoral collaborative research culminated into discussions around setting up of a Centre for Zoonoses Research, in partnership with the Indian Council of Agricultural Research (ICAR) . SettingThe review of the institutional capacity for research on zoonoses has also shown that a majority of the investments that have gone into building institutional capacity, as well as research output on priority zoonoses from India, have been produced by the human health sector as opposed to the veterinary sector. Thus, it is no surprise that zoonoses research output in India has been found wanting in its policy relevance . A relatThus, intersectoral mechanisms aimed at operationalising One Health approach based policies appear to be a set of uncoordinated ad-hoc efforts. It is difficult to point out a single factor that has led to this inertia. A multitude of factors may have had contributory effects. EIDs have been perceived as a human health problem, thereby impeding sectorally integrated policies. There is a lack of evidence on operational frameworks, largely driven by a disconnect between research output and policy needs. A mismatch in sectoral capacities, against the backdrop of vastly stretched existing human, animal health and wildlife disease management systems, has resulted in competing priorities and reactive actions in the event of emergencies. This interplay of multiple factors has led to a lack of appreciation of the benefits of the One Health approach, failing to trigger investments, and appropriate effective intersectoral action. However, the biggest missing link has been an overarching One Health policy, or at least a One Health orientation of existing sectoral policies.Preparing ourselves for the infectious disease challenge of the 21st century would mean that we have to go beyond the eco-epidemiological approaches and address the vast systemic weaknesses in dealing with EIDs through a holistic approach instead. The key to this holistic approach is to establish linkages between the human health, animal health and husbandry, agriculture, and environment sectors. Response in one sector should incorporate impact assessment and mitigate downstream adverse effects on the other sectors as well .Central to this holistic approach should be a policy framework that recognises the EID challenges that India is up against and endorses the need for intersectorality. From such policies should flow operational frameworks that allow partnerships not just across sectors, but also across disciplines. The policy should provide an enabling environment for building core capacity in sectors that play a critical role in responding to EID challenges.India’s Draft National Health Policy 2015, which was framed in response to the changing healthcare needs of the nation, was the perfect opportunity to leverage systems into breaking out of their water-tight, siloed existence. While the usual process for drafting of health policies in India considers representation of experts from within the sector and interfacing with those from outside, the 2015 draft was unique as it was put in the public domain after drafting  and sought comments from all relevant stakeholders. Unfortunately, in spite of being informed by adequate sectoral views and dialogues, the document fails to even mention the terms “zoonoses” and “emerging infectious diseases” . AdditioOn the other hand, it is interesting to note that there are examples within South Asia that have demonstrated the commitment to deal with the emerging issues following the One Health approach. Bangladesh, for example, has an overarching National Health Policy, and a separate policy framework outlining the Strategic Framework for One Health Approach to Infectious Diseases . The proGlobally, there is an impending shift in policy making frameworks as the world is set to migrate from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs) with the end of the MDG-period on 31st December, 2015. Some observers have expressed their concern about the diffused nature of the health-related targets adopted by the SDGs . HoweverIn the absence of a cogent policy environment, India’s approach to dealing with EID events has been reactive at best, and absent, at worst. The lack of an existing framework to guide intersectoral liaison has further impeded responsiveness to EID events, thus contributing to the vulnerabilities, both health and economic. Investments need to be made to establish or re-establish such linkages before cross-sectoral policy dialogues are initiated. In order to reduce redundancy and duplication of policy directives, it is essential that the draft National Health Policy considers elements of transdisciplinarity, which inform mechanisms for establishment of multisectoral approaches to dealing with EID challenges through the One Health approach. It is time that the political and technical leadership in India across sectors recognises the threat from EIDs and responds suitably.


Research focusing on management of foot health has become more evident over the past decade, especially related to chronic conditions such as diabetes. The level of methodological rigour across this body of work however is varied and outputs do not appear to have been developed or translated into clinical practice. The aim of this systematic review was to assess the latest guidelines, standards of care and current recommendations relative to people with chronic conditions to ascertain the level of supporting evidence concerning the management of foot health.A systematic search of electronic databases  for literature on recommendations for foot health management for people with chronic conditions was performed between 2000 and 2016 using predefined criteria. Data from the included publications was synthesised via template analysis, employing a thematic organisation and structure. The methodological quality of all included publications was appraised using the Appraisal for Research and Evaluation (AGREE II) instrument. A more in-depth analysis was carried out that specifically considered the levels of evidence that underpinned the strength of their recommendations concerning management of foot health.The data collected revealed 166 publications in which the majority (102) were guidelines, standards of care or recommendations related to the treatment and management of diabetes. We noted a trend towards a systematic year on year increase in guidelines standards of care or recommendations related to the treatment and management of long term conditions other than diabetes over the past decade. The most common recommendation is for preventive care or assessments (e.g. vascular tests), followed by clinical interventions such as foot orthoses, foot ulcer care and foot health education. Methodological quality was spread across the range of AGREE II scores with 62 publications falling into the category of high quality (scores 6–7). The number of publications providing a recommendation in the context of a narrative but without an indication of the strength or quality of the underlying evidence was high (79 out of 166).It is clear that evidence needs to be accelerated and in place to support the future of the Podiatry workforce. Whilst high level evidence for podiatry is currently low in quantity, the methodological quality is growing. Where levels of evidence have been given in in high quality guidelines, standards of care or recommendations, they also tend to be strong-moderate quality such that further strategically prioritised research, if performed, is likely to have an important impact in the field.The online version of this article (10.1186/s13047-017-0232-3) contains supplementary material, which is available to authorized users. Chronic conditions represent a global health burden . Their iDespite this need for the management of foot problems, provision of podiatry services is an area that lacks guidance. Feedback from people who have chronic conditions suggests that they are not accessing care for foot problems , 16, 17 There has been increased attention to evidence informed medicine and the desire for reproducibility in choice of foot-care tailored to individual patient needs , 18–22. Guidelines, standards of care and recommendations for management of foot health have become more evident over the past decade, particularly in the management of foot problems related to the manifestations of diabetes . The impTo provide a narrative synthesis on the specific characteristics of guidelines and recommendations for foot health management using criteria from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist .To assess the methodological quality of included studies against the Appraisal of Guidelines for Research and Evaluation (AGREE II) document .To determine the level of evidence used in guidelines and recommendations for foot health management.The aim of this investigation was to systematically review the literature related to guidelines, standards of care and current recommendations concerning the management of foot health for people with chronic conditions. The findings of this study will be of interest to podiatrists and health care professionals by identifying the evidence-based behind interventions for foot health management, which can then be used to support and guide practice. Specific objectives were:Search criteria for the systematic review were identified using the “PICO” statement. Search terms were defined by three experts in podiatry  and the final list agreed through a consensus meeting. Electronic databases  were searched for English language publications and translations reporting recommendations for the management of foot health for people with chronic conditions between 2000 and 2016. The year 2000 was considered an appropriate point to commence the literature search, given the establishment of degree education in podiatry from 1993, and the subsequent development of postgraduate and post-doctoral qualifications and research skills within the profession.Searches were performed using the following text word terms and MeSH headings: foot, chronic, chronic disease, long term care, neurodegenerative diseases, multiple sclerosis, arthritis, lung diseases, emphysema, diabetes mellitus, hypertension, cerebrovascular disorders, myocardial ischemia, heart failure, colonic diseases, human immunodeficiency virus, osteoporosis, fibromyalgia, neoplasms, mental disorders, depression, asthma, chronic obstructive pulmonary disease, thyroid diseases, hyperlipidaemia, psoriatic arthritis, gout, ankylosing spondylitis, colitis, scleroderma, practice guidelines, algorithms.Hand searches of bibliographic references identified additional publications. Grey literature was included based on an initial search using the terms foot, feet and podiatry and rerun in conjunction with the terms guideline, recommendation and management to ensure that the search had captured all relevant sources. Publications identified through the grey literature and hand searches were not restricted by date. The systematic literature search was facilitated by a medical librarian at the Bodleian library, University of Oxford. The full search strategy can be seen in Additional file A publication was included if it met all the following criteria:Includes the management of foot healthProvides recommendations for the management of foot health, e.g. guidelines, guidance documents, standards of care, treatment algorithms and clinical pathways..Excluded publications were those that did not fulfil the above criteria on population group, were not related to the management of foot health, such as technical and methodological papers, and were not formal publications presenting guidelines or recommendations . Literature identified from the electronic search strategy was excluded if published outside the date range 2000 to 2015.Two independent reviewers (KE and LM) selected eligible publications based on titles and abstracts. Potentially relevant publications were subject to full-text screening. Disagreement between reviewers was resolved by consultation with a third reviewer from a panel of qualified podiatrists and experts in the field of podiatry and foot and ankle research . Data was extracted from the identified literature based on the criteria given in the PRISMA (2009) checklist . The PRIThree independent expert reviewers  assessed all the included publications July 2016) for quality using the AGREE II checklist . The AGR016 for qData from the included publications was synthesised via template analysis, employing a thematic organisation and structure. Template analysis is a process by which textual data is organised and analysed according to themes, allowing unstructured textual material to be categorised into meaningful datasets. Indexing sections of text relevant to a theme also permits the development of codes which emerge from the data . PredeteWhere stated, the level of evidence supporting the recommendations related to foot health management was extracted and interpreted according to the GRADE  system . The GRAThe search strategy retrieved 5379 citations from electronic and grey literature sources. In total, 1938 duplicate citations were removed between the electronic and grey literature sources. Results from the electronic search were then subject to title screening according to the review selection criteria with 856 citations being excluded; results from the grey literature were not subject to title screening as this was deemed inappropriate due to the use of short titles for the majority of articles, and all were put forward for screening by abstract. Following abstract screening, 2368 citations were found ineligible with 122 citations being included from hand searching the bibliographies of excluded papers. The search process was then repeated for 2015 to 2016 to ensure that the findings of the review would be as up-to-date as possible, and this resulted in the identification of an additional 14 publications. From full-text screening, 187 articles were considered ineligible, and the remaining 166 publications were included in the final review.The abstracts of all publications found were exported from the databases and collated into a Microsoft® Excel (2010) spreadsheet  for scoring for inclusion (1) or exclusion (0).Screening by abstract resulted in the exclusion of 2358 citations. An additional 122 relevant citations were also identified from hand searching bibliographies of any publications excluded at this stage. Of the 339 citations that were put forward for full-text screening, 152 were included in the final review.The full text version of all publications found were exported from the databases and collated into a second Microsoft® Excel 2010) spreadsheet for scoring for inclusion (1) or exclusion (0). Four reviewers  independently screened the full text citations against the inclusion criteria. All publications that met the inclusion criteria were selected, however only the most recent versions were included such that 152 were put forward for review. The literature search process was repeated for any publications that had been released until September 2016 to make the review as up-to-date as possible. An additional 14 publications were identified, bringing the final total up to 166. Fig. 0 spreadsOf the 166 included publications, 74 (45%) were from the grey literature, 65 (39%) were from electronic databases and 27 (16%) were from hand searches.The 166 included papers were published between 1986 and 2016; of these, the majority (11.5%) were published in 2011. Prior to 2000, the studies represented are those identified from the grey literature for which no date criteria were imposed. Importantly, the distribution of guidelines, standards of care and recommendations concerning the management of foot health in people with chronic conditions shows a steadily increasing trend over time  of the 166 included publications were based in, or included, the United Kingdom  of the 166 included publications were reported as guidelines; this included Global or National guidelines, clinical guidelines, best practice guidelines, evidence-based guidelines and guideline summaries Fig. . Among tOf the 166 included publications, the majority 61.5%) were guidelines, standards of care or recommendations related to the treatment and management of diabetes or the diabetic foot , preventative care and assessments along with clinical interventions and foot health education are themes that are covered the most; on the other hand, comparatively little attention is given here to areas such as core podiatry and podiatric surgery. Recommendations for core podiatry tend to feature the most in publications with an AGREE II grade of 3 or below, indicative of low methodological quality, as do those for podiatric surgery, although these are comparatively few in number overall.Of the included papers that have a quality threshold score of 4 and above for reasonable to high methodological quality , the difference between evidence and narrative based publications is more apparent (14+ papers).From those papers that reported levels of evidence alongside recommendations, this data was then extracted and used to populate a data extraction form  were guidelines, standards of care or recommendations that were focussed on the treatment and management of diabetes. Methodological quality of the included publications ranged from high to low according to the AGREE II rating system  suggestiExamining patterns across the 166 publications would suggest that the majority of supporting evidence for foot health management is included within UK guidelines, recommendations or standards of care, followed by the US, Europe and Australia. This is not surprising as our search was limited to English only publications, however of note, within these countries podiatry is a recognised allied health discipline , 33. PodGuidelines, standards of care and recommendations play an important role in synthesising evidence for health care and health policy information however according to the AGREE II consortium  the poteFrom our review, we also established that it was rare that a podiatrist or foot care specialist was included as a stakeholder in the higher scoring publications. This is of concern as the recommendations contained within guidelines are defined by the scope of the stakeholders. Stakeholders advise guideline developers in searching for, selecting, critiquing and combining data . WithoutThe strength of recommendations within guidelines, recommendations or standards of care is informed by the quality of the research evidence on which they are based , 25. FolWhere a level of evidence was given, this tended to be in the higher scoring publications for methodological quality and related to GRADE  system  as stronAccording to GRADE, for those themes with emerging good quality evidence, further research, if performed, is likely to have an important impact on confidence in the estimate of the effect and may change the estimate . As the The findings of this systematic review need to be considered in the context of several limitations. First the scrutiny for evidence for ‘podiatry’ was determined a priori by the authors as being most accessible from guidelines as they usually incorporate research evidence into their clinical recommendations. In this instance it would have been inappropriate to select publications by single interventions due to the wide range of interventions related to management of foot health / podiatry in long term conditions and the multi-professional nature involved in the interventions. As only English-language publications were included in the review this may have resulted in additional relevant, high-quality evidence from non-English publications being omitted.The hand searching process also procured a number of publications not identified from the electronic database search. This may be due to the grey literature and hand searched references not being restricted by date as had the electronic searches. This highlights the differences in approach required in searching the electronic and grey literature, and the challenges inherent in designing an inclusive search strategy. In view of this, the grey literature search in particular may not have captured all relevant articles; however, every attempt was made to minimise the potential of ‘missed’ literature by developing the search strategy with input from experts in the field of podiatry and foot health care, and guided by a specialist in designing literature search strategies.the extensive user testing done on the GRADE system could be one factor that has contributed to its popularity among guideline developers” [The reader needs also be aware that while the GRADE system is widely adopted by medical researchers, it does have its limitations. Often manuscripts retrieved from the grey literature, such as observational studies, narratives and clinical expert opinion, tend to be classified as being low methodological quality; however in the absence of any other more suitable system it was decided to use GRADE as “elopers” .Lastly, quality of evidence was determined by methodological assessment of the publications in accordance with the AGREE II consortium and interpretation of cited evidence  through Gathering evidence for the effectiveness of core podiatry  and the effectiveness of podiatric surgery should be a high priority for the podiatry and foot and ankle research communities.Professional bodies and the foot and ankle research communities should have a coordinated podiatry  representation on key policy and national and international guideline development committees that have a focus on foot and ankle health and management.Professional bodies and the foot and ankle research communities should have coordinated collaboration for collection of outcomes data and evidence that demonstrates the value and impact of podiatry and foot health care on patients.Future guidelines, standards of care and recommendations should follow a recognised framework (e.g. AGREE II) and use one validated standardised system for grading evidence (i.e. GRADE) for podiatry and foot health care or alternatively have a system that will enable comparability between grading systems (as attempted to do in this paper).It is clear that evidence needs to be accelerated and in place to support the future of the podiatry and foot health clinical workforce. In this systematic review, we have found that the field has an emergent evidence base that is becoming more established year on year. We have also discovered small but relevant numbers of high level evidence for the effectiveness of podiatry and foot health management especially concerning assessment for monitoring and prevention of serious foot complications associated with chronic conditions. Where levels of evidence have been given in high quality guidelines, standards of care or recommendations, they also tend to be strong-moderate quality such that further strategically prioritised research, if performed, is likely to have an important impact in the field.The results from this study will help inform the stakeholders and users of podiatry services such as podiatry clinicians, clinical guideline developers or policymakers on evidence for foot health management in their decision making.Additional file 1: Appendix A. Electronic search strategy: an example using Embase. (DOCX 84 kb)Additional file 2: Appendix B. Scoring of included papers against AGREE II criteria for quality assessment. (DOCX 140 kb)Additional file 3: Appendix C. Types of evidence within the included publications. (DOCX 100 kb)Additional file 4: Appendix D. Levels of evidence where reported from included studies. (DOCX 41 kb)Additional file 5: Appendix E. Levels of Evidence for Recommendations concerning Foot Health Management. (DOCX 28 kb)