Wastage of Health Resources during COVID-19 in Iran: Lessons for Health Policy and Management

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This study assessed the extent of wastage of COVID-19 vaccines, diagnostic kits, and pharmaceutical products in Iran during the pandemic and examined the implications for health policy. Methods: A descriptive, quantitative design was used, analyzing national-level data from 50 medical universities across Iran between 2021 and 2023. Distribution, utilization, and wastage data were extracted from Ministry of Health databases. A bottom-up costing approach was used to estimate the financial burden of these losses. Results: Of over 145 million COVID-19 vaccine doses distributed, 18.3% were wasted. Additionally, 21.1% of medications and 29.5% of diagnostic kits were discarded due to expiration or non-utilization. Key factors contributing to wastage included poor inventory management, frequent revisions of clinical protocols, and reduced demand in later pandemic stages. Conclusion: The findings highlight structural inefficiencies in health resource management and emphasize the need for reforms, including real-time monitoring systems and improved cross-sectoral coordination to reduce waste and enhance future preparedness. Health sciences/Health care Health sciences/Medical research resource wastage health sector COVID-19 Iran Introduction In healthcare systems, 'resource wastage' refers to services and processes that are either harmful, ineffective, or could be replaced by more cost-effective alternatives offering equal or greater benefits (1). This inefficiency is evident on a global scale, with an estimated 20% to 40% of healthcare expenditures being wasted, pointing to a significant lack of accountability and oversight in healthcare delivery. As a result, it is critical to adopt strategies that are not only cost-effective but also equitable, benefiting both society at large and individuals. Achieving this requires the implementation of healthcare delivery models that balance the provision of essential services, ensuring resources are used efficiently to meet the health needs of the population (2). Iran, with a population of approximately 85 million (3), a GDP per capita of about 4,400 USD (4), and annual per capita healthcare expenditures of around 570 USD (5), operates under a mixed healthcare system where the public, private, and nonprofit sectors collaborate in financing and delivering healthcare services (6). Over the past two decades, healthcare expenditures in Iran have increased significantly, from roughly 80 USD per capita in 2000 to about 470 USD in 2019. This rising trend in healthcare spending, driven in part by inflation and exchange rate fluctuations, may present challenges in the future. If these trends continue, Iran could face substantial difficulties in securing the necessary resources to sustain and improve its healthcare system (7). According to the latest World Bank report, the global share of healthcare expenditures as a percentage of GDP in Iran was 6.7% in 2019 (8). The escalating costs within healthcare systems can be attributed to two principal domains. The first encompasses structural shifts such as demographic changes, including population aging—and epidemiological transitions—while the second pertains to alterations in health-related behaviors and the growing medicalization of society, factors largely beyond the direct influence of healthcare systems (9). Epidemiological transitions, particularly outbreaks of infectious diseases such as viral epidemics, can swiftly overwhelm the capacities of governments and healthcare infrastructures, compelling them to make complex and often urgent decisions regarding the optimal allocation of scarce resources. Such decisions frequently involve the prioritization and distribution of medical interventions, including hospital beds, pharmaceuticals, and medical equipment (10( The COVID-19 pandemic has emerged as a critical challenge for health systems worldwide. The global outbreak of this virus was designated the sixth Public Health Emergency of International Concern (PHEIC) by the World Health Organization (11). In Iran, the Ministry of Health and Medical Education officially confirmed the country’s first two cases of COVID-19 in the city of Qom on February 17, 2020. In response, the government established the “National Committee for the Management and Control of COVID-19,” initiating a series of coordinated policies and programs aimed at preventing and mitigating the spread of the virus (12). By August 21, 2023, official data from Iran’s Ministry of Health reported a cumulative total of 7,613,532 confirmed COVID-19 cases. Throughout the country, 57,123,082 diagnostic tests had been administered by that date. Of those infected, 7,374,684 individuals had either recovered or been discharged from medical facilities, while the death toll had reached 146,321. On the vaccination front, 65,238,921 people had received their first dose, 58,633,579 had completed their second, and an additional 31,733,012 had received a third or subsequent booster dose. In total, 155,605,512 vaccine doses have been administered nationwide (13). The interaction between the COVID-19 virus and the healthcare system is inherently bidirectional. On the one hand, the system’s capacity to respond effectively influences the course of the pandemic; on the other hand, the virus itself, along with national strategies deployed to control it, directly impacts the functioning of the health system. Furthermore, the financial performance of the health sector plays a critical role in shaping its ability to deliver high-quality healthcare services to the population (14). Iran faced a myriad of challenges and complexities in dealing with the COVID-19 virus. Key obstacles included limitations in diagnostic testing, vaccine shortages, and economic sanctions. Inadequate diagnostic testing and insufficient surveillance of new viral variants led to a significant reduction in the country's ability to prevent and control the spread of the virus. These issues not only strained the healthcare system but also hindered effective policy implementation and response strategies. Additionally, vaccine shortages caused by sanctions and supply chain issues hinder the country's ability to establish adequate vaccination coverage and control the spread of the disease. Economic sanctions also obstructed the provision of essential medical equipment and supplies needed to combat the virus and mitigate its impact on Iranian society by creating financial and economic constraints. In summary, these challenges significantly limited Iran's capacity to control the spread of COVID-19 and protect public health (15). Materials and Methods All methods were performed in accordance with the relevant guidelines and regulations · Study Framework: This study is a descriptive analysis designed to estimate the number of wasted resources used for the diagnosis, prevention, and treatment of COVID-19, utilizing existing data. On the basis of the collected information, the study focuses on gathering and describing the data, as well as estimating the costs incurred owing to resource waste at the national level. · Research setting The statistical population in this study included all medical universities and healthcare centers across the country. The necessary data related to vaccines, diagnostic kits, and medications were collected from the universities through a predesigned electronic form created by the research team and via official correspondence. All universities that fully completed the electronic form were considered eligible for inclusion, whereas those that submitted incomplete forms or contained outlier data were followed up by phone to ensure the accuracy and completeness of the data. If, after the follow-up, the data remained incomplete or contained outliers, those universities were excluded from the analysis. Given the descriptive nature of this research, descriptive statistics, including the mean, frequency, and mode, were used to describe the research objectives. · Tools and Data Collection Techniques : The electronic data collection form was designed to gather information related to vaccines, diagnostic kits, and medications. To ensure its validity, the content and form of the electronic registration form were first reviewed and approved. Then, via a bottom-up cost calculation approach, the data recorded by universities in relevant systems—specifically related to vaccine registration, COVID-19 diagnostic tests, and pharmaceutical inventory management under the Ministry of Health's Health Deputy—were identified and measured from 2020--2022. To perform cost estimation, it is necessary to first identify, measure, and value the resources (16). For identification, all items related to vaccines, diagnostic kits, and medications were collected. To determine the consumed resources, a chain model (comprising input-process-output) was used. This model serves as a framework for describing the relationships between resources, activities, and outcomes, specifying the service delivery process (input-operations-output). With its systematic structure, this model aids in the planning, execution, and evaluation of system performance, as well as improving results (Table 1). In the healthcare sector, a logical model can assist in identifying and reducing resource waste while enhancing service quality (17 . ( For measurement, the quantities of produced, consumed, and wasted items were collected from the Vaccine Cold Chain System, the Laboratory Affairs System, and the Pharmaceutical Inventory Registration System. For valuation, the price of each item was obtained from the Food and Drug Organization, along with the approved tariffs of the Ministry of Health, Treatment, and Medical Education for this time period, and each item was then evaluated. · Data Analysis: To assess and monitor costs in the management of the COVID-19 epidemic, the logical model was used as a framework for identifying, measuring, and valuing the resources consumed in response to the COVID-19 pandemic within the scope of primary healthcare activities in the Iranian Health Network (IHN). The amount of resource waste in the management of COVID-19, including vaccines, diagnostic kits, medications, and medical supplies, was estimated. The results were analyzed as indicators of resource consumption in the health Deputy sector and were examined via descriptive statistical indices. The output of this phase is an estimate of the financial burden of wasted resources during the COVID-19 epidemic at Iran's universities of medical sciences and healthcare services. "The results of the logical model indicate that to reduce disease transmission and prevalence, the use of available vaccines on the market is essential (Table 1). The first major source of resource waste during the COVID-19 epidemic was vaccines. With the outbreak of the COVID-19 virus, several public and private entities in Iran, driven by various motivations, developed vaccines. Among the 10 major COVID-19 vaccine projects in Iran, 9 vaccines successfully passed clinical trials, and six vaccines received emergency use authorization from the country's Food and Drug Organization. Among the approved vaccines, three—SpikoGen, Razi Cov Pars, and Pasteur Cov—were developed through international collaboration and technology transfer, whereas the others—Cov Iran Barakat, Fakhra vac, and Noura vac—were domestically produced (18). "Estimation of COVID-19 Vaccine Wastage The data required for this study were obtained from the country’s medical universities and health service institutions via an electronic data collection form and were submitted to the Iranian Ministry of Health. According to the study findings, the vaccines included in Iran's national COVID-19 vaccination program included the following: Sputnik V (Doses I and II), Sinopharm, Bharat, AstraZeneca, COV Iran Barkat Plus, Spikogen, Pasto Co vac Plus, Fakhra, COV Pars, Pasto Co vac, and Noora. As of September 2023, a total of 145,260,965 doses of COVID-19 vaccines had been distributed in Iran. Of this amount, 26,586,937 doses, equivalent to 18.3%, were reported as wasted. Among the domestically produced vaccines, COV Iran Barkat had the highest waste rate. However, imported vaccines such as Sinopharm also resulted in a significant level of waste. (See Table 2). The wastage ratio of each vaccine (dose) relative to the total number of doses distributed for that specific vaccine shows that the Fakhra vaccine has the highest wastage rate among Iranian vaccines, at 91.7%. In contrast, the Chinese Sinopharm vaccine presented the lowest wastage rate among imported vaccines, at 4%. Overall, when the wastage of each vaccine relative to the total number of vaccines was considered, the Barkat vaccine had the highest wastage rate, at 22.4%, whereas Sputnik II presented the lowest wastage rate, at 1.3%. Furthermore, within Iran's national vaccination program, the highest vaccination coverage was achieved by the Sinopharm vaccine, accounting for 94.2% of total vaccinations, whereas the lowest vaccination rate was associated with the domestically produced Noora vaccine. Finally, a comparison of the total number of vaccines received (145,260,965 doses) and the total number of vaccines administered (114,678,626 doses) revealed that 78.9% of the received vaccines were administered (see Table 2). · Estimation of Wastage in Medications for the Treatment of COVID-19 Although no proven antiviral drug has been identified for the treatment of COVID-19 to date, various drugs have been introduced on the basis of conducted studies, which may be used under specific conditions for treatment. According to the data recorded by universities, the medications used in Iran include chloroquine and hydroxychloroquine, Kaletra tablets, lopinavir/ritonavir, remdesivir, and atazanavir/ritonavir. In this study, out of a total of 1,979,735 blister packs of medication distributed, 21.1% were wasted due to expiration or nonconsumption. Hydroxychloroquine phosphate had the highest consumption rate (85.6%) and the lowest waste rate (14.4%), while lopinavir/ritonavir presented the highest waste rate, at 47.9%. More detailed information about each medication can be found in Table (3). · Estimation of Wastage in COVID-19 Diagnostic and Laboratory Kits The findings of this study indicated that rapid diagnostic tests (RDTs) accounted for the highest usage rate among all diagnostic kits, with a 77.6% consumption rate. These kits also demonstrated a relatively lower waste rate (22.4%) than the other test kits did. However, owing to their high distribution volume, RDTs contributed the largest share of total waste, accounting for 17.9% of all wasted diagnostic kits. In contrast, manual extraction kits had the lowest usage rate (35.8%) and the highest waste rate (64.2%) among all categories. Overall, out of 10,442,935 distributed diagnostic and laboratory kits, a total of 7,363,512 kits (70.5%) were utilized, whereas 3,079,423 kits (29.5%) were discarded due to expiration or defects. These findings highlight the critical need for improved inventory management and warehousing practices to reduce kit waste and disposal rates (see Table 4). Discussion In today’s world, health systems are confronting unprecedented challenges stemming from limited financial resources alongside the continuous rise in healthcare costs. This dual pressure underscores the critical need for adopting optimized management strategies that enable efficient resource allocation and enhance preparedness for unexpected events. To be effective, such strategies must be grounded in rigorous data analysis and empirical evidence, aiming to minimize resource waste and avoid unnecessary expenditures. To minimize resource waste and avoid unnecessary expenditures, evidence- and data-driven strategies must lie at the core of decision-making processes. This includes prioritizing preventive measures and primary care, with the goal of reducing reliance on more complex and costly treatments in the future. This study aimed to estimate the economic burden resulting from resource wastage in the management of the COVID-19 pandemic within Iran’s healthcare sector. Three primary areas of waste were identified: vaccines, diagnostic and laboratory kits, and pharmaceuticals and medical supplies. The extent of waste in each category was quantified and assessed via quantitative data. Vaccine waste is a common occurrence in any vaccination program and has been closely monitored during the COVID-19 pandemic. While some level of waste is expected, unnecessary and preventable waste has emerged as a significant concern. A review of various studies, such as one conducted in Georgia, identified key reasons for vaccine wastage, including low demand for available vaccines, misinformation, and uncertainty regarding the safety of the vaccines. These factors resulted in the waste of 400,000 doses of the Pfizer, Sinopharm, and AstraZeneca vaccines ( 19 ). Our findings indicate that, in Iran, more than 6,756,988 doses of Sinopharm, AstraZeneca, and Sputnik vaccines have either expired or wasted. One of the primary causes of vaccine waste was the decline in vaccine demand following a reduction in the severity of the epidemic, coupled with an oversupply of vaccines. This decline in demand was directly linked to changes in communication strategies and therapeutic protocols. Specifically, the absence of effective campaigns to encourage vaccination during the later stages of the epidemic led to the expiration of a significant number of vaccine doses. The results of the Lazarus study on COVID-19 vaccine waste in various countries, including Hong Kong, African countries (Liberia, Malawi, Gambia, Guinea, Sierra Leone, Comoros, and Congo), the Netherlands, Ireland, Spain, Australia, the United Kingdom, and South Korea, revealed that approximately 11,540,000 doses of various vaccines were wasted. The primary cause of this waste was attributed to logistical issues, including expiration dates, transportation, and maintaining the cold chain ( 20 ). Taking these factors into account, our study also reported the waste of 26,586,937 doses of both domestic and imported vaccines. Another cause of vaccine wastage, as identified in our study and not typically highlighted in other studies on vaccine wastage, was related to domestically produced vaccines. Specifically, the variety and diversity of domestically produced vaccines, combined with delays in obtaining international approvals for their validation, may have contributed to the wastage of Iranian vaccines. As a result, the waste of these vaccines in the vaccination program was reported to be approximately 19,054,460 doses. According to a study conducted by Bol J in 2021, the results revealed that the waste of viral vaccines, such as those for measles and BCG, averaged 59% due to the nature of the vaccines and the conditions of their storage after preparation ( 21 ). In our study, owing to the similarity of the storage conditions of COVID-19 vaccines with those of other live viral vaccines, the total wastage of vaccines relative to the total number of vaccines received was approximately 18.3% (total vaccine waste/total vaccines received) *100. This wastage rate is considerably lower than that reported in other studies, and this discrepancy may be due to the acute nature of the COVID-19 epidemic in the community, as well as the increased number of individuals seeking vaccination for disease prevention and fear of illness. Another study conducted by Dkhar SA in 2021 revealed that the utilization rate of weakened live viral vaccines, such as the yellow fever vaccine, and their administration to the population was 81.6% of the total number of vaccines ( 22 ). In our study, the utilization rate of weakened live viral COVID-19 vaccines and their administration in the target population was approximately 78.9% (total number of vaccines administered/total number of vaccines) *100. This discrepancy is likely due to factors such as limited individual visits, vaccine hesitancy, and the reduced prevalence of COVID-19 in our community. Another focus of resource waste in the management of the COVID-19 epidemic was waste in diagnostic and laboratory kits. Access to accurate and reliable laboratory results has always been one of the key goals of laboratory systems. Despite the critical role that laboratory services play in diagnosing and managing many pathologies, they are often considered cost centers in the healthcare sector ( 23 ). In Iran, in addition to identifying the first cases of infection and considering the importance of laboratory diagnosis in the rapid identification of patients, a wide network of molecular diagnostic laboratories for SARS-CoV-2, known as reference COVID-19 laboratories, was established to increase the capacity and speed of laboratory response in diagnostic services related to COVID-19 ( 24 ). The diagnostic and laboratory kits used in these centers include PCR molecular diagnostic kits, manual extraction kits, device-based extraction kits, and rapid test kits sourced from various brands. Various studies have also addressed the importance of diagnostic and laboratory costs related to this disease. One of the fundamental needs of medical diagnostic laboratories is diagnostic and laboratory kits, which are used to assess and monitor the status of diseases. In disease diagnosis, the quality and accuracy of the kits, as well as the use of appropriate laboratory equipment, play crucial roles in confirming and diagnosing diseases. If these factors are not given proper attention, the treatment process and timely diagnosis of the disease will be delayed ( 25 ). In Iran, in relation to diagnostic testing, reference laboratories were established and equipped by medical universities at the provincial level. In these reference laboratories, depending on the needs of the equipment and the type of tests conducted, various diagnostic kits, such as device-based extraction kits, manual extraction kits, laboratory molecular diagnostic kits, and rapid diagnostic kits, are used. Various studies have indicated that diagnostic tests for COVID-19 are undoubtedly useful epidemiological tools, especially for estimating the prevalence of asymptomatic COVID-19 cases. If only 5% or more of the population has been infected with SARS-CoV-2, conducting millions of antibody tests may not significantly contribute to clarifying the overall picture of disease prevalence and may not be necessary ( 26 ). A study conducted by Vatandoost and colleagues in 2023, which focused on the challenges of resource management and underlying factors during the COVID-19 pandemic in Iran, revealed that factors such as a decrease in patient visits for diagnostic tests, excessive procurement of diagnostic and laboratory kits without assessing disease status, and failure to redistribute diagnostic kits with near-expiration dates were some of the reasons for resource waste in the area of diagnostic and laboratory kits ( 27 ). In our study, the wastage of 3,079,423 diagnostic-laboratory COVID-19 kits in the country's medical universities was reported, with the reasons for this wasting resembling the findings of the Vatandoost study. Another area of resource waste that we focused on in the health sector was medications. The constant changes in treatment protocols and the waste of significant quantities of medications in various forms were due to the lack of a proper drug distribution system, incorrect procurement and storage practices, and the absence of accurate drug supervision and control ( 28 ). The main reasons for this waste could be the continuous changes in therapeutic protocols, inaccurate estimates of medication needs, and issues in the storage and distribution of drugs. These issues highlight the importance of better management of the drug supply and consumption cycle. Since the beginning of the pandemic, the list of prescribed medications for COVID-19 patients in Iran has been constantly changing due to conflicting opinions from specialists regarding the effectiveness and treatment of medications. There has been no nationwide consensus on the introduction of appropriate drugs for the COVID-19 pandemic ( 29 ). Inefficient drug management, especially in the public sector of developing countries, is a major challenge, and improving it can lead to cost savings and increased access to medications for the population ( 30 ). An evaluation conducted between 2012 and 2014 in the Federal City of Addis Ababa revealed that the main reasons for drug and medical supply were poor management, lack of auditing procedures, transparency, and accountability in Ethiopia’s pharmaceutical system. These issues can increase healthcare costs and disrupt improvements and optimization of the pharmaceutical system ( 31 ). The results of the study by Abera Bedasa Alemu and colleagues in 2023 also revealed that drug waste in Ethiopia occurred due to the delivery of drugs close to their expiration date to healthcare centers, sudden changes in treatment protocols, and excessive drug stockpiling due to incorrect forecasting of drug demands during the COVID-19 epidemic. Inadequate inventory control was responsible for a loss of 4–9% of the drugs in the supply systems. More than half of the drugs were inappropriately prescribed, distributed, or sold. This issue is more prevalent in developing countries, especially where there are limited regulatory procedures for drug usage. Improving precise inventory management and effective regulatory measures can help prevent waste of drugs and valuable resources ( 32 ). According to a study by M. Roustit on the drug hydroxychloroquine and its effect on COVID-19, under laboratory conditions, this drug has demonstrated effectiveness against the SARS-CoV-2 virus. However, by mid-2020, clinical data were not able to confirm the efficacy of these drugs in patients with COVID-19. On the other hand, the unscientific promotion of this drug led to the execution of more than one hundred studies, jeopardizing resources and delaying accurate trials for the treatment of COVID-19 ( 33 ). In line with the results of other studies, considering various causes, our study reported the waste of 401,602 thousand blister packs of different drugs used to treat COVID-19 in the health sector. Among the total available drugs, 20% were wasted and removed from the drug distribution cycle. This figure is significantly greater than the results of other studies and highlights the need for better management of the supply‒demand cycle under abnormal and unpredictable conditions. • Limitations of the Study The lack of an integrated information registration system for vaccines, medications, supplies, and diagnostic kits has led to fragmentation and inconsistency of the available data. There is an absence of comprehensive information regarding the price per dose for vaccines, diagnostic-laboratory kits, and medications. Insufficient collaboration and attention in transmitting information and providing appropriate responses by some universities under the jurisdiction of the Ministry of Health. Some officials are reluctant to share information because of the sensitivity of the issue and political and security concerns, particularly regarding vaccines. Conclusion In a context where financial resources in the healthcare sector are limited and healthcare costs are continuously rising, the use of logical planning and the adoption of effective decision-making are essential to minimize unnecessary expenditures and resource waste. This study revealed that, in the planning and management of the COVID-19 epidemic within the healthcare sector, significant amounts of vaccines, diagnostic kits, and medications were wasted. These wastages not only resulted in the depletion of financial resources but also contributed to a reduction in the effectiveness of health programs and the creation of additional challenges in epidemic control. To reduce these burdens, it is essential to implement effective measures. One such measure is precise inventory management and the enhancement of supervisory systems. This includes the implementation of advanced inventory management systems to control the expiration dates of vaccines and medications, as well as optimizing distribution processes to ensure the timely delivery of resources to required points. To minimize resource waste, it is recommended that advanced inventory management systems and demand forecasting systems be utilized at all medical universities. These systems can enable real-time tracking of vaccines and medication inventories and prevent premature expiration. Furthermore, the use of artificial intelligence algorithms to predict the demand for diagnostic kits and medications on the basis of epidemiological data can help avoid overordering resources. Additionally, increasing transparency and collaboration between health organizations is of paramount importance. Establishing an integrated system for recording and managing information related to vaccines, diagnostic kits, and medications can significantly improve transparency. In resource-limited settings, implementing prioritization frameworks can greatly enhance resource allocation. To achieve this, the use of an importance-performance matrix is recommended. This matrix can assist decision-makers in allocating resources to activities that have the greatest impact on reducing waste. For example, prioritizing vaccines with imminent expiration dates or distributing diagnostic kits to regions with higher prevalence rates can increase efficiency. Additionally, strengthening collaboration and information exchange between universities and health centers is essential for greater coordination and minimizing resource waste. By implementing these measures, significant reductions in resource waste can be achieved, leading to improvements in the efficiency of healthcare programs. Using the findings of this study as a foundation for developing health policies and programs can help prevent similar issues in the future and ensure better management in the face of upcoming epidemics. These strategies play crucial roles in enhancing the efficiency and effectiveness of the public health system. According to a report from the World Health Organization, globally, more than 50% of vaccines are wasted under normal circumstances. The range set by the Global Alliance for Vaccines and Immunization (GAVI)[1] for vaccine wastage is between 5% and 25% (34). During the COVID-19 epidemic, vaccine wastage rates for the coronavirus were reported to be as high as 30% (20). Considering these figures, when evaluating the success of Iran's vaccination program in reducing vaccine waste, if the total amount of vaccine waste (26,586,937 doses) is divided by the total number of vaccines received (145,260,965 doses), a rate of 18.3% is obtained. This percentage reflects the satisfactory performance of the Iranian Ministry of Health's vaccination program. [1] Global Alliance for Vaccines and Immunizations Declarations · Ethics approval and consent to participate : Ethical approval and participant consent: This study was conducted in accordance with the ethical guidelines approved by the Ethics Committee of Kerman University of Medical Sciences, with reference number IR.KMU.REC.1401.253. Consent for publication: All participants in this study voluntarily and knowingly consented to the publication of the research results in scientific journals. They emphasized that their personal privacy would be preserved and that any identifiable information in the article would be presented anonymously. Participation in this study and the publication of its results were voluntary and without any discrimination against the participants. If individuals wish to receive a copy of the final results of this study, they may contact the corresponding author. · Availability of data and materials: The datasets analyzed in this study are not publicly available due to privacy concerns and organizational regulations. However, reasonable requests for data access may be considered upon contacting the corresponding author. · Funding : This study did not receive any specific grants from organizations associated with the public, commercial, or nonprofit sectors. · Authors' contributions: Each of the authors played a significant role in the design, data collection, analysis, and interpretation of the study. Seyed Saeed Tabatabai, Mohsen Baroni, Vahid Vatandoost, Reza Esmaeili and Reza Hashemipour contributed comprehensively to the drafting and content review of the main manuscript. All the authors have read and approved the final version of the manuscript. · Acknowledgments: "The results of this research project are based on part of the findings from a doctoral thesis with reference code 401000260 at Kerman University of Medical Sciences. The authors would like to thank the assistants, managers, and experts from the Ministry of Health, Treatment, and Medical Education of Iran who voluntarily participated in this study and shared their perspectives and experiences on the factors leading to resource waste in the management of the COVID-19 epidemic in healthcare centers. References Parker D, Newbrander W, editors. Tackling wastage and inefficiency in the health sector. World health forum 1994; 15 (2): 107-131; 1994. World Health Organization. Global strategy on human resources for health: Workforce 2030. 2016. presidency of the I.R.I plan and budegt organization. Iran statistical center 2023 [cited 2023 September 2, ]. 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Depiction of Health. 2022;13(Suppl 1):11-21. Rahmati F, Jalili S. Clinical manifestations and diagnostic methods of covid-19. New Cellular and Molecular Biotechnology Journal. 2020;10(40):9-24. Medicine TLR. Testing for covid-19. 2020. Vatandoost V, Tabatabaee SS, Okhovati M, Barooni M. Explaining the challenges of resources management and its underlying factors in covid-19 era in iran: A qualitative study. BMC public health. 2023;23(1):2118. Mortazavi A, Hajebi G. Issues and problems related to the administration of medical services covered by the hospital pharmacy in beheshti university of medical sciences. Journal of Research in medicine. 2002;26(3):205-15. Daneshpazhooh M, Mahmoudi H. Covid-19: The experience from iran. Clinics in Dermatology. 2021;39(1):23-32. Narasimhan V, Brown H, Pablos-Mendez A, Adams O, Dussault G, Elzinga G, et al. Responding to the global human resources crisis. The Lancet. 2004;363(9419):1469-72. Carnevale JB, Hatak I. Employee adjustment and well-being in the era of covid-19: Implications for human resource management. Journal of business research. 2020;116:183-7. Alemu AB, Ibrahim NA, Argaw KW. Magnitude of medicine wastage and perceived contributing factors among public health facilities in dire-dawa city administration, in mid covid-19 pandemic in ethiopia: Retrospective, cross-sectional study. Integrated Pharmacy Research and Practice. 2023:61-75. Roustit M, Guilhaumou R, Molimard M, Drici M-D, Laporte S, Montastruc J-L, et al. Chloroquine and hydroxychloroquine in the management of covid-19: Much kerfuffle but little evidence. Therapies. 2020;75(4):363-70. World Health Organization. Monitoring vaccine wastage at country level: Guidelines for programme managers. World Health Organization, 2005. Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6637991","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":531618015,"identity":"7816b2ab-ae04-4bbe-b7b3-622d64fece84","order_by":0,"name":"Seyed Saeed Tabatabaee","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Saeed","lastName":"Tabatabaee","suffix":""},{"id":531618016,"identity":"b7f11a33-bd86-4795-a713-917072f3912c","order_by":1,"name":"Mohsen Barouni","email":"","orcid":"","institution":"Kerman University of Medical 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17:05:13","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115986,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-6637991/v1/7318e2f02a6197a9259c7955.html"},{"id":94859908,"identity":"0465e9f9-eef9-40e9-9674-c8bc8ab328a0","added_by":"auto","created_at":"2025-10-31 12:54:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":521834,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6637991/v1/2d4fe5da-f337-4269-8eb3-0f98ef3ff958.pdf"},{"id":94037652,"identity":"993c7e29-dc6b-48e6-aa07-e9e7f20d95c1","added_by":"auto","created_at":"2025-10-21 17:05:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":38376,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6637991/v1/340d6a10c032368d22eb1abc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Wastage of Health Resources during COVID-19 in Iran: Lessons for Health Policy and Management","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn healthcare systems, 'resource wastage' refers to services and processes that are either harmful, ineffective, or could be replaced by more cost-effective alternatives offering equal or greater benefits (1). This inefficiency is evident on a global scale, with an estimated 20% to 40% of healthcare expenditures being wasted, pointing to a significant lack of accountability and oversight in healthcare delivery. As a result, it is critical to adopt strategies that are not only cost-effective but also equitable, benefiting both society at large and individuals. Achieving this requires the implementation of healthcare delivery models that balance the provision of essential services, ensuring resources are used efficiently to meet the health needs of the population (2).\u003c/p\u003e\n\u003cp\u003eIran, with a population of approximately 85 million (3), a GDP per capita of about 4,400 USD (4), and annual per capita healthcare expenditures of around 570 USD (5), operates under a mixed healthcare system where the public, private, and nonprofit sectors collaborate in financing and delivering healthcare services (6). Over the past two decades, healthcare expenditures in Iran have increased significantly, from roughly 80 USD per capita in 2000 to about 470 USD in 2019. This rising trend in healthcare spending, driven in part by inflation and exchange rate fluctuations, may present challenges in the future. If these trends continue, Iran could face substantial difficulties in securing the necessary resources to sustain and improve its healthcare system (7).\u0026nbsp;According to the latest World Bank report, the global share of healthcare expenditures as a percentage of GDP in Iran was 6.7% in 2019 (8). The escalating costs within healthcare systems can be attributed to two principal domains. The first encompasses structural shifts such as demographic changes, including population aging—and epidemiological transitions—while the second pertains to alterations in health-related behaviors and the growing medicalization of society, factors largely beyond the direct influence of healthcare systems (9).\u003cbr\u003eEpidemiological transitions, particularly outbreaks of infectious diseases such as viral epidemics, can swiftly overwhelm the capacities of governments and healthcare infrastructures, compelling them to make complex and often urgent decisions regarding the optimal allocation of scarce resources. Such decisions frequently involve the prioritization and distribution of medical interventions, including hospital beds, pharmaceuticals, and medical equipment (10(\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic has emerged as a critical challenge for health systems worldwide. The global outbreak of this virus was designated the sixth Public Health Emergency of International Concern (PHEIC) by the World Health Organization (11). In Iran, the Ministry of Health and Medical Education officially confirmed the country’s first two cases of COVID-19 in the city of Qom on February 17, 2020. In response, the government established the “National Committee for the Management and Control of COVID-19,” initiating a series of coordinated policies and programs aimed at preventing and mitigating the spread of the virus (12). By August 21, 2023, official data from Iran’s Ministry of Health reported a cumulative total of 7,613,532 confirmed COVID-19 cases. Throughout the country, 57,123,082 diagnostic tests had been administered by that date. Of those infected, 7,374,684 individuals had either recovered or been discharged from medical facilities, while the death toll had reached 146,321. On the vaccination front, 65,238,921 people had received their first dose, 58,633,579 had completed their second, and an additional 31,733,012 had received a third or subsequent booster dose. In total, 155,605,512 vaccine doses have been administered nationwide (13). The interaction between the COVID-19 virus and the healthcare system is inherently bidirectional. On the one hand, the system’s capacity to respond effectively influences the course of the pandemic; on the other hand, the virus itself, along with national strategies deployed to control it, directly impacts the functioning of the health system. Furthermore, the financial performance of the health sector plays a critical role in shaping its ability to deliver high-quality healthcare services to the population (14).\u0026nbsp;Iran faced a myriad of challenges and complexities in dealing with the COVID-19 virus. Key obstacles included limitations in diagnostic testing, vaccine shortages, and economic sanctions. Inadequate diagnostic testing and insufficient surveillance of new viral variants led to a significant reduction in the country's ability to prevent and control the spread of the virus. These issues not only strained the healthcare system but also hindered effective policy implementation and response strategies. Additionally, vaccine shortages caused by sanctions and supply chain issues hinder the country's ability to establish adequate vaccination coverage and control the spread of the disease. Economic sanctions also obstructed the provision of essential medical equipment and supplies needed to combat the virus and mitigate its impact on Iranian society by creating financial and economic constraints. In summary, these challenges significantly limited Iran's capacity to control the spread of COVID-19 and protect public health (15).\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eAll methods were performed in accordance with the relevant guidelines and regulations\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eStudy Framework:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a descriptive analysis designed to estimate the number of wasted resources used for the diagnosis, prevention, and treatment of COVID-19, utilizing existing data. On the basis of the collected information, the study focuses on gathering and describing the data, as well as estimating the costs incurred owing to resource waste at the national level.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eResearch\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical population in this study included all medical universities and healthcare centers across the country. The necessary data related to vaccines, diagnostic kits, and medications were collected from the universities through a predesigned electronic form created by the research team and via official correspondence. All universities that fully completed the electronic form were considered eligible for inclusion, whereas those that submitted incomplete forms or contained outlier data were followed up by phone to ensure the accuracy and completeness of the data. If, after the follow-up, the data remained incomplete or contained outliers, those universities were excluded from the analysis. Given the descriptive nature of this research, descriptive statistics, including the mean, frequency, and mode, were used to describe the research objectives.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eTools and Data Collection Techniques\u003cspan dir=\"RTL\"\u003e:\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe electronic data collection form was designed to gather information related to vaccines, diagnostic kits, and medications. To ensure its validity, the content and form of the electronic registration form were first reviewed and approved. Then, via a bottom-up cost calculation approach, the data recorded by universities in relevant systems\u0026mdash;specifically related to vaccine registration, COVID-19 diagnostic tests, and pharmaceutical inventory management under the Ministry of Health\u0026apos;s Health Deputy\u0026mdash;were identified and measured from 2020--2022.\u003c/p\u003e\n\u003cp\u003eTo perform cost estimation, it is necessary to first identify, measure, and value the resources (16). For identification, all items related to vaccines, diagnostic kits, and medications were collected. To determine the consumed resources, a chain model (comprising input-process-output) was used. This model serves as a framework for describing the relationships between resources, activities, and outcomes, specifying the service delivery process (input-operations-output). With its systematic structure, this model aids in the planning, execution, and evaluation of system performance, as well as improving results (Table 1). In the healthcare sector, a logical model can assist in identifying and reducing resource waste while enhancing service quality (17\u003cspan dir=\"RTL\"\u003e. (\u003c/span\u003eFor measurement, the quantities of produced, consumed, and wasted items were collected from the Vaccine Cold Chain System, the Laboratory Affairs System, and the Pharmaceutical Inventory Registration System. For valuation, the price of each item was obtained from the Food and Drug Organization, along with the approved tariffs of the Ministry of Health, Treatment, and Medical Education for this time period, and each item was then evaluated.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eData Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo assess and monitor costs in the management of the COVID-19 epidemic, the logical model was used as a framework for identifying, measuring, and valuing the resources consumed in response to the COVID-19 pandemic within the scope of primary healthcare activities in the Iranian Health Network (IHN). The amount of resource waste in the management of COVID-19, including vaccines, diagnostic kits, medications, and medical supplies, was estimated. The results were analyzed as indicators of resource consumption in the health Deputy sector and were examined via descriptive statistical indices. The output of this phase is an estimate of the financial burden of wasted resources during the COVID-19 epidemic at Iran\u0026apos;s universities of medical sciences and healthcare services.\u003c/p\u003e\n\u003cp\u003e\u0026quot;The results of the logical model indicate that to reduce disease transmission and prevalence, the use of available vaccines on the market is essential (Table 1). The first major source of resource waste during the COVID-19 epidemic was vaccines. With the outbreak of the COVID-19 virus, several public and private entities in Iran, driven by various motivations, developed vaccines. Among the 10 major COVID-19 vaccine projects in Iran, 9 vaccines successfully passed clinical trials, and six vaccines received emergency use authorization from the country\u0026apos;s Food and Drug Organization. Among the approved vaccines, three\u0026mdash;SpikoGen, Razi Cov Pars, and Pasteur Cov\u0026mdash;were developed through international collaboration and technology transfer, whereas the others\u0026mdash;Cov Iran Barakat, Fakhra vac, and Noura vac\u0026mdash;were domestically produced (18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026quot;Estimation of COVID-19 Vaccine Wastage\u003c/strong\u003e\u003cbr\u003eThe data required for this study were obtained from the country\u0026rsquo;s medical universities and health service institutions via an electronic data collection form and were submitted to the Iranian Ministry of Health. According to the study findings, the vaccines included in Iran\u0026apos;s national COVID-19 vaccination program included the following: Sputnik V (Doses I and II), Sinopharm, Bharat, AstraZeneca, COV\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eIran Barkat Plus, Spikogen, Pasto\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eCo\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003evac Plus, Fakhra, COV\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003ePars, Pasto\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eCo\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003evac, and Noora.\u003cbr\u003e\u0026nbsp;As of September 2023, a total of 145,260,965 doses of COVID-19 vaccines had been distributed in Iran. Of this amount, 26,586,937 doses, equivalent to 18.3%, were reported as wasted.\u003cbr\u003eAmong the domestically produced vaccines, COV\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eIran Barkat had the highest waste rate. However, imported vaccines such as Sinopharm also resulted in a significant level of waste. \u003cstrong\u003e(See Table 2).\u003c/strong\u003e The wastage ratio of each vaccine (dose) relative to the total number of doses distributed for that specific vaccine shows that the Fakhra vaccine has the highest wastage rate among Iranian vaccines, at 91.7%. In contrast, the Chinese Sinopharm vaccine presented the lowest wastage rate among imported vaccines, at 4%. Overall, when the wastage of each vaccine relative to the total number of vaccines was considered, the Barkat vaccine had the highest wastage rate, at 22.4%, whereas Sputnik II presented the lowest wastage rate, at 1.3%. Furthermore, within Iran\u0026apos;s national vaccination program, the highest vaccination coverage was achieved by the Sinopharm vaccine, accounting for 94.2% of total vaccinations, whereas the lowest vaccination rate was associated with the domestically produced Noora vaccine. Finally, a comparison of the total number of vaccines received (145,260,965 doses) and the total number of vaccines administered (114,678,626 doses) revealed that 78.9% of the received vaccines were administered (see Table 2).\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eEstimation of Wastage in Medications for the Treatment of COVID-19\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough no proven antiviral drug has been identified for the treatment of COVID-19 to date, various drugs have been introduced on the basis of conducted studies, which may be used under specific conditions for treatment. According to the data recorded by universities, the medications used in Iran include chloroquine and hydroxychloroquine, Kaletra tablets, lopinavir/ritonavir, remdesivir, and atazanavir/ritonavir. In this study, out of a total of 1,979,735 blister packs of medication distributed, 21.1% were wasted due to expiration or nonconsumption. Hydroxychloroquine phosphate had the highest consumption rate (85.6%) and the lowest waste rate (14.4%), while lopinavir/ritonavir presented the highest waste rate, at 47.9%. More detailed information about each medication can be found in Table (3).\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eEstimation of Wastage in COVID-19 Diagnostic and Laboratory Kits\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The findings of this study indicated that rapid diagnostic tests (RDTs) accounted for the highest usage rate among all diagnostic kits, with a 77.6% consumption rate. These kits also demonstrated a relatively lower waste rate (22.4%) than the other test kits did. However, owing to their high distribution volume, RDTs contributed the largest share of total waste, accounting for 17.9% of all wasted diagnostic kits.\u003c/p\u003e\n\u003cp\u003eIn contrast, manual extraction kits had the lowest usage rate (35.8%) and the highest waste rate (64.2%) among all categories. Overall, out of 10,442,935 distributed diagnostic and laboratory kits, a total of 7,363,512 kits (70.5%) were utilized, whereas 3,079,423 kits (29.5%) were discarded due to expiration or defects. These findings highlight the critical need for improved inventory management and warehousing practices to reduce kit waste and disposal rates (see Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn today\u0026rsquo;s world, health systems are confronting unprecedented challenges stemming from limited financial resources alongside the continuous rise in healthcare costs. This dual pressure underscores the critical need for adopting optimized management strategies that enable efficient resource allocation and enhance preparedness for unexpected events. To be effective, such strategies must be grounded in rigorous data analysis and empirical evidence, aiming to minimize resource waste and avoid unnecessary expenditures. To minimize resource waste and avoid unnecessary expenditures, evidence- and data-driven strategies must lie at the core of decision-making processes. This includes prioritizing preventive measures and primary care, with the goal of reducing reliance on more complex and costly treatments in the future. This study aimed to estimate the economic burden resulting from resource wastage in the management of the COVID-19 pandemic within Iran\u0026rsquo;s healthcare sector. Three primary areas of waste were identified: vaccines, diagnostic and laboratory kits, and pharmaceuticals and medical supplies. The extent of waste in each category was quantified and assessed via quantitative data. Vaccine waste is a common occurrence in any vaccination program and has been closely monitored during the COVID-19 pandemic. While some level of waste is expected, unnecessary and preventable waste has emerged as a significant concern. A review of various studies, such as one conducted in Georgia, identified key reasons for vaccine wastage, including low demand for available vaccines, misinformation, and uncertainty regarding the safety of the vaccines. These factors resulted in the waste of 400,000 doses of the Pfizer, Sinopharm, and AstraZeneca vaccines (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Our findings indicate that, in Iran, more than 6,756,988 doses of Sinopharm, AstraZeneca, and Sputnik vaccines have either expired or wasted. One of the primary causes of vaccine waste was the decline in vaccine demand following a reduction in the severity of the epidemic, coupled with an oversupply of vaccines. This decline in demand was directly linked to changes in communication strategies and therapeutic protocols. Specifically, the absence of effective campaigns to encourage vaccination during the later stages of the epidemic led to the expiration of a significant number of vaccine doses. The results of the Lazarus study on COVID-19 vaccine waste in various countries, including Hong Kong, African countries (Liberia, Malawi, Gambia, Guinea, Sierra Leone, Comoros, and Congo), the Netherlands, Ireland, Spain, Australia, the United Kingdom, and South Korea, revealed that approximately 11,540,000 doses of various vaccines were wasted. The primary cause of this waste was attributed to logistical issues, including expiration dates, transportation, and maintaining the cold chain (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Taking these factors into account, our study also reported the waste of 26,586,937 doses of both domestic and imported vaccines. Another cause of vaccine wastage, as identified in our study and not typically highlighted in other studies on vaccine wastage, was related to domestically produced vaccines. Specifically, the variety and diversity of domestically produced vaccines, combined with delays in obtaining international approvals for their validation, may have contributed to the wastage of Iranian vaccines. As a result, the waste of these vaccines in the vaccination program was reported to be approximately 19,054,460 doses. According to a study conducted by Bol J in 2021, the results revealed that the waste of viral vaccines, such as those for measles and BCG, averaged 59% due to the nature of the vaccines and the conditions of their storage after preparation (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In our study, owing to the similarity of the storage conditions of COVID-19 vaccines with those of other live viral vaccines, the total wastage of vaccines relative to the total number of vaccines received was approximately 18.3% (total vaccine waste/total vaccines received) *100. This wastage rate is considerably lower than that reported in other studies, and this discrepancy may be due to the acute nature of the COVID-19 epidemic in the community, as well as the increased number of individuals seeking vaccination for disease prevention and fear of illness. Another study conducted by Dkhar SA in 2021 revealed that the utilization rate of weakened live viral vaccines, such as the yellow fever vaccine, and their administration to the population was 81.6% of the total number of vaccines (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In our study, the utilization rate of weakened live viral COVID-19 vaccines and their administration in the target population was approximately 78.9% (total number of vaccines administered/total number of vaccines) *100. This discrepancy is likely due to factors such as limited individual visits, vaccine hesitancy, and the reduced prevalence of COVID-19 in our community. Another focus of resource waste in the management of the COVID-19 epidemic was waste in diagnostic and laboratory kits. Access to accurate and reliable laboratory results has always been one of the key goals of laboratory systems. Despite the critical role that laboratory services play in diagnosing and managing many pathologies, they are often considered cost centers in the healthcare sector (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In Iran, in addition to identifying the first cases of infection and considering the importance of laboratory diagnosis in the rapid identification of patients, a wide network of molecular diagnostic laboratories for SARS-CoV-2, known as reference COVID-19 laboratories, was established to increase the capacity and speed of laboratory response in diagnostic services related to COVID-19 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The diagnostic and laboratory kits used in these centers include PCR molecular diagnostic kits, manual extraction kits, device-based extraction kits, and rapid test kits sourced from various brands. Various studies have also addressed the importance of diagnostic and laboratory costs related to this disease. One of the fundamental needs of medical diagnostic laboratories is diagnostic and laboratory kits, which are used to assess and monitor the status of diseases. In disease diagnosis, the quality and accuracy of the kits, as well as the use of appropriate laboratory equipment, play crucial roles in confirming and diagnosing diseases. If these factors are not given proper attention, the treatment process and timely diagnosis of the disease will be delayed (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In Iran, in relation to diagnostic testing, reference laboratories were established and equipped by medical universities at the provincial level. In these reference laboratories, depending on the needs of the equipment and the type of tests conducted, various diagnostic kits, such as device-based extraction kits, manual extraction kits, laboratory molecular diagnostic kits, and rapid diagnostic kits, are used. Various studies have indicated that diagnostic tests for COVID-19 are undoubtedly useful epidemiological tools, especially for estimating the prevalence of asymptomatic COVID-19 cases. If only 5% or more of the population has been infected with SARS-CoV-2, conducting millions of antibody tests may not significantly contribute to clarifying the overall picture of disease prevalence and may not be necessary (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). A study conducted by Vatandoost and colleagues in 2023, which focused on the challenges of resource management and underlying factors during the COVID-19 pandemic in Iran, revealed that factors such as a decrease in patient visits for diagnostic tests, excessive procurement of diagnostic and laboratory kits without assessing disease status, and failure to redistribute diagnostic kits with near-expiration dates were some of the reasons for resource waste in the area of diagnostic and laboratory kits (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In our study, the wastage of 3,079,423 diagnostic-laboratory COVID-19 kits in the country's medical universities was reported, with the reasons for this wasting resembling the findings of the Vatandoost study. Another area of resource waste that we focused on in the health sector was medications. The constant changes in treatment protocols and the waste of significant quantities of medications in various forms were due to the lack of a proper drug distribution system, incorrect procurement and storage practices, and the absence of accurate drug supervision and control (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The main reasons for this waste could be the continuous changes in therapeutic protocols, inaccurate estimates of medication needs, and issues in the storage and distribution of drugs. These issues highlight the importance of better management of the drug supply and consumption cycle. Since the beginning of the pandemic, the list of prescribed medications for COVID-19 patients in Iran has been constantly changing due to conflicting opinions from specialists regarding the effectiveness and treatment of medications. There has been no nationwide consensus on the introduction of appropriate drugs for the COVID-19 pandemic (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Inefficient drug management, especially in the public sector of developing countries, is a major challenge, and improving it can lead to cost savings and increased access to medications for the population (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). An evaluation conducted between 2012 and 2014 in the Federal City of Addis Ababa revealed that the main reasons for drug and medical supply were poor management, lack of auditing procedures, transparency, and accountability in Ethiopia\u0026rsquo;s pharmaceutical system. These issues can increase healthcare costs and disrupt improvements and optimization of the pharmaceutical system (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The results of the study by Abera Bedasa Alemu and colleagues in 2023 also revealed that drug waste in Ethiopia occurred due to the delivery of drugs close to their expiration date to healthcare centers, sudden changes in treatment protocols, and excessive drug stockpiling due to incorrect forecasting of drug demands during the COVID-19 epidemic. Inadequate inventory control was responsible for a loss of 4\u0026ndash;9% of the drugs in the supply systems. More than half of the drugs were inappropriately prescribed, distributed, or sold. This issue is more prevalent in developing countries, especially where there are limited regulatory procedures for drug usage. Improving precise inventory management and effective regulatory measures can help prevent waste of drugs and valuable resources (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). According to a study by M. Roustit on the drug hydroxychloroquine and its effect on COVID-19, under laboratory conditions, this drug has demonstrated effectiveness against the SARS-CoV-2 virus. However, by mid-2020, clinical data were not able to confirm the efficacy of these drugs in patients with COVID-19. On the other hand, the unscientific promotion of this drug led to the execution of more than one hundred studies, jeopardizing resources and delaying accurate trials for the treatment of COVID-19 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In line with the results of other studies, considering various causes, our study reported the waste of 401,602 thousand blister packs of different drugs used to treat COVID-19 in the health sector. Among the total available drugs, 20% were wasted and removed from the drug distribution cycle. This figure is significantly greater than the results of other studies and highlights the need for better management of the supply‒demand cycle under abnormal and unpredictable conditions.\u003c/p\u003e\n\u003ch3\u003e• Limitations of the Study\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe lack of an integrated information registration system for vaccines, medications, supplies, and diagnostic kits has led to fragmentation and inconsistency of the available data.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThere is an absence of comprehensive information regarding the price per dose for vaccines, diagnostic-laboratory kits, and medications.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eInsufficient collaboration and attention in transmitting information and providing appropriate responses by some universities under the jurisdiction of the Ministry of Health.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSome officials are reluctant to share information because of the sensitivity of the issue and political and security concerns, particularly regarding vaccines.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn a context where financial resources in the healthcare sector are limited and healthcare costs are continuously rising, the use of logical planning and the adoption of effective decision-making are essential to minimize unnecessary expenditures and resource waste. This study revealed that, in the planning and management of the COVID-19 epidemic within the healthcare sector, significant amounts of vaccines, diagnostic kits, and medications were wasted. These wastages not only resulted in the depletion of financial resources but also contributed to a reduction in the effectiveness of health programs and the creation of additional challenges in epidemic control. To reduce these burdens, it is essential to implement effective measures. One such measure is precise inventory management and the enhancement of supervisory systems. This includes the implementation of advanced inventory management systems to control the expiration dates of vaccines and medications, as well as optimizing distribution processes to ensure the timely delivery of resources to required points. To minimize resource waste, it is recommended that advanced inventory management systems and demand forecasting systems be utilized at all medical universities. These systems can enable real-time tracking of vaccines and medication inventories and prevent premature expiration. Furthermore, the use of artificial intelligence algorithms to predict the demand for diagnostic kits and medications on the basis of epidemiological data can help avoid overordering resources. Additionally, increasing transparency and collaboration between health organizations is of paramount importance. Establishing an integrated system for recording and managing information related to vaccines, diagnostic kits, and medications can significantly improve transparency. In resource-limited settings, implementing prioritization frameworks can greatly enhance resource allocation. To achieve this, the use of an importance-performance matrix is recommended. This matrix can assist decision-makers in allocating resources to activities that have the greatest impact on reducing waste. For example, prioritizing vaccines with imminent expiration dates or distributing diagnostic kits to regions with higher prevalence rates can increase efficiency. Additionally, strengthening collaboration and information exchange between universities and health centers is essential for greater coordination and minimizing resource waste. By implementing these measures, significant reductions in resource waste can be achieved, leading to improvements in the efficiency of healthcare programs. Using the findings of this study as a foundation for developing health policies and programs can help prevent similar issues in the future and ensure better management in the face of upcoming epidemics. These strategies play crucial roles in enhancing the efficiency and effectiveness of the public health system. According to a report from the World Health Organization, globally, more than 50% of vaccines are wasted under normal circumstances. The range set by the Global Alliance for Vaccines and Immunization (GAVI)[1] for vaccine wastage is between 5% and 25% (34). During the COVID-19 epidemic, vaccine wastage rates for the coronavirus were reported to be as high as 30% (20). Considering these figures, when evaluating the success of Iran\u0026apos;s vaccination program in reducing vaccine waste, if the total amount of vaccine waste (26,586,937 doses) is divided by the total number of vaccines received (145,260,965 doses), a rate of 18.3% is obtained. This percentage reflects the satisfactory performance of the Iranian Ministry of Health\u0026apos;s vaccination program.\u003c/p\u003e\n\u003cp\u003e[1] Global Alliance for Vaccines and Immunizations\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e· \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: Ethical approval and participant consent: This study was conducted in accordance with the ethical guidelines approved by the Ethics Committee of Kerman University of Medical Sciences, with reference number IR.KMU.REC.1401.253.\u003c/p\u003e\n\u003cp\u003eConsent for publication: All participants in this study voluntarily and knowingly consented to the publication of the research results in scientific journals. They emphasized that their personal privacy would be preserved and that any identifiable information in the article would be presented anonymously. Participation in this study and the publication of its results were voluntary and without any discrimination against the participants. If individuals wish to receive a copy of the final results of this study, they may contact the corresponding author.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets analyzed in this study are not publicly available due to privacy concerns and organizational regulations. However, reasonable requests for data access may be considered upon contacting the corresponding author.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eFunding\u003c/strong\u003e: This study did not receive any specific grants from organizations associated with the public, commercial, or nonprofit sectors.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e Each of the authors played a significant role in the design, data collection, analysis, and interpretation of the study. Seyed Saeed Tabatabai, Mohsen Baroni, Vahid Vatandoost, Reza Esmaeili and Reza Hashemipour contributed comprehensively to the drafting and content review of the main manuscript. All the authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\"The results of this research project are based on part of the findings from a doctoral thesis with reference code 401000260 at Kerman University of Medical Sciences. The authors would like to thank the assistants, managers, and experts from the Ministry of Health, Treatment, and Medical Education of Iran who voluntarily participated in this study and shared their perspectives and experiences on the factors leading to resource waste in the management of the COVID-19 epidemic in healthcare centers.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eParker D, Newbrander W, editors. Tackling wastage and inefficiency in the health sector. World health forum 1994; 15 (2): 107-131; 1994.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Global strategy on human resources for health: Workforce 2030. 2016.\u003c/li\u003e\n\u003cli\u003epresidency of the I.R.I plan and budegt organization. Iran statistical center 2023 [cited 2023 September 2, ]. Available from: https://www.amar.org.ir/english#10291052-national-statistics.\u003c/li\u003e\n\u003cli\u003eThe World Bank. Gdp per capita (current us$) - iran, islamic rep. 2023 [cited 2023 September 2]. Available from: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=IR.\u003c/li\u003e\n\u003cli\u003eThe world Bank. Current health expenditure per capita (current us$) - iran, islamic rep. 2020 [cited 2023 09/19]. Available from: https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=IR.\u003c/li\u003e\n\u003cli\u003eRamazani RK. Constitution of the islamic republic of iran. Middle East Journal. 1980;34(2):181-204.\u003c/li\u003e\n\u003cli\u003eWorld Bank. Current health expenditure per capita (current us$) - iran, islamic rep. 2019 [cited 2022/03/21]. Available from: https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=IR.\u003c/li\u003e\n\u003cli\u003eworld bank. Current health expenditure (% of gdp) - iran, islamic rep. 2019 [cited 2022 03/04]. Available from: https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=IR.\u003c/li\u003e\n\u003cli\u003eMasoudi Asl I, Bakhtiari Aliabad M, Akhavan Behbahani A, Rahbari Bonab M. Health care costs in iran and how to control it. Iran J Health Insur. 2019;1(4):117-27.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Medical Education. Ethical considerations for allocation of scarce resources: National Institutes of Health of the Islamic Republic of Iran; 2016.\u003c/li\u003e\n\u003cli\u003eVetter P, Eckerle I, Kaiser L. Covid-19: A puzzle with many missing pieces. British Medical Journal Publishing Group; 2020.\u003c/li\u003e\n\u003cli\u003eAbdi M. Coronavirus disease 2019 (covid-19) outbreak in iran: Actions and problems. Infection Control \u0026amp; Hospital Epidemiology. 2020;41(6):754-5.\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Medical Education. The latest information about covid-19 2023 [cited 2023 August 21]. Available from: https://behdasht.gov.ir/thumbnail/450-300_100/uploads/1/2023/Aug/21/30%20%D9%85%D8%B1%D8%AF%D8%A7%D8%AF.jpg.\u003c/li\u003e\n\u003cli\u003eKwon S, Kim E. Sustainable health financing for covid‐19 preparedness and response in asia and the pacific. Asian Economic Policy Review. 2022;17(1):140-56.\u003c/li\u003e\n\u003cli\u003eworld health organization. Response to covid-19 in iran 2021 [cited 2023 8/21]. Available from: https://www.who.int/about/accountability/results/who-results-report-2020-mtr/country-story/2021/iran.\u003c/li\u003e\n\u003cli\u003eDrummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes: Oxford university press; 2015.\u003c/li\u003e\n\u003cli\u003eHayes H, Parchman ML, Howard R. A logic model framework for evaluation and planning in a primary care practice-based research network (pbrn). The Journal of the American Board of Family Medicine. 2011;24(5):576-82.\u003c/li\u003e\n\u003cli\u003eGhanei M, Mohabattalab A, Fartash K, Kolahchi N, Khakdaman A, Kaghazian H, et al. Exploring the experience of developing covid-19 vaccines in iran. Clinical and Experimental Vaccine Research. 2023;12(1):1.\u003c/li\u003e\n\u003cli\u003eAladashvili G, Nebieridze A, Pkhakadze G, Nadareishvili I. Recognizing vaccine wastage in georgia. Public Health Challenges. 2022;1(4):e46.\u003c/li\u003e\n\u003cli\u003eLazarus JV, Karim SSA, Van Selm L, Doran J, Batista C, Amor YB, et al. Covid-19 vaccine wastage in the midst of vaccine inequity: Causes, types and practical steps. BMJ Global Health. 2022;7(4):e009010.\u003c/li\u003e\n\u003cli\u003eBol J, Anyuon NA, Mokaya EN. Assessment of vaccine wastage in south sudan. Pan African Medical Journal. 2021;40(1).\u003c/li\u003e\n\u003cli\u003eDkhar SA, Quansar R, Haq I, Khan SMS. Vaccine usage and wastage in a designated yellow fever vaccination center in north india. Clinical and Experimental Vaccine Research. 2021;10(3):240.\u003c/li\u003e\n\u003cli\u003eMirjalili MR, Namayandeh SM, Lotfi MH, Dehghani MR, Mirzaei M, Talebi AR, et al. Covid-19 seroepidemiology study of yazd province, first peak, spring 2020: A population-based cross-sectional study. The Journal of Shahid Sadoughi University of Medical Sciences. 2021;28(12):3338-50.\u003c/li\u003e\n\u003cli\u003eSafadel N, Samiee SM, Dahim P, Khodaverdian K, Roodaki MM, Anjarani S, et al. The process of establishing and managing a laboratory diagnostic network in the covid-19 pandemic in iran. Depiction of Health. 2022;13(Suppl 1):11-21.\u003c/li\u003e\n\u003cli\u003eRahmati F, Jalili S. Clinical manifestations and diagnostic methods of covid-19. New Cellular and Molecular Biotechnology Journal. 2020;10(40):9-24.\u003c/li\u003e\n\u003cli\u003eMedicine TLR. Testing for covid-19. 2020.\u003c/li\u003e\n\u003cli\u003eVatandoost V, Tabatabaee SS, Okhovati M, Barooni M. Explaining the challenges of resources management and its underlying factors in covid-19 era in iran: A qualitative study. BMC public health. 2023;23(1):2118.\u003c/li\u003e\n\u003cli\u003eMortazavi A, Hajebi G. Issues and problems related to the administration of medical services covered by the hospital pharmacy in beheshti university of medical sciences. Journal of Research in medicine. 2002;26(3):205-15.\u003c/li\u003e\n\u003cli\u003eDaneshpazhooh M, Mahmoudi H. Covid-19: The experience from iran. Clinics in Dermatology. 2021;39(1):23-32.\u003c/li\u003e\n\u003cli\u003eNarasimhan V, Brown H, Pablos-Mendez A, Adams O, Dussault G, Elzinga G, et al. Responding to the global human resources crisis. The Lancet. 2004;363(9419):1469-72.\u003c/li\u003e\n\u003cli\u003eCarnevale JB, Hatak I. Employee adjustment and well-being in the era of covid-19: Implications for human resource management. Journal of business research. 2020;116:183-7.\u003c/li\u003e\n\u003cli\u003eAlemu AB, Ibrahim NA, Argaw KW. Magnitude of medicine wastage and perceived contributing factors among public health facilities in dire-dawa city administration, in mid covid-19 pandemic in ethiopia: Retrospective, cross-sectional study. Integrated Pharmacy Research and Practice. 2023:61-75.\u003c/li\u003e\n\u003cli\u003eRoustit M, Guilhaumou R, Molimard M, Drici M-D, Laporte S, Montastruc J-L, et al. Chloroquine and hydroxychloroquine in the management of covid-19: Much kerfuffle but little evidence. Therapies. 2020;75(4):363-70.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Monitoring vaccine wastage at country level: Guidelines for programme managers. World Health Organization, 2005.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"resource wastage, health sector, COVID-19, Iran","lastPublishedDoi":"10.21203/rs.3.rs-6637991/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6637991/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eEffective management of health resources during crises, such as pandemics, is crucial for preventing waste and ensuring system efficiency. This study assessed the extent of wastage of COVID-19 vaccines, diagnostic kits, and pharmaceutical products in Iran during the pandemic and examined the implications for health policy.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA descriptive, quantitative design was used, analyzing national-level data from 50 medical universities across Iran between 2021 and 2023. Distribution, utilization, and wastage data were extracted from Ministry of Health databases. A bottom-up costing approach was used to estimate the financial burden of these losses.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eOf over 145\u0026nbsp;million COVID-19 vaccine doses distributed, 18.3% were wasted. Additionally, 21.1% of medications and 29.5% of diagnostic kits were discarded due to expiration or non-utilization. Key factors contributing to wastage included poor inventory management, frequent revisions of clinical protocols, and reduced demand in later pandemic stages.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eThe findings highlight structural inefficiencies in health resource management and emphasize the need for reforms, including real-time monitoring systems and improved cross-sectoral coordination to reduce waste and enhance future preparedness.\u003c/p\u003e","manuscriptTitle":"Wastage of Health Resources during COVID-19 in Iran: Lessons for Health Policy and Management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-21 17:05:08","doi":"10.21203/rs.3.rs-6637991/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fde4ae5a-c24c-4f5f-b3af-3fcb80bf7abb","owner":[],"postedDate":"October 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56520656,"name":"Health sciences/Health care"},{"id":56520657,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-10-31T12:54:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-21 17:05:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6637991","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6637991","identity":"rs-6637991","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}