"The variety of wound products in Iran is greater than the other countries in the region. Therefore, wound care has good job opportunities and a great market in Iran."
"Fortunately, unlike other products that have become more expensive as a result of sanctions, wound products have not increased much in price during the embargo period."
" Without tracking and control, the wound care situation in Iran is unlikely to be improved, and it will undoubtedly get worse."
Dr Ghaderi received his PhD in Surgical Nursing, majoring in Wounds, from the Hajat Tape University of Ankara and after returning to his homeland, he has served the country for 15 years in the field of wound management at various levels. From October 2016, he was in charge of developing wound care programs for the Ministry of Health for one year; he has also been worked as a wound counsellor in the nursing department of Tabriz University of Medical Sciences for many years. Also, he is directly involved in wound healing and generously shares his experiences and education with those involved in wound care throughout the country. Dr Ghaderi is one of the most prominent teachers in this field, and he has trained many of today's best wound therapists.
We met Dr Ghaderi at the Faculty of Welfare and Rehabilitation, Iran University of Medical Sciences in Tehran. He has come to Tehran from Tabriz to hold a diabetic foot wound care course, and despite his great fatigue due to the long travel and the great energy he had spent on teaching, he still warmly answered our questions.
As someone active both in the government and the private sector for many years in the area of wounds, how do you evaluate the level of the Iranian wound care market compared to other countries in the region, and what can be done to improve it?
Compared to the neighbouring countries, although we are not better than them, it can be argued that we are not worse than them. For example, wound healing in the manner we perform it in Iran cannot be observed in Turkey. In Turkey, all medical procedures are performed in hospitals. Wound therapists are not defined in Turkey as they are in Iran. In some hospitals, there are wound care centres where trained nurses engage in treating wounds under the supervision of specialists. In Turkey, even private outpatient injection tasks are not available for nurses. The situation is worse in Iraq. Wound care is rarely done even in the hospital. In most cities of Azerbaijan, there is no wound care. They come to Tabriz to treat the wounds because there is no specialized equipment and modern bandages in Azerbaijan. The majority of Iraqi patients also come to Ahvaz for wound healing. In my opinion, the variety of wound products in Iran is greater than the countries in the region. Therefore, it has a good labour and sales market have in Iran.
You have also been in charge of developing a wound care program at the Ministry of health. Unfortunately, there are no accurate statistics on therapists in the country. That's why people enter wound healing without any filters. However, in your opinion, to which field of study does the work status of wound therapists relate in Iran and how many wound therapists are active in the country?
According to my field of study, which is a specialized doctorate in surgical nursing surgery, majoring in wound care, I held this responsibility from October 2016 to October 2017, at the suggestion of the Deputy Minister of Nursing. Before that, there was no committee at all. We only engaged in planning for the first six months; the guidelines, job descriptions of therapists, and assessment forms were developed; then during the second six month, i.e. from April 2017, the programs started to be operationalized. We had planned to have one person in charge of the wound committee at each university of medical sciences who was supposed to be present at the university for at least two days. The task of the person in charge of the committee was to implement the decisions made by the Ministry and the university. In each hospital, depending on their specialities and the majors they had, one to three people should be defined as wound therapists. According to the committee's decisions, the wound therapist must be a nurse and have at least a bachelor's degree. This procedure is used everywhere in the world.
I held 14 explanatory sessions for educational supervisors, infection control and safety officials in ten major preparation regions in the country and all provinces. So that they could get acquainted with the work of wound therapists, to know what the common hospital-acquired wounds are and what assessments and preventions are required for wounds. It was decided that this training would be held in all universities and hospitals in a cascade manner. It was planned to determine and select the type of dressing used in hospitals according to the view of the hospital's wound therapist and the under the supervision and assistance of the person in charge of the university's wound committee. After the end of my one-year mission, which coincided with the change of the Nursing Deputy of the Ministry, unfortunately, with the misconceptions that were raised, the Nursing Deputy of the Ministry was convinced to believe that the necessary training had been provided. There was no need for the Wound Committee. And the remaining job was assigned to each university individually. And as a result, this made abortive all the attempts and work done during that one year.
How many therapists do you think are active in the country?
We had previously defined that each hospital, whether academic, private or even a hospital such as The Oil company's hospital, should have one to three therapists, depending on the type and number of hospital beds. And in some cases, depending on the needs of the cities for nursing care and wound care centres.
Due to the good turnover in the wound area, many general practitioners have also entered the room.
Yes. That's right. Perhaps the most massive audience for training courses was general practitioners. Doctors can only be involved in examining and diagnosing a wound, but their job is not to treat it. Wound healing should be done by a trained nurse.
What is your opinion about the brands available on the market? Do these brands meet the demands of wound therapists?
Almost all the products in the market are relatively identical and have very little difference. In some cases, we need unique products. For example, the foam products of the two companies are not very different from each other, and both can be used in the right place. But in the case of Pemphigus and EB, for example, only the silicone foam should be used to prevent skin peeling. The quality and price are decisive in choosing the type of dressing product, which is determined by the therapist. Fortunately, unlike other products that have become more expensive as a result of sanctions, wound products have not increased much in price during the embargo period.
It seems that most therapists still prefer foreign products over Iranian products. What is your opinion about this issue?
One of the reasons for this is that Iranian products have just introduced to the market and are not so well known. Therapists also do not take risks in order not to lose the credibility of their work. The second reason, in my opinion, is that foreign products have a great variety. In foreign products, we see all types of foam and all kinds of shapes. We have alginate and Hydrofiber dressings. We have different types of hydrogels and hydrocolloids, which in turn have different types. Unfortunately, Iranian products are limited and provide a little choice for the therapist. Although I have been using foreign products for a long time, I also use some Iranian products, and I am satisfied with their quality. For example, the artificial skin of some companies is mostly of an Iranian origin and has excellent quality. I do not mind whether the products are Iranian or foreign. When needed, I choose products that are both of good quality and great variety. However, suppose the product is of an Iranian origin, which is suitable in terms of quality compared to the foreign counterparts. In that case, I choose an Iranian one so that it would be cost-effective for my patient.
Observations show that Iranian therapists have focused more on ointments, creams and dressings, and that vacuum therapy, phototherapy, etc., which are common in the world, are less considered in Iran. Why do you think less work has been conducted in this field in Iran?
There are no self-employed therapists in other countries. Wound healing is widespread in clinics and hospitals. For example, in Turkey, you do not see small private clinics for injections and dressing jobs as they are in Iran, let alone the wound care centres. They are all public centres. The government pays the costs. Therapists, who are self-employed and without being associated with any wound centre, indeed cannot afford such an expense. But that makes sense for clinics or hospitals because they will have more clients. Most therapists who work with a personal business card at home do not have a special place to install this equipment, and it is not possible to move them. So they prefer to use the same cream, ointment and dressing, as it is both cheaper and more convenient. Unfortunately, these people sometimes challenge other treatments, such as ozone, vacuum therapy and so on.
Given the good economic environment created by wound care, it can provide a good incentive for people to be trained, certified and start working in this field. Does the Iranian market have a place for more nurses to enter this field?
The fact is that we do not have a scheduled and systematic course provided by the Ministry. During my tenure in the Ministry, it was supposed to hold three to six month-courses to train a therapist, rather than two or three day-courses, which unfortunately was not realized. Some centres offer relatively long courses, but they are not according to a scheduled systematic plan, and the educational materials are subjectively selected according to taste. Indeed, a few day-courses are not sufficient for training wound therapists, and they are just a general introduction to the principles of wound healing. According to the decisions of the Ministry of Health's Wound Committee, wound teachers must have a master's or doctoral degree in nursing and have several years of experience working with wounds. Nursing experts can work in practical and internship classes in hospitals as instructors. Wound product preparation and distribution companies can hold cognitive training classes to provide knowledge, to show how to use the products and give the participants a certificate with the same title.
The question here is how many visits a real wound specialist or therapist, who has passed the course, does have per day that has created such a boom market?
Due to the high frequency of diabetic, pressure-caused ulcers, vascular wounds, burns, etc., if the wound centres use educated and skilled therapists, use new equipment and have good advertisements, the rate of income is high. Even visiting patients at home is prevalent. Wound healing is a team effort. The collaboration of orthopaedic, endocrinology and infectious disease specialists with a good wound therapist will lead to the best results. Teaching is also teamwork. I teach wound management, and the related experts or companies teach vacuum therapy, PRP, magneto-therapy, and other courses. During my tenure at the Ministry, I proposed that two courses be held for nurses. A Wound Fellowship Course for M.S students of nursing and a wound practitioner course for nursing graduates. It means that an M.S nursing student would attend a 6-month course and become a wound practitioner, or they can pass a two-year course to become a wound fellowship. Unfortunately, this proposal was not implemented.
Suppose that five years have been passed since now, what do you think will be the perspective for the wound care market after these five years?
The situation is getting better for some reasons. First, the issue of the wound has been considered as a speciality. Second, the number of complaints will have increased. People previously didn't have enough information in this regard. However, at present, they would complain as soon as the therapy is not effective, and the issue will be investigated to know who has dealt with the prevention and treatment and how these have been done. Therefore, now it has been determined that the procedures must be done by whom and how. Thus, the necessary steps must be taken to find out who is signing and who is going to be responsible. However, some work needs to be done. In Tabriz, we have designed unique forms for pressure-caused wounds and hospital-acquired wounds, and all the hospitals fill out the forms at the end of each month and deliver them to the university wound committee. Despite these forms that are sent to the university, if a complaint is made, it can be pursued, and the person responsible for the mistake will be held accountable.
According to the existing sanctions and the country's limitations to supply essential items, can Iranian brands maintain their performance in the next five years or will the rate of imports increase?
Imports are now available, and all brands still exist as before; unless a company chooses not to continue. It is only a matter of supporting domestic production that the Ministry has instructed medical centres to use Iranian products as much as possible, and I have heard that these companies are also being given loans.
Do you think we will achieve the good quality you expect in the next five years?
If there are enough supervision and monitoring, I would say yes. Without the necessary tracking and control, the situation is unlikely to be improved, and it will undoubtedly get worse. When there is an obligation to use Iranian products instead of a foreign product, and the Iranian product is of low quality, the situation will get worse.
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