In many countries, providing resources to cure patients suffering from End Stage Renal Disease (ESRD) has been a major problem, and Iran is no exception. “After the 1979 Iranian revolution, materials for dialysis were in short supply and there was no system of cadaveric donation. If you lost kidney function, you either went abroad for transplantation or died in Iran. The Ministry of Health set up two renal transplantation teams in the mid-1980s. … Demand rose swiftly [and] soon rumours developed that money was being exchanged.” 
Since the mid-1980s, many countries have passed legislation prohibiting monetary compensation for the donation of kidneys and other organs for transplant, with altruism being the predominant motive in most nations. “Unfortunately, the altruistic supply of organs has been less than adequate [in Iran], and severe organ shortage has resulted in many patient deaths.  A number of transplant experts have been convinced that providing financial incentives to organ sources as an alternative to altruistic organ donation needs careful reconsideration.”
This was the challenge facing the Iranian government, and one which was particularly acute with regard to kidney donations. “In the past three decades, advances in immunosuppressive therapy and organ transplant technology have improved patient and graft survival rates in renal transplant recipients. Available data show that renal transplantation, not dialysis, has become the treatment of choice.” 
In 1988, the Iranian government introduced a compensation scheme for living donors who were unrelated to the organ recipient. This renal transplantation programme was funded and regulated by the government. It had the following objectives:
- To establish a regularised system of kidney donation.
- To eliminate the long waiting list of patients requiring kidney transplants.
“In June 2000, the Organ Transplantation Brain Death Act was legislated by the Majles [Iranian parliament] followed by the establishment of the Iranian Network for Transplant Organ Procurement in 2002.”  This Act regulates the procurement of organs from clinically brain-dead patients.
The public impact
As a result of the payments in money and in kind for kidneys “the number of renal transplants performed substantially increased such that in 1999, the renal transplant waiting list was completely eliminated.”  (This finding is disputed in some quarters.)
“By the end of 2006, 21,359 kidney transplants were performed in Iran from living related donors (15.2%), living unrelated donors (79.6%), and deceased donors (5.2%).”  Furthermore, the annual number of kidney transplants was steadily increasing from fewer than 100 in 1986 to 1858 in 2000, reaching the whole activity to 26.5 kidney transplants per million population per year.
Deceased kidney transplantation has increased from less than one percent of all kidney transplants in 2000 immediately after the 2000 Act, but even so “cadaveric kidney transplant accounted for [only] about 13% of the annual transplantations in Iran (243 cases in 2006).” 
Public Confidence Good
There are no surveys from the time of the introduction of the 2000 legislation. However, a “cross-sectional study [was] conducted between February 2009 and November 2010, [in which] two interviewers contacted 1379 people through random digit dialling for phone interviews.”  The subjecting was: “Tehran citizens in regard to donating their organs in case of brain death.”  There was a high level of willingness to donate but few had actually done so. “Among the  respondents, 84.6% were willing to donate. Of these, 94.6% were willing to complete a donor card as well, but only 10.7% of them already had one.” 
Stakeholder Engagement Good
The main stakeholder is the Iranian government. “In 1985, the high expense of renal transplantation abroad and the increasing number of patients who were on the renal transplant waiting list prompted the Iranian health authorities to establish renal transplant facilities inside the country.  “ Then, in 1988 the government funded, regulated, and compensated the “living-unrelated” donor renal transplantation program.
“The Dialysis and Transplant Patients Association (DATPA) helps patients to locate a suitable living-unrelated donor”, and maintains a list of voluntary living donors.  The medical profession was also inevitably engaged. The transplants were administered in public hospitals and teaching hospitals.
Political Commitment Strong
The Iranian government took an active role in introducing compensation schemes for living kidney donors and post-mortem donors (see Stakeholder engagement above). They also made significant efforts to educate donors and safeguard the interests of patients and donors:
- The administration has increased its efforts to inform and educate people to willingly become donors, which is why the donor card system was created.
- A section that has also been added to driver’s licenses in Iran that indicates the license holder’s decision to donate his/her organs.
- The state guarantees a cash reward of the equivalent of about £300 to each donor, and one year of medical insurance.
- “To prevent kidney tourism, recipients in Iran have to share the nationality of their donors, and Iran recently banned kidneys for all foreigners except refugees in Iran from Afghanistan.” 
Clear Objectives Good
The objectives were clearly stated at the outset, but measureable metrics to track progress were not provided. This is illustrated through the two overarching objectives of the initiative:
- To establish a formal regulated system of kidney donation.
- To reduce and eliminate the long waiting list of patients requiring kidney transplants.
The system was conducted as a private system which was taken over by the government. “Iran began allowing donors to be paid — first in a private system, and then, in the mid-1990s, in a state-regulated system in which the government paid donors the equivalent of about $3,500 in Iranian currency.” 
Although there was no existing model where donors were paid to register for post-mortem donation, “Iran's cadaveric kidney donation system is similar to that of many other countries” (see Management below). 
There was no comparable system of payments for organ donation – either for living donors or those who registered as donors – in other parts of the world. Also, there were no mention of any feasibility study before Iran adopted this policy.
The programme is managed by the DAPTA (Dialysis and Transplant Patients Association) and monitored by the Ministry of Health.
All renal transplant teams belong to university hospitals, and the government pays all of the hospital expenses of renal transplantation.
“Iran's cadaveric kidney donation system is similar to that of many other countries.  It is centralised under the Ministry of Health and removal of organs requires either a donor card signed by the deceased or family consent. Organ procurement organisations and brain death identification units identify potential donors and procure organs, ensuring transparency in the process of matching donors and recipients. In university hospitals, each case of brain death is determined by five physicians, one of them being a specialist in forensic medicine appointed by the Ministry of Health.”
A national registry is maintained with details of registered donors, which is then matched to patient needs.
The most significant indicator to measure the success of the 2000 legislation is the number of cadaveric kidney transplants and that number as a proportion of the whole (13% in 2006).
One of major provisions of the law in Iran was fair compensation for the donors. This factor enabled more donors to come forward and also prevented a black market organ trade that was prevalent before. Problems, though, have emerged since then. “With time, inflation eroded the comparative value of the government’s payment.  The number of [Iranian] rials paid has not risen and now the payment is worth only about $350. So private payments from recipients are now sought, to encourage donors.”
In Iran, the legal kidney market has prevented the development of the black markets and kidney tourism seen in many other countries. To prevent kidney tourism, recipients in Iran have to share the nationality of their donors, and Iran recently banned kidneys for all foreigners except refugees in Iran from Afghanistan, who can only donate to fellow-Afghans in Iran. “‘Starting on Sept. 21, 2014, no more organ transplant operations will be performed on non-Iranians,’ Iranian officials announced.” 
An important group in Iran is clearly the Shi’ite clerics. “A controversial aspect of the topic of transplant is the religious aspect.  While there have been differences of opinion among Iranian Shi’ite clerics about this matter in the past, the  organ transplant bill ... further paved the way for the procedure. There are still mixed views concerning the details, but Iranian clerics generally accept the procedure. The matters in which nuances become apparent are transplanting the organ(s) of a male to a female or vice-versa, and transplanting organs of a non-Muslim to a Muslim, or vice-versa.” This suggests that they are broadly aligned with the government but take issue on matters of detail.