The ratio of the highest-to-lowest age-standardised death rates in provinces remained almost constant from 1991 to 2019 (2♰ vs 1♹ appendix p 41). The absolute difference between the highest and the lowest life expectancy across provinces was 12♵ years in 1991, which declined to 8♲ years in 2019, indicating a convergence ( appendix p 37). From 1991 to 2019, life expectancy at birth increased from 68♹ (95% UI 68♲–69♶) to 77♸ (77♵–78♰), with diverse provincial patterns by sex ( figure 1 appendix pp 36, 58). In 2019, life expectancy for female individuals in Iran was 79♶ years (95% UI 79♲–79♹) and 76♱ years (75♶–76♵) for male individuals. From the late 1990s to 2019, the total fertility rate decreased steadily from 4♲ (95% UI 3♷–4♶) to 1♸ (1♴–2♴), which resulted in an apparent ageing of the population in this period ( appendix pp 34, 62). Iran's total population increased from 58♵ million (95% UI 53♳–63♵) in 1990 to 84♳ million (77♳–91♹) in 2019 because of high fertility rates in the early 1990s ( appendix pp 33, 56). Given the future burden of COVID-19 in the coming years, and the probable continuation of sanctions and their impact on Iran's economy and the function of the health-care system, policies should focus on maintaining the infrastructure and the financing of the health-care system, human resources, and equality and quality of health-care services, and setting priorities favouring fatal causes in vulnerable populations with restricted access to health care. Economic and social development in Iran is linked to the decreased burden of certain conditions, such as injuries and certain environmental risk factors however, policies to control non-communicable diseases, such as substance-use disorders and mental disorders, and certain risk factors, including metabolic risk factors, have not been successful. Evidence shows that the expanded health-care system has been quite successful in halting communicable, maternal, and neonatal diseases. This study shows a demographic transition leading to population growth and ageing, and an increase in life expectancy, along with an epidemiological transition. The Lancet Regional Health – Western Pacific.The Lancet Regional Health – Southeast Asia.The Lancet Gastroenterology & Hepatology.

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