Abstract
BackgroundInsufficient transparency in prioritization of health services, multiple health insurance organizations with various and not-aligned policies, plus limited resources to provide comprehensive health coverage are among the challenges to design appropriate Health Insurance Benefit Package (HIBP) in Iran. This study aims to analyze Policy Process of Health Insurance Benefit Package in Iran.MethodData were collected through semi-structured interviews with 25 experts, plus document analysis and observation, from February 2014 until October 2016. Using both deductive and inductive approaches, two independent researchers conducted data content analysis. We used MAXQDA.11 software for data management.ResultsWe identified 10 main themes, plus 81 sub-themes related to development and implementation of HIBP. These included: lack of transparent criteria for inclusion of services within HIBP, inadequate use of scientific evidence to determine the HIBP, lack of evaluation systems, and weak decision-making process. We propose 11 solutions and 25 policy options to improve the situation.ConclusionThe design and implementation of HIBP did not follow an evidence-based and logical algorithm in Iran. Rather, political and financial influences at the macro level determined the decisions. This is rooted in social, cultural, and economic norms in the country, whereby political and economic factors had the greatest impact on the implementation of HIBP. To define a cost-effective HIBP in Iran, it is pivotal to develop transparent and evidence-based guidelines about the processes and the stewardship of HIBP, which are in line with upstream policies and societal characteristics. In addition, the possible conflict of interests and its harms should be minimized in advance.
Highlights
Insufficient transparency in prioritization of health services, multiple health insurance organizations with various and not-aligned policies, plus limited resources to provide comprehensive health coverage are among the challenges to design appropriate Health Insurance Benefit Package (HIBP) in Iran
The epidemiological transition fueled the constant increasing of demand for healthcare services, which led into spiraling health expenditures, which in turn revealed the importance of developing a HIBP
During the past four decades, a series of policies are developed and implemented in Iran that indicate the necessity of developing a basic health insurance package: Until now, no practical policy or scientific method is developed to design the implementation path of macro policies related to the HIBP in Iran
Summary
Insufficient transparency in prioritization of health services, multiple health insurance organizations with various and not-aligned policies, plus limited resources to provide comprehensive health coverage are among the challenges to design appropriate Health Insurance Benefit Package (HIBP) in Iran. Iran’s health system has been facing a series of challenges in developing and implementing appropriate HIBP, i.e., lack of shared perspectives among policy-makers, insufficient transparent prioritizing criteria, ambiguous and unclear organizational structures and unsustainable resources [8, 9]. The Iranian Supreme Council of Health Insurance (ISCHI) is in charge of the process of decision-making for inclusion of a specific healthcare service into the basic insurance package. Such decisions have been taken based on the bargaining power of various parties attending the ISCHI’s meetings. The insurance corporations mainly take into account the financial burden of services [10]
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