https://equityhealthj.biomedcentral.com/articles/10.
1186/s12939-020-01372-4
http://www.us-iran.org/resources/2018/8/27/myth-vs-fact-irans-health-care
UHC – Universal Health Coverage
Expenditure- the action of spending funds
PHC – Primary Health Care
LMICS – low, middle-income countries
SHI – social health insurances
OOP – out-of-pocket expenses
IHIO - Iranian Health Insurance Organization
SSO - Social Security Organization
Iran is an upper-middle-income country, located in the Middle East. It is the 17th largest country in the
world with a population density of 51 people per km2. According to the last survey (2015), the mean
health literacy level in Iran was 10.2±3.8 (out of 20).
The Iranian healthcare system has a well-defined three-tier structure, comprising primary, secondary,
and tertiary facilities. In 2016, Iran spent 8.1% GDP on health (the equivalent of US$ 415.4 per capita),
with a share of out-of-pocket (OOP) expenditure falling from 80.5% (in 1995) to 38.8% (in 2016) of
current health expenditure. The sources of funds to finance health care services are multiple and include
(besides OOP payments) government funds, general taxation, health insurance, and individual
donations. PHC is provided nationwide free-of-charge to all Iranian citizens by public/private partnership
and coordinated/regulated by the Ministry of Health and Medical Education (MoHME). The secondary
health care is delivered via a network of district health clinics, which is an independent authority from
the MoHME, provided by hospitals and coordinated/regulated by treatment deputy of medical
universities under the supervision of MoHME. Tertiary health services are provided predominantly in big
cities by private and public hospitals and coordinated/regulated by MoHME.
Over the last 4 decades, many initiatives have been implemented to accomplish equitable accessible
health care for all Iranian citizens. The latest reform to address universal health coverage (UHC) is Health
Transformation Plan (HTP). Health insurance reforms, especially health transformation plan (HTP) in
2014, helped to progress towards UHC and health equity by expanding population coverage, a benefits
package, and enhancing financial protection. The plan created a new sub-fund within the Iranian Health
Insurance Organization titled Universal Health Coverage. Free Universal Health Coverage expanded the
basic health insurance coverage to include the 11 million previously uninsured Iranian people (mainly
self-employed) which increased the overall population coverage up to 96% [52, 53]. By implementing
this reform, the government announced reaching UHC by 2025. This programme is still available today,
however under stricter regulations.
Despite being one of the most modern health systems in the world, there are many challenges that
jeopardize achieving UHC in Iran.
In order to overcome them, the Ministry of Health and Medical Education and health insurance schemes
should devise and follow the policies to control health care expenditures. Working mechanisms should
be implemented to extend free health insurance coverage for those in need. More studies are needed
to evaluate the impact of health insurance reforms in terms of health equity, sustainability, coverage,
and access. A comprehensive, long-term master plan is needed to avoid different or even opposing
reforms that have little benefit, high costs, and are beyond the control of the government. Integrated
and coordinated stewardship in all parts of the health system should be considered to implement
reforms efficiently.
As in the course of last four decades, The Islamic Republic of Iran has been initiating a number of health
systems reforms, i.e., the establishment of an extensive Primary Health Care (PHC) network, the family
physician program, and recently Health Transformation Plan (HTP), to pave the way towards UHC
[18, 19]. These reforms resulted in significant achievements in strengthening the health system. For
example, following HTP, the share of health expenditures from the gross domestic product increased
from 6.5% in 2012 to 8.9% in 2015. The share of public expenditures from THE also increased from
33.3% in 2012 to 51.3 in 2015.
To overhaul the health system and also address the health financing challenges (e.g., high OOP and
catastrophic health expenditure), a series of policy interventions called Health Transformation Plan
(HTP) was implemented in May 2014 mainly by increasing the share of public budget for the health
sector [45, 46]. The Plan’s purpose was to reduce OOP payments and financial burden in the public
health sector (HTP generally does not provide financial support for patients getting health services from
private health sector), by lowering coinsurance rates in the public sector and the provision of free-of-
charge health insurance coverage (government paid the whole premium on behalf of the uninsured
population).
Overall, the HTP implementation led to a sharp increase in health care utilisation due to improved
financial accessibility. In deprived areas of Iran, many more hospitals and health facilities were built, and
others were renovated. In the remote areas, the number of hospital beds and health care staff
(physicians, nurses and midwives) was increased [55].
This rural-focused approach aimed to improve health equity between urban and rural populations
The Iranian health system has become more efficient, responsive and equitable, thanks to a range of
initiatives. These include assessing needs and integrating new health programmes; designing the
structure of the service delivery system based on needs; establishing performance-based payment
systems and an online electronic information system; establishing a monitoring and evaluation system
for services, and extensive assessment of people’s satisfaction; developing an appropriate structure of
the health team; and creating basic structures for evaluating quality and quantity of services. The system
has reaped significant health benefits for the Iranian people, and serves as an example for other settings
globally, providing lessons for other countries and communities embarking on their own paths towards
UHC.
As in the course of last four decades, The Islamic Republic of Iran has been initiating a number of health
systems reforms, i.e., the establishment of an extensive Primary Health Care (PHC) network, the family
physician program, and recently Health Transformation Plan (HTP), to pave the way towards UHC
[18, 19]. These reforms resulted in significant achievements in strengthening the health system. For
example, following HTP, the share of health expenditures from the gross domestic product increased
from 6.5% in 2012 to 8.9% in 2015. The share of public expenditures from THE also increased from
33.3% in 2012 to 51.3 in 2015. Nevertheless, several challenges continued to exist, the most important
of which is inefficiency in the health system [20]. Health costs will be raised; the economic status is not
promising [21, 22], which makes the implementation of “resilient economy” policies inevitable [23], now
more than ever [24, 25]. Hence, it is essential to measure the health system performance variations
within two main dimensions of UHC (service coverage and financial protection), in relation to levels of
health spending, and to make the health system more efficient as to ultimately convinced the
government and the public that the highest cost is worth the value.
Health insurance reforms, especially health transformation plan (HTP) in 2014, helped to
progress towards UHC and health equity by expanding population coverage, a benefits
package, and enhancing financial protection. However, several challenges can jeopardize
sustaining this progress. There is a lack of suitable mechanisms to collect contributions from
those without a regular income. The compulsory health insurance coverage law is not
implemented in full. A substantial gap between private and public medical tariffs leads to high
out-of-pocket health expenditure. Moreover, controlling the total health care expenditures is not
the main priority to make keeping UHC more sustainable.
To achieve UHC in Iran, the Ministry of Health and Medical Education and health insurance
schemes should devise and follow the policies to control health care expenditures. Working
mechanisms should be implemented to extend free health insurance coverage for those in
need. More studies are needed to evaluate the impact of health insurance reforms in terms of
health equity, sustainability, coverage, and access.
Evidence suggests that despite the introduction of the universal basic benefits package under
the SHI fund in Iran, inequalities in health financing indicators and access to health care
services continue to exist, particularly for low-income groups and rural residents [10, 11]. Some
of the reforms that contributed towards achieving UHC were previously analysed (e.g., Family
Physician program, PHC, hospital autonomy, and Health Transformation Plan implementation
[3, 12,13,14,15,16,17,18,19]); however, more studies need to evaluate the impact of the health
insurance reforms implemented in Iran.
Despite passing several major polices over previous decades, progress towards achieving UHC
was not satisfactory in all three dimensions (i.e., population coverage, health services coverage
and financial support for health expenditure). Despite the repeated emphasis in the upstream
documents (e.g., third to sixth five-year development plans, Mega Health Policies (2014)) on the
need to extend health insurance coverage to all Iranians, reduce OOP health expenditure, and
provide equitable access to health care services, self-employed continued to lack health
insurance coverage and had to pay OOP for all health expenses.
According to the Statistical Centre of Iran, about 20% of Iran’s economy is informal [50]. In most
cases, the informal economy sector cannot afford to pay the voluntary premium; hence, they
cannot access health services. It has been one of the chronic challenges towards reaching and
keeping UHC in Iran. Among those with health insurance coverage but under different health
insurance schemes, there was a great inequity in terms of access to health care services due to
variation in coverage, as well as amounts of coinsurances for the same services [17]. Many
expensive health care services (e.g., drugs for cancer patients) were not included in the BHIBPs
or access to them was impeded by high copayment. These OOP payments were especially high
for beneficiaries under the coverage of IHIO and SSO. As a result, following the National Health
Accounts, OOP expenses for the whole population increased from 46.2% in 2003 to 53.8% of
total health care expenditures in 2008. Informal payments were common in the health system.
According to the National Health Accounts, informal payments formed 14% out of 53% OOP
expenditures [50]. The percentage of households facing catastrophic health expenditure varied
from 8.3 to 22% [45, 51].
To overhaul the health system and also address the health financing challenges (e.g., high OOP
and catastrophic health expenditure), a series of policy interventions called Health
Transformation Plan (HTP) was implemented in May 2014 mainly by increasing the share of
public budget for the health sector [45, 46]. The Plan’s purpose was to reduce OOP payments
and financial burden in the public health sector (HTP generally does not provide financial
support for patients getting health services from private health sector), by lowering coinsurance
rates in the public sector and the provision of free-of-charge health insurance coverage
(government paid the whole premium on behalf of the uninsured population). To achieve the
aim, a new sub-fund was created within the IHIO titled “Universal Health Coverage Fund” for
those who covered by the government freely. Before HTP, self-employed had to pay the half of
the premium, and the government paid the rest. By launching free Universal Health Coverage
Fund in 2014, self-employed individuals that were previously under the coverage of Iranian sub-
fund with less than three million population shifted to this free Fund. Also, a part of SSO
beneficiaries moved to IHIO to enjoy free health insurance coverage (in SSO, health insurance
coverage is not delivered alone, beneficiaries should pay for other benefits such as retirement
or unemployment as well).
Free Universal Health Coverage Fund expanded the basic health insurance coverage to include
the 11 million previously uninsured Iranian people (mainly self-employed) which increased the
overall population coverage up to 96% [52, 53]. By implementing this reform, the government
announced reaching UHC by 2025. “In HTP, health authorities decided to cover those people
without coverage freely. To our surprise, in the 2016 census, 10.3 % of the population stated
that they have no health insurance. That is why in the sixth national development plan, it was
stipulated again that health insurance coverage should be mandatory.” [A senior health
insurance manager].
Further improvements were made by revising medical tariffs and content of the BHIBP as the
third phase of the HTP to improve financial protection and health equity for patients [51]. For
instance, approximately 1700 previously excluded health services were added to the BHIBP and
assigned medical tariffs. Additionally, to make medical tariffs more realistic in order to tackle
informal payments, MoHME and HCHI revised medical tariffs fundamentally after 30 years
which led to an increase in medical tariffs on average by 120% [12, 54]. Health insurance
schemes coverage was also extended to include some expensive pharmaceuticals (including 53
medicines for cancer treatment). Health insurance funds became liable for the provision of
additional incentives to encourage medical personnel to work in deprived and remote areas, as
well as working only in public health hospitals. In June 2018, 80 cheap and common medicines
were excluded from BHIBP (they are still under coverage for patients under 12).
Overall, the HTP implementation led to a sharp increase in health care utilisation due to
improved financial accessibility. In deprived areas of Iran, many more hospitals and health
facilities were built, and others were renovated. In the remote areas, the number of hospital
beds and health care staff (physicians, nurses and midwives) was increased [55].
According to the history of the health insurance system in Iran, and despite making great
progress in all three aspects of UHC including population coverage, benefits package (covering
more health services) and financial protection (increasing the depth of benefits package and
financial support) as a result of health insurance reforms over the last decades especially by
launching HTP to achieve UHC, there are still several unsolved challenges.
Although health insurance coverage became compulsory in Iran since the fifth national
development plan, still no effective and applicable mechanisms have been introduced yet to put
into effect the law of compulsory health insurance coverage for rural residents and the self-
employed. It makes keeping UHC more challenging. Although HTP expanded benefits package
and increased financial protection for patients in the public health sector, people (mainly IHIO
and SSO’ beneficiaries) still have to pay the gap between private and public medical tariffs in
the case of getting health services in the private health sector which is prevailing for outpatient
services. “Financial support for patients in hospitals” program still provides inspiring extra
financial protection for patients using inpatient services in the public hospitals although it
stopped providing financial support for outpatient services since May 2019. Currently, it does
not support those who have no insurance coverage, which can reduce health equity as,
unfortunately, a considerable part of these people are from disadvantaged groups. This program
also does not support patients receiving their health care services from the private health sector.
Providing UHC for the self-employed is still a major challenge in Iran, even 26 years after the
passing of the UHI law. The fact that insurance coverage is non-compulsory, the large scale of
the informal economy in Iran (about 20%), the financial inability of people to pay the premiums,
the shortages and instability of government financial support for the constant development of
insurance coverage for villagers and the self-employed, as well as not devising reliable methods
to engage rural people and self-employed in paying at least a part of premiums are among the
main reasons for not achieving extending coverage for all self-employed. Apart from poor
people, providing free health insurance coverage for about 23 million rural citizens and 11
million self-employed persons have imposed a high financial burden on the government and
jeopardise the sustainability of UIC in Iran. By launching free Universal Health Coverage Fund
in 2014, those who were participating in paying health insurance premiums including the self-
employed and a part of SSO beneficiaries with voluntarily based coverage moved to IHIO to
enjoy free health insurance coverage. In reality, just a part of 11 million persons covered by this
project was new and did not have previous insurance coverage. This harmed moving towards
reaching UHC and health equity, as those who got used to paying premiums shifted to free
coverage again, and no distinguishing method was applied to extend health insurance coverage
just for real underprivileged groups. Introduction of the means-testing project by IHIO in
November 2019, can improve health equity by targeting those people in need although
according to the current results of the means-testing project, majority of rural dwellers and self-
employed still should be covered freely by the government. This program is at its beginning, and
how it is going to affect the UHC is not clear. Although alongside the ability to pay, it should be
mandatory for all to get health insurance coverage, which remains to be challenging.
