. Effat Mohammadi; . Ahmad Reza Raissi; . Mohsen Barooni; . Massoud Ferdoosi; . Mojtaba Nuhi
Volume 4, Issue 5 , November 2014, , Pages 1-9
Abstract
Introduction and Objectives: Health system reforms are the most strategic issue that hasbeen seriously considered in healthcare systems in order to reduce costs and increaseefficiency ...
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Introduction and Objectives: Health system reforms are the most strategic issue that hasbeen seriously considered in healthcare systems in order to reduce costs and increaseefficiency and effectiveness. The costs of health system finance in our country, lack of universalcoverage in health insurance, and related issues necessitate reforms in our health systemfinancing. The aim of this research was to prepare a structure of framework for social healthinsurance in Iran and conducting a comparative study in selected countries with social healthinsurance. Materials and Methods: This comparative descriptive study was conducted in threephases. The first phase of the study examined the structure of health social insurance in fourcountries – Germany, South Korea, Egypt, and Australia. The second phase was to developan initial model, which was designed to determine the shared and distinguishing points of theinvestigated structures, for health insurance in Iran. The third phase was to validate the finalresearch model. The developed model by the Delphi method was given to 20 professionals infinancing of the health system, health economics and management of healthcare services. Theircomments were collected in two stages and its validity was confirmed. Findings: The study ofthe structure of health insurance in the selected countries shows that health social insurance indifferent countries have different structures. Based on the findings of the present study, the currentsituation of the health system, and the conducted surveys, the following framework is suitable forthe health social insurance system in Iran. The Health Social Insurance Organization has a uniqueservice by having five funds of governmental employees, companies and NGOs, self‑insured,villagers, and others, which serves as a nongovernmental organization under the supervisionof public law and by decision‑ and policy‑making of the Health Insurance Supreme Council.Membership in this organization is based on the nationality or residence, which the insured bypaying the insurance premiums within 6-10%of their income and employment status, areentitled to use the services. Providing servicesto the insured are performed by indirectforms. Payments to the service providers forthe fee of inpatient and outpatient servicesare conservative and the related diagnosticgroups system. Conclusions: Payingattention to the importance of modification ofthe fragmented health insurance system andfinancing the country’s healthcare can reducemuch of the failure of the health system,including the access of the public to healthservices. The countries according to the degree of development, governmental, and private insurance companies and existing rules mustuse the appropriate structure, comprehensive approach to the structure, and financing of thehealth social insurance on the investigated basis and careful attention to the intersections anddifferentiation. Studied structures, using them in the proposed approach and taking advantagesof the perspectives of different beneficiaries about discussed topics can be important and efficientin order to achieve the goals of the health social insurance.
