Document Type : Original Article

Authors

• . Effat Mohammadi
• . Ahmad Reza Raissi ¹
• . Mohsen Barooni ²
• . Massoud Ferdoosi ¹
• . Mojtaba Nuhi

¹ Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan

² Department of Health Management and Economics, Kerman University of Medical Sciences, Kerman, Iran

Abstract

Introduction and Objectives: Health system reforms are the most strategic issue that has
been seriously considered in healthcare systems in order to reduce costs and increase
efficiency and effectiveness. The costs of health system finance in our country, lack of universal
coverage in health insurance, and related issues necessitate reforms in our health system
financing. The aim of this research was to prepare a structure of framework for social health
insurance in Iran and conducting a comparative study in selected countries with social health
insurance. Materials and Methods: This comparative descriptive study was conducted in three
phases. The first phase of the study examined the structure of health social insurance in four
countries – Germany, South Korea, Egypt, and Australia. The second phase was to develop
an initial model, which was designed to determine the shared and distinguishing points of the
investigated structures, for health insurance in Iran. The third phase was to validate the final
research model. The developed model by the Delphi method was given to 20 professionals in
financing of the health system, health economics and management of healthcare services. Their
comments were collected in two stages and its validity was confirmed. Findings: The study of
the structure of health insurance in the selected countries shows that health social insurance in
different countries have different structures. Based on the findings of the present study, the current
situation of the health system, and the conducted surveys, the following framework is suitable for
the health social insurance system in Iran. The Health Social Insurance Organization has a unique
service by having five funds of governmental employees, companies and NGOs, self‑insured,
villagers, and others, which serves as a nongovernmental organization under the supervision
of 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 by
paying the insurance premiums within 6-10%
of their income and employment status, are
entitled to use the services. Providing services
to the insured are performed by indirect
forms. Payments to the service providers for
the fee of inpatient and outpatient services
are conservative and the related diagnostic
groups system. Conclusions: Paying
attention to the importance of modification of
the fragmented health insurance system and
financing the country’s healthcare can reduce
much of the failure of the health system,
including the access of the public to health
services. The countries according to the degree of development, governmental, and private insurance companies and existing rules must
use the appropriate structure, comprehensive approach to the structure, and financing of the
health social insurance on the investigated basis and careful attention to the intersections and
differentiation. Studied structures, using them in the proposed approach and taking advantages
of the perspectives of different beneficiaries about discussed topics can be important and efficient
in order to achieve the goals of the health social insurance.

Keywords

• Health insurance
• health insurance structure
• insurance
• selected countries