Hayati et al.

BMC Res Notes (2019) 12:575

https://doi.org/10.1186/s13104-019-4618-0 BMC Research Notes

RESEARCH NOTE Open Access

Legal and policy requirements of basic

health insurance package to achieve universal
health coverage in a developing country
Ramin Hayati1, Mohammad Javad Kabir2, Zahra Kavosi3, Peivand Bastani3*  , Ghasem Sobhani4
and Hamideh Javadinasab5

Abstract 
Objectives:  This study has analyzed the policy-making requirements related to basic health insurance package at the
national level with a systematic view.
Results:  All the documents presented since the enactment of universal health insurance in Iran from 1994 to 2017
were included applying Scott method for assuring meaningfulness, authenticity, credibility and representativeness.
Then, content analysis was conducted applying MAXQDA10. The legal and policy requirements related to basic health
insurance package were summarized into three main themes and 11 subthemes. The main themes include three
kinds of requirements at three level of third party insurer, health care provider and citizen/population that contains
5 (financing insurance package, organizational structure, tariffing and purchasing the benefit packages and integra-
tion of policies and precedents), 4 (determining the necessities, provision of services, rules relating to implementation
and covered services) and 2 (expanded coverage of population and insurance premiums) sub themes respectively.
According to the results, Iranian policy makers should notice three axes of third party insurers, health providers and
population of the country to prepare an appropriate basic benefit package based on local needs for all the people
that can access with no financial barriers in order to be sure of achieving UHC.
Keywords:  Universal health coverage, Legal requirements, Basic health insurance package, Document analysis, Iran

Introduction Iran as a developing country in Middle East with

Access to basic health services with no financial limit about 80 million population and 6.8% allocation of gross
is one of the most important goals of governments [1]. domestic product (GDP) to health sector tries to move
Emphasis has been put on utilization of health services at toward UHC [5]. Looking over the country’s policies,
the highest possible level in WHO’s report and the most constitution of Islamic Republic of Iran articles 2 and 29
countries’ constitutions [2]. WHO has recommended the explicitly emphasized on individuals’ access to healthcare
use of social health insurance as an effective strategy to and insurance [6]. Fifth 5-year development plan of soci-
reduce financial barriers to access health [3]. Nowadays, oeconomic also considered expansion of health oriented
health insurance is considered as a path to achieve uni- insurance [7].
versal health coverage (UHC). In addition to protecting Despite the emphasis of the policies, national evidences
financial risks, UHC covers two other dimensions: popu- show that lack of sustainable provision of financial
lation coverage and services package [4]. resources, inequitable and inefficient services delivered
by Iranian health system and lack of governance are the
main challenges in achieving UHC [8], other Iranian evi-
dences indicate that although national efforts have led to
*Correspondence: bastanip@sums.ac.ir
3
Health Human Resources Research Center, School of Management decrease the amount of out of pocket payment (OOP)
and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran from 80.5 to 59.5% from 1995 to 2014, there is a long way
Full list of author information is available at the end of the article to achieve UHC [9]. Lack of scientific and cost effective

© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creat​iveco​mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hayati et al. BMC Res Notes (2019) 12:575 Page 2 of 7

health basic benefit package in the country may be con- Council [http://www.centi​nsur.ir], High Council of
sidered as another reason for losing to achieve UHC in Health Insurance [http://www.mcls.gov.ir], Parliament
spite of the coverage of about 90–95% of the whole popu- Research Center [http://www.rc.majli​s.ir], and Medical
lation by any of the insurance companies [10, 11]. Council [http://www.irimc​.org] at macro level. Docu-
Other evidences emphasize that non-appropriate ments on the sites of universities of medical sciences
approach and process of these national insurance compa- and health insurance and social security departments
nies especially in the scope of designing suitable health in provinces (micro level) were excluded. Table  1 shows
basic benefit package along with inappropriate alloca- those included documents regarding Scott method.
tion of financial resources to purchase health priorities
can intensify the problem [12]. Iranian Health service
packages are economically provided by two separate Data analysis
organizations; the first one is the primary healthcare Documents were analyzed applying both explicit and
package delivered by Ministry of Health, accounts for implicit methods [19–21]. In explicit analysis, emphasis
about 35–30% of the health sector’s costs. The second was put on content analysis of the documents directly
is the basic health insurance package, financed by insur- referring to the basic health insurance package. The
ance organizations under the supervision of the Ministry explicit analysis was done several times by two members
of Social Welfare [13] in which the inclusion of different of the research team. After several times of reviewing,
services to the package has occurred through bargaining, specified words were determined in Microsoft Office to
political negotiations and health care providers’ views be entered into M ­ AXQDA10 at the next step to identify
[10, 11]. the themes and subthemes. This process continued until
As it is obvious, policymakers need to have access to a development of the intended content framework.
variety of documents as well as research papers for pro- Implicit analysis included documentations involving
posing basic benefit package [14] however, traditional similar concepts and issues, such as universal health cov-
methods based on political lobbying and health provid- erage, health insurance, purchasing health services, and
ers’ conflict of interest are generally used in the common healthcare financing.
process of Iranian policy-making [15, 16]. According to In implicit analysis approach, after reading the texts
what was said, the present study aims to analyze legisla- for several time, meaningful units were identified, coded,
tive documents, legal and policy requirements associ- and modified by the research team to find out the final
ated with the basic health insurance package in the last codes [22–25]. At the next step, the texts were entered
20 years to highlight the way of presenting an appropriate into ­MAXQDA10 to identify the themes and sub-themes.
package toward UHC.

Main text Table 1  Categories of the final studied documents

Methods Number Categories of final studied documents No
Study design of documents
This is a qualitative content analysis with inductive 1 Socio-economic and cultural development 4
approach conducted in 2018. Scott 4-step method plan (second, third, fourth, and fifth)
included authenticity, credibility, meaningfulness and 2 Budget law (1994–2017) 21
representation of the data was used to extract the rele- 3 Documents of High Council of health insur- 162
vant documents [17, 18]. ance
4 Related rules 7
Study population     Universal Insurance Act
    Organizing health act
The research population included all documents avail-     Targeting subsidies law
able at the legislation level since approval of the universal     Civil services management law
insurance law (1994). The period of selecting documents     Comprehensive welfare la
    Comprehensive veterans services law
were, from 1 January 1994 to 31 December 2017. These
5 Related policies 2
documents were examined through the websites of the
    General policies of health
main organizations that have a political role in health     Policies of resistance economy
decision making the same as: Ministry of Health [http:// 6 Other related documents 4
www.behda​sht.gov.ir], Health Insurance Organiza-     Document of 20-year visions
tion [http://www.ihio.gov.ir], Social Security Organiza-     Circular of health sector evolution plan
tion [http://www.tamin​.ir], Management and Planning     Map of health system evolution
    Health scientific road map
Organization [http://www.mporg​.ir], Central Insurance
Hayati et al. BMC Res Notes (2019) 12:575 Page 3 of 7

This process continued until development of the intended package in preventive, therapeutic, rehabilitation, pro-
content framework. motive and palliative services.
All stages of analysis were conducted by two members Provision of the above services according to the popu-
of the research team who had no conflict of interests with lation’s need and trying to achieve necessary credits for
the subject and the selected organizations. competing with other provider agencies in contracting
the third party insurers.
Results Rules relating to implementation of health basic benefit
According to the results, three main themes were package through creating the necessary measures, notify-
achieved during content analysis based on a theoretical ing mechanisms for universal and compulsory health and
framework of healthcare triangle. This triangle shows cooperating between all basic insurance organizations
the interactions among “citizens/population” and “third- and providers was another subtheme in this axis.
party insurer” and “healthcare providers” as the main The last subtheme was covered services emphasizing
requirements to achieve health insurance and UHC. high risk groups, children and women and considering
As Table  2 indicates, 11 related subthemes were cat- high priority services like infertility treatment and pri-
egorized for each of the three main themes. These sub- mary health care.
themes were synthesized through content analysis and
integration of 55 final codes that were achieved explicitly Citizen/population requirements
or implicitly from the documents retrieved and included The last axis has two subthemes containing: first,
in the study. Followings are more clarification about each expanded coverage of population that means increasing
main theme and its related subthemes: the coverage of population containing headed household,
residents of villages/cities with less than 20,000 peo-
Third party insurer requirements ple, all uninsured Iranians and developing urban inpa-
In this axis, five sub themes are appeared as follows: tient scheme to underserved poor populations and then,
Financing insurance package by main insurance organi- Insurance premium that focuses on collecting rational
zations in the country allocating an appropriate ratio of incremental insurance premiums as a per capita from all
GDP and governmental budget to health sector along insured population along with considering the share of
with seeking sustainable financial resources as insurance employees premiums that was paid by executive organi-
premiums and taxes. zations as the agent of citizens.
Making an obligation to improve the organizational
structure of the insurance companies and determining Discussion
the hierarchy of regulation setting along with correcting Findings showed that three main requirements are men-
the mechanism of referral system for all insured people. tioned in Iranian national documents with a growing
Tariffing the services included in health basic package trend in the last two decades consisting the third party
in an appropriate and scientific way using actual prices insurer, health care provider and citizen/population
based on activity costing and local evidences. requirements all of them need to be considered by policy
Integrating of policies and precedents in a way that makers to achieve UHC.
all insurance companies can access to a comprehensive In the first axis, third party insurer, the structure of the
electronic database of the insured information and their insurance organization and the integration of policies
medical and health records and try to eliminate the over- must be considered as well as financing, tariffing and pur-
lap that is now existed in utilization of some packages by chasing health basic benefit package. In this regard WHO
a single insured from different insurance organizations’ recommended options, for low- and middle-income
services. countries, for increasing the share of health from the
The last subtheme in this axis, was Purchasing the ben- general budget [26]. This recommendation is considered
efit packages applying strategic purchasing through cus- by Iranian policy makers so that the 2015 budget for the
tomized guidelines and creating the power of win–win health sector increased by nearly 70% compared to 2014
contracting between purchasers and providers. [27]. However the sustainability and reallocation of these
funds must be noticed in a way of achieving UHC. Typi-
Health care provider requirements cal instability of financial resources was found in Mongo-
This axis consists of four subthemes as follows: Deter- lia where more than 95% of the population was covered
mining the health and treatment necessities of the com- in 1996 after which, a decreasing trend of population
munity according to their age, sex and epidemiological coverage was experienced because of financial instability
description of the diseases and presenting a cost-effective [28].
Hayati et al. BMC Res Notes (2019) 12:575 Page 4 of 7

Table 2  The main themes and sub-themes of legal and policy requirements of basic health insurance package from 1994
to 2017
Themes Sub themes Final codes

Third party insurer requirements Financing insurance package Increasing the health share from GDP
Providing sustainable financial resources
Management of resources
Financing the healthcare insurance
Adaptation of measurements for reimbursement
Allocation of 10% of car insurance premiums for accident injuries
Organizational structure Integrating all medical funds to the Medical Services Insurance
Establishing a High Council of Health Insurance
Defining the country’s medical treatment system
Making comprehensive healthcare system based on referral system
Tariffing the service package Using actual prices and approved per capita rate for health care
Setting yearly tariff of services by High Council of Health Insurance
Developing healthcare services and tariffs based on evidences
Integration of policies and precedents Organizing integrated health insurance services based on IT and EHR
Establishment of Iranian insurance database and elimination of overlap
Providing principles for contracting, behaving and monitoring insurers
The same instructions to examine medical claims
Entering new services to approve practical guidelines by MOH
Purchasing the benefit packages Strategic purchasing of health services from all sectors by HIO
Purchasing comprehensive basic and supplementary health services
Requiring evaluation of health technologies for health interventions
Performance of quality-based payment
Development of clinical guidelines
Definition framework contracts for basic health services
Contracting providers complying with Article 17 universal insurance law
Health care provider requirements Determining the necessities Determination of comprehensive healthcare services package by MOH
Defining uniform basic health insurance services for the population
Determining of the covered basic health insurance package in three levels
Updating uniform approach of the list of basic insurance commitments
Provision of services Reinforcement of competitive market to provide medical insurance
Defining providing mechanism to the insured health sector evolution plan
Providing insurance services based on rules/regulations of High Council
Avoiding contract with providers aren’t interested in UHC cooperation
Supplying the entire requirements covered by the basic insurance package
Rules relating to implementation Creating the necessary measures for establishment of health insurance
Notifying mechanisms for universal and compulsory health insurance
Cooperating between all basic insurance organizations Ministry of Health
Covered services Full coverage of basic health needs for members of the Community
Reviewing the basic insurance package with health orient approach
Paying attention to health promotion and prevention activities
Allocating appropriate facilities for women
Insurance coverage for infertility treatment
Hayati et al. BMC Res Notes (2019) 12:575 Page 5 of 7

Table 2  (continued)
Themes Sub themes Final codes

Citizen/population requirements Expanded coverage of population Basic health insurance is universal and mandatory
Implementing the plan of mandatory insurance of wage earners
Providing free basic health insurance to all Iranian uninsured
Coverage of all foreigners residing in the country
Coverage of headed households
Coverage of residents of villages/cities with less than 20,000 people
Free urban inpatient scheme to underserved poor populations
Targeted advocacy to empower supported individuals and institutions
Establishment of basic social security and health insurance
Insurance premium Premium per capita healthcare coverage for insured people
Paying the share of employees premiums by executive organizations
Using world experience as insurance calculations framework
Defining basic medical insurance of villagers and nomads

Emphasis on marked taxes is also one way to increase and outpatient services could not be sufficient. This expe-
the share of health resources. This type of tax directly rience is confirmed by India, Kenya, and the Philippines
improves health outcomes through reducing demands for which initially covered inpatient services, are now mov-
harmful goods [29]. This happened in South Korea [30] ing toward covering primary and preventive services,
and Ghana [29] and almost 3.1% of the insurance fund recognizing the fact that although outpatient services
was provided in South Korea in 2010. Moreover, health may be costly, they can lead to a greater impact on health
insurance policymakers in Nigeria [26] proposed tax outcomes [26].
bills to mobile phones as a way of financing health cov- Finally, the last axis, citizen/population requirements
erage. Such these issues must be considered as funding focused on expanding population and their insurance
mechanisms helping third party insurers collect revenues premiums. In this regard, evidences show different coun-
and allocate them to the most needed health services to tries have adopted various policies achieving UHC; in
achieve UHC. South Korea and Vietnam, first the formal sector was
Another important topic in this axis is changing the covered and then, the informal sector and whole popu-
structure of insurers. The experiences show that one lation was expanded [35]. On the other hand, India has
basic measure for achieving UHC, especially in develop- allocated significant subsidies to the target population
ing countries, is reduction of fragmentation of the insur- and has tried to expand financial protection through
ance fund [29, 31, 32]. This concern can be disappeared increasing tax revenues [36]. Furthermore, instead of
through implementing a new structure and integration considering multiple programs for different groups of
the insurers’ financial resources in an a single and uni- population, some countries have implemented integrated
form insurance organization as it is mentioned in Article coverage programs for all populations [37].
38 of the fifth 5-year development plan [33].
The second axis of the present results, health provider
requirements, includes determining the necessities, Conclusion
provision and covered services and also rules relating Results show that Iranian policy makers should notice
to implementation health basic benefit package. In this three axes of third party insurers, health providers and
regard, evidences show that by moving toward UHC, population of the country to prepare an appropriate basic
health systems have no way but to establish the basic benefit package based on local needs for all the people
health insurance package [13]. What is covered by insur- that can access with no financial barriers. In this way
ance plans is important according to their ultimate effect UHC can be assured in this developing country.
on public health and financial protection [26]. An impor-
tant issue is attending to all areas of services from pro- Limitations
motion to palliative care [34]. So it is important for Iran Documents alone are not able to express all the facts
to determine the services included in national basic ben- related to politics. It is recommended to apply multiple
efit package in all levels according to the local needs. It methods sequentially or simultaneously in another quali-
is obvious that for obtaining this goal including inpatient tative study. Obviously, application of documentations
Hayati et al. BMC Res Notes (2019) 12:575 Page 6 of 7

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