In this section, first, we present findings of the retrospective qualitative analysis of the HIBP policies, followed by the results of policy options analysis.
Four main issues (i.e. agenda setting, policy development, policy implementation, and evaluation), 10 themes, and 78 sub-themes were identified (table 1).
- Agenda setting: To identify issues related to the Problem stream, Politics stream and Policies stream, the Kingdon multistream model was used (15). Besides, 12 extra sub-themes were identified.
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 (e.g. the NHI Act of 1995, Supreme’s leader mega policies for health, and instruction of strategic purchasing):
"Resource scarcity has always been an important problem for HIBP and, therefore, insurance organization always try to avoid implementing the HIBP …" (R 12).
Until now, no practical policy or scientific method is developed to design the implementation path of macro policies related to the HIBP in Iran. Issues such as lack of scientific criteria or evidence to develop or revise the HIBP and ignoring the epidemiological transition led into exacerbation of this problem:
"Currently, our problem is that we mistakenly consider the HIBP as strategic purchasing, but it must be mentioned which services are covered, based on what evidences and for whom, and why this package should be bought, what criteria should be used, I mean, why a service should be included in the HIBP" (R 26).
In addition to political supports to HIBP that were endorsed by the sequential National Development Plans (NDPs), the Supreme leader’s mega policies for health (2013) were a turning point in providing political support for the HIBP. The mega policies attracted more attention to the health sector and led to allcation of extra funds towards the health sector:
"In the eleventh government, government attention to the health sector problems and challenges significantly increased and continues" (R 11).
Our investigation showed that HIBP -related policies have always been developing, but the three streams of problem, policy, and politics never came together. Inadequate systematic revisions and approaches to the HIBP resulted in insufficient growth of policies stream, which in turn prevented the policy window to become fully open.
- Policy development: two main themes (stewardship of policy making, and method and trend of decision-making) and 15 sub-themes were identified.
- Stewardship of the policy-making
We identified 65 documents containing various policies that were, directly or indirectly, related to the HIBP. The most obvious one was Article 29 of the constitution, which endorses social security as a right for all citizens:
“Having social security, in terms of retirement, unemployment, elderly, inability to work, orphanage, financial needs, accidents, health-care services and medical care, is a universal right for all Iranians” (Article 29 of the constitution).
The MOHME is in charge of drafting health sector policies, while the MOCLSW contributes to developing the draft policies related to the HIBP. The MOHME is also responsible to get the policy approval in liaison with four levels: The ISCHI, the cabinet, parliament, and supreme leader’s office.
- Methods and trends of decision-making
The 3rd National Development Plan (NDP) of Iran endorsed health insurance, health system financing and HIBP -related issues for the first time, which were repeated in the next NDPs. Nevertheless, no organized decision-making process was designed to implement such policies. Consensus-making by officials and policy-makers (traditional negotiation style) was used to define the HIBP, where bargaining power had (and still has) an important role in influencing the decisions. The lack of transparency resulted in weak stewardship for HIBP-related policies:
"A serious problem occurs in the system … because of the bargaining power of some policy-makers, some services won't be included in the HIBP, while some unnecessary services are included, and it’s a serious problem in IHS" (R 6).
- Policy implementation: two main themes (policy implementation timeline and the process of HIBP implementation), plus 38 subthemes were identified here.
- Policy implementation timeline
On the basis of the changes in the content of the benefit package, decision-making method, and the stewardship of decision-making, the implementation and revisions of HIBP-related policies can be categorized into five periods: before 1993, 1994 to 2003, 2004 to 2006, 2007 to 2014, and after 2014. Before 1993 and the enactment of the Universal Health Insurance Act (UHIA), health laws were mainly focused on service coverage, whilst there was no comprehensive document to define the services that each health insurance organization should cover.
In 1993, by the enactment of the UHIA and establishment of the ISCHI, coherence of health insurance policies increased. The ISCHI was initially affiliated to the MOHME, while most of its members came from various health insurance organizations, plus the Iranian Medical Association (IMA). The ISCHI was responsible to make decisions about inclusion and/or exclusion of medical services into the HIBP. No debate among experts took place to make such decisions.
In 2004, the ISCHI was transferred to the newly established MOCLSW. During this period, the decision criteria to include new services were frequency and utilization patterns, which were based on the insurance organizations’ reports. In 2007, the biggest change occurred in the HIBP governance, when the ISCHI began to uniform the HIBP among all health insurance organizations. All covered services were published in a book, called "basic package of 2007". After the enactment of the fifth NDP in 2012, the MOCLSW started a new reform to evaluate the HIBP. Although those measures were based on a scientific methodology –called "new HIBP"-, the previous package was enacted in reality.
The Health Transformation Plan (HTP) that was implemented in 2014 also affected the HIBP through revising the medical tariffs as well as the new Relative Value Unit (RVU) Book. In this book, all services that are available in Iran’s health system, i.e. procedures, surgeries, imaging, and laboratories are listed; those services which did not cover by any insurance organizations, are marked with an asterisk (*).
"…By 2013, the book of RVU was published. This book includes all new and old health services. It was considered as a HIBP revision, the book was intended to revise the tariff but In fact, there was some kind of review HIBP…” (R 19)
- The process of the HIBP implementation
Since 1993, all decisions about including and/or excluding a service within the HIBP are made by the ISCHI, with the participation of related stakeholders. When a new service is proposed to be included in the HIBP, the ISCHI invites various stakeholders (i.e. permanent members of the HHIC, and representatives of the MOHME, health insurance organizations, and the IMA as well as other members from professional associations), to attend in a meeting and to discuss the agenda. The process and methods of holding these meetings have not changed significantly ever since, with consensus building among members as the dominant method for making decisions. The bargaining power of health insurance organizations is mainly focused on the financial burden of services, while professional associations may attempt to exaggerate the importance of proposed services. Except for a few cases, no specific criteria and/or method (e.g. cost-effectiveness studies, guidelines) is used to make such decisions. As a rule, several meetings (in some cases it may take several years) are held to make a decision. Services with a high financial burden should be confirmed by the cabinet:
"In some cases, health insurance organizations propose a service, all propositions, either from the MoHME or MoCLSW, send to the HCHI for expert analysis. There is a waiting list. Representatives from the different organizations as well as MoHME and MoCLSW debate. If consensus is on its inclusion, the cabined must confirm the decision" (R 3).
- Evaluation of HIBP-related policies: evaluation refers to the investigation of whether the goals of the policies were achieved and whether an implementation gap exists. Three main themes were identified: revision of the HIBP, revising the methods and decisions, and evaluating the aims of HIBP -related policies. 13 sub-themes were also identified.
Since 1993, any revision in the HIBP has been mainly focused on creating a more coherent and evidence-based package. In some cases (e.g. in 2007, 2012, and 2014), revisions were temporary and without a defined methodology. The findings showed that no purposive and fundamental revision was conducted. We identified a series of reactional, vs proactive, changes in the content of HIBP. Rarely, in less than 10 cases, an emerging need led to inclusion or exclusion of some medicines, medical equipment, and services into/from the HIBP:
"It's more than 30-years that we have the HIBP, but there is not a defined method for including a new and better service. Whether it should replace the older service or not"(R 4).
Exclusion of over-the-counter (OTC) drugs was one of the main recent changes. In 2012, an expert panel was established for exclusion of OTC drugs from the HIBP and allocating the released funds for medicines related to special diseases.
- Revising the methods and decisions
Processes that are related to the inclusion and/or exclusion of services/drugs into/from the HIBP are not evaluated and revised yet. Meanwhile, due to technological advances or the introduction of lower-cost interventions, revisions deem necessary, some committed HIBP are not covered:
"We never tried to revise the covered services. As well, we never tried to evaluate the HIBP" (R 12).
- Evaluating the aims of HIBP-related policies
Despite the legislator’s emphasis on the annual revision of necessary commitments by health insurance organizations, this is only available for medicines packages and its execution was not regular. In 2007, Article 3 of the comprehensive welfare and social security system Act resulted in a big improvement towards a more transparent decision making about the HIBP and increasing the awareness about insurance services. According to the RVU Book (2015), coverage of inpatient and Para-clinic services included in the HIBP was 88 and 89.9%, respectively. Moreover, the National Health Accounts (NHA) (2013) showed that financial burden of uncovered services, those excluded from the HIBP, was only 6%.
Limitations and Solutions
After analyzing the interviews, fourteen challenges and constrains regarding the HIBP policies were identified. A summary of identified issues and problems is described in table 2; it is worth noting that there are no priorities in the identified limitations.
11 solutions and 25 policy options were extracted, at least two policy options per each solution. Consequently, based on the pros and cons of each one as well as appropriateness and feasibility criteria, they were prioritized by an expert panel (Table 3).