Policy Options to Reduce Fragmentation in the Pooling of Health Insurance Funds in Iran

Document Type : Policy Brief


1 Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Development Policy and Practice, Royal Tropical Institute, Amsterdam, The Netherlands

3 Department of Physiology, School of Medicine, Shahed University, Tehran, Iran

4 Department of Health Services Management, School of Management and Medical Informatics, Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran


There are fragmentations in Iran’s health insurance system. Multiple health insurance funds exist, without adequate provisions for transfer or redistribution of cross subsidy among them. Multiple risk pools, including several private secondary insurance schemes, have resulted in a tiered health insurance system with inequitable benefit packages for different segments of the population. Also fragmentation might have contributed to inefficiency in the health insurance systems, a low financial protection against healthcare expenditures for the insured persons, high coinsurance rates, a notable rate of insurance coverage duplication, low contribution of well-funded institutes with generous benefit package to the public health insurance schemes, underfunding and severe financial shortages for the public funds, and a lack of transparency and reliable data and statistics for policy-making. We have conducted a policy analysis study, including qualitative interviews of key informants and document analysis. As a result we introduce three policy options: keeping the existing structural fragmentations of social health insurance (SHI) schemes but implementing a comprehensive “policy integration” strategy; consolidation of existing health insurance funds and creating a single national health insurance scheme; and reducing fragmentation by merging minor well-resourced funds together and creating two or three large insurance funds under the umbrella of the existing organizations. These policy options with their advantages and disadvantages are explained in the paper.


Main Subjects

  1. Takian A, Rashidian A, Kabir MJ. Expediency and coincidence in re-engineering a health system: an interpretive approach to formation of family medicine in Iran. Health Policy Plan. 2011;26(2):163-173. doi:10.1093/heapol/czq036
  2. Kavosi Z, Rashidian A, Pourreza A, et al. Inequality in household catastrophic health care expenditure in a low-income society of Iran. Health Policy Plan. 2012;27(7):613-623. doi:10.1093/heapol/czs001
  3. Doshmangir L, Rashidian A, Ravaghi H, Takian A, Jafari M. The experience of implementing the board of trustees’ policy in teaching hospitals in Iran: an example of health system decentralization. Int J Health Policy Manag. 2015;4(4):207-214. doi:10.15171/ijhpm.2014.115
  4. Doshmangir L, Rashidian A, Jafari M, Takian A, Ravaghi H. Opening the black box: the experiences and lessons from the public hospitals autonomy policy in Iran. Arch Iran Med. 2015;18(7):416-424.
  5. Rashidian A, Khosravi A, Khabiri R, et al. Islamic Republic of Iran's Multiple Indicator Demograpphic and Healh Survey (IrMIDHS) 2010. Tehran: Ministry of Health and Medical Education; 2012.
  6. Iran health in fifth Economic, Social and Cultural Development Plan (Persian). Tehran; 2009.
  7. Jadidfard MP, Yazdani S, Khoshnevisan MH. Social insurance for dental care in Iran: a developing scheme for a developing country. Oral Health Dent Manag. 2012;11:189-198.
  8. Ibrahimipour H, Maleki M-R, Brown R, Gohari M, Karimi I, Dehnavieh R. A qualitative study of the difficulties in reaching sustainable universal health insurance coverage in Iran. Health Policy Planning. 2011;26(6):485-495. doi:10.1093/heapol/czq084
  9. Karasawa Y, Hozumi Y, Imamura S, Kuroyanagi T. JMA—President’s Speech. JMA. 2009;52(1):121.
  10. The regulations of fifth Economic, Social and Cultural Development Plan. Tehran: Iranian Parliament; 2011.
  11. Wang H, Switlick K, Ortiz C, Zurita B, Connor C. Health Insurance Handbook: How to Make It Work. World Bank Publications; 2012.
  12. Davari M, Haycox A, Walley T. The Iranian health insurance system; past experiences, present challenges and future strategies. Iran J Public Health. 2012;41(9):1-9.
  13. The regulations of fourth Economic, Social and Cultural Development Plan. Tehran: Iranian Parliament; 2004.
  14. Bärnighausen T, Sauerborn R. One hundred and eighteen years of the German health insurance system: are there any lessons for middle-and low-income countries? Soc Sci  Med. 2002;54(10):1559-1587. doi:10.1016/s0277-9536(01)00137-x
  15. Atun R, Aydın S, Chakraborty S, et al. Universal health coverage in Turkey: enhancement of equity. Lancet. 2013;382(9886):65-99. doi:10.1016/s0140-6736(13)61051-x
  16. Yardim MS, Cilingiroglu N, Yardim N. Financial protection in health in Turkey: the effects of the Health Transformation Programme. Health Policy Plan 2014;29(2):177-192. doi:10.1093/heapol/czt002
  17. Yıldırım HH, Yıldırım T. Healthcare financing reform in Turkey: context and salient features. Journal of European Social Policy. 2011;21(2):178-193. doi:10.1177/0958928710395045
  18. Kwon S. Healthcare financing reform and the new single payer system in the Republic of Korea: Social solidarity or efficiency? Int Soc Secur Rev. 2003;56(1):75-94. doi:10.1111/1468-246x.00150
  19. Kwon S. Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage. Health Policy Plan. 2009;24(1):63-71. doi:10.1093/heapol/czn037
  20. Maeda A, Araujo E, Cashin C, Harris J, Ikegami N, Reich MR. Universal health coverage for inclusive and sustainable development: a synthesis of 11 country case studies. World Bank Publications; 2014.
  21. Thomson S, Foubister T, Mossialos E. Financing health care in the European Union Challenges and policy responses. Copenhagen: WHO, EMPL; 2009.
  22. Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet. 2012;380(9845):933-943. doi:10.1016/s0140-6736(12)61147-7
  23. Thabrany H. Politics of National Health Insurance of Indonesia: A New Era of Universal Coverage. Paper presented at: The 7th European Conference on Health Economics; Center for Health Economic and Policy Studies, University of Indonesia;  2008.
  24. Thabrany H. Social health insurance in Indonesia: current status and the proposed national health insurance. Paper presented at: Social Health Insurance Workshop by WHO SEARO; March 13-15, 2003.
  25. Rashidian A, Eccles MP, Russell I. Falling on stony ground? A qualitative study of implementation of clinical guidelines’ prescribing recommendations in primary care. Health Policy. 2008;85(2):148-161. doi:10.1016/j.healthpol.2007.07.011
  26. Hajimahmoodi H. Common basic health benefit package for all Iranians: a solution to implement health system macro-policies. Tehran:Iran Health Insurance Organization; 2014.
  27. Takian A, Rashidian A, Doshmangir L. The experience of purchaser–provider split in the implementation of family physician and rural health insurance in Iran: an institutional approach. Health Policy Plan. 2015;1:11. doi:10.1093/heapol/czu135
  28. Wilsford D. Path dependency, or why history makes it difficult but not impossible to reform health care systems in a big way. J Public Policy. 1994;14(3):251-283. doi:10.1017/s0143814x00007285
  29. Marnani AB, Teymourzadeh E, Bahadori M, Ravangard R, Pour JS. Challenges of a large health insurance organization in Iran: A Qualitative Study. International Journal of Collaborative Research on Internal Medicine & Public Health. 2012;4:1050-1062.
  30. National Health Accounts Islamic Republic of Iran, 2008.
  31. 31.   Schäfer W, Kroneman M, Boerma W, et al. The Netherlands: health system review. Health Syst Transit. 2010;12(1):v-xxvii.
  32. Carrin G, James C. Reaching universal coverage via social health insurance: key design features in the transition period. Geneva: WHO; 2004.
  33. Smith PC, Witter SN. Risk pooling in health care financing: the implications for health system performance: World Bank, Washington, DC; 2004.