Universal health coverage in Iran
Authors: Seyyed Meysam Mousavi, Jamil Sadeghifar
Journal: The Lancet Global Health (2016)

Universal health coverage (UHC) as a target in the health Sustainable Development Goals (SDGs) empowers countries to seize the exceptional chance to reach a great convergence in global health.1Pablos-Mendez A Cavanaugh K Ly C The new era of health goals: universal health coverage as a pathway to the Sustainable Development Goals.Health Systems & Reform. 2016; 2: 15-17Crossref Scopus (13) Google Scholar In recent years, many countries have adopted UHC as an aspiration for national policy2Reich MR Harris J Ikegami N et al.Moving towards universal health coverage: lessons from 11 country studies.Lancet. 2016; 387: 811-816Summary Full Text Full Text PDF PubMed Scopus (180) Google Scholar and WHO pointed out that all countries could take actions to move more rapidly towards it.3WHOFact sheet: Universal health coverage (UHC). World Health Organization, Geneva2015http://www.who.int/mediacentre/factsheets/fs395/en/Google Scholar To achieve UHC in Iran, the Government of President Hassan Rouhani designed and adopted the Health Transformation Plan (HTP) in 2014. Apparently inspired by the experience of Thailand and Turkey, the plan called the biggest revolution in the health system. According to the World Bank statistics from 2013,4World BankWorld Development Indicators, Out of pocket health expenditure (as a percentage of total health expenditure). World Bank, 2013http://data.worldbank.org/indicator/SH.XPD.OOPC.TO.ZSGoogle Scholar out-of-pocket expenditures (OOPs) in Iran constituted about 52·1% of total expenditure on health,4World BankWorld Development Indicators, Out of pocket health expenditure (as a percentage of total health expenditure). World Bank, 2013http://data.worldbank.org/indicator/SH.XPD.OOPC.TO.ZSGoogle Scholar for which Iran was ranked 13th among WHO Regional Office for the Eastern Mediterranean (EMRO) countries. According to WHO brief report,5WHOCountry Cooperation Strategy for WHO and Islamic Republic of Iran 2010–2014. World Health Organization, Geneva2010Google Scholar OOPs were one of the main flaws of Iran's health system. The main goal of HTP was to promote the financial protection to improve efficiency, equity, and effectiveness, through eight service packages. Despite a drop in government revenues because of latest oil price shocks, by assigning a new funding through HTP implementation, the budget of Ministry of Health (MOH) was increased from 6·7% in 2013 to 10·3% in 2015.6Ministry of Health and Medical Education. Total Health Expenditure as %GDP in Islamic Republic of Iran.http://behdasht.gov.ir/?siteid=1&pageid=1508&newsview=131077Google Scholar Such increase in the MOH budget was quite essential, and should have been applied much earlier. Some of the major reasons for this delay in funding increase were the negative economic growth caused by the US economic sanctions and the deficient attention of former government to the health sector. As experienced by many countries, the allocation of financial resources to health-care priorities is good per se, but it obviously cannot solve any problems alone; it rather requires the following conditions: (1) an appropriate priority-setting and resource management through family physicians; (2) a powerful single-payer health insurance; and (3) sustainability of the reform. Despite successful implementation of PHC in Iran, which was described by WHO as an incredible masterpiece and a successful model,7Tavassoli M Iranian health houses open the door to primary care.Bull World Health Organ. 2008; 86: 585-586Crossref PubMed Scopus (36) Google Scholar the family physician programme is yet to be implemented. Because of inequality in the distribution of health-care services and concentration of hospitals in the large metropolises and the consequent indirect costs, patients who are poor or reside in rural areas have a hard time finding access to such services. Family physicians play a key role in reducing health-care costs, promoting the availability of health-care services, enhancing the effectiveness of interventions, and improving the patient's satisfaction.8Takian A Doshmangir L Rashidian A Implementing family physician programme in rural Iran: exploring the role of an existing primary health care network.Fam Pract. 2013; 30: 551-559Crossref PubMed Scopus (81) Google Scholar, 9Arab M Torabipour A Rahimifrooshani A Rashidian A Fadai N Askari R Factors affecting family physicians' drug prescribing: a cross-sectional study in Khuzestan, Iran.Int J Health Policy Manag. 2014; 3: 377Crossref Scopus (10) Google Scholar Moreover, studies done before and after the implementation of HTP reveal that the increase in consumer price index (CPI) is higher in the health sector than in all other sectors.10Moradi-Lakeh M Vosoogh-Moghaddam A Health Sector Evolution Plan in Iran; Equity and Sustainability Concerns.Int J Health Policy Manag. 2015; 4: 637Crossref Scopus (166) Google Scholar Family physicians can have a substantial role in managing the demands and thus rectifying those issues. That is why the family physician programme should have been inserted into the HTP concurrently along with the other eight service packages, a necessity that unfortunately was ignored. Experience of many countries has shown that a powerful single-payer health insurance could lead to the promotion of financial protection and equity in health-care expenditures. One of the main important steps to achieve UHC, especially in developing countries is the reduction of fragmentation of insurance funds. Iran has a combination of 17 insurance funds with different bases for membership, resulting in several problems: incomplete population coverage, overlap in population coverage, inappropriate service coverage, and public dissatisfaction. Because of unusual resistance from the insurance funds for merging, it seems that a step by step approach must be applied, and that the first necessary step is not structural merging, but rather running the same policies and regulations for funds. Sustainability of reforms (financial and managerial) is crucial for a successful implementation. Financially, the budget allocated to MOH comes from three sources: public funds (main source), cutting fossil fuel subsidies, and value-added tax (VAT). Iran's public funds, which derive from crude oil sales are considered unsustainable sources because of fluctuation in global prices. That is why sustainable sources such as VAT must constitute the large share of the budget allocated to MOH. Managerially, most reforms in Iran have faced frequent changes in top-level and middle-level managers, which have caused many policies to be abandoned. Therefore, managerial appointments in health sector should be based on meritocratic principles. Finally, to achieve UHC in Iran, policy makers should adopt the intersectoral collaboration to successfully implement HTP. Also, comprehensive measurements, especially province-specific assessments and monitoring of the progress of HTP to track the eight service packages are crucial. We declare no competing interests.