Table 3 Solutions and policy options derived from the policy process analysis for the HIBP
From: Health insurance benefit package in Iran: a qualitative policy process analysis
Solutions | Policy options/description | Pros | Cons | Average Necessity and feasibility (+_) standard deviation (1–10) |
|---|---|---|---|---|
Differentiating between HIBP(s) from services that can be provided | Defining necessary services benefit package and financing it by government and defining the higher level package that its financing is elective | Creating elective options for patients/ people and financial savings for the government | Establishing limitations on access to higher level services | 7.8 ± 1 |
Defining “necessary primary services HIBP” and financing it by the MoHME and also a “HIBP for secondary and tertiary necessary services” and financing it by insurance organizations | Ensure easy and free access to primary services, more effective management of curative services with stewardship of health insurance organizations | Inadequate attention of insurance organizations to the importance of preventive and screening services | 5 ± 2.55 | |
Developing a HIBP that can be provided in all levels and financing it by health insurance organizations | Matching the HIBP with society’s health needs | Probability of increasing the number of covered services without considering available resources of health insurance organizations has increased | 5.3 ± 2.3 | |
Using scientific evidences to make HIBP-related decisions | Collecting and reviewing demographic information | Prioritizing services and evidence-based decision-making, indeed the HIBP should be targeted | Lack of precise information systems to determine the burden and pattern of diseases, by age groups | 7.6 ± 1.5 |
Conducting HTA studies | Developing a cost effective HIBP based on the comprehensive needs | These studies are cost driven and adequate experts to conduct them are not available | 6.9 ± 1.6 | |
Considering cultural problems and needs in developing the HIBP (i.e. religious beliefs and cultural behaviors) | Increasing the acceptability of services for targeted populations, increasing equity in health | Increasing the probability of health expenditure soaring for the health system | 4.6 ± 1.7 | |
Considering intervention’s QALY and DALY (analyzing the epidemiologic profile, and determining interventions based on it) | Prioritizing services that have more influence on life expectancy and quality of life | Ethical and social criteria are neglected | 6.7 ± 1 | |
Estimating the financial burden of diseases | Direct, indirect and intangible costs | Creating a systemic view or considering costs carried out by patients and avoiding catastrophic expenditures | Ignoring the necessity of covering some services that based on economic terms should not be covered | 6.6 ± 1.6 |
Employing multi-criteria decision-making methods to develop the HIBP | Considering criteria that are related to economic aspects of services (cost effectiveness, budget impact, reducing poverty, quality and quantity of evidences and equity in better access to health-care services | More economic mix of services and avoiding exorbitant costs; transparency of definitions and prioritizing economic criteria | Some decision have unethical economic consequences | 7.6 ± 1.1 |
Mixing cost and effectiveness and economic and socio-economic criteria in related decisions (using multi-criteria decisions) | Creating a comprehensive view or considering all criteria that affects the decisions; increasing cost-effectiveness of the HIBP | Collecting information is time-consuming, and such decisions are costly | 7.9 ± 1 | |
Controlling inclusion of drugs, services and equipment that their effectiveness is not proved | The MoHME’s intervention in licensing new drugs and technologies or developing and implementing laws and regulations to restrict and control them | Increasing the control over services that can be provided, and, therefore, preventing the inclusion of services that are not cost effectiveness | A prolonged period is required to update health services of the country | 8 ± 1.1 |
Organizing services/ drugs list that are covered or not covered | Developing a waiting list to include/exclude services/drugs (due to technological changes, policy change, new diseases patterns) | More efficient management of decisions to include/exclude services/drugs and facilitating annual revisions | More health human resources as well as continuous monitoring are required | 8 ± 0.7 |
Creating a decision-making framework based on mathematical models and defined criteria | Weighting predetermined criteria and determining how to mix them by mathematical models | Transparency of method and process of decision-making and determining weights of criteria to make decisions | Possibility of conflict with ethical values in decision’s outcomes | 6.7 ± 1 |
Expanding the package of services that can be provided | Expanding the HIBP by providing extra resources | Increasing access to health-care services | Services utilization is out of control and is creating exorbitant costs | 5.8 ± 1.3 |
Expanding the HIBP along with developing guidelines and standards for services provision | Increasing cost-effectiveness of services, reducing induced demand | Access to services can potentially be decreased | 7 ± 1.2 | |
Expanding the HIBP along with developing specialized packages for each level of the health system | Increasing cost -effectiveness of services, reducing induced demand | Access to services can potentially be decreased | 7.7 ± 1.2 | |
Policies should be based on study’s findings and expert’s opinions | Macro decisions be made at higher levels and following that performing expert studies to increase efficacy of implementation | Clear tasks of middle and lower levels, converging tasks at lower levels | Environmental problems and issues are not reflected in macro decisions | 7 ± 1.2 |
Proposing policies by expert level and following that developing and notifying policies at macro level | Developing evidence-based policies | Prolonging decision-making process | 7.3 ± 1.2 | |
Determining macro-level decisions orientation and following that developing expert-based policies | Transparency of overall strategies and finally making evidence-based decisions | Possibility of different interpretations that may be different from macro policies | 7.9 ± 1.3 | |
Organizing ISCHI meeting on including/excluding a service/drug/ equipment | Developing specialized forms which contain key criteria such as cost-effectiveness | Increasing efficacy of decisions through systematic process and defined participation of stakeholders | Challenges may arise in exceptional cases | 8.3 ± 1 |
Revision and evaluation of the HIBP, both services-and- drugs related | Categorizing services/ drugs in three different lists (i.e. must be under coverage, can be covered, and must not be covered). Then, conducting cost-effectiveness studies for those services that can be covered | Making the HIBP cost-effective by spending minimum time and cost | HTA studies are not performed for all services; categorization may be biased | 7.9 ± 1.3 |
Conducting HTA studies for all services/drugs that can be provided, then revising the HIBP | Having a HIBP with cost-effective services, as much as possible | HTA studies are highly time and cost consuming; social criteria may be neglected | 6.1 ± 1.6 | |
Perform the first method for the services in the package and the requirement for the HTA to include the new services / drug into the package | The HIBP will be cost-effective; these studies will be institutionalized in deciding about including services/ drugs | HTA studies are not performed for all services; categorization may be biased | 7.5 ± 1.1 | |
Conducting second method and mandating HTA studies | Having a HIBP with highest possible of cost-effective services/drugs; these studies will be institutionalized in deciding about including services/ drugs | HTA studies are highly time and cost consuming; social criteria may be neglected | 6.6 ± 1.8 | |
Determining the minimum expected level of health with measurable indicators to identify the situation or measuring the gap between coverage level and defined standards | Developing the HIBP based on the country’s needs | Lack of scientific evidences and field studies; conducing required studies require extra resources | 5.8 ± 1.7 |