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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