BMC Research Notes

, 12:575 | Cite as

Legal and policy requirements of basic health insurance package to achieve universal health coverage in a developing country

  • Ramin Hayati
  • Mohammad Javad Kabir
  • Zahra Kavosi
  • Peivand BastaniEmail author
  • Ghasem Sobhani
  • Hamideh Javadinasab
Open Access
Research note



This study has analyzed the policy-making requirements related to basic health insurance package at the national level with a systematic view.


All the documents presented since the enactment of universal health insurance in Iran from 1994 to 2017 were included applying Scott method for assuring meaningfulness, authenticity, credibility and representativeness. Then, content analysis was conducted applying MAXQDA10. The legal and policy requirements related to basic health insurance package were summarized into three main themes and 11 subthemes. The main themes include three kinds of requirements at three level of third party insurer, health care provider and citizen/population that contains 5 (financing insurance package, organizational structure, tariffing and purchasing the benefit packages and integration of policies and precedents), 4 (determining the necessities, provision of services, rules relating to implementation and covered services) and 2 (expanded coverage of population and insurance premiums) sub themes respectively. According to the results, Iranian policy makers should notice three axes of third party insurers, health providers and population of the country to prepare an appropriate basic benefit package based on local needs for all the people that can access with no financial barriers in order to be sure of achieving UHC.


Universal health coverage Legal requirements Basic health insurance package Document analysis Iran 



World Health Organization


universal health coverage


Access to basic health services with no financial limit is one of the most important goals of governments [1]. Emphasis has been put on utilization of health services at the highest possible level in WHO’s report and the most countries’ constitutions [2]. WHO has recommended the use of social health insurance as an effective strategy to reduce financial barriers to access health [3]. Nowadays, health insurance is considered as a path to achieve universal health coverage (UHC). In addition to protecting financial risks, UHC covers two other dimensions: population coverage and services package [4].

Iran as a developing country in Middle East with about 80 million population and 6.8% allocation of gross domestic product (GDP) to health sector tries to move toward UHC [5]. Looking over the country’s policies, constitution of Islamic Republic of Iran articles 2 and 29 explicitly emphasized on individuals’ access to healthcare and insurance [6]. Fifth 5-year development plan of socioeconomic also considered expansion of health oriented insurance [7].

Despite the emphasis of the policies, national evidences show that lack of sustainable provision of financial resources, inequitable and inefficient services delivered by Iranian health system and lack of governance are the main challenges in achieving UHC [8], other Iranian evidences indicate that although national efforts have led to decrease the amount of out of pocket payment (OOP) from 80.5 to 59.5% from 1995 to 2014, there is a long way to achieve UHC [9]. Lack of scientific and cost effective health basic benefit package in the country may be considered as another reason for losing to achieve UHC in spite of the coverage of about 90–95% of the whole population by any of the insurance companies [10, 11].

Other evidences emphasize that non-appropriate approach and process of these national insurance companies especially in the scope of designing suitable health basic benefit package along with inappropriate allocation of financial resources to purchase health priorities can intensify the problem [12]. Iranian Health service packages are economically provided by two separate organizations; the first one is the primary healthcare package delivered by Ministry of Health, accounts for about 35–30% of the health sector’s costs. The second is the basic health insurance package, financed by insurance organizations under the supervision of the Ministry of Social Welfare [13] in which the inclusion of different services to the package has occurred through bargaining, political negotiations and health care providers’ views [10, 11].

As it is obvious, policymakers need to have access to a variety of documents as well as research papers for proposing basic benefit package [14] however, traditional methods based on political lobbying and health providers’ conflict of interest are generally used in the common process of Iranian policy-making [15, 16]. According to what was said, the present study aims to analyze legislative documents, legal and policy requirements associated with the basic health insurance package in the last 20 years to highlight the way of presenting an appropriate package toward UHC.

Main text


Study design

This is a qualitative content analysis with inductive approach conducted in 2018. Scott 4-step method included authenticity, credibility, meaningfulness and representation of the data was used to extract the relevant documents [17, 18].

Study population

The research population included all documents available at the legislation level since approval of the universal insurance law (1994). The period of selecting documents were, from 1 January 1994 to 31 December 2017. These documents were examined through the websites of the main organizations that have a political role in health decision making the same as: Ministry of Health [], Health Insurance Organization [], Social Security Organization [], Management and Planning Organization [], Central Insurance Council [], High Council of Health Insurance [], Parliament Research Center [], and Medical Council [] at macro level. Documents on the sites of universities of medical sciences and health insurance and social security departments in provinces (micro level) were excluded. Table 1 shows those included documents regarding Scott method.
Table 1

Categories of the final studied documents


Categories of final studied documents

No of documents


Socio-economic and cultural development plan (second, third, fourth, and fifth)



Budget law (1994–2017)



Documents of High Council of health insurance



Related rules


    Universal Insurance Act

    Organizing health act

    Targeting subsidies law

    Civil services management law

    Comprehensive welfare la

    Comprehensive veterans services law


Related policies


    General policies of health

    Policies of resistance economy


Other related documents


    Document of 20-year visions

    Circular of health sector evolution plan

    Map of health system evolution

    Health scientific road map

Data analysis

Documents were analyzed applying both explicit and implicit methods [19, 20, 21]. In explicit analysis, emphasis was put on content analysis of the documents directly referring to the basic health insurance package. The explicit analysis was done several times by two members of the research team. After several times of reviewing, specified words were determined in Microsoft Office to be entered into MAXQDA10 at the next step to identify the themes and subthemes. This process continued until development of the intended content framework.

Implicit analysis included documentations involving similar concepts and issues, such as universal health coverage, health insurance, purchasing health services, and healthcare financing.

In implicit analysis approach, after reading the texts for several time, meaningful units were identified, coded, and modified by the research team to find out the final codes [22, 23, 24, 25]. At the next step, the texts were entered into MAXQDA10 to identify the themes and sub-themes. This process continued until development of the intended content framework.

All stages of analysis were conducted by two members of the research team who had no conflict of interests with the subject and the selected organizations.


According to the results, three main themes were achieved during content analysis based on a theoretical framework of healthcare triangle. This triangle shows the interactions among “citizens/population” and “third-party insurer” and “healthcare providers” as the main requirements to achieve health insurance and UHC.

As Table 2 indicates, 11 related subthemes were categorized for each of the three main themes. These subthemes were synthesized through content analysis and integration of 55 final codes that were achieved explicitly or implicitly from the documents retrieved and included in the study. Followings are more clarification about each main theme and its related subthemes:
Table 2

The main themes and sub-themes of legal and policy requirements of basic health insurance package from 1994 to 2017


Sub themes

Final codes

Third party insurer requirements

Financing insurance package

Increasing the health share from GDP

Providing sustainable financial resources

Management of resources

Financing the healthcare insurance

Adaptation of measurements for reimbursement

Allocation of 10% of car insurance premiums for accident injuries

Organizational structure

Integrating all medical funds to the Medical Services Insurance

Establishing a High Council of Health Insurance

Defining the country’s medical treatment system

Making comprehensive healthcare system based on referral system

Tariffing the service package

Using actual prices and approved per capita rate for health care

Setting yearly tariff of services by High Council of Health Insurance

Developing healthcare services and tariffs based on evidences

Integration of policies and precedents

Organizing integrated health insurance services based on IT and EHR

Establishment of Iranian insurance database and elimination of overlap

Providing principles for contracting, behaving and monitoring insurers

The same instructions to examine medical claims

Entering new services to approve practical guidelines by MOH

Purchasing the benefit packages

Strategic purchasing of health services from all sectors by HIO

Purchasing comprehensive basic and supplementary health services

Requiring evaluation of health technologies for health interventions

Performance of quality-based payment

Development of clinical guidelines

Definition framework contracts for basic health services

Contracting providers complying with Article 17 universal insurance law

Health care provider requirements

Determining the necessities

Determination of comprehensive healthcare services package by MOH

Defining uniform basic health insurance services for the population

Determining of the covered basic health insurance package in three levels

Updating uniform approach of the list of basic insurance commitments

Provision of services

Reinforcement of competitive market to provide medical insurance

Defining providing mechanism to the insured health sector evolution plan

Providing insurance services based on rules/regulations of High Council

Avoiding contract with providers aren’t interested in UHC cooperation

Supplying the entire requirements covered by the basic insurance package

Rules relating to implementation

Creating the necessary measures for establishment of health insurance

Notifying mechanisms for universal and compulsory health insurance

Cooperating between all basic insurance organizations Ministry of Health

Covered services

Full coverage of basic health needs for members of the Community

Reviewing the basic insurance package with health orient approach

Paying attention to health promotion and prevention activities

Allocating appropriate facilities for women

Insurance coverage for infertility treatment

Citizen/population requirements

Expanded coverage of population

Basic health insurance is universal and mandatory

Implementing the plan of mandatory insurance of wage earners

Providing free basic health insurance to all Iranian uninsured

Coverage of all foreigners residing in the country

Coverage of headed households

Coverage of residents of villages/cities with less than 20,000 people

Free urban inpatient scheme to underserved poor populations

Targeted advocacy to empower supported individuals and institutions

Establishment of basic social security and health insurance

Insurance premium

Premium per capita healthcare coverage for insured people

Paying the share of employees premiums by executive organizations

Using world experience as insurance calculations framework

Defining basic medical insurance of villagers and nomads

Third party insurer requirements

In this axis, five sub themes are appeared as follows: Financing insurance package by main insurance organizations in the country allocating an appropriate ratio of GDP and governmental budget to health sector along with seeking sustainable financial resources as insurance premiums and taxes.

Making an obligation to improve the organizational structure of the insurance companies and determining the hierarchy of regulation setting along with correcting the mechanism of referral system for all insured people.

Tariffing the services included in health basic package in an appropriate and scientific way using actual prices based on activity costing and local evidences.

Integrating of policies and precedents in a way that all insurance companies can access to a comprehensive electronic database of the insured information and their medical and health records and try to eliminate the overlap that is now existed in utilization of some packages by a single insured from different insurance organizations’ services.

The last subtheme in this axis, was Purchasing the benefit packages applying strategic purchasing through customized guidelines and creating the power of win–win contracting between purchasers and providers.

Health care provider requirements

This axis consists of four subthemes as follows: Determining the health and treatment necessities of the community according to their age, sex and epidemiological description of the diseases and presenting a cost-effective package in preventive, therapeutic, rehabilitation, promotive and palliative services.

Provision of the above services according to the population’s need and trying to achieve necessary credits for competing with other provider agencies in contracting the third party insurers.

Rules relating to implementation of health basic benefit package through creating the necessary measures, notifying mechanisms for universal and compulsory health and cooperating between all basic insurance organizations and providers was another subtheme in this axis.

The last subtheme was covered services emphasizing high risk groups, children and women and considering high priority services like infertility treatment and primary health care.

Citizen/population requirements

The last axis has two subthemes containing: first, expanded coverage of population that means increasing the coverage of population containing headed household, residents of villages/cities with less than 20,000 people, all uninsured Iranians and developing urban inpatient scheme to underserved poor populations and then, Insurance premium that focuses on collecting rational incremental insurance premiums as a per capita from all insured population along with considering the share of employees premiums that was paid by executive organizations as the agent of citizens.


Findings showed that three main requirements are mentioned in Iranian national documents with a growing trend in the last two decades consisting the third party insurer, health care provider and citizen/population requirements all of them need to be considered by policy makers to achieve UHC.

In the first axis, third party insurer, the structure of the insurance organization and the integration of policies must be considered as well as financing, tariffing and purchasing health basic benefit package. In this regard WHO recommended options, for low- and middle-income countries, for increasing the share of health from the general budget [26]. This recommendation is considered by Iranian policy makers so that the 2015 budget for the health sector increased by nearly 70% compared to 2014 [27]. However the sustainability and reallocation of these funds must be noticed in a way of achieving UHC. Typical instability of financial resources was found in Mongolia where more than 95% of the population was covered in 1996 after which, a decreasing trend of population coverage was experienced because of financial instability [28].

Emphasis on marked taxes is also one way to increase the share of health resources. This type of tax directly improves health outcomes through reducing demands for harmful goods [29]. This happened in South Korea [30] and Ghana [29] and almost 3.1% of the insurance fund was provided in South Korea in 2010. Moreover, health insurance policymakers in Nigeria [26] proposed tax bills to mobile phones as a way of financing health coverage. Such these issues must be considered as funding mechanisms helping third party insurers collect revenues and allocate them to the most needed health services to achieve UHC.

Another important topic in this axis is changing the structure of insurers. The experiences show that one basic measure for achieving UHC, especially in developing countries, is reduction of fragmentation of the insurance fund [29, 31, 32]. This concern can be disappeared through implementing a new structure and integration the insurers’ financial resources in an a single and uniform insurance organization as it is mentioned in Article 38 of the fifth 5-year development plan [33].

The second axis of the present results, health provider requirements, includes determining the necessities, provision and covered services and also rules relating to implementation health basic benefit package. In this regard, evidences show that by moving toward UHC, health systems have no way but to establish the basic health insurance package [13]. What is covered by insurance plans is important according to their ultimate effect on public health and financial protection [26]. An important issue is attending to all areas of services from promotion to palliative care [34]. So it is important for Iran to determine the services included in national basic benefit package in all levels according to the local needs. It is obvious that for obtaining this goal including inpatient and outpatient services could not be sufficient. This experience is confirmed by India, Kenya, and the Philippines which initially covered inpatient services, are now moving toward covering primary and preventive services, recognizing the fact that although outpatient services may be costly, they can lead to a greater impact on health outcomes [26].

Finally, the last axis, citizen/population requirements focused on expanding population and their insurance premiums. In this regard, evidences show different countries have adopted various policies achieving UHC; in South Korea and Vietnam, first the formal sector was covered and then, the informal sector and whole population was expanded [35]. On the other hand, India has allocated significant subsidies to the target population and has tried to expand financial protection through increasing tax revenues [36]. Furthermore, instead of considering multiple programs for different groups of population, some countries have implemented integrated coverage programs for all populations [37].


Results show that Iranian policy makers should notice three axes of third party insurers, health providers and population of the country to prepare an appropriate basic benefit package based on local needs for all the people that can access with no financial barriers. In this way UHC can be assured in this developing country.


Documents alone are not able to express all the facts related to politics. It is recommended to apply multiple methods sequentially or simultaneously in another qualitative study. Obviously, application of documentations along with other data collection methods, as interviews or observations, can help researchers reach more comprehensive understanding.



This article is part of a Ph.D. thesis in the field of health care management, and it was approved by Shiraz University of Medical Sciences, Shiraz, Iran (94-7402). The authors express their gratitude to Shiraz University of Medical Sciences and Iran Health Insurance Organization that contributed to the implementation of this study.

Also, the authors would like to thank Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript.

Authors’ contributions

PB and RH searched the relevant database and included the appropriate document according to the study objectives. At the same time, PB supervised the whole thesis. MJK participated as the co-supervisor of the study. ZK designed the study and participated in final reviewing and technical editing of the manuscript. At the same time, she was another co-supervisor of the study. GHS and HJ participated in preparation of the initial draft of the article. All authors read and approved the final manuscript.


This research was funded by Shiraz University of Medical Sciences, Shiraz, Iran. This fund was only allocated to the study for covering data collection and purchasing the software of data analysis. The university (as a funding institute) did not have any other role in the design of the study nor data analysis, interpretation of data and writing the manuscript.

Ethics approval and consent to participate

Ethics approval for this study was granted by the ethics committee of the Shiraz University of Medical Sciences as number 94 -7503.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.


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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  1. 1.Student Research Committee, School of Management and Medical InformaticsShiraz University of Medical SciencesShirazIran
  2. 2.Health Management and Social Development Research CenterGolestan University of Medical SciencesGorgānIran
  3. 3.Health Human Resources Research Center, School of Management and Medical InformaticsShiraz University of Medical SciencesShirazIran
  4. 4.Social Determinants in Health Promotion Research Center, Hormozgan Health InstituteHormozgan University of Medical SciencesBandar AbbasIran
  5. 5.Secretariat for Supreme Council of Health and Food SecurityMinistry of Health and Medical EducationTehranIran

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