مجله بیمه سلامت ایران
سال سوم شماره 2 (پیاپی 9، تابستان 1399)

Achieving the universal health coverage in each country is different according to cultural, social, economic conditions, available resources and development infrastructure, which in Iran over the past few decades, several efforts have been made in this field. The aim of this study is to gain successful experiences of countries such as Malaysia, Thailand, Chile, Costa Rica, Cuba, Sweden and some countries in different continents with different health care systems that have achieved universal health coverage.

This study is a review study. The bulk of the data studied is related documentation, including official published reports, articles, books, regulations, and newsletters that search for keywords such as insurance, universal health coverage, and health. Health, Health System, Financial Resources and Health System Performance in external databases such as Google Scholar, Web of Science and websites such as World Bank, World Health Organization, Also, the use of some internal databases such as Iranmedex and holding meetings with the beneficiaries of the Ministry of Health in Iran has been obtained. All data were analyzed by using content analysis method.

Today, there is no single global model for designing health insurance systems. Countries differ in terms of priorities, population covered, degree of development, type of government system and other factors, and each has its strengths and weaknesses. Countries must evaluate these strengths and weaknesses with their economic, political, and executive priorities, needs, and constraints, and select the best system.

Successful countries in the field of universal health coverage have also benefited from the political and financial commitments of their government and the private sector has acted as a complement to the public sector. Recognizing the health needs for a regular and coordinated referral system is one of the reasons for improving public health coverage. Universal health coverage is a time-consuming process that Iran has come very close to this great goal in the past few years with the implementation of the Health Transformation Plan.

The present study explains and examines the role of sustainable economy development on the insurance industry and health with a case study of public and private health insurance in the Iranian legal system; Also, it pays attention only to the issue of health insurance and avoids entering into other aspects of social security and welfare, and intends to review the appropriate criteria for the implementation of basic health insurance in order to achieve universal insurance coverage and be assessed on the basis of priority. Paying attention to these areas, especially in developing countries, which face widespread resource constraints on the one hand and widespread health needs on the other, can strengthen organizational rationalism and planning and achieve greater resource utilization. The results of the present study indicate that cooperation between influential institutions is of great importance in the implementation of health programs. Another example of the impact of institutions on health is the international insurance coverage program. Another way is to attract private sector investors to the health sector. In Iran, the implementation of the Health Transformation Plan, if sustainable financial resources are developed, in addition to increasing patient satisfaction with public hospital services, can improve the quality of health services.

Hospital deductions are predominantly costs that are spent by the hospital, but are not funded and reimbursed. The deductions are 10-30% of the hospital income, of which more than 20% of these deductions are applied to the documents through the hospitals themselves. The purposes of this research is to examining the deductions imposed by insurance organization and hospitals, as well as identifies the causes of these deductions and provide practical solutions for reducing deductions.

The present study is a descriptive-analytic study that was done retrospectively and a combination of quantitative and qualitative methods. The statistical population consisted of a set of hospitals providing health services in the country. The sampled hospitals were 14 units. The number of medical records in order to examine the insurance deductions, using the Cochran method, was estimated at 1715 cases. Data analysis was performed using descriptive and analytical methods in accordance with each of the levels of subtraction. At each end of the analysis, the amount of deduction was extracted from each case.

on average (geometric mean), there is a 87% probability of not registering at least one service in a medical record. The highest financial burden due to the lack of registration of the service at HIS occurs in private hospitals at a rate of 558241 Rials per case. There was a significant correlation between the type of hospital and the set of factors examined about the causes of the deficit in the audit by the hospital income experts (P <0.001). Anesthesiology/ Consultant (15.27%) is the most common cause of the deduction by the insurance companies. The average cost of a deduction applied to a medical record in is 3,873,723 Rials, which accounts for 5.5% of the total cost of each medical record.

Analysis of the findings shows that a high cost of hospital-provided services for patients is not reimbursed to the hospital. This challenge depends on many factors, in which not only insurance organizations, but also hospitals and service providers, who are in charge of the service record and financial statements regulators, are affected.

Health insurance is one of the health requirements that is being considered by governments in most developed and developing countries. Since the insurance industry is one of the most important components of financial system, it is necessary to investigate the effect of financial reform policies on development of this industry, especially health insurance development.

This study, investigate how financial reform policies, including the overall financial reform index, and also the sub-indicators of interest rate control, privatization, entry barriers, capital market liberalization and securities market policies, affect the health insurance development for 30 selected developing countries during 2000-2018. This research is a practical and quantitative study that has been performed using dynamic panel estimation using Generalized Method of Moments.

The results of this study show financial reforms can lead to development of health insurance in developing countries, however, the interactive results show increasing economic development level can increase this effect. Sub-indicators of entry barriers reduction and privatization in the basic and interactive models have a dominant, positive and significant effect on the health insurance development. The capital flow liberalization is significant in the basic model but is not significant under the influence of economic development and expansion of financial markets; also, the securities market policies has no significant effect on health insurance development in developing countries. The interest rate control has a significant relationship with health insurance development in a market-based system only.

As a general conclusion from this study, it can be stated that high government intervention in developing countries is one of the deterrents to financial systems and their impact on insurance sector. The results of this study showed that most financial reform policies, independently or under the influence of conditional variables, have a positive effect on health insurance development, therefore, developing countries can consider implementing these policies as a medium-term solution to improve public health and develop health insurance.

The health system is one of the most important pillars needed by human societies and participation in the health system is considered as a suitable tool to encourage people to develop and improve health activities in their lives. The present study aims to determine the framework and dimensions of public participation in the health system and examines the experiences of selected countries.

The present study is a comparative study that was conducted in 2009-2010. The comparative study collected data from 5 countries: England, Mexico, Norway, Singapore and Iran and was examined in eight components. To analyze the data, comparison tables were used, which include a comparison of dimensions obtained from the study of the pattern of public participation in the health system of selected countries.

The findings of the study showed that in the studied countries, in order to promote public participation in the health system, strategies such as the development of new information technologies, reducing government ownership and social inequality, reforming the health system and Benefit from creating appropriate structures for grassroots participation, developing non-governmental organizations, and emphasizing and promoting moral and cultural values.

The concept of public participation needs more information transparency and the impact of factors such as economic factors, the creation of appropriate organizational structures and information technology on it should be further discussed and localized according to the conditions of the country.

 Health has always been one of the most important concerns of mankind, and without oral and dental health, the bodychr('39')s general health cannot be guaranteed. Having health insurance has always been one of the factors facilitating the use of health services and this study is aimed to identify and investigate the impact of insurance coverage on the use of family dental services in Iran.

 The present study is a descriptive-analytical and cross-sectional study based on data from National Expenditure Survey by Statistics Center of Iran during 2013-2012. Logistic regression model was used to estimate the effect of independent variables on the dependent variable. The sample size of the study was 116469 households in rural areas and 112685 households in urban areas and 229154 households in the country as a whole. Data were analyzed using Microsoft Access, Microsoft Excel and 14 STATA software.

 Of the 229,154 households surveyed, 11,392 households (4.98%) had dental services during the 6-year period. The results show that provinces with a high level of development (in terms of access to health services) had higher use of dental services (p-value<0/001). Urban households with insurance coverage, more literate people, and households with fewer elderly people have used dental services (p-value<0/001). Wealthier households (higher income quintiles) than poor households (lower income quintiles.  And families that had self-care (using floss, toothbrushes and toothpaste) had more dental services than families who did not (p-value<0/001).

 Effective evidence-based interventions to improve the use of dental services among uninsured households, elderly people, low education status, residents of less developed provinces, and rural households should be prioritized by policy makers and planners.

The increasing demand for health services has made the health system constantly faced with inconsistent challenges of improving performance and cost control. The prerequisite for taking appropriate cost control measures is a detailed description of the situation. The aim of this paper is to identify the most expensive outpatient laboratory services covered by the Health Insurance Organization and cost control strategies.

This study was a cross-sectional descriptive study that was done in 2017 based on data from 2015. Laboratory cost data were obtained from the Medical Records System of the Provincial Health Insurance Offices of the whole country and analyzed using Excel 2013 software. Chiefs of provincial Medical Records Bureau and responsible experts were asked to propose cost-cutting interventions pertaining to identified the costliest services. Suggested interventions were reviewed and after excluding duplicates, they were categorized as specific interventions for each service and non-specific interventions.

The most costly outpatient laboratory services accounted for approximately half of the costs of the Iranian Health Insurance Organization. TSH measurement tests, blood cholesterol, CBC and vitamin D levels are at the top of the costly lab services. The most important cost control interventions include family physician and referral system implementation, monitoring of physicians and Para clinical centers, insurance aggregation, observing costly centers, preparing performance reports to physicians, empowering insureds and creating electronic health records.

It is suggested that appropriate policies regarding the strategies proposed here by insurance organizations and the Ministry of Health and Medical Education need be taken into consideration in order to more effectively control and manage the rising costs of health services.

Day-to-day power distribution and separation of powers, in addition to territorial dimensions, is also expanded into subjective and technical dimensions and is divided into smaller and smaller branches to allow for monitoring through reduced power. One of the technical and subject areas that has important policy implications is the area of ​​health and social security, which even in the most neoliberal governments has a large share of the budget and has a strong lobby and lack of judicial oversight. It can lead to bad decisions and wasted resources and opportunities. For this reason, there are usually two types of oversight in this area, one being political or public oversight that is vague and inefficient, and the other being effective and transparent judicial oversight. This type of oversight has entered the political arena since the US Supreme Court formulated the doctrine of the "political question" and rendered "democratic rights" out of the jurisdiction of the unaccountable and unrepresentative judiciary and made decisions on certain issues such as "politics". Public court, education, health, immigration and labor and the environment and ... "which was later called a policy judiciary. This research, which uses a library, descriptive and analytical approach to examine the legalization of health and social security policy, has concluded that judicialisation in this area is unprecedented and if it is in line with the constitutional criteria of a democratic society. , Leads to the development of health and social security, but not to major crashes, undermining health and further violations of rights and corruption.