what are the potential advantages and disadvantages of

RESEARCH ARTICLE Open Access

What are the potential advantages anddisadvantages of merging health insurancefunds? A qualitative policy analysis fromIranMohammad Bazyar1, Vahid Yazdi-Feyzabadi2* , Nouroddin Rahimi3 and Arash Rashidian4

Abstract

Background: In countries with health insurance systems, the number and size of insurance funds along with theamount of risk distribution among them are a major concern. One possible solution to overcome problemsresulting from fragmentation is to combine risk pools to create a single pool. This study aimed to investigate thepotential advantages and disadvantages of merging health insurance funds in Iran.

Methods: In this qualitative study, a purposeful sampling with maximum variation was used to obtainrepresentativeness and rich data. To this end, sixty-seven face-to-face interviews were conducted. Moreover, adocumentary review was used as a supplementary source of data collection. Content analysis using the ‘frameworkmethod’ was used to analyze the data. Four trustworthiness criteria, including credibility, transferability,dependability, and confirmability, were used to assure the quality of results.

Results: The potential consequences were grouped into seven categories, including stewardship, financing,population, benefit package, structure, operational procedures, and interaction with providers. According to theinterviewees, controlling total health care expenditures; improving strategic purchasing; removing duplication inpopulation coverage; centralizing the profile of providers in a single database; controlling the volume of providedhealth care services; making hospitals interact with single insurance with a single set of instructions for contracting,claiming review, and reimbursement; and reducing administrative costs were among the main benefits of merginghealth insurance funds. The interviewees enumerated the following drawbacks as well: the social securityorganization’s unwillingness to collect insurance premiums from private workers actively as before; increaseddissatisfaction among population groups enjoying a generous basic benefits package; risk of financial fraud andcorruption due to gathering all premiums in a single bank; and risk of putting more financial pressure on providersin case of delay in reimbursement with a single-payer system.

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* Correspondence: [email protected] Policy, Health Services Management Research Center, Institute forFutures Studies in Health, Kerman University of Medical Sciences, HaftbaghHighway, Kerman, IranFull list of author information is available at the end of the article

Bazyar et al. BMC Public Health (2020) 20:1315 https://doi.org/10.1186/s12889-020-09417-7

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Conclusion: Merging health insurance schemes in Iran is influenced by a wide range of potential merits anddrawbacks. Thus, to facilitate the process and lessen opponents’ objection, policy makers should act as brokers bytaking into account contextual factors and adopting tailored policies to respectively maximize and minimize thepotential benefits and drawbacks of consolidation in Iran.

Keywords: Health insurance, Merger, Policy analysis, Advantage, Disadvantage, Fragmentation

BackgroundIn countries in which health insurance is the primarysource of health financing, the number and size of insur-ance funds along with the amount of risk distributionamong them are a major concern [1–3]. Health finan-cing experts should bear in mind the degree of fragmen-tation in health financing as it may lead to inequity inaccess to health care services for different populationgroups.Fragmentation should not be considered as a problem

per se. However, differences among health insuranceschemes in the following aspects should be taken intoaccount by health policy makers to examine whether thesituation is satisfactory. These criteria include: 1) thepercent of the whole population under the coverage ofeach health insurance scheme; 2) the extent of differ-ences in contribution rates, basic benefits packages, thequality of health care received by members of differentrisk pools; and, more importantly, 3) variations in usercharges and the amount of out-of-pocket payments paidby different beneficiaries belonging to different insuranceschemes for the same health services used by them [4].The larger the gaps are, the more health financing ex-perts should be worried about the fragmentation’s healthequity impacts. One possible solution to overcome prob-lems resulting from fragmentation is to combine riskpools to create fewer and larger ones, ideally a singlepool [5, 6]. Reducing fragmentation provides more fi-nancial protection from a given level of prepaid funds,which is the critical objective of universal coverage [7].

Health insurance system in Iran and the challenge offragmentationHealth insurance organizations in Iran are divided intothree groups according to their functions:

1. Basic health insurance organizations: Amongsuch organizations are the Iran Health InsuranceOrganization (IHIO) [previously called the MedicalServices Insurance Organization (MSIO)] withseveral separate sub-funds for government em-ployees, rural residents, the self-employed and theirdependents, the poor, and other groups (e.g., collegestudents, seminary students, clergymen, and someprofessional associations), the Social Security

Insurance Organization (SSO) covering all peopleemployed in the formal private sector and their de-pendents, and the Armed Forces Medical ServicesInsurance Organization (AFMSIO) [8],

2. Institutional organizations: It includes about 17funds such as the municipality, the PetroleumIndustry Health Organization, the NationalBroadcasting Organization, banks, and otherorganizations. Each organization provides requiredinsurance services for its employees individually as afringe benefit [9], and

3. Commercial organizations: Among them are Iran,Asia, Alborz, Mellat, Pasargadae, and Atieh SazaneHafez Health Insurance Organizations, of which thelatter often operates in the form of voluntarysupplementary private insurance [10–15].

In recent years, there has been growing concern aboutproblems attributed directly or indirectly to fragmenta-tion in the Iranian health financing system. Among theseproblems are inequity in health service utilization and fi-nancial protection among different groups of people [13,16]; high out-of-pocket expenditures [12, 13, 17]; highoccurrence and intensity of catastrophic health expendi-tures [18, 19]; low financial protection against health ser-vices for insured people [10, 20]; population coverageduplication [10, 12]; failing to reach universal healthcoverage; lack of transparency and no reliable data inpopulation coverage; per capita health expenditures, andcontribution rates [10]. Such problems have urged policymakers to pass the 2010 Act to merge all the existinghealth insurance funds (basic health insurance schemesand institutional funds) into MSIO, aiming to create asingle health insurance organization [9, 21].

Objectives of the studyThis study aims to investigate what potential advantagesand disadvantages merging health insurance funds inIran may bring to the health insurance system in par-ticular and the health system in general, in Iran. Themerging health insurance is a context-sensitive issue,and exploration of its advantages and disadvantages hasreceived scant attention in qualitative analyses in the re-search literature. Thus, this study may provide valuableinsights into moving toward a decision on the merging

Bazyar et al. BMC Public Health (2020) 20:1315 of 15

health insurance in developing countries such as Iran.Lessons from this study can be applicable for policymakers from other countries, especially those with lowand middle incomes, trying to merge existing health in-surance schemes in order to strengthen risk pooling.

MethodsThis qualitative study was conducted in 2014–2015. Thispaper is part of a larger study about “analysis for policy”of merging social health insurance (SHI) funds in Iran.

ParticipantsA purposeful sampling with maximum variation wasused to obtain representativeness and rich data by in-cluding a wide range of extremes. As the use of max-imum variation sampling is a well-established approachto limit the possibility of selecting narrow or few casesfrom one with wide variation [22]. To develop an initiallist of stakeholders (including organizations, institutions,political groups, etc.), a number of qualitative Iranian pa-pers on health financing, health insurance, and

consolidation articles of the SHI Funds Law adopted inthe Fifth Five-Year National Economic, Social and Cul-tural Development Plan, were reviewed. Furthermore,the advice of members of the research team familiar withthe context of the health insurance system in Iran wasaddressed. Table 1 shows the list of different stake-holders from which the interviewees were selected.As members of the research team were quite familiar

with the Iranian health financing system and the mainpolicy actors, an initial list of key informants for eachstakeholder was selected by the research team purpose-fully for doing interviews. Key informants with outstand-ing experience, work, research, and knowledgebackground in the area of Iranian health financing wereselected. The interviewees were mainly the top managersand key policy actors. Of course, in 9 cases, interviewswere conducted with front-line employees in differentdepartments of health insurance organizations and hos-pitals to get more detailed information and more pro-found insight into the challenges, benefits, anddrawbacks of merging health insurance funds in Iran.

Table 1 The main stakeholders of merging health insurance funds in Iran

Setting Organizations, Institutions, political groups, and individuals No.

Health Insurance System The Ministry of Cooperatives, Labor and Social Welfare including the High Council of the HealthInsurance

3

Iran Health Insurance Organization 16

Social Security Organization 8

Armed Forces Health Insurance 2

Imam Khomeini Relief Committee 2

Insurance companies 3

Municipality of Tehran 2

Petroleum Industry Health Organization 3

Ministry of Health and MedicalEducation (MoHME)

Health Technology Assessment (HTA), Standard and Tariff Office 3

Supreme Council for Health Policy Making 2

Deputy for Medical and Curative Affairs 1

Former Minister 1

Budget and Performance Monitoring Office 2

Health Care Providers The Medical Council of Islamic Republic of Iran 3

Iranian Medical Council 2

Hospitals (staffs responsible for reviewing medical records according to different principles of differenthealth insurance funds for reimbursement)

2

Society of Radiology 1

Pharmacists Association 1

Association of General Practitioners 1

Supervisory/regulatory Organizations Planning and Budget Organization 2

Parliament Research Center 1

Parliament Representatives 4

Medical Sciences Universities Academician familiar with Iranian health system and health financing concepts 2

Sum 67


Overall, sixty-seven, face-to-face interviews were con-ducted. Out of sixty-seven interviewees, sixty-two weremale, and five were female. Participants’ age ranged from33 to 80 years. Other additional stakeholders and key in-formants were identified through snowball sampling andinformation derived from the analysis of interviews andrelevant documents.Interviews continued until there was no more key in-

formant and stakeholder and also no more new ideaswere identified, and saturation was reached. The docu-mentary review in line with interviews was used as asupplementary source of data collection to investigatethe aims, intentions and reasons for moving toward tomerging health insurance funds and identifying the po-tential drawbacks and merits of it. The principles of theFive-Year National Economic, Social and Cultural Devel-opment Plans; the 20-Year National Vision; the mainlaws and reforms in the history of developments in Iran-ian health insurance; TV programs, TV interviews, re-ports, declarations, newspapers, and proceedings of theIranian Parliament on the Law of Consolidation wereamong the documents examined and analyzed.

Conceptual frameworkA semi-structured interview guide (see Additional file 1)was developed for this study to conduct the interviews.For the study, to develop the interview guide questionsand finding an appropriate conceptual framework tocover all aspects of merging and to organize the findings,a conceptual framework was derived from the WorldBank [23]. The World Bank framework includes eight el-ements to design and establish a health insurance sys-tem: feasibility of insurance design, financingmechanisms, population coverage, basic benefit package,provider engagement, organizational structure, oper-ational processes, and monitoring and evaluation. As theauthors believed that this framework was comprehensiveenough to cover the main aspects of the health insur-ance system, it was selected to classify the advantagesand disadvantages of the merging of health insuranceschemes in Iran. The interview guide was pilot tested bydoing three introductory interviews.

Data collectionAt the beginning of each interview, by explaining thepurpose of the study and ensuring the confidentiality ofinterview content and anonymity, the interviews weretaped with one voice recorder. Interviewees were free tochoose where they liked to be interviewed, which in allcases, interviews were done in the workplace of the in-terviewees. Besides the researcher and participants, noone else was attended during the interviews. In threecases, the participants did not allow voice-recording(they were afraid as the topic was political); therefore,

notes of the main points were taken down. Also, fieldnotes were made during and/or after the interviews toget the most out of the interviews. The minimum, max-imum, and average times of interviews were 10, 120, andabout 50 min, respectively. In seven cases, the interviewslasted for two or three sessions because intervieweeswere busy trying to finish the interview in one session.Some of them were eager to give more information, andin some cases, the interviewer had to refer again later formore details or to complete omitted information. In thecase of document review, the list of related documents,and their source for the collection were identified. Web-sites of organizations including Majlis, MoHME, IranianMedical Council, and Health Insurance organizationswere reviewed and related in print documents were alsocollected in person.

Data analysisContent analysis using the ‘framework method’ was usedto analyze the qualitative data. It is worth mentioningthat this method can also be applied in deductive, in-ductive, or combined types of qualitative analysis [24].The five-stage process of qualitative data analysis wasdone: understanding (familiarization), identifying a the-matic framework (thematic), coding (indexing), chartingand mapping, and interpretation [25]. All the interviewswere done, transcribed, and initially indexed by one au-thor (MB). Interviews were analyzed with the WorldBank framework (both inductive and deductive ap-proach) using MAXQDA12 software.

TrustworthinessFor assuring the quality of results, we employed fourtrustworthiness criteria suggested by Lincoln and Guba[26]. Credibility was met with a prolonged engagementwhereby the principal investigator (MB) continuouslyworked nearly 12 months with the qualitative data. Fur-thermore, member-checking validation was used by de-livering some transcribed interviews to the respectiveparticipants. They then asked them to ensure that thereis a good correspondence between their findings and theparticipants’ perspectives. To improve credibility, par-ticularly for this study, we focused on the contrary andopposite cases to provide a comprehensive picture de-rived from the pros and cons of merging. The researchteam search for and discuss elements of the data that donot support or appear to contradict patterns or explana-tions emerging from data analysis and deviant cases infindings were incorporated in the analysis process untilit can explain or account for a majority of cases. Thetransferability and reflexivity of our qualitative findingshave been enhanced by the maximum variation samplingtechnique and the detailed description of the health in-surance context in Iran. Dependability of the research


was assured by an auditing approach in which the VYFaccompanying by an external auditor engaged in criticalcomments in the coding process and analyzing of tran-scribed interviews as well as cross-checked the data wecollected. To increase confirmability, we employed amethods triangulation approach, including document re-view, interviews with key informants, and other inform-ative sources to check out the consistency andcomplementary of findings generated by different datacollection methods.

ResultsThe advantages and disadvantages of merging health insur-ance funds derived from the interviews were classified inthe following categories: stewardship, financing, population,basic benefits package, structure, operational processes, andinteraction with providers. The key advantages and disad-vantages of merging health insurance funds in Iran ob-tained from the interviews are presented in Table 2.

StewardshipIn 2004, by creating the Supreme Council of Health Insur-ance (SCHI) under the Ministry of Cooperatives, Laborand Social Welfare, a purchaser-provider split occurred inthe Iranian health system to move toward strategic pur-chasing and boost competition among health care pro-viders. According to studies, after the split, lack ofcoordination between two the ministries caused new chal-lenges for Ministry of Health and Medical Education todevise and implement health reforms without control offinancial resources [27]. Apart from this, fragmentation inhealth insurance caused each insurance scheme to behavedifferently and follow different health policies, and also,implement policies issued by SCHI differently. Accordingto the interviews, merging can solve these challenges to agreat extent. According to the findings, merging and cre-ating a single national health insurance system can pro-vide a situation, in which it is easier to control total healthcare expenditures as well as to formulate and implementmore reliable health policies for the health system.

"…I'm really tired of attending meetings of the familyphysician and referral system. I've probably attendedmore than 50 large meetings regarding launching afamily physician and referral system myself. We sawthat the IHIO representative wanted something dif-ferent, the SSO' agent spoke differently, and theAFMSIO's representative said something else. If I, asMoHME, wanted to implement a family physicianreferral system, whose opinion should I accept? ..."(P2, a policy maker in the health insurance system)

"…The Social Security Organization doesn’t imple-ment whatever approved by HCHI or implement

them with delay…" (A parliamentarian, Nabz, a TVprogram about the Iran health system problems)

"…wherever monopoly is formed, accountability is re-duced. Since all people have to get their services onlyfrom one organization with the same quality andquantity, this causes reduced responsiveness as thisorganization has no competitors. … the same thinghappened to our car industry as a result of monop-oly. …" (P20, a manager in one of the health insur-ance organizations)

FinancingFragmentation in health financing in Iran has causedeach health insurance scheme to follow its policies. Inthe long run, it led to differences in contribution rates,out-of-pocket payment rates, and coinsurance rates; dif-ferent levels of financial protection; and an uneven dis-tribution of public subsidies among different insuredgroups. Apart from reducing inequities, the intervieweesbelieved that merging could improve the collection,management, pooling, and allocation of financial re-sources to purchase health services for beneficiaries.

"… About 23 million rural citizens are covered freelyby IHIO; the government pays for them. Is there thisadvantage for workers? Aren’t they Iranian? isn’t itdiscrimination?" (Nabz, a TV program about theIran health system problems, a key policy actor)

"When you have duplication in coverage, more pub-lic budget is spent. It means that the governmentpays twice as the employer for the same group ofpopulation…" (P38, a policy maker in one of thesupervisory organizations)

PopulationIn the population area, the following subjects were themain topics, on which merging of health insurance fundsmay have positive or negative impacts: extending cover-age for those without health insurance and removing theproblem of duplication in population coverage.

"… When the supervisory and legislative agencies re-quested (health insurance schemes for) the numberof insured people, adding the numbers together, wesaw that the total number was larger than the wholepopulation of the country, and at the same time, wehad ten million people uninsured. …" (P38A, a pol-icy maker in one of the supervisory organizations)

"… One of the merits of merging is unifying the popu-lation's information. According to the Iranian census,77 million people are known; when you combine and


Table 2 The advantages and disadvantages of merging health insurance funds in Iran derived from the interviews

Theme Sub-theme Pros of Merging Health Insurance Funds in Iran Cons of Merging Health Insurance Funds in Iran

Governance/Stewardship

The accountability of healthinsurance regarding insureds’needs and demands

• Increasing the accountability of the healthinsurance system regarding how to generateand use financial resources to meet insureds’needs by creating a single health insurance fund

• The risk of objection by workers as they mayconsider the social security organizationresponsible for their treatment

• The bad memory of the past related to theMinistry of Health and Medical Education(MoHME) for not being responsive to how andwhere it spent the health premiums of the socialsecurity organization’s beneficiaries

• Reducing accountability by the creation of amonopoly in the health insurance system likewhat happened in the car industry in Iran

The control of health careexpenditures

• Multiple health insurance schemes, leading to anincrease in inflation and purchase of healthservices at higher prices

• Reducing the cost of the health insurancesystem by eliminating duplication in insurancecoverage and solving the problem of usinghealth insurance cards by those withoutinsurance coverage

• Cost control by implementing strategicpurchasing

• Better supervision of health care providers bycentralizing their profiles in a single database,reducing fraud, and controlling the volume ofprovided health care services

The power of healthinsurance supervision

• Providing a better chance to enhancesupervision by reducing delay in payment andtimely reimbursement of health care providers

• Improving the quality of health services byproviding better supervision and higherpurchasing power

• Improving the supervision by adding personnelmerged into the regulatory area

• The lack of chance for enhancing the supervisoryrole of health insurance schemes as they haveno real power to supervise the quality of healthservices at the current situation

• Not envisaging the task of supervision for healthinsurance in the Merger Law in the Fifth NationalEconomic, Social, and Cultural Development PlanAct

• Reducing the control of other health insuranceschemes on how the Iran Health InsuranceOrganization (IHIO) spends health insurancepremiums

• The risk of increasing supervision costs for otherhealth insurance schemes to examine how theirpremiums are spent by IHIO (the sameexperience happened in 1983, when acommission was established in each province tosupervise the quality of treatment for the socialsecurity organization’s beneficiaries provided bythe regional health centers of the Ministry ofWelfare and Wellbeing)

• The risk of not being able to supervise andcontrol the national insurance scheme as it maybecome so powerful

The health systemmanagement

• Easier alignment of a single insurance schemewith the policies of MoHME

• Easier implementation of clinical guidelines• The interaction of MoHME with a singleinsurance scheme with a single set ofinstructions

• Putting an end to different policies issued bydifferent insurance schemes in dealing withhealth problems (e.g., updating the table forprices of medicines

• Eliminating the challenge of unifying healthinsurance schemes with different regulations asan obstacle to implement health reforms such asa family physician program

• Improving the health financing equity by settingthe same coinsurance rates for differentpopulation groups


Table 2 The advantages and disadvantages of merging health insurance funds in Iran derived from the interviews (Continued)


The transparency of healthinformation and policymaking

• Providing a more reliable planning and policymaking strategy by centralizing health insuranceinformation in a single data bank

• Making a more precise prediction of financialresources and annual budget required for thehealth insurance system by providingtransparency in per capita health insuranceexpenditures and eliminating duplication inpopulation coverage

Policy making andstewardship in the basichealth insurance system

• Increasing the power of the health insurancesystem to formulate and implement healthpolicies

• An easier and faster process of making healthpolicies by creating a single scheme

• Organizing different health policies and decisionsissued by different health insurance schemes bymerging

Financing Health insurance premiums • Reducing premiums as a result of reducing costs

The ability to create newresources

• Other health insurers may lose motivation tocollect premiums and transfer them to IHIO (theunwillingness of the social security organizationto collect insurance premiums from workers)

Per capita premiums andactuary calculations

• More reliable calculations of per capitapremiums by removing duplication in insurancecoverage

Patient risk pooling • Equity in risk pooling for all population groupsas rich schemes have no contribution in thewhole risk pooling

• Not considering merging as a solution toimprove risk pooling because more than 90% ofthe whole population is under coverage of IHIOand SSO

Financial inflows andoutflows

• Easier monitoring of accounting and financialprocesses

• More transparent and stable insurance financialinflows and outflows as a redult of merginghealth insurance funds

• More transparent financial flows in the currentfragmented situation as each scheme has itsown separate financial flows

• Keeping separate financial accounts for sub-funds under IHIO for higher transparency in reve-nues and expenses

The estimation andmanagement of financialresources in the healthinsurance system

• Easier estimation of the amount of requiredfinancial resources for the following year bycreating a single insurance system

• Better management of health insurancepremiums by pooling them in one place

• Saving the public budget by removing coverageduplication

• Being able to define a new role for healthpremiums by centralizing them in a single fund

• Obtaining more financial support from thegovernment for basic health insurance

Patient financial protection • Paying lower premiums for the treatment oflow-income people as a result of merging

• Expanding benefits packages by saving resources• Better controlling the high cost of healthservices

• Reducing out-of-pocket payments by purchasinghealth services at lower prices with singleinsurance

• The need to increase premiums and resources toreduce people’s payments

The financial stability ofhealth insurance

• Increasing the financial viability of the wholehealth insurance system by using singleinsurance

• The appropriate size of IHIO and SSO at thecurrent fragmented situation (IHIO and SSO arebig enough and there is no need forconsolidation)

Saving financial resources • Increasing financial resources and improvinghealth benefits packages by reducingadministrative costs

• Organizing financial resources spent by thegovernment as the employer for different




population groups by merging

Equity in the distribution ofsubsidies in the healthinsurance system

•Difficulty in providing all population groups withthe same share of governmental subsidies in afragmented health insurance system

A more efficient use ofhealth insurance premiums

• Imposing expenditures by non-contracted healthcare providers at the current fragmented system

• Paying for luxury and expensive private hospitals’health services at the current fragmented system

• Relying on fee-for-services payment methodwithout having effective supervision and controlon the amount and quality of provided healthservices at the current fragmented system

• Using health premiums more efficiently byeliminating induced demands and moral hazards

Paying higher prices for health care services bywell-off and small insurance schemes due to nothaving any chance to follow strategic purchasingin the current fragmented situation

Having no chance to implement real strategicpurchasing unless setting real medical tariffsaccording to real prices

Population Reaching universal coverage • Fragmentation in the health insurance system asa barrier to reach universal coverage in the threeareas of population, health services, and financialprotection

Population coverageduplication

• Eliminating duplication in population coverage• Eliminating inequity in access to health servicesdue to health insurance coverage duplication;currently, due to this issue, different groups ofpeople use different benefit packages withdifferent services and financial protectionbelonging to various health insurance schemes)

• Centralizing health profiles and healthexpenditure profiles of beneficiaries in a singledatabase

• Reducing the misuse of multiple healthinsurance cards by health service providers andpatients

The number of insuredpeople

• Providing precise and reliable statistics about thenumber of insured people by creating a singledatabase and removing duplication

BasicBenefitPackage

The focus of health provision(primary health services orhospital-based services)

• Neglecting prevention and public health servicesas a result of fragmentation

• Providing a better chance to focus on and paymore attention to public health and preventiveservices by creating a single health insurance

The distinction betweenbasic and supplementaryhealth insurance

• Eliminating the current interference betweenbasic and supplementary health insurance (inIran, according to the national health lawssupplementary are supposed to cover only thosehealth services not covered by basic healthinsurance funds)

Equity in the basic benefitspackage

• Strengthening benefits packages forunderprivileged groups by setting the samebenefits package for all population groups

• Putting an end to discrimination and provisionof generous health services for privileged groups

• Currently, various funds react differently tochanges in prices of medicines and medicalequipment, and also, to changes in the basicbenefits package. In the case of high fluctuationor high inflation in prices, the health insurancefunds may update the prices they cover indifferent time lags which causes differentpopulation groups pay different amount of out-of-pocket expenditures for the same medicinesor medical supplies.

• The lack of justice due to poor infrastructure andhealth care facilities in villages and deprivedareas

• No justification for providing the same benefitsto all insureds (different population groups withdifferent health needs, expectations, andaffordability)




The satisfaction of insuredpeople

• Increasing the satisfaction of insured people bystrengthening and upgrading the basic benefitspackage

• Resolving dissatisfaction among the public as aresult of disparity and injustice in benefitspackages in the current fragmented situation

• Increasing satisfaction by improving competitionamong health service providers

• Providing equal access to health care for allinsured people

• Increasing dissatisfaction among populationgroups enjoying generous benefits package inthe current fragmented situation

• Concerns about sharing privileges with othergroups of insured people (e.g., sharing free-of-charge health services in health centers and hos-pitals belonging to SSO)

Structure Creativity, innovation, anddynamism in insurance

• Increasing the dynamics and creativity indevising new mechanisms to run activities withcreation of single insurance (no chance to usecreativity made by other health insurance funds)

• Killing creativity, as, currently, each healthinsurance fund attempts to improve the qualityof its own services

Administrative and overheadcosts

• Reducing administrative and overhead costs byremoving parallel structures of insurance in allthe provinces (each social health insurancescheme has its own headquarter in eachprovince)

• Reducing administrative costs by reducing thenumber of employees and top managers

• Reducing personnel costs in the long run as alldepartments and employees in each healthinsurance fund with the same job descriptionwould be merged and there would be no needto recruit the same number of personnel asbefore

• Reducing supervisory costs by unifying thecontent of contractions between healthinsurance schemes and hospitals with healthcare providers

• No tangible reduction in administrative costs inthe short run due to political resistance againstdownsizing

• Emphasis on reducing administrative costs as aninadequate target for insurance merging

Operationalprocedures

The monitoring andsupervision of health careproviders

• Better recognizing drug interactions• Resolving the issue of abuse and fraud by healthcare providers in the current fragmentedsituation

• Easier monitoring and control of providers bycreating a single central profile for each provider

Administrative and financialinstructions

• Unifying financial and administrative regulationsand instructions and reducing the complexity ofdifferent regulations for health care providers

• Unifying operational instructions to enhance thethe whole health insurance system performance

• Formulating new regulatory instructions for theprivate health sector

• Formulating new regulations to organize asupplementary health insurance market bycreating a strong single basic health insurancefund

Interactionwithproviders

Competition in the healthsystem

• Creating competition among providers bycreating a single-payer system

• Improving the performance of health insurancesystem by merging as there is no realcompetition among health insurance funds inthe current fragmented situation

• Eliminating competition between basic healthinsurance schemes

The control of providers • Changing providers’ behavior by makingfinancial leverage

• Reducing costs imposed by non-contractedproviders

• Resolving the issue of the non-compliance of pri-vate health care providers due to the fragmen-ted health insurance system

• Resolving the issue of the need for smallinsurance to contract with the provider at ahigher price due to fragmentation

• The risk of putting health care providers intodifficulty by misusing the power of monopsonyand not fulfilling commitments


unify all health insurance databases, it will makethose people without insurance coverage clear. Whyis making it clear impossible now!? Since they arescattered in 17 databases; merging makes it clearwho has several insurance cards and who has nocoverage …" (P26, a parliamentarian)

"… The fragmentation and duplication of health in-surance coverage make it difficult to calculate theper capita expenditures accurately. As a result, thecomputation of insurance premiums will be blurred.…" (P17, a former manager in one of the health in-surance organizations)

Basic benefits packageThe first advantage mentioned by most of the inter-viewees in this aspect was providing an equitable basicbenefits package for all Iranians. According to the inter-views, high inequity in benefits packages under thecoverage of insurance schemes has led to high dissatis-faction among people, which is unacceptable and againstnational values and constitution. The existing discrepan-cies between various demographic groups in terms oftypes of health services that they can receive, amount offinancial compensation offered for each health service,and number and types of health care facilities (public orprivate health sector) where they can receive their



Bargaining power • Increasing the bargaining power of insurers bymoving from a multiple-payer system to a single-payer system

• The lack of authority of insurance funds tobargain and determine medical tariffs

Strategic purchasing • Boosting strategic purchasing, as each insurancefund follows a certain approach in the currentfragmented situation

• Increasing fund flexibility by pooling financialresources

• Enhancing strategic purchasing by improvingfinancial resources and faster reimbursement

• Improving strategic purchasing by avoidinghigher payments by small insurance funds

• Providing better financial resource managementby creating a single-payer system and masspurchasing

• Better controlling the private sector by strategicpurchasing

• The lack of need to subject strategic purchasingto single insurance

• The inability to buy health services at lowerprices due to low and unrealistic tariffs

• The unavailability of insurance at affordableprices and single-rate sales by MoHME

Reimbursement to theprovider

• Making timely reimbursement of providers • The risk of putting more financial pressure onproviders in case of delay in reimbursement bythe single-payer (currently, providers are reim-bursed by different insurance funds with differ-ent time tables)

• The risk of putting more financial pressure onproviders by following strict financial regulations

Modifying the paymentsystem

• Providing a better opportunity to design andimplement new payment methods by a singleinsurance fund

The interaction of healthinsurance system with healthcare providers and hospitals

• Formulating new single instructions for providersand finishing different intricate details ofregulations of multiple insurance funds

• The lack of need to appoint different staff toaudit different medical health records belongingto different health insurance funds

• Unifying the regulations of purchasing healthcare services from providers

• Unifying the details of basic benefits packages(using the same services, using the same pricesfor pharmaceuticals and medical supplies, usingthe same reference pricing, using the sameexceptions, using the same coinsurance rates fordifferent services and patients, etc.) for allhospitals

• Reducing transaction costs and preparingdifferent insurance bills

Organizing private healthsectors

•Resolving the issue of low and delayedreimbursement provided by basic healthinsurance funds


services will be abolished by providing a single health in-surance system for all demographic groups.

"… We (health insurance experts in Iran) believethat we are moving toward public health-based ser-vices (conserving health status); but, what we aredoing now is providing hospital-based services…" (Amanager in one of the Health InsuranceOrganizations)

"…the main focus of some health insurance funds ison business, and not on health…" (A parliamentar-ian, Nabz, a TV program about the Iran health sys-tem problems)

StructureThe interviewees believed that main advantages in thissection were related to the reduced administrative andoverhead costs as a result of eliminating parallel struc-tures of insurance in the provinces of Iran and reducingthe number of top managers and employees.

"… all insurance funds have their own offices in dif-ferent provinces. Different insurance companies havetheir own offices, general directors, secretaries, cars,traveling costs, seminars, and so on. …" (P7, aparliamentarian)

"… Meanwhile, these 18 companies have createdtheir specific funds; they pay high salaries to theirCEOs and boards of directors. If they are merged, in-stead of having 18 boards of trustees including 60 to70 top managers, we face one board of trustees. …"(A parliamentarian, Nabz, a TV program about theIran health system problems)

Operational processesEliminating different instructions applied by health in-surance funds to review claims and provide better super-vision and management of health care providers bymerging their health profiles in a single database was themain advantage stated by the interviewees.

"… Overall, the fragmentation of insurances hasmany challenges. One of the challenges is that thereare different guidelines and rules. It confuses pro-viders; it even confuses the medical association; regu-lations existing in IHIO are different from those inthe social security organization (SSO), with one cov-ering different and more health services compared tothe other one. The depth of coverage of the armedforces is the most. A physician must make severallists for different insurance schemes, which meansthat both the physician and his secretary should put

more time to prepare them; this increases adminis-trative costs. …" (P18, a policy maker in the healthinsurance system)

"… when I [pharmacist] buy a drug, I get a fee listfrom the IHIO website, and also, I have to check outthe fee list of SSO. For example, for Albumin, IHIOcharges 31,000 Tomans, Imam Khomeini Founda-tion charges 38,000 Tomans, and Social Securitycharges 27,000 Tomans. …" (P5, a manager in one ofthe health insurance organizations)

Interaction with providersMerging and creating health insurance schemes can in-fluence the interaction with health care providers invarious ways. Merging can positively influence the fol-lowing areas: competition among health care providers,strategic purchasing and supervising health care pro-viders, reimbursement and moving toward new paymentmethods, and the principles of contraction withproviders.

"… The next problem is that medical fraud is easierto occur in a fragmented health insurance contextbecause providers' medical profiles are not central-ized in a single database. Someone may misuse aninsurance scheme, and it takes time to recognize thisfraud based on other health insurance schemes. …"(P17, a former manager in one of the health insur-ance organizations)

"… When the profile of a physician is centralized inone database, you can see how much drugs or para-clinical diagnostic tests they have prescribed, andyou can supervise them better. Doctors are intelli-gent; they obey health insurance schemes with strictrules, but they may play games with other schemes.With single insurance, doctors are reimbursed by asingle-payer system. So, you can conduct taxation af-fairs easier. The current fragmented situation is bet-ter for those doctors who want to avoid paying taxes"(P18, a policy maker in one of the health care pro-vider associations).

DiscussionThe successful merge of health insurance funds likeother health policies is dependent on identifying anddealing with a wide range of different factors rooted inthe contextual factors in each country. This issue is ofparamount importance, particularly in developing coun-tries that are faced with limited sources and differentstructural, institutional, and political conditions. Thisstudy aimed to realize the advantages and disadvantagesof moving toward a decision for the merger of health


insurance funds. The results of this study indicated thatthere are different positive and negative consequencesfor merging health insurance funds in Iran, which arecategorized into seven categories, including governance/stewardship, financing, population, basic benefit package,structure, operational procedures, and interaction withproviders. These themes are subdivided into thirty-sevensub-categories representing a wide range of differentpolicy aspects to pay close attention to dealing with themerging of health insurance funds.It is worth to specify that what kind of problems the

consolidation of health insurance schemes can solve inthe health system and health financing area. Also, theclear explanation of potential achievements can be ef-fective in supporting the implementation of the programand reducing the resistance by opposing actors.According to the results, combination and changing fi-

nancial flows, and the increase in the power of thehealth insurance system, can improve the equity inhealth financing. Although health equity improvementscannot be attributed only to the consolidation or reduc-tion in the numbers of health insurance funds, consoli-dation can be effective to a great extent in reducing thecurrent inequity. For instance, out-of-pocket share inTurkey accounted for 19% of the total health costs 3years after the implementation of the program, whichwas considered fairly low [28]. In South Korea, the samecontribution rates were developed for all the self-employed across the country as a result of the merger[29].Bigger funds will improve the economies of scale,

which will, in turn, maximize the benefits provided forthe members. According to the findings, reducing ad-ministrative costs by reducing the number of health in-surance organizations in all provinces and reducing thenumber of top managers and employees can be attrib-uted to the merger as one of the first advantages whichcomes to mind. Similarly in Korea, after the merger ofthe regional funds of the self-employed with the fund ofgovernment employees and school teachers in 1998, 227insurance funds of the self-employed and 19 funds ofthe government employees were reduced to 162 regionalfunds, and the number of personnel was reduced from10,849 to 9073 in December 1999 [27]. Reducing admin-istrative costs has been emphasized in international lit-erature as one of the advantages of having fewer riskpools [29–32].The international experiences show that the single-

payer system is more powerful and efficient in control-ling the total health care expenditures [29, 30]. Regard-ing risk pooling efficiency and financial stability, thesingle-payer is more preferable [33]. The collection ofcontributions will be integrated with other social insur-ance funds as a result of merging. In addition to the

improvement of equity in contributions and reduction ofadministrative costs [29], the single-payer system hasmore bargaining with providers through creating a mon-opolistic purchaser [29]. The single insurance has thecapacity and inclination to purchase medical care cau-tiously, which will improve the efficiency of the new sys-tem [29]. Also, the single insurance system will increasethe competition among providers, since the single insur-ance is the only payer and provides providers a freechoice [30].The single insurance system can enhance insurance

packages and extend the coverage in favor of the poorand the members of weaker insurances. For instance, itis expected that in Indonesia, the uniform service pack-age for civil servants and the private sector employeeswill create better clarity, equity, and understanding ofthe package for providers and members [30].It is also worth mentioning that the experience of

other countries moved toward merging shows that thesingle insurance system can provide an opportunity tohighlight some neglected health insurance policy deci-sions previously in the fragmented health insurance sys-tem at a national level [29]. According to the interviews,currently, the main focus of health insurance schemes inIran is on hospital-based services. Despite the fact thatPHC in Iran is financed by the government and providedby the district health network, the interviewees criticizedthe current situation, believing that the health insurancesystem failed to address public health and preventiveservices and also to preserve health at the outset, which,in turn, led to high expenditure on health care. In thecurrent fragmented situation, health insurance schemesstruggle to cover more secondary and tertiary health ser-vices, while merging can help to focus on public healthservices and prevention as a policy to move towards fi-nancial resources management by controlling health careexpenditures in the long term.Typically, one of the consequences of the multiple in-

surances is that despite existing different health insur-ance organizations alongside each other, a part of thepopulation is not covered by any insurance for differentreasons [34, 35]. Creating a single health insurance data-base would make it easier to eliminate duplication andidentify those who have no coverage, which will pave theway toward reaching universal coverage.Besides the positive effects, merging may cause unpre-

dicted side-effects in the health system in the short andlong run, which need to be mitigated. A single-payermay reduce efficiency due to increasing the bureaucracyand decreasing responsiveness; however, in Iran wherepeople do not have real right to choose between differ-ent funds (people are assigned to different insurancefunds according to their job status or where they live),the efficiency lost as a result of merging may not be


significant [29]. In a single-payer system, the insureddoes not have the chance to choose and changing the in-surer when the health services are not satisfactory, whichcan lead to dissatisfaction, especially in affluent families.However, we need to know that the right to choose theprovider is much more valuable and significant than theright to choose the insurer. Insurers are only payers andhave little effect on the process and outcomes of thetreatment. In the single-payer system, the free choice ofthe provider and increased competition among providerscan increase the satisfaction of the beneficiaries [30, 32].According to the consolidation law in Iran, it is sup-

posed that by merging, all health insurance schemes areresponsible for collecting their contributions and allocat-ing their share to the IHIO. Some of the intervieweeswere concerned about SSO’s unwillingness to collectpremiums as actively as before, as the financial resourceswill not be managed and spent by the SSO. In SouthKorea, health experts are concerned that as the financialresources are going to be shared with the whole popula-tion, collection of the contributions from the self-employed after merging may not be done as actively asbefore [29].In contraction with health care providers, interviewees

mentioned that currently, each health insurance schemefollows its regulations for contracting and also forreviewing claims and reimbursement. Apart from in-creasing complexity, hospitals have to appoint specificemployees to deal with different regulations issued bydifferent health insurance schemes, which increase ad-ministrative costs. Creating a single insurance schemewould make it much easier and simpler to work withone insurance scheme and one set of rules. Since thesecond half of 2019, IHIO has recently started to launchnew projects to handle claims and also manage the refer-ral system based on an electronic system. Although sucha good initiative increases the speed, accuracy, and ef-fectiveness of claims handling and referral systems, othermajor health insurance organizations such as SSO andAFMSIO use non-electronic systems that make it moredifficult for health care providers to work with differentsystems of health insurance.Interviewees mentioned contradictory ideas about the

impact of merging on the reimbursement process. Mer-ging may improve or even worsen the time of reim-bursement. Some indicated that health insuranceschemes currently behave differently in terms of thetime of payment and the amount of payment for thesame health services. Health care providers express theirconcern about how merging is going to change theprocess of payment. Health care providers said they arecurrently paid by several schemes on different periods oftime, in the case of delay in payment by one or twoschemes, health care providers resort to other schemes

with on-time reimbursement. Nevertheless, they worrythat by creating a single-payer, in the case of delay in re-imbursement, the financial security of health care pro-viders would be jeopardized.

Study strength and limitationsA vital strength of the present study is that we inter-viewed with a maximum variation of stakeholders withconfirming and disconfirming perspectives about the ad-vantages and disadvantages which may enhance thetrustworthiness of results. This helps clarify the path ofmoving toward the implementation of consolidation lawin Iran. This study was conducted after passing the Con-solidation Law in Iran when the government was man-dated to implement the law. Whereas no action has yetbeen taken, it provides a natural policy environment inwhich the expectations of the stakeholders in the imple-mentation of the law, as well as their conflicting inter-ests, could be better captured in the study. Of course,these data must be interpreted with caution because it isnot conclusive which advantage or disadvantage men-tioned by interviewees may occur in the real-world afterthe implementation of the law. Furthermore, in some as-pects such as stewardship or financing, there were con-trasted and opposite opinions mentioned by informantsabout the advantages or disadvantages of the consolida-tion. It is not clear which stakeholder correctly pointsout the advantages or disadvantages or gives a more ac-curate interpretation of what will happen in reality. Atthe same time, some of the interviewees may have hadlimitations in expressing their opinions due to politicalconsideration and their day-to-day responsibilities andinstitutional positions. This means that we also contendthat key stakeholders interviewed might have been af-fected by social desirability and position bias, whichmeans that they may have described what they thoughtwe want to hear, rather than the reality. Some of themmay have provided politically acceptable and satisfactoryresponses concerning their roles and responsibilities. Inthe deal with these problems, we used triangulation ofdata collection methods, including interviews, documentanalysis, and some mass media sources, and comparedpeople with different viewpoints, opposing and support-ing the policy. Also, triangulation of sources and as wellas providing ample opportunities to the interviewees toexpress their deep understandings of the context, raisedthe credibility, confirmability, and reflexivity of the re-sults. Last but not least, these findings may be somewhatlimited by subjectivity. Although we used different datasources and analyzed the data by peer debriefing to en-hance the trustworthiness of the results, the interpreta-tions may persist subjectively, and our results cannotclaim a whole truth. As the philosophical research


paradigm is a constructive approach rather than a posi-tivism one, this situation is unavoidable and isdefensible.

ConclusionsThe present study was designed to investigate differentstakeholders’ viewpoints about the potential advantagesand disadvantages of health insurance funds consolida-tion in Iran, a law passed but not implemented. Bothproponents and opponents tended to highlight potentialbenefits and drawbacks of merging in a way to encour-age or hinder taking steps toward implementing the law.The act of proponents could have been effective in pre-venting the implementation of the law in Iran as the op-ponents tried to signalize the drawbacks and disparagethe merits of merging or attribute the current problemsin the health insurance system to other things ratherthan fragmentation. The most prominent finding toemerge from this study is that consolidation implemen-tation in Iran may be influenced by a wide range ofmerits and drawbacks in governance/stewardship, finan-cing, population, benefit package, the structure of healthinsurance, operational procedures, and interaction withproviders. This study helps to inform policy makers inlow resource settings about the potentially expected ben-efits and detriments when moving toward the imple-mentation of this law. In summary, the followingbenefits were raised as the main benefits of merginghealth insurance funds in Iran: controlling total healthcare expenditures; centralizing the profile of providers ina single database; reducing fraud and controlling the vol-ume of provided health care services; making hospitalsinteract with single insurance with a single set of in-structions for contracting, claiming review and reim-bursement; reducing administrative and overhead costsand reducing the number of employees. Following con-sequences were mentioned as main potential drawbacksof merging health insurance funds which should be ad-dressed by the policy makers carefully: the social securityorganization’s unwillingness to collect insurance pre-miums from private workers actively as before; increaseddissatisfaction among population groups with generousbenefits package; risk of financial fraud and corruptiondue to gathering all premiums in a single bank; and riskof putting more financial pressure on the providers incase of delay in reimbursement by the single-payer.All these results are highly context-sensitive, and there

is a trade-off between benefits and drawbacks before andafter consolidation. Thus, policy makers should act asbrokers taking into account the contextual factors andadopting tailored policies to maximize the potentiality ofrealizing the benefits and devise precautions to minimizethe likely drawbacks of consolidation.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12889-020-09417-7.

Additional file 1. Interview guide. The Interview guide includes theopen-ended questions which were asked from interviewees.

AbbreviationsAFMSIO: Armed forces medical services insurance organization; IHIO: Iranhealth insurance organization; MHIF: Merging health insurance funds;MoHME: Ministry of health and medical education; SCHI: Supreme council ofhealth insurance; SHI: Social health insurance; SSO: Social securityorganization

AcknowledgmentsWe are grateful to the “Health Technology Assessment, Standardization, andTariff Department” of the Iranian Ministry of Health and Medical Education(MoHME), which facilitated the data gathering for carrying out the study.

Authors’ contributionsMB participated in designing the study, gathering data, analyzing andinterpreting data, and writing the manuscript. AR made substantialcontributions to the design and analysis of all phases of the main study andalso the conception and design of the paper. VYF contributed to peerdebriefing and acted as a disinterested peer in an analytical session toexplore aspects of the coding and inquiry of results. VYF and NR worked onthe development, editing, and finalizing of the draft of the paper. All authorsread and approved the manuscript.

FundingWe are thankful to all who participated in the study and enriched ourfindings by sharing their valuable experience and information. TehranUniversity of Medical Sciences financially supported this study with grantnumber 8921860001. We are also grateful to the “Health TechnologyAssessment, Standardization, and Tariff Department” of the Iranian Ministry ofHealth and Medical Education, which provided the financial resourcesrequired for carrying out the study. The research team was obliged toaddress the requirements mentioned in the “Request for Proposal” providedby the funders. It is worth mentioning that an observatory team on behalf offunders reviewed the study design proposed by the research team forseveral times. However, they did not participate in the collection, analysis,and interpretation of data and in writing the manuscript.

Availability of data and materialsAll raw data have been prepared in Persian (not English). However, thecorresponding author will gladly provide any supporting materials uponrequest.

Ethics approval and consent to participateThe ethics committee of Tehran University of Medical Sciences approved thisstudy with ethical approval code 8921860001. The consent we obtainedfrom the study participants was verbal, and the institutional review boardapproved the use of verbal consent.

Consent for publicationWe got the consent of the interviewees to participate and record theirvoices and for direct quotes from their interviews to be published in thismanuscript with the protection of their anonymity and confidentiality.

Competing interestsAlthough Dr. Rahimi, the co-author of this manuscript, is one of the key pol-icy actors and quite familiar with the health financing system in Iran, he justhelped us clarify the advantages and disadvantages of merging proposed bythe respondents. No overstatement or understatement was made in citingthe benefits and drawbacks of merging. All other authors declare that theyhave no competing interests.

Author details1Health Policy, Department of Health Promotion, Faculty of Health, IlamUniversity of Medical Sciences, Ilam, Iran. 2Health Policy, Health Services


https://doi.org/10.1186/s12889-020-09417-7

https://doi.org/10.1186/s12889-020-09417-7

Management Research Center, Institute for Futures Studies in Health, KermanUniversity of Medical Sciences, Haftbagh Highway, Kerman, Iran. 3Iran HealthInsurance Organization in Ilam, Ilam, Iran. 4Information, Evidence, andResearch Department, World Health Organization, Regional Office for theEastern Mediterranean, Cairo, Egypt.

Received: 2 March 2020 Accepted: 20 August 2020

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