The Dilemma of Underutilized Health Insurance: A Matched Case-Control Study Investigating Reasons in Iran’s Free Universal Health Insurance
Abstract
Background: In May 2014, the Iranian government announced it would cover all uninsured Iranians. Despite free-of-charge insurance, the studies found that the coverage still needed to be completed (93%). This study aimed to understand why certain population groups remain without insurance despite the accessibility of free-of-charge coverage. This issue is not unique to Iran; it is prevalent in many other countries where, despite free coverage, not all individuals avail themselves of it, thereby exposing themselves to risks.
Methods: In a matched case-control study, 89 non-insured patients were compared with 178 hospital-based controls with health insurance (2:1). The samples were recruited at one of the leading public hospitals in the country (Imam Khomeini Hospital Complex in Tehran) in 2019. Two insured controls were selected and matched for age (± five years) and sex for each person without insurance. A conditional logistic regression was performed to assess the magnitude of effects and the goodness of fit test used to examine the model.
Results: Unemployment (Odds Ratio (OR)=8.33, 95% Confidence interval (CI): 1.05-50.0), being single (OR=3.69, CI: 1.18-11.55), low economic status (OR=1.85, CI: 1.02-3.33) and attitude towards performance of health insurance (OR=0.86, CI: 0.75-0.99) were affected not having health insurance.
Conclusion: Approaches that cover the entire population may struggle to ensure no one is left without needed services. There is a need for greater focus on vulnerable groups to achieve universal health coverage conscientiously. Moreover, improved services and education can positively shape public perceptions of insurance efficacy, affecting their enrollment choices.Health sector reform
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2. Group WHOaWB (2014). Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets. Geneva: WHO, https://www.who.int/publications/i/item/monitoring-progress-towards-universal-health-coverage-at-country-and-global-levels-framework-measures-and-targets. Last accessed November 18, 2023.
3. Savedoff WD, de Ferranti D, Smith AL, Fan V (2012). Political and economic aspects of the transition to universal health coverage. Lancet, 380(9845):924-32.
4. Bourne PA (2009). Health insurance coverage in Jamaica: Multivariate Analyses using two cross-sectional survey data for 2002 and 2007. IJCRIMPH, 1:195-213. https://citeseerx.ist.psu.edu/viewdoc/download?rep=rep1&type=pdf&doi=10.1.1.211.9561
5. Vialle-Valentin CE, Ross-Degnan D, Ntaganira J, Wagner AK (2008). Medicines coverage and community-based health insurance in low-income countries. Health Res Policy Syst, 6:11.
6. Dong H, Kouyate B, Cairns J, Mugisha F, Sauerborn R (2003). Willingness-to-pay for community-based insurance in Burkina Faso. Health Econ, 12(10):849-62.
7. Bahadori M, Farzaneh A , Nejati M(2011). Prioritizing research needs: insights from a healthcare organization in Iran. Arch Pharm Pract, 2:135.
8. Firth J, Nelson EA, Briggs M, Gorecki C (2011). A qualitative study to explore the impact of foot ulceration on health-related quality of life in patients with rheumatoid arthritis. Int J Nurs Stud, 48(11):1401-8.
9. Ibrahimipour H, Maleki MR, Brown R, Gohari M, Karimi I, Dehnavieh R (2011). A qualitative study of the difficulties in reaching sustainable universal health insurance coverage in Iran. Health Policy Plan, 26(6):485-95.
10. Bourne PA, Rhule J (2009). Good health status of rural women in the reproductive ages. IJCRIMPH, 1:132-155.
11. Davari M, Haycox A, Walley T (2012). The Iranian Health Insurance System; Past Experiences, Present Challenges And Future Strategies. Iran J Public Health, 41(9):1-9.
12. Takian A, Rashidian A, Kabir MJ (2011). Expediency and coincidence in re-engineering a health system: an interpretive approach to formation of family medicine in Iran. Health Policy Plan, 26(2):163-73.
13. Sajadi HS, Majdzadeh R (2019). From Primary Health Care to Universal Health Coverage in the Islamic Republic of Iran: A Journey of Four Decades. Arch Iran Med, 22(5):262-268.
14. Maleki MR, Ebrahimipour H, Karimi I, Gouhari MR (2010). Sustainable universal health insurance coverage barriers in Iran: 2007. PAYESH, 9:173-187.
15. Dehnavieh R, Rahimi H (2017). Basic Health Insurance Package in Iran: Revision Challenges. Iran J Public Health, 46(5):719-720.
16. Harirchi I, Hajiaghajani M, Sayari A, et al (2020). How health transformation plan was designed and implemented in the Islamic Republic of Iran? Int J Prev Med, 6;11:121.
17. Dehnavieh R, Tabibi SJAD, Maleki MR, Rashidian A, Noorihekmat S (2010). Information criteria for basic health insurance package in Iran from health insurance organization's view. Health Information Management, 7:109-118.
18. National Institute for Health Research IR. Iran (2019). Basic Health Insurance Coverage before and after implementation of the Universal Health Insurance Program and Health Transformation Plan. (in Persian) https://nih.tums.ac.ir/Item/624. Last accessed November 18, 2023.
19. Manenti A(2011). Health situation in Iran. Med J Islam Repub Iran, 25 (1) :1-7.
20. Schneider P (2004). Why should the poor insure? Theories of decision-making in the context of health insurance. Health Policy Plan, 19(6):349-55.
21. Propper C (1993). Constrained choice sets in the U.K. demand for private medical insurance. J Public Econ, 51:287-307.
22. Kirigia JM, Sambo LG, Nganda B, Mwabu GM, Chatora R, Mwase T (2005). Determinants of health insurance ownership among South African women. BMC Health Serv Res, 5(1):17.
23. Kimani J, Ettarh R, Warren C, Bellows B (2014). Determinants of health insurance ownership among women in Kenya: Evidence from the 2008-09 Kenya demographic and health survey. Int J Equity Health, 13:27.
24. Iqbal M, Chowdhury AH, Mahmood SS, Mia MN, Hanifi SMA, Bhuiya A (2017). Socioeconomic and programmatic determinants of renewal of membership in a voluntary micro health insurance scheme: evidence from Chakaria, Bangladesh. Glob Health Action, 10:1287398.
25. Markowitz MA, Gold M, Rice T (1991). Determinants of health insurance status among young adults. Med Care, 29(1):6-19.
26. Boateng D, Awunyor-Vitor D (2013). Health insurance in Ghana: evaluation of policy holders’ perceptions and factors influencing policy renewal in the Volta region. Int J Equity Health, 12:50.
27. Rhine SL, Ng YC (1998). The effect of employment status on private health insurance coverage: 1977 and 1987. Health Econ, 7:63-79.
28. Trujillo AJ (2003). Medical care use and selection in social health insurance with an equalization fund: evidence from Colombia. Health Econ, 12(3):231-246.
29. Liu TC, Chen CS (2002). An analysis of private health insurance purchasing decisions with national health insurance in Taiwan. Soc Sci Med, 55(5):755-74.
30. van Hees SGM, O'Fallon T, Hofker M, Dekker M, Polack S, Banks LM, Spaan E (2019). Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review. Int J Equity Health, 18:134.
31. Kirigia JM, Preker A, Carrin G, Mwikisa C, Diarra-Nama AJ (2006). An overview of health financing patterns and the way forward in the WHO African Region. East Afr Med J, 83(9 Suppl):S1-28.
32. Mathauer I, Schmidt JO, Wenyaa M (2008). Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand. Int J Health Plann Manage, 23:51-68.
33. Kimani D, Muthaka D, Manda D (2004). Healthcare Financing Through Health Insurance in Kenya: The Shift to A National Social Health Insurance Fund. KIPPRA Discussion Paper No 42.
34. Phelps CE (1973). Demand for Health Insurance: A Theoretical and Empirical Investigation. Santa Monica, CA: RAND Corporation. https://www.rand.org/pubs/reports/R1054.html. Last accessed November 18, 2023.
35. Nosratnejad S, Rashidian A, Mehrara M, Jafari N, Moeeni M, Babamohamadi H (2016). Factors Influencing Basic and Complementary Health Insurance Purchasing Decisions in Iran: Analysis of Data From a National Survey. World Med Health Policy, 8:179-196.
36. Kiplagat I, Muriithi M, Kioko U (2013). Determinants of Health Insurance choice in Kenya. Eur Sci J, 9(13):452–468.
37. Maina JM, Kithuka P, Tororei S (2016). Perceptions and uptake of health insurance for maternal care in rural Kenya: a cross sectional study. Pan Afr Med J, 23:125.
38. Shehrin Shaila M. Micro health insurance in Bangladesh: prospects and challenges [PhD thesis]. Australian Centre for Economic Research on Health (ACERH). The Australian National University; 2015. https://web.archive.org/web/20200217081944id_/https://openresearch-repository.anu.edu.au/bitstream/1885/106397/1/Mahmood%20S%20S%20Thesis%202015.pdf
39. Beck T, Webb I (2003). Economic, Demographic, and Institutional Determinants of Life Insurance Consumption across Countries. World Bank Econ Rev, 17:51-87. https://www.jstor.org/stable/3990045
40. Smith JP, Kington RS (1997). Race, Socioeconomic Status, and Health in Late Life. In: National Research Council (US) Committee on Population; Martin LG, Soldo BJ, editors. Racial and Ethnic Differences in the Health of Older Americans. Washington (DC): National Academies Press (US);. 4. https://www.ncbi.nlm.nih.gov/books/NBK109835/. Last accessed November 18, 2023.
| Files | ||
| Issue | Vol 52 No 12 (2023) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/ijph.v52i12.14325 | |
| Keywords | ||
| Health sector reform Financial protection Health insurance Universal health coverage | ||
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How to Cite
1.
Khatooni E, Ahmadnezhad E, Olyaee Manesh A, Majdzadeh R. The Dilemma of Underutilized Health Insurance: A Matched Case-Control Study Investigating Reasons in Iran’s Free Universal Health Insurance. Iran J Public Health. 2023;52(12):2643-2650.
