Policy analysis of the Universal Public Health Insurance program for Afghan refugees in Iran: a protocol study

Abstract

Background

Given the recent global events leading to the migration of millions of people to various countries, this study seeks to identify the weaknesses and challenges in refugees’ access to healthcare services and propose solutions to reduce the financial burden on the health system and enhance the effectiveness of the Universal Public Health Insurance (UPHI) program. The ultimate goal is to improve the health of Afghan refugees in Iran. Therefore, this study aims to examine the insurance policies of the seven countries with the highest number of refugees worldwide and compare them with Iran.

Method

This is a qualitative study that will consist of three phases, encompassing a total of 7 steps. The initial phase involves conducting a comparative study among selected countries to identify UPHI coverage policies or programs for refugees. The second phase, which is the core of the study, involves analyzing health policies using the conceptual framework known as the "policy triangle framework." In the final phase, a panel of experts will present policy proposals based on their experiences and in alignment with the identified cases. These proposals will be prioritized using a prioritization matrix and policy dialogue.

Discussion

This research aims to examine the structural and policy challenges of health insurance for refugees in host countries, alongside an in-depth analysis of Iran’s insurance policies. It seeks to propose solutions such as sustainable financing methods, facilitating access to health services, and improving coordination between governmental and international organizations to implement health policies for current and future refugee-hosting countries effectively. Furthermore, the findings of this study could effectively guide decision-making and resource management for policymakers in countries with refugee populations.

Background

Today, one of the important goals of governments is to ensure the health and well-being of their populations, including equitable access to healthcare for all citizens, which they are trying to achieve [1]. In September 2015, the heads of all the United Nations (UN) member states agreed to put the world on a path of sustainable development by 2030. For this purpose, among the 17 Sustainable Development Goals (SDGs) outlined by the UN [2, 3], the third goal focuses on ensuring healthy lives and promoting well-being for people of all ages, including vulnerable groups such as immigrants and refugees [4].

In recent decades, conflicts, violence, war between countries, and human rights violations have forced millions of people to migrate and seek refuge in other countries. Immigrants and refugees are particularly vulnerable populations on the way to achieving Universal Health Coverage (UHC) [5,6,7,8]. According to the UN Refugee Agency, by 2023, over 108.4 million people were forcibly displaced worldwide due to persecution, violence, and human rights violations. Of these, 35.3 million were refugees, 62.5 million were internally displaced persons, and 5.2 million required international support. Notably, more than half of the world's refugees originated from three countries: Syria (6.8 million), Ukraine (5.7 million), and Afghanistan (5.7 million). Iran currently hosts an estimated 8 million Afghans, most of whom are undocumented [9]. The country ranks first globally for the largest number of registered refugees. Despite commendable efforts to provide healthcare services, refugees in Iran face numerous barriers to accessing care [10].

Refugees typically encounter numerous administrative, financial, legal, and linguistic barriers to accessing healthcare services [5, 11, 12]. Additionally, many countries restrict access to healthcare for newly arrived asylum seekers and refugees [10]. In Iran, despite hosting the largest number of refugees in the world and providing healthcare services that surpass the global average, there are significant problems and challenges. Among the most important issues faced by refugees in Iran regarding access to insurance and healthcare services are the following: the treatment costs for illegal refugees are much higher than normal rates [13,14,15,16]; low access for illegal immigrants and passport holders to the Universal Public Health Insurance (UPHI) scheme [9, 16,17,18]; reluctance to visit healthcare facilities and unwillingness to be hospitalized due to lack of insurance [15]; inability to pay for medical expenses and insurance premiums [14, 15]; lack of coverage for certain services under basic insurance and high out-of-pocket expenses [15, 18]; the poor economic status of refugees [15, 16, 18]; financial pressure on the insurance organization due to the moral hazards associated with refugees [15]; lack of awareness among Afghan migrants about health insurance schemes [9]; scattered financial support from international organizations [13]; and cultural differences [16, 18]. Providing health and medical care for asylum seekers and refugees is part of the legal responsibilities of host countries [19].

In response to the health care needs of refugees, in 2015 Iran expanded the UPHI plan to cover all registered (legal) refugees in the country. During the four phases of the UPHI Refugee Project, an average of 112,000 refugees were covered each year. Most of the insured were also vulnerable refugees [20].

Despite these challenges, Iran remains committed to including vulnerable populations in its national healthcare plans. However, the country requires active collaboration with non-governmental and international organizations to sustain and improve healthcare services for refugees [20,21,22]. In this regard, Iran, despite the lack of resources, has tried to provide healthcare services to all refugees, regardless of whether they have a permit to be in the country.

However, few studies have examined how insurance coverage impacts refugees' access to healthcare in Iran [13, 14, 20, 23,24,25]. Additionally, given the significance of this issue and the financial burden it imposes on the country, No detailed study has thoroughly analyzed refugee insurance policies and their implementation and compares them with health insurance policies in leading countries. Therefore, this study is designed and executed to achieve a better understanding of the structure and policymaking processes in this field, to explore the roles of key stakeholders in the policymaking process, to identify contextual factors influencing the environment, and to assess to what extent these policies have faced challenges in formulation and implementation, as well as how effectively they have achieved their initial objectives. In this context, the present study will focus on analyzing the policymaking framework for the Universal Public Health Insurance program for Afghan refugees in Iran.

Method

Study design

This is a qualitative study. In the work process of this study, various methods of comparative review and qualitative methods will be used to answer the main question of the study. In the main process of the study, which is the analysis of health policy, the conceptual framework (policy triangle framework) will be used. The presentation of policy proposals by the panel of experts will be under the experiences of the experts and in line with the identified cases, and finally, we will strengthen the study by using the prioritization matrix and policy dialogue policy.

The goals of this study are to align the general policies of the country's health system with the policies of the World Health Organization (WHO) and the United Nations to cover universal health, to choose the country's health strategies and programs, to identify gaps in the health system, and to provide policy solutions to manage and cover these gaps. The conceptual model of the research is designed based on several WHO and UN models that show financing and access to health services [26,27,28] (Fig. 1).

Fig. 1

Conceptual model of research [26,27,28]

This study will be conducted in three main phases that have 7 steps (Fig. 2).

Fig. 2

Schematic design of materials and methods

Phase 1: Identify basic refugee health insurance coverage policies or programs in the world.

This step will be done as a comparative study. Databases are being systematically searched from inception date to the present: Science Direct, PubMed, Scopus, Web of Science, Embase, as well as Google Scholar search engine. We will also search the gray literature. One of the best methods for learning from the experiences of other countries is conducting comparative studies. In this context, to gain the most extensive and valuable experiences from the countries involved with refugee policies and programs, this study selects eight countries (Turkey, Iran, Colombia, Germany, Pakistan, Poland, the Netherlands, and Lebanon) that have the highest number of refugees worldwide or have had significant encounters with the issue of refugees due to their situation. Below are the reasons for selecting these countries:

• Hosting the largest number of refugees according to the UNHCR 2023 report: (Iran, Turkey, Colombia, Germany, Pakistan) [29]

• Because of the recent Ukraine-Russia war and the migration of millions from Ukraine to neighboring countries: Poland and the Netherlands

• Lebanon: Due to the significant number of refugees, particularly Palestinians, relative to its population

From the keywords Refugee*, "Forcibly displaced", "Forced migration", "Asylum Seeker", health insurance*, "Health coverage", "Health Finance*", Iran, Germany, Colombia, Turkey, Pakistan, Netherlands*, Holland, Poland, and Lebanon will be used to search the databases. Also, abstracts of articles presented at conferences, as well as studies that are not reported about refugees or are about other countries, will be excluded from the study. A researcher-constructed data collection checklist, derived from the components of the study’s conceptual framework for comparative analysis, will be employed to gather data on the selected countries. (Table 1). To analyze the data, the thematic analysis method will be used, which is a method to identify, analyze and report the patterns (themes) in the text and is very useful in qualitative data analysis [30,31,32,33].

Table 1 The content of the comparative table

Phase 2: Policy analysis of the UPHI program for Afghan refugees in Iran.

The second stage of the study will be done in four parts. In this study, the policy-making model will be used for the policy analysis of the basic health insurance program for Afghan refugees in Iran. This model covers 4 general parts which include: content, structure, stakeholders, and policy-making process [34].

Step 1: Content analysis of the UPHI policies for Afghan refugees in Iran.

In this part of the study of all the contents related to the policy of the UPHI program for refugees in Iran, including Meetings of the board, conditions of contracts, invitations, instructions, announcements, official and scientific speeches, evaluation documents, and other items will be identified and analyzed if they are accessed.

Step 2: Analysis of the policy context of the UPHI for Afghan refugees in Iran.

In this part of the study, the UPHI policies of Afghan refugees in Iran will be examined according to the PESTEL framework (Fig. 3). This model is designed in six political, environmental, social, technological, economic and legal sectors [35, 36].

Fig. 3

PESTEL framework for context analysis [36, 35]

Step 3: Analysis of key stakeholders related to the UPHI program for Afghan refugees in Iran.

In this section, all interested and influential people and organizations in the field of UPHI program for Afghan refugees in Iran will be identified and analyzed. For this purpose, the stakeholders analysis guidance of the WHO [37] will be selected and used. According to this guidance, analyzing things such as process planning, choosing and defining a policy, identifying key stakeholders, compiling (adapting) tools, collecting and recording information, completing (preparing and compiling) the stakeholder table, analyzing the stakeholder table and using the information will be conducted.

Step 4: Analysis of the policy process of the UPHI for Afghan refugees in Iran.

This part of the study will be done in 4 parts: agenda setting, policy design, policy implementation, and policy evaluation. Shiffman's model will be used in the agenda stage of the policy-making process. This model provides a basic framework for the analysis of factors determining political priority, which consists of 4 indicators of actors' power, idea, political context, and the nature of the issue, and each of these indicators also includes several factors that shape political priority [38]. In the policy design section, the process and policy design method of the Universal Public Health Insurance program for Afghan refugees in Iran will be analyzed. In the policy implementation section, the implementation method (top-down, bottom-up, combined, and similar) will be examined. In the policy evaluation section, the policy performance and achievements of the Universal Public Health Insurance program for Afghan refugees in Iran will be examined and extracted. In this part of the study, it will be tried to extract and design suitable indicators for measurement and evaluation by reviewing the literature and interviewing experts. The primary and raw indicators considered for this section include the following (this list will probably change after reviewing the literature):

• Number of private individuals/organizations interested in participating in the UPHI refugee program

• Coverage of services and covered persons

• The quality of service

• Satisfaction of service recipients (receivers)

• Costs of providing services

To collect data related to policy documents, a researcher-developed data extraction table will be used for document review. For analyzing qualitative data relevant to each section, thematic analysis and framework analysis methods will be utilized [39], which are methods for identifying, analyzing, and reporting patterns (themes) within the text, widely used in qualitative data analysis [40, 41]. Depending on the study’s objectives and the type of data obtained, either inductive or deductive approaches will be employed [39]. Guba and Lincoln’s criteria of credibility, confirmability, dependability, and transformability are adapted to enhance rigor in research [42]. In this regard, results will be presented to interviewees during the interviews, after their completion, and following their analysis; Feedback will be received and then they will be modified if there are contradictions. Coding will be carried out independently by two researchers. Participation in interviews will be arranged with prior coordination, agreement on time and place, and the right to terminate the interview by the interviewees. MAXQDA2020 software will be used for data management and organization. This qualitative phase’s strategy is content analysis.

Phase 3: Formulation and presentation of policy proposals regarding UPHI for refugees for policy-makers.

This phase of the study will be done in three steps: expert panel, prioritization matrix and policy dialogue. Before starting this phase of the study, the research team will first prepare policy proposals and a plan for review by the expert panel according to the integration of the results obtained from the previous two phases and according to the obtained results.

Step 1: Expert panel meeting to provide policy and program proposals for policy-makers.

In this part of the study, the meeting of the expert panel with the participation of experts to obtain the same recommendations and opinions of the experts in connection with the formulation and presentation of policy and program proposals for basic universal health insurance for refugees for policy-makers and the need to achieve a level of consensus It will be done in negotiations, and such a consensus will usually be achieved through the power of analysis and negotiation of the panel of experts. Also, if there is a serious disagreement among the panel members, it is stated clearly so that it does not remain in a state of ambiguity. Also, all the dimensions and proposals compiled in the panel meetings are discussed one by one, so that in case of ambiguity or disagreement, each item is discussed by the panel and finally, with the opinions of experts, it is removed or included in the proposal package.

Step 2: Prioritization of the policy and program proposals of the UPHI for refugees for policymakers using the prioritization matrix.

In this section, by using the survey form, all program and policy proposals approved by the expert panel will be sent and collected to key specialists and experts involved in the basic health insurance program for Afghan refugees in Iran. This survey, which will be used with a prioritization matrix and will proceed with a Delphi approach, will be used to reach a consensus on policy proposals. To prioritize policy proposals, criteria such as the importance of the proposal, the cost of implementing the policy or program, the feasibility and ability to do it, the duration of implementation and the application of these strategies will be used to improve the current insurance program. The average of comments in each axis is determined, an average above 3.5 will be acceptable and an average below 3.5 will be rejected.

Step 3: Policy and programmatic prioritization of the UPHI of refugees for policymakers using policy dialogue.

In the last part of the study, the policy dialogue method will be used as a part of the decision-making and policy-making processes. This method helps to develop or implement a policy change after conducting evidence-based discussions, workshops and consultations on a specific issue. To use the policy dialogue method, six steps include: setting a specific goal, setting a date and agenda, identifying key stakeholders, creating practical arrangements, engaging and preparing the participants, ensuring the knowledge and skills of the facilitator, and preparing the facilitator/ Facilities will be considered [43]. Finally, in this part of the study, after completing and using the prioritization matrix, experts again discuss the prioritization of the options to reach a final consensus following the policy options are prioritized and presented by them.

Discussion

The health of immigrants and refugees is a significant concern for international communities and host countries. Despite efforts to provide universal access to healthcare, challenges and inequalities persist between immigrant populations and host communities regarding access to services. Financial constraints remain a primary barrier to addressing the healthcare needs of refugees and immigrants in many countries [30].

Refugees, as one of the most vulnerable social groups, face significant challenges in accessing healthcare services, which can have broader impacts on public health and the economy of host countries. Studies highlight that inadequate access to healthcare among refugees not only exacerbates the spread of communicable diseases but also poses risks to the public health security of host nations [20, 44, 45]. In this regard, providing insurance coverage to refugees is a critical step toward ensuring social justice and access to basic healthcare. It also helps improve refugees' health outcomes while reducing the financial burden on public and private healthcare systems. Health diplomacy, as an effective strategy, through fostering international collaborations, can assist governments and non-governmental organizations in designing comprehensive solutions to address this crisis.

Furthermore, strengthening partnerships with global organizations such as the UN and the WHO can support the development of sustainable health policies for refugees. These organizations can coordinate with governments and local entities to identify and allocate financial resources for refugee healthcare services and develop strategies to reduce social and economic tensions in host countries. Therefore, improving the health status of refugees is not only a humanitarian action but also a strategic necessity for enhancing political and social stability in host regions. Ultimately, such measures can contribute to the establishment of a comprehensive and sustainable system aimed at managing global migration and health challenges and improving the quality of life for both refugees and host communities.

In Iran, the sixth development program emphasizes that foreign nationals residing in the country should have health insurance coverage [46]. However, despite the implementation of the Universal Public Health Insurance (UPHI) plan, a significant portion of registered refugees and all undocumented refugees still lack insurance coverage [47], This gap often results in severe financial challenges when accessing healthcare, leading many refugees to forego necessary treatment. Therefore, countries like Iran, with limited financial resources, need sustainable financing mechanisms to extend healthcare coverage to all refugees and immigrants. For this reason, the current study can use the methodology of policy analysis of the existing insurance plan and the use of global experiences and meetings of national experts to reassess the country's insurance programs related to refugees and immigrants and, if necessary, plan the redesign of insurance policies.

This study employs a mixed-method approach, incorporating a comparative review, qualitative studies involving policy analysis (using the policy triangle model), expert panels, and the Delphi technique (priority matrix), ensuring comprehensiveness through a multifaceted examination and comparison of experiences from different countries. Furthermore, standard frameworks such as the policy triangle and PESTEL analysis, which assess political, economic, social, technological, environmental, and legal aspects of policies, will be employed. Qualitative evaluations using Lincoln and Guba’s criteria will enhance the validity and reliability of the findings. The active involvement of experts and scholars reduces the risk of bias, ensuring well-documented and evidence-based recommendations for improving refugee insurance policies. The results of this study will help policy-makers, planners and officials in the country to cover all refugees and immigrants in the health issue by providing a deeper understanding and more complete knowledge of the aspects of refugee health policy-making in Iran. It is expected that the present study will provide a suitable and valuable analysis to evaluate and improve the performance of insurance coverage for immigrants and refugees at the national and international levels.

The findings of this study will be published in an open-access journal to make the results widely available to policy-makers and people working in the field of refugees and migrants. In addition, the results will be presented in the relevant national and international meetings/conferences/conferences.