The Weight of Inequality and Injustice in Iran’s Insurance and Health System

There are variables such as smoking, excessive alcohol consumption, unhealthy nutrition, sedentary lifestyle, and obesity that can weaken our health; factors that can often be countered with awareness of their effects. However, there are many factors that individuals have little ability to combat in terms of their impact on health and quality of life.

One of these is air pollution or water pollution that we are forced to use; in fact, factors linked to our environment that affect our lives, and factors that led to this year’s World Health Day being designated with this title: “Our Health, Our Planet’s Health.”

There is also an indicator that shows another dangerous and effective factor whose impact on people’s health and quality of life is inevitable: our socio-economic status. Poverty can also severely affect people’s health and quality of life. Lack of access to appropriate economic and social conditions can make us sick and even cause us to die sooner than expected.

The effects of these two factors on our health can be observed at all stages of life. The description of systematic differences and potentially unequal allocation provided to citizens based on economic, social, and geographical groups in access to treatment and health services can be described with the term “health injustice.”

In other words, if factors such as place of residence, education, race, occupation, and gender determine your economic status and access to health services and medicine, even clean water and food, mental well-being, and access to treatment and prevention services at any level (public and specialized), it means your society suffers from injustice in the health sector.

Poverty, a Factor in Increasing Health Injustice

Poverty is actually an important factor that makes the issue of inequality and the increase in various variables affecting justice in access to public health and treatment services an undeniable topic in examining the causes of death and decline in quality of life. On the other hand, if we consider diplomacy, economy, and politics as the three pillars of a country’s decision-making in the health sector, discrimination and economic gaps and discriminatory policies can affect people’s life expectancy.

Given the existence of approximately forty million people below the poverty line, increased unemployment and marginalization, and the allocation of about 80 percent of household budgets for half the population solely to obtain food supplies, it can be predicted that a large percentage of the population cannot afford treatment and medical care costs.

“Children born in poor families are more likely to develop diseases. Mothers who do not have adequate nutrition during pregnancy are more likely to give birth to children with lower intelligence quotients and physically weaker bodies that are more susceptible to disease. Many of these children, if they survive until age five, may suffer from weakness and hunger and may not perform adequately physically and mentally in school and may drop out very soon.”*

Mortality of mothers during pregnancy and childbirth and lactation is also significantly higher in poor and marginalized areas that lack access to health care services than in cities.

Likewise, in deprived provinces plagued by discrimination, these statistics increase; provinces such as Sistan and Baluchestan, Hormozgan, and South Khorasan.

The Link Between Climate Injustice and Health Injustice

The lack of effective programs to control the effects of environmental degradation on people’s health can also be a factor in increasing health injustice.

Health is a multi-axial and multi-variable process. Justice in health and treatment services was also raised as a key issue in the third to sixth development plans. If we know that the World Health Organization defines health as a state of complete physical, mental, and social well-being of an individual, we will confirm that in this way people’s health is directly linked to variables that form their daily living environment, from the air they breathe to the water they consume and the energy sustainably available to them.

Increasing days with poor air quality, the spread of water scarcity in cities and villages, forced migrations linked to climate change that often lead to marginalization, the minimal share of governments in managing and eliminating waste, and lack of oversight of the production and maintenance process of agricultural products are only some of the environmental factors affecting people’s health that are decided upon in the political and economic sphere of a country.

In this sector too, provinces that face the most climate problems have the least ability to adapt to the new conditions imposed on their geography. Regarding this set of silent deaths, there are not even clear statistics.

Insurance and Health’s Share in the 1401 Budget

The sixth development plan states: “The government is obligated to, in order to realize general health policies, ensure sustainable financing for the health sector, quantitative and qualitative development of health insurance, and management of health resources through the insurance system centered on the Ministry of Health, Treatment, and Medical Education by the end of the first year of program implementation, to take measures based on general health policies. (In this article, it refers to at least 10 government responsibilities in this regard.)

Empowerment and self-reliance of underprivileged groups in programs related to welfare and social security, and increasing and improving the quality and safety of comprehensive and integrated health services and care within the health and treatment network aligned with the tiered and referral system are only examples of these programs and objectives.

If we consider health a public good, providing all timely, appropriate, and sufficient services and care for all citizens can be considered a form of fair distribution of health services. Some define this justice as the absence of systematic differences in social and economic institutions and balanced and uniform access to treatment and health services.

The deputy for development management and resources of the Ministry of Health announced that a significant portion of the ministry’s budget will be spent on paying the salaries of the ministry’s staff. If, according to him, even up to 80 percent of this ministry’s budget is spent on current affairs and payments, what about the health and treatment service projects that have been delayed for years? Organizational tasks such as providing family doctors proportional to the number of citizens, building appropriate infrastructure for access to electronic health records, pricing health and treatment sector services, providing necessary facilities for rural health and treatment centers, and other matters.

The chairman of the Iranian Health Economics Association also believes that given the rampant inflation in Iran, “suboptimal and inflationary budgeting in health and treatment will have doubled adverse effects, and the price of medicine and medical supplies with the elimination of preferential currency will increase 400 to 700 times. This price increase will result in increased deductibles and out-of-pocket payments for the insured and crushing treatment costs for the uninsured.”

The Iranian Health Insurance Organization had announced that the budget needed by this organization differs by more than 20 thousand billion tomans from what was approved in the 1401 budget. The Minister of Cooperatives, Labor, and Social Welfare recently announced: “In social security we are facing a severe budget deficit. We ended last year with an average monthly deficit of four thousand billion tomans, which equals 48 thousand billion tomans annually.”

The Social Insurance Fund for Farmers, Villagers, and Nomads, following the fourth development plan, eleven years after its establishment, covers only one million and 400 thousand people, while according to 1395 statistics, at least 26 million people of Iran’s population are farmers and nomads.

According to a World Health Organization report, the percentage of out-of-pocket health expenditures by people in Iran in 1393 was 5.52 percent, in 1394 it was 1.25 percent, in years 1395 and 1396 it was 8.47 percent, and in 1397 it reached 35 percent.*

For comparison, one can point to Qatar, where the average percentage of out-of-pocket expenses over these five years was 7 percent and households facing catastrophic health costs was about 0.6 percent. These figures demonstrate the effectiveness of insurance in ensuring fair access to treatment services.

With the inconsistency of insurance types and unclear allocation of resources in the current year and the elimination of medicine currency, it can be predicted how much deeper the gap in access and distribution of treatment co-payments will be compared to previous years.

Doctor Per Capita and Hospital Beds

Another important criterion and factor in health justice is equal access to general and specialized medical services as well as access to hospital beds. The importance of these factors became even clearer especially after the coronavirus pandemic and the increasing impacts of events like floods and droughts. From air pollution to diseases transmitted through water and soil contamination in cities and villages that lack access to appropriate treatment facilities, it can even lead to human disasters.

Examples experienced in Sistan and Baluchestan in the death and disability of water-carrier children or the problem of transferring pregnant rural and nomadic women to health centers or the lack of access for city residents like Ahvaz with that high level of pollution and frequent dust storms to specialized hospitals for respiratory system diseases are clear examples of this injustice in health and treatment services.

The per capita ratio of general practitioners in Iran is even lower than many of our neighboring countries: 11.7 doctors per 10,000 people. In Sistan and Baluchestan province, there are fewer than seven doctors per 10,000 people. This statistic decreases to approximately half when accessing specialized doctors. There are approximately six specialist doctors per 10,000 people.

The hospital bed index is also one of the most important factors in justice in access to treatment and health services worldwide. Iran is among the world’s leading countries in having the lowest number of hospital beds relative to population. According to the spokesman of the Ministry of Health and Treatment in 1397, this figure was reported as an average of 1.7 beds per 1,000 people, which is distributed in a highly unjust manner (Chart No. 2). Two provinces with hospital bed ratios of less than one are Sistan and Baluchestan and Alborz Province.

Inequality in the health sector in Iran has social, economic, policy, and governance factors. The level of education of individuals, their place of residence and living, the possibility of self-education, and employment security are important and effective social factors in this regard. However, the economic capacity of families also determines what portion of household income can be spent on health and treatment care and pre-care and is also very effective in the lifestyle of individuals.

But for all matters, it is this set of political and administrative governance that is the guarantor. For this reason, justice in health and equal access to treatment and care services is considered one of the most important measures of welfare and development of a country.

* Source: Report on Poverty and Inequality in Health and Public Health, prepared at the Ministry of Cooperatives, Labor, and Social Welfare, Deputy for Social Welfare, Office of Social Welfare Studies, Bahman 1399

Source: Radio Farda