Website: http: jebhpme.ssu.ac.ir EBHPME 2019; 3(2): 139-53 pISSN: 2538-5070 EBHPME COMPARATIVE STUDY Evidence Based Health Policy, Management & Economics Health Policy Research Center, Shahid Sadoughi University of Medical Sciences

Identification of the Main Elements of Single Payer System; A Comparative Study Ali Aboutorabi 1, Saman Ghasempour 2*, Behzad Najafi 3, Sirous Panahi 4 1 School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran 2 Health Management and Economics Research centre, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran 3 School of Health Management and Information Sciences, Tabriz University of Medical Sciences, Tehran, Iran 4 School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Article History: Background: Progress towards universal coverage requires adequate capital in health Received: 22 Jan 2019 sector. Investing and optimal allocation of resources in this sector will contribute to the Revised: 27 Mar 2019 development and reduction of poverty in countries in order to achieve the goals of Accepted: 26 June 2019 health system. Therefore, the more people contribute to risk sharing, we have lower financial risks in facing the issue. The single payer system as a public health coverage *Corresponding Author: model seeks to expand the insurance coverage scope at community level. The present Saman Ghasempour study aimed to identify the main elements of S-PS to conduct a comparative study. Health Management and Methods: A comparative study was conducted to describe the fundamental of Economics Research centre, financing and the provision of services in selected countries - Germany, Thailand, School of Health Turkey, and Colombia, as well as to achieve the main elements of S-PS. In addition, Management and Information the health system of Iran has been studied. The basis for selection of countries was Sciences, Iran University of health system Garden typology. The main criteria for selection or rejection of studies Medical Sciences, Tehran, were the separation of health services provider from financial functions; has allowed a Iran. single department to purchasing process. Email: Results: single payer system in two functions of health system, namely, financing and [email protected] providing health care; consolidation resources (reducing fragmentation by creating a Tel: single pooled fund and achieve massive purchase of health care through the insurance +98-9388310017 agent as single purchaser) and ensuring community health (delivery of services by the network of providers represented by Health Promotion Organization) represents 12 main organizational elements. Conclusion: the multiple insurers and payers of health care in Iran are both inequity and ineffective. And its integration is not a simple task. Iranian financing policies should aimed to achieving universal health coverage by creating greater risk pooling

Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] and becoming aware of the important tasks of insurance system; take advantage of the strength in numbers, setting the principles of cross-subsidy and preventing adverse reaction. It is important not to put together a long-term, coherent plan to reach the S-PS.

Keywords: consolidation, Health Insurance funds, health care reform, multiple pools, Single Payer System Citation This paper should be cited as: Aboutorabi A, Ghasempour S, Najafi B, Panahi S. Identification of the Main Elements of Single Payer System; A Comparative Study. Evidence Based Health Policy, Management & Economics. 2019; 3(2): 139-53.

Copyright: ©2019 The Author(s); Published by Shahid Sadoughi University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Identification of the Main Elements of Single Payer System Aboutorabi A, et al.

Introduction ccording to the World Health Organization, transferring resources to insurance funds, how to A three ultimate goals of health systems, pool them and how to allocate those resources (9). including population-based health promotion, The pattern of many countries shows that, in line responding to public expectations, and protecting with economic and justice developments, health and against costly health (1). Therefore, progress welfare categories was initiated on the government towards universal coverage requires investment in agenda (4). Over the past three decades, bad health sector and government encouragement (2). experiences have arisen in health sector financing Investment and optimal flow of resources (especially from Out-of-pocket payments method); allocation in this sector to achieve the goal of moreover challenges remain both in terms of health healthy individuals leads to development and outcomes and systems performance (2). The reason reduction of poverty in countries (3). for reform of twentieth century was not only the A set of control levers, including financial sanction of health system, but the efficiency; the support, the payment system, organization, equity of the referral system and responding to regulations, and behavior of citizens can help people’s expectations; were also the goals of these health systems in achieving these goals (4). reforms (1). Meanwhile, financing as one of government Resource strategy in most countries follows a concerns (5) plays a prominent role in performance combination of financing methods for determining of their health systems (6); since the success of health system credentials (6). This combination is financing system is a direct consequence of three directly the result of determinants of financing in components: availability of funds, proper financial those countries (10).The model of health systems incentives for providers, and ensuring that all based financing method and origin of resources, people have access to health care services(1). which has a strong impact on reform in that area. Therefore, health systems will not be solely The results show that countries without significant responsible for improving the individuals' health, changes in the sources of health funds have been but will be obliged to protect populations with high able to make important reforms in the financing expected health care use, and do not suffer system after seeking unit insurance. Mainly the financial hardship paying for them (5). In order to merger and engagement of tax policies has taken ensure that people have access to services they place with the financial goals of a wider need- targeting based on social categories and macroeconomic level (7). Similar to Thailand and medical condition- consolidation in health Spain (11), the transition took place from a largely insurance funds, integration purchasing power and worker-employer contribution system to a single provision services is a vital financing functions model of regional financing (general taxation). In that directly related to protection against financial the Republic of Moldova (12), the National risks (1, 7). Therefore, make contribution to health Insurance Company, by drawing main sources of system (taxes and/or insurance) as soon as funds (payroll tax and general revenue); pooling Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] contribute to risk sharing (2). This will ensure that general budget revenues with a Compulsory Health health system is equity in pooling and minimized Insurance Fund. Indonesia (13) and South Korea potential financial risks in facing the issue (3,6). (14, 15), National Health Insurance – Based health Demographic profiles, social values, system; as well as Costa Rica (16, 17), benefiting environmental factors, economic activity and from comprehensive social security system, political structure are important determinants of achieving universal coverage through S-PS. In both mandated and external pressures that have these countries, according to the General Health strongly influence on health financing (8). In Insurance Act, there is a single framework for addition to the impact of these factors, the main pooling income tax and mandatory insurance issue in financing health sector is the effectively contribution that led to complete merging of all

140 Volume 3, Issue 2, June 2019; 139-53 Identification of the Main Elements of Single Payer System Aboutorabi A, et al.

insurance funds and creating a single scheme. spending more than developed countries in Iranian Turkey (18, 19) with its Health Transformation health system, there are poor technical efficiency Program are moving to reduce fragmentation in the with growing costs of health care services (26, 27) way resources in health insurance system. The and there is no insurance coverage for a large results of these comprehensive reforms was merge group of people (28). It seems that universal various funds, integration of insurer's scheme and coverage can only be attempted with a moving reveal the existence of cross-subsidy, which towards the single payer system. S-PS as a model quickly reached the frontier of universal coverage of UHC (20) seeks to convert OOPs payments into than many European countries. prepaid funding; expand risk pooling among the The single-payer system as National Health rich and the poor, the young and the old, and the Insurance shows a keen strategic sense to achieve healthy and the sick;. Moreover S-PS seeks to UHC in which a single public or quasi-public merge all existing health resources; separate agency handles all health care financing (20, 21). purchasing from provision functions with high- The single-payer system has successfully level contracts between provider and provision; incorporated a unitary mechanism based on a and ultimately covering the majority of people limited number of revenue with a centralized (22).The present study aimed to identify the main financing system (collection of resources and components of the single payer system in selected redistribution fund) and to pay (strategic countries to carry out a comparative study. purchasing in its operations) for health care Materials and Method providers with delivery predetermined list of A comparative study was conducted to explain medical precautions (similar benefit package) (20, the provider and provision of health system 22, 23). Co-payments, deductibles, and out of performance in selected countries, as well as to pocket will be minimized, and by merging all of achieve the main elements of Single Payer System. the resources together, a comprehensive access to The basis for selection of countries was Garden services will be used with gate-keeping provisions typology of health insurance system (29, 30), (21). On the provider side; strategic approach of including (a) Countries with SHI system,( as in health sources management influence on financing Austria, Belgium, France and Germany), (b) functions and how to reallocation of financing Countries with NHI system (such as South Korea, resources. On the other side on health service Canada, Finland, Colombia, and Sweden, (c) NHS provision, single-payer dominates technical and system (as in Denmark, Greece, Turkey and the human resources; level of efficiency and United Kingdom, (d) In practice most countries productivity of health-care delivery (24,25). The have mixed models (Iran, Australia, Iceland, Japan single-payer system also has the effect of and Thailand are in this group). Only a few generating income, determining profits, and countries such as United States have adjusting payment system (24). predominantly private health insurance financed In Iran, plurality of resources and their systems. Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] separation and more mixed provision of services To compare and analyze the lessons from each are inequitable and ineffective (7.26). There are no of these countries, reviewing studies in health care specific financing regulations for revenue system documents was limited to 5 countries - collection, pooling of revenue and risk, and Germany, Iran, Thailand, Turkey and Colombia. purchasing services (10). The majority of The main criterion in choosing countries, the collection of funds is highly regressive and paying health sector funding reforms firmly placed on for in-patient and out-patient health services is moving towards separate health service provision accompanied with large out-of-pocket. More than from health providers in these countries. Its 50% of these payments are made in the informal intention was to review and expression of part for additional health services (7). Despite the

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theoretical debates and empirical evidence for multifactorial and complex environment like selected countries, by data collection used through political structure, socioeconomic context, cultural library review on type of health systems and their are other affective aspects on health system performance; the data were redirected to identify functions. Some of these factors might not be easy the main elements of single payer system. to replicate. The Single administrative body in Turkey, Thailand and Colombia has successfully Results Country and schemes overview increased over the past 8 years to focus on equity The purpose of this study is to identify the main (of access, financial risk protection) as well as elements of a single payer system. On average, focusing on efficiency (health outcomes). (See primary data collection was carried out from 2009 tables 2 and 3). to 2017 in selected countries. This paper includes 5 Health Care system arrangements countries in the world with a health insurance plus In all countries governments are the oversight of health care type schemes i.e. Germany, Iran, the entire system. The Ministries of health have a Thailand, Turkey and Colombia. Results are large part of the stewardship of health systems for reported in accordance with the final set of their populations. Also, the Ministry of Labor and indicators. This is a mix of lower- to upper-middle Social Affairs (SSO) is main responsible body in and high-income countries that are also included as the insurance system which is generally a differs a way to capture their reform experiences over the characteristic of governance, policy, supervision, past over few decade since introduction. These central regulation, and decentralized management countries have taken different steps to reduce the from free market economy, communist economy number of insured funds, in order to equalize the and socialist models. Consequently, the effects of package of services to expand insurance coverage sub-functions and agents affiliated with each of and subsequently have achieved different levels of Ministries vary in different systems. success. The major differences in health systems have Generally health care reform in these countries likely influenced by differences in financing has taken place to follow the separation of health system and health care delivery system. Overall service provision from health providers as the path evidence shows a wide range of difference models of achieving universal health coverage. Results in revenue collection, pooling and purchasing, shows Iran succeed in achieving minimum 65% which are generally influenced by their policy in UHC. Indeed, the countries that have come closest financing and health care system. There is no to achieving targets -for example, Germany 81% specific way to develop a financing system to UHC- do generally have more to spend on health. achieve UHC. Understanding level of success in Other countries are better able to provide each health care systems (single-payer or multiple- affordable health services. Table 1 provides payer) is focused on measuring level of success in information for these 5 countries on 15 measures insurance management activities. The WHO of key indicators and health system characteristics.

Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] shifted emphasis to health financing function. It As indicated by the goal, fragmentation in seems the design and implementation of the three setting health care system can also be inefficient. key health financing functions are the likely laying the Principles of the health care system such determinants of the success or failure of a health as the main bodies determining procedures in financing system to achieve targets. Table 4 shows health care delivery, multiplicity in managing the the financing methods and health services delivery insured’s health care and multiple funding by the selected countries. channels and pools, each of with its own The Single-Payer Profile administrative costs, duplicate effort, are expensive A single-payer national health program is one to run and require coordination. Similarly, due to entity that financed by taxes, collects funds and

142 Volume 3, Issue 2, June 2019; 139-53 Table 4: main elements of single payer system in comparison with main agents' health system in the selected countries

Identification of the Main Elements of Single Payer System Aboutorabi A, et al.

pays for health care to cover the costs of schools, polyclinics, urban and rural health centers, essential healthcare for all residents. Their etc.). At the same time, this separation has definition is also inclusive of subnational systems, permitted a single agency within the Ministry of which is establish decentralize (regional and Social Affairs or Health Insurance Organizations - national level) and organize administratively the NHI Fund- to focus on coverage issues independent on tow Markets; (Health Care (including both comprehensive package of care Provision Market and Health Insurance market) to and universal coverage). This fund becomes the capturing the benefits that would offer. Separating key pooling and sole purchasing agency for health purchasing from provision functions has allowed care services in every region. Table 5 shows main Ministry of Health as a single department to charge elements of single payer system in comparison with application and administration of health care with main agents' health system in the selected providers' network (including hospitals, medical countries. Table 1. Key Economic, Health Spending, Health status and Delivery Indicators by study years (2009-2017)

literacy Rate, total indicator Population Income groups GDP Per capita Poverty Rate (Ages 15 and Country (in1000 people) (in Classification) (US$) (% of population) above) Year 2009 2017 2017 to 2009 2009 2017 2009 2017 2009 2017 Germany 81,902 82,695 High 41,732.7 44,469.9 - - 95 95 Iran 73,687 81,162 Upper-middle 5,619.1 5,415.2 1.0 0.3 83.9 84.7 Thailand 66,881 69.037 Lower to upper middle 4,212.1 6,593.8 0.2 - 96.3 93.1 Turkey 71,339 80,745 Upper-middle 9,036.3 10,540.6 0.9 0.2 90.8 95.6 Colombia 45,416 49,065 Upper-middle 5,148.4 6,301.6 9.3 4.2 93.2 94.2 Mortality rate, under Maternal mortality Indicator Life expectancy, Physicians (per Hospital Beds 5 (per1,000 live rate (per 100000 Country total (years) 1,000 people) (per 1,000 people) births) live births) Year 2009 2017 2009 2017 2009 2015 2009 2017 2009 2017 Germany 80 81 4 4 7 6 3.6 4.2 8.2 8.1 Iran 73 76 21 14.5 28 25 0.9 1.4 1.7 1.6 Thailand 74 75 14 10 23 20 0.3 0.5 2.2 2.1 Turkey 74 75 21 12 27 16 1.6 1.7 2.4 2.7 Colombia 73 74 19 15 73 64 1.5 1.8 1.5 1.5 UHC Index, Public health Out-of-pocket Indicator Health spending, health spending, total Compulsory expenditure (as % (as % of total Country per capita (US$) (as % of GDP) coverage (% of of total spending) spending) population) Year 2009 2016 2009 2017 2009 2017 2009 2017 2009 2015 Germany 4,742.25 4,591.85 11.4 11.3 83.6 84.5 13.8 12.5 83.3 81 Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] Iran 367.6 366 7.5 7.6 36.6 53.4 56 40.2 60 65 Thailand 152.45 217.1 3.9 3.8 75.5 77 16 11.8 58 75 Turkey 500 454.6 5.5 4.1 80 78 14.5 17 58.6 71 Colombia 329.1 374.2 6.4 6.2 71 66 20.5 18.3 56 76

Source: World Bank national accounts data, and OECD National Accounts data files

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Table 2. Main bodies responsible for setting Health care System and determining Insurance System

Single or Title Stewardship role Health insurance Type of health Type of health multiple Country in health system authority system insurance insurance Ministry of Health & Ministry of labor Social insurance, Social Security Germany Multiple insurance hygiene and social Affairs private market scheme Ministry of Health Ministry of Labor Iran and Medical General health care Multiple insurers Multiple insurance and Social Welfare Education National Health three public health Major financing Thailand MOPH Ministry of Finance Plan insurance schemes Agencies Ministry of Health General health Social Security Turkey Ministry of health single insurance and SSI insurance scheme Institution by HTP Ministry National National Social Colombia Ministry of Health single insurance of Social Protection Development Plan Health Insurance

Table 3. Coordination’s and funding methods to delivery health services

Title Coordination's to Funding for Over the basic payers delivery centers Country payment health care coverage SHI Insured and by public and Mixture contract by OOP, employees Covered Germany Sickness funds private provisions Per diems, salaries, and general (100%) FFS,DRG government mixture of party both public and Public Office with Mainly OOP and Covered (76 - Iran payers private Internal Contract by general 85%) (SSIO-IHIO-IKRF- sectors FFS government MSO...) Mixture of major by public and third -party payer Mainly Covered Thailand payer insurers private centers Contract to provisions Governmental (100%) (SSO-CGD…) by per capita budget and taxes Single buyer public and private service contracts as OOP, employees Covered (76 - Turkey agency sector facilities per global budget and general 83%) (GHIS) government mixture of two mix of public and Contract through national Covered Colombia regimes(CR-SR) private for tertiary managed competition government (100%)

care transfers Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ]

144 Volume 3, Issue 2, June 2019; 139-53 Identification of the Main Elements of Single Payer System Aboutorabi A, et al.

Table 4. Overview of health financing system and health care delivery system in case study countries

Functions Financing arrangement Health Care Provision Country revenue Collection pooling purchasing Main sources of SF transfer to Central Reallocation includes both public and private financing is SHI with its Pool (health fund)- SF pay for health providers in Primary and 132 SF- general tax care providers Specialist health services Germany revenue by Gov OOP my supplements for superior For supply of hospital beds there (31) PHI are offered by 42 accommodation is Regional government funds and 30 very small authorities plan capacities insurer. others OOP & NGO IHIO, SSO, MSO, IKRF complex and fragmented sources led Primary care are free of charge in and numerous insurance to mixed pool and purchase with direct gov center. Iran funds out of pocket (OOP) payments Public private providers for (32) secondary and tertiary health care facilities. payroll taxes collect by four major agencies: CGD for Urban: coverage of PHC, district SSO- revenue departments CSMBS- health centers and community Thailand collect by BB- premium SSO for SHI- NHSO for UCS, out-of- hospitals by local Gov.- private (33) collect by Private pocket user fees, and PHI hospitals insurance for voluntary Rural: PHC provided by Gov. Main sources (indirect all public funds have GHIS is For Primary care there is no co- taxes) collected by been merged under monopsonic payment is levied collected by the Ministry the SSI power to There are secondary or tertiary Turkey of Finance to SSI SSK for Green Card purchase from health care facilities (inpatient or (34) P- taxes collected by SSK all hospitals outpatient) provide mainly in public and private sector contributions collected by Sources from SR, NHST can Coverage of Services to SGP to SR CR, Casaj, national purchase supplement the Benefits Packages Solidarity fund to CR budget and other services within at all levels. including; health local tax revenues from revenues were the range of posts, centers, ambulatory and Colombia ―sin taxes‖ by Gov. bundled into negotiate high-complexity hospitalization (35) contributions from family FOSYGA’s contracts benefits funds or Cajas premium have been guided by FOSYGA balance Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ]

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Table 4. main elements of single payer system in comparison with main agents' health system in the selected countries Health Insurance Market Health Care Provision Market central level: Ministry of Labor and Social Welfare At central level: Ministry of Health regional level: Health Insurance Organization (insurance centers) At regional level: providers' network (hospitals, clinics, urban and rural health centers)

bodies NHI department High Council of Information taxation Population Health card Health Promoting clinical center- Reimbursement Price/fee Benefit package Insurance Record System system Record Organization guidelines referral regulation/ setting System system

Single insurance The organization Information fiscal policy Based on guarantee the oversight of health Design referral and mixes of provider negotiations at Designing the

schemes that are of relations technology Based determine the Cross- equal rights of plans, providers, Methodology gatekeeping payment methods the central level similar and/ or

Payer option done centrally between insurance on place of level and subsidized citizens to Purchase and and Principles (using DRG an or local level, acceptance rang

function or by regional department and residence, amount of and targeting receive similar service-quality of Care important part of determined by of benefit branches of the health care population contributions subsidies to and standard monitoring, perform the purchasing third-party payers package single insurance providers’ movements, based on clear the neediest benefit as unified channel arrangement) or the

fund and network, based on Patient, covered regulatory population package selling health government and

perform as an predetermined prescriptions and frameworks service, determined provider effective agreements identifying poorer by its policyholders purchaser citizenship Managed Federal joint based on a federal Health Tax Identifying SHI booklet Representative of Under the Free choice DRG weights are Based on Mainly based Competitive committee and information Approved in needy people providers supervision of among defined at the reference prices on SHI benefit Germany Network - SHI medical system from Parliament and the Federal many central level and (RBRVS). package. Set by Patient Funds review board FSORKI (Value-added supporting joint providers rates are set at Established at federal law (by the FIA) which are joint tax) them Committee - and the local level or central and/or (SGB-V) institution of all Monitored by insurance with insurer local level.

SFs and providers insurance companies Negotiation on funds point value Multi-insurance Office of the Annual statistics, Determine the Based on Various Various providers There is no Free choice global budget- fee are negotiated comprehensive

Iran Supreme national and taxable Financial insurance incentive to among for service with each insurer package with - Insurance Board regional report amount to be Capacity booklet comply with health care accompanied with

paid - the Tax Measurement the treatment providers different franchise office protocol and prepayment LHF, NHSO performed in conducted by general poor is Health citizen THPF responsible HTA PHC Mainly Based on NHSO Manual for mainly public

Thailand and local district by PAO NSO and taxation as subsidized card for systematically guidelines, gatekeeping capitation and fee paying health care with some governments with DODC Socioeconomic the main through the registration coordinating(DHO, designated by function for service on providers based private have matching Supervision Survey source of MHI schemes allowed PO,DH,CH) with NHSO and quality, by arranged by funding finance receive a financial MOPH, agreement NHSO MOPH

public health institutions between MSDHS and CEO services and MOPH

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Unit Insurance General Council, Information and Based on subsidized by SSI General Directorate diagnosis and An Case-Mix and P4P Capitation or receive similar (Homogeneous Board and health statistics level of the Beneficiaries licenses all treatment integrated systems for salary negotiated benefits – no

Turkey and Structured Ministry of Labor collected by participation government have identity insurance centers guidelines for referral purchase inpatient by interested structure for Financing are managerial COICOP and and tax. from general cards- SSK and hospitals in to primary care system services from all parties at central health System) authorities TURKSTA determine by budget with Green market and hospitals based on level between technology parliament Card responsive to DRG groups government assessment

and central Ministry of Health and/or SSO and Gov. providers managed accreditation PT- index known cover subsidized There is CNSSS (the Clinical Free choice Are free to the fee schedules CNSSS is

Columbia competition in system based on as SISBEN premiums for regime for freedom government body) program within establish payment has used by the policy-making health The contracts the poor poor people choosing in charge of design by network, mechanisms for MPS and CNSSS authority over insurance signed with the through from SR, among a set of monitoring health CNSSS use of services (mainly for fixed benefits markets by CNSSS and NSHI General partial public or plan and managing gatekeepers use UPC) premium (setting packages NHST taxation subsidies are private of the FOSYGA floors) providing insurance from MPS

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Discussion also responsible for providing health insurance to Today, considering the increasingly growing the population. The purchase operation is based on transnational relationships, it is necessary to use predetermined prepayments (e.g., insurance rights international experiences in order to establish a set and compulsory insurance coverage), as well as of health system policies and goals. In the present contracts (between the insurer and provider study, we aimed to examine the main components representative). The final step is to set tariffs and of single-payer healthcare and to compare the negotiation policies and design insurance packages political and organizational commitments of health to trace the payment mechanisms (i.e., diagnostic personnel in five countries, including Germany, related grouping or DRG). Iran, Thailand, Turkey, and Colombia. According to the study of policy-making There are various factors which contribute to strategies in different countries, it is essential to reforms in response to major social, political, and separate the client from the health provider in economic changes in different countries. single-payer healthcare. Single-payer-style health Assessment of the single-payer system indicated care system financing is associated with a 12 major components in the system of healthcare reduction in the share of health care in the GDP. delivery and health insurance. These components The insurance agent accounts for the mass were identified with regard to the financial purchase of health insurance services, while the performance, structure, and methods of health health unit representative is responsible for the service delivery in different countries. They were mass delivery of healthcare services. To regulate classified and reported based on similarities in the health insurance market in a single-buyer function and performance. Based on experience system, the principles of health financing, such as and reports from different countries, in order to insurance system policies, public insurance and ensure universal health coverage, the first step is to contributions, benefit packages, insurance establish independent policies and regulations with premiums, and treatment costs, are considered. respect to the type of insurance system and health Also, in the health network, it is important to financing. manage and organize healthcare centers, design The next step is to create a network of health healthcare packages, and set tariffs for these providers (e.g., service rating, clinical guidelines, services. tariff structure, and payment mechanism) and Social values, justice, and economic capacity in insurance units (e.g., insurance agent, insurance every healthcare system are determinants of the fund, health insurance card, insurance council, health system financing. One of the most important information systems, and targeted allocation of factors in financing the health sector is the political resources). In the healthcare system, integration of structure of the system. Commitment and political health insurance packages and expansion of support are the prerequisites for comprehensive insurance coverage are achieved before the general insurance in a single-payer system. For instance, integration of insurance resources, the most Thailand (35), which has made major progress in Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] important outcome of which is social justice. public health coverage, is entirely committed to Other advantages of this system include financial protection in order to provide public increased efficiency, resource management, insurance and public access to healthcare services. insurance system efficiency, effective financial In public health, it is important to integrate protection and monitoring mechanisms, and health resources and prevent inconsistencies in increased accountability of the healthcare budgeting. Turkey (34) has taken some important personnel. In this system, the insurance agent, as steps in this area. Following the establishment of the health sector purchaser, is responsible for Turkey's Integrated Social Assistance System, five regulating healthcare services. The representatives major insurance funds were integrated. In both of insurance companies and their sub-networks are Turkey and Thailand, governmental funding (e.g.,

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tax financing and compulsory insurance) accounts According to a study by Abolhalaj, with regard to for the largest share of total health care the high level of cash transactions in Iran, design expenditure. These processes ensure that a wide of tax and free-trade policies can be an objective range of high-quality care services are provided for approach to reduce the share of direct payments in the public. Also, changes in the system should be Iran (7,26,39). Fatahzadeh also described the accompanied by the elimination of ambiguities and decline in cash transactions as a necessity to stakeholder alignment. In this regard, the results of promote social justice and patient protection6. a study by Baziar, entitled "Analysis of Germany’s (31) reconstruction of its social Policymaking Strategies for Health Insurance insurance system was accomplished by setting a Funds in Iran", highlighted the importance of limit for direct payments. In order to minimize the social solidarity, in addition to political financial burden of the health sector on the general commitment, in integration of insurance resources population, risk mitigation, as well as factors such (36). as gender, age, and individual status, was taken In Chile (2,37), extensive governmental and into consideration. Overall, rational distribution of institutional support for integration of public and contributions with regard to individual or private health insurance, besides allocation of household income has resulted in Germany’s health resources, can guarantee public insurance success in providing free health services to low- coverage in this country. On the other hand, the income groups, elderly populations, and chronic financial instability of health insurance in South patients. On the other hand, there are multiple Korea (15) has increased the need for insurance funds in France, which aim at targeted governmental interventions. To overcome this coverage of different social classes and issue, support and proper management are populations; in this system, health insurance taxes necessary, as lack of support by political figures are mostly collected from eligible households. In and lack of financing by the government can cause addition, state-supported supplementary health irreparable damage to the health system. insurance is provided for economically Furthermore, integration of the demographic disadvantaged groups (40). information system is one of the most important In Turkey’s (41,19) universal insurance system, prerequisites for public insurance coverage. In given the uniform health expenditures for all Thailand, Turkey, and Colombia, advanced populations, the effect of reduced direct payment databases are used to identify low-income groups, can be seen in all income areas. In addition, low- tax levels, insurance coverage, health costs, income groups receive health subsidies. This resource expenditure, and finally assessment and process in Colombia (24,26) covers the most monitoring of reform outcomes, as confirmed in a disadvantaged groups in the community in a study by Ebrahimpour (38). However, there are purposeful manner by facilitating cash payments major challenges, such as shortcomings of for this group. In South Korea (14), the insurance payment systems, low capacity of information coverage was universal before integrating the Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] systems, ineffective tax systems, and most insurance funds with the aim of creating a support importantly, lack of effective tools for measuring system for the vulnerable population (3-5% of and identifying vulnerable groups in Iran’s health Korea’s population). Janfada also stated that it is system; in fact, overcoming these technical issues important to identify vulnerable groups and is a costly endeavor (36,28). provide insurance for them (42). Reduction of direct payments, increase of Conclusion prepayments and contributions for estimating the Studies show that distribution and dispersion of level of patient protection, and governmental insurance funds (at different income and commitment are major achievements of single- management levels), as well as inconsistencies in payer versus multi-payer insurance systems.

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the delivery of health services, are the main regardless of their experiences and characteristics reasons for differences in insurance policies and (e.g., executive and structural factors, financial health centers. The main components of single- capacity, regulations, and economic, political, payer systems coordinate the delivery of health social and cultural context) can only exacerbate the services and change the financing system by problems. Therefore, the single-payer system can integrating all funds. Therefore, in structural and be integrated in Iran by identifying the current executive actions of single-payer systems, the status of healthcare system, estimating the health client and provider are separated in two outcomes, and evaluating weaknesses and markets of health insurance and healthcare. opportunities for improvement. In the second Separation of purchasing from provision functions section of this study, we will discuss the concept of allows one department to concentrate fully on single-payer systems.It is recommended that future planning, negotiating, monitoring, and evaluating studies focus on identifying the requirements for the performance of health providers. It removes successful implementation of a single payer system conflicts of interest in the purchasing relationship in Iran health system, predicting the outcomes and that might compromise the efficiency of the future prospects of this system. purchasing process. Therefore, financing policies There was no significant limitation for the in Iran should aim at increasing risk accumulation, present study understanding the main responsibilities of Conflicts of interest insurance systems, considering the law of large Authors declare that they have no conflict of numbers, and avoiding reverse risk. Recognition of interests. each component described in the present study can not only improve the performance of Iran’s health Acknowledgments system, but also establish the single-payer system This article was a part of a research project in different health systems. approved by the Faculty of Management and The main characteristics of single-payer Information Technology of Iran University of healthcare include coordination of health system Medical Sciences with the Approved Number goals, structure and performance of health (IUMS / SHAMIS_95_9311552005). Authors are insurance, and insurance outcomes (e.g., sincerely grateful to all those involved in this promotion of public health, fair health insurance study. coverage, provision of free care services, and Authors’ contributions reduction of direct payments). It is obvious that Nadjafi B designed research. Aboutorabi A, there are many challenges and shortcomings in Ghasepour S and Panahi S participated in data implementing the single-payer system in Iran's collection and the related information. Nadjafi B healthcare. The findings showed that adaptation of analyzed data. Ghasempour S wrote the paper. All policies and programs from other countries, authors read and approved the final manuscript.

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Appendix Abbreviations AHBs Area Health Boards IKRF Imam Khomeini Relief SGP National transfers for Foundation health AFMS Armed Forces Medical IHIO Iranian Health Insurance SF Sickness Funds O Service Organization Organization BB Bureau Budget LHF Local Health Fund SHI Social Health Insurance CGD Comptroller General MOPH Ministry of Public health S/MHI Statutory/mandatory Department Health Insurance CSMB Civil Servant Medical MPS Ministerio de la Protección SISBEN System for identifying S Benefit Scheme Social Beneficiaries (Ministry of Social Protection) CNSS Consejo Nacional de MSDH Ministry of Social S-PS Single- payer system S Seguridad Social en Salud S Development and Human (National Health and Social Security Security Council) COIC Classification of Individual NHST National Health Super in SR Subsidized Regime OP Consumption by Purpose Tendency CR Contributory Regime NHSO National Health Security SSK Sosyal Sigortalar Kurumu

Downloaded from jebhpme.ssu.ac.ir at 18:24 IRST on Friday October 1st 2021 [ DOI: 10.18502/jebhpme.v3i2.1225 ] Office Social Insurance Organization)) DH/C District Hospital NSO National Statistical Office SSS Social Security Scheme H (Community Hospital) DRG Diagnosis Related Groups N/SHI National/Social Health SSO Social Security Office/ NHS Insurance Organization National Health Service D/ District/ Provincial Health P4P Pay for performance T/PAO Tambon/Provincial PHO Office Administrative Organization EPS Empresas Promotoras de PHI Private Health Insurance THPF Thai Health Promotion

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Salud (Health Promoting Foundation Companies) FSO Federal Statistical Office PPP purchasing power parity TURKS Turkish Statistical Institute TA FIA Federal Insurance PS Partial Subsidies UCS/ Universal Coverage Authority UHC Scheme GHIS General Health Insurance PCUs Primary care provider units UPCs Per Capita Payment Unit Scheme HF Health Funds PT- Proxy means Test index HCI High Council of Insurance index HPO Health Promoting RBRV Resource-Based Relative Organization S Value Scale

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