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Current Challenges in Delivering Social Security Health Insurance

Current Challenges in Delivering Social Security Health Insurance. Social Security Organization. Achievements and Challenges of Social Security Health Insurance: The Experience of the Islamic Republic of Iran. Meeting of Directors of Social Security Organizations in Asia and the Pacific

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Current Challenges in Delivering Social Security Health Insurance

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  1. Current Challenges in Delivering Social Security Health Insurance Social Security Organization Achievements and Challenges of Social Security Health Insurance: The Experience of the Islamic Republic of Iran Meeting of Directors of Social Security Organizations in Asia and the Pacific Seoul, Korea 9 - 11 November 2005

  2. Health • Definition: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO

  3. Dimensions of Health Planning • All Ages • Both Sexes • Comprehensive • Integrated Biological Factors Social Factors Psychological Factors Spiritual Factors Preventive Care Therapeutic Care Rehabilitative Care

  4. IRAN in Perspective • Area: ………………………………… 1/648/000 sq. km • Population: ………………………… 68 millions • Labor Force: ………………………. 15.4 millions • Labor Structure: …………………... 23% Agriculture, 32% Industry, 45% Service Sector • 42.28% of Population Under Age 15

  5. IRAN in Perspective • 23 Million Students in School • 2.1 Million Students in University • Iran Has the 4th Largest Oil Reserves of the World • Iran Has the 2nd Largest Gas Reserves of the World • Iran Has the 2nd Largest Copper Reserves of the World • GDP: 108.2 billion US$ (2002) • GDP Growth for 2003: 6.4% • GDP Per Capita: 7,217 US$ PPP (2002)

  6. National Health Indicators:

  7. Social Protection Programs • The right to social security is embedded in the Constitution: • To benefit from social security with respect to retirement, unemployment, old age, disability, absence of a guardian, and benefits relating to being stranded, accidents, health services, and medical care and treatment, provided through Insurance or other means, is accepted as a universal right. The government must provide the foregoing services and financial support for every individual citizen by drawing, in accordance with the law, on the national revenues and funds obtained through public contributions. Article 29

  8. Social Protection Programs • The social protection programs in Iran are legislated by the Ministry of Welfare and Social Security and are carried out by several organizations, the largest of which is the Social Security Organization (SSO).

  9. Social Protection ProgramsHistorical Backgrounds • Unemployment and injury benefits existed in 2500 years ago in the construction of “Persepolis Palaces”.

  10. Social Protection ProgramsContemporary Era • 1931 Railway Workers Provident Fund • 1952 SS Legal Bill Ratified • 1975 Modern SSO was born SSO National Headquarters

  11. Social Security Organization Defined Benefit Scheme Coverage includes: 1- Formal Blue-collar workers 2- Self-employed 3- Voluntary insured persons PLUS their dependants This Means43% of the whole Population and 62% of the Urban Population Total number of insured under the SSO scheme: 27/000/000

  12. Extension of Coverage Slide1of 2 Whole Package of SS Benefits 1979……….17% 2004………43% 1979……….9% 2004………21% SSO Scheme Other Schemes 64%

  13. Extension of Coverage Slide 2 of 2 Health Care Coverage X1000 94%

  14. Rate of Contribution 30% of the Payroll 20%Employer Government 3% Employee 7%

  15. SSO Benefits Lump sum compensation Family allowance Work related total and partial disability Old age pension Payment of allowance to the women as head of the family Expenses of prosthesis & orthos Unemployment pension Survivor’s pension Benefit in kind for pensioners Health care Sickness benefit Funeral grant Maternity benefit Marriage grant Accommodation and travel expenses of patients Housing allowance

  16. An Iranian Proverb Sound wisdoms dwell only in healthy bodies.

  17. Preventive, Curative, and Rehabilitative Care Out-patient & In-patient Medical Services All Types of Surgeries Emergency Medical Services Dental Care Medical Imaging and Laboratory Services All Types of Medications Child and Maternity Care Rehabilitation Services Providing and Replacing Orthos & Prosthetic Appliances SSO Medical Services Slide1of 2

  18. Preventive, Curative, and Rehabilitative Care Daily allowances during temporary incapacity Transfer to a hospital in another area or district for treatment and care, if necessary Periodical Examination of Workers who Deal with Hazardous Substances Medical Examination of Workers upon Recruitment and Annually During Employment SSO Medical Services Slide2 of 2

  19. SSO’s Health Care Networks SSO Health Direct Health Network (DHN) Indirect Health Network (IHN)

  20. Direct Health Network (DHN) • 76 Modern Hospitals • 11,000 Beds (8,981 Active) • 270 Clinics and Polyclinics • 49 Centers for Occupational Medicine • 112 Medical Commissions • 34,000 Staff (6000 Physicians)

  21. Indirect Health Network (IHN) • SSO Have Contracts With 95% of All Providers of Health Care in Iran: -Independent Physicians and . Dentists………………...............28,417 - Hospitals………………………..772 - Private Clinics…………………750 - Public Clinics………………….4,102 - Drugstores……………………..6,461 - Medical Labs…………………..1,752 - Imaging Centers……………....1,286 - Independent Hemodialysis & Lithotripsy Centers……………199 - Independent Physiotherapy….970 - Miscellaneous…………………..70 Total……………………………..44,779

  22. Administration of DHN & IHN

  23. SSO’s Health Care Challenges Achievements

  24. 1-Comprehensive and Diverse Services Achievements

  25. 2-Full Geographic Coverage • The Direct and Indirect Health Networks of the SSO cover the entire country, including the rural and remote areas in all 31 provinces. Equitable Access Achievements

  26. DHN

  27. 3-Continuous Quality Improvement TQM Achievements Improves the Quality of Care Enhances Customer Satisfaction Increases Productivity

  28. 3-Continuous Quality Improvement ISO 9001:2000 Achievements

  29. 3-Continuous Quality Improvement Integrated Management System ISO 9001: 2000 SA 8000 Achievements ISO 14000 ISO 18000

  30. 4-E-health SSO e-health Plan • Phase 1: Hospitals & Clinics • Phase 2: Medical Documents Offices • Phase 3: National SSO Health Portal • Phase 4: Smart Electronic Health Card Achievements e-Care

  31. 5-Modern Therapeutic Services • Non-invasive Medical Treatment Plan • Medical Equipment Calibration Plan • Mutual Medical Projects with France, US, Germany, South Africa, Kuwait, Tajikistan, Azerbaijan, and Malaysia. Achievements

  32. 1-Steep Increase in Health Care Costs Challenges

  33. 1-Steep Increase in Health Care Costs • The major factors responsible for the increase in health care cost : • Inflation • Health care technology • Shifting trends of diseases • Sub-standard workplace environment • Yearly increase in medical tariffs and salaries • Beneficiaries’ heightened expectations • Increase in life expectancy and consequent aging of the covered population • Increase in the number of beneficiaries (Dependency Ratio) • Simultaneous and unlimited access to both the DHN & IHN • Improper and deficient regulation of health market Challenges

  34. 2-Lack of Referral System • A referral system is a system where patients are first treated by a general practitioner or a family doctor and if necessary, are referred to specialists. Referral System Challenges Good Governance Cost Containment

  35. 3-Absence of a Requisite Medical Culture in the Society Provider Challenges Regulator Consumer

  36. 3-Absence of a Requisite Medical Culture in the Society • To overcome the problem, SSO has launched an extensive public programme to educate the insured and their families on issues such as: • Physical fitness • Dental care • Nutritional information and eating habits • New born care • Smoking • Blood pressure • Diabetes • Medication misuse • Breast feeding • Sexually transmitted diseases Challenges

  37. 4-Population Ageing Improved Health Higher Life Expectancy Longer Retirement Health care expenses at age range of 20-30 Health care expenses at age range of 60-70 Health care expenses at age range of 80-90 Challenges A 3As 10As

  38. Demographic Indicators:World and Asia Source: WWW.UN.Org

  39. 4-Population Ageing • One SSO research shows that only 4% of the insured population in Tehran is above 65 , however, this group consumed 36% of the SSO in-patient budget of the Capital city. • An American study indicates population over 65: Challenges • 13% of the population • 36% of hospital stays • 49% of all hospital care • 50% of all physician work hours • 40% of healthcare dollars

  40. 4-Population Ageing • People over 65 account for: • The Iranian population above 60 will double in ten years and reach to more than 12 millions. • 40% of surgical procedures • 50% of emergency operations • 75% of surgery-related deaths Challenges

  41. 5-Political Pressure to Reduce Contribution • Macro-economic constraints have always led governments to turn to social security funds as abundant resources in solving state problems. Challenges Awareness Activities

  42. Social Security: Welfare and Social Justice for All Thankyou

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