Transcript Current Challenges in Delivering Social Security Health

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
Health
• Definition: Health is a state of
complete physical, mental and
social well-being and not merely
the absence of disease or
infirmity.
WHO
Dimensions of Health Planning
• All Ages
• Both Sexes
• Comprehensive
• Integrated
Biological Factors
Social Factors
Psychological Factors
Spiritual Factors
Preventive Care
Therapeutic Care
Rehabilitative Care
IRAN in Perspective
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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
IRAN in Perspective
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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)
National Health Indicators:
Health Investment: GDP/ Health
Life Expectancy at Birth (M/F)
6%
70.3 Yr (68.6 / 72)
Infant Mortality Rate (Per, 1000 live births)
26
Under-five Mortality Rate (Per, 1000 live Births)
42
Maternal Mortality Rate (Per, 100,000 live Births)
37.4
Annual population growth rate (%), 1993 to 2003
1.3
Number of Physicians
Number of Hospitals & Day Clinics (public &
70,000
850 with 104,000 beds
private)
Number of Public Health &Treatment Clinics
Number of Rural Health Houses
Access to Primary Health Care (PHC)
Health Care Insurance Coverage
4900
16,800
100 %-Urban / 95%-Rural
94%
Social Protection Programs
Article 29
• 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.
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).
Social Protection Programs
Historical Backgrounds
• Unemployment and injury benefits existed in
2500 years ago in the construction of
“Persepolis Palaces”.
Social Protection Programs
Contemporary Era
• 1931 Railway Workers Provident Fund
• 1952 SS Legal Bill Ratified
• 1975 Modern SSO was born
SSO National
Headquarters
Social Security Organization
Defined
Benefit
Scheme
Coverage includes:
1- Formal Blue-collar workers
2- Self-employed
3- Voluntary insured persons
PLUS
their dependants
Total number of insured
under the SSO scheme:
27/000/000
This Means 43%
of the whole
Population
and 62% of the
Urban Population
Extension of Coverage Slide1of 2
Whole
Package
of SS
Benefits
SSO Scheme
Other Schemes
1979……….17%
2004………43%
1979……….9%
2004………21%
64%
Extension of Coverage Slide 2 of 2
Health Care Coverage
X1000
22,250
6,800
4,200
2,750
27,000
1000
SSO
RPHI
MSIO
IKRF
AF MSIO
Others
Without Coverage
4,000
94%
Rate of Contribution
30% of the Payroll
Employer 20%
Government 3%
Employee 7%
SSO Benefits
Old age
pension
Work related
total and partial
disability
Family
allowance
Unemployment
pension
Survivor’
s pension
Expenses of
prosthesis &
orthos
Health
care
Sickness
benefit
Benefit in kind
for pensioners
Maternity
benefit
Marriage
grant
Housing
allowance
Lump sum
compensatio
n
Payment of
allowance to the
women as head of
the family
Funeral
grant
Accommodation
and travel expenses
of patients
An Iranian Proverb
Sound wisdoms dwell
only in healthy bodies.
SSO Medical Services
Slide1of 2
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 Slide2 of 2
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’s Health Care Networks
SSO
Health
Direct Health Network (DHN)
Indirect Health Network (IHN)
Direct Health Network (DHN)
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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)
Indirect Health Network (IHN)
• SSO Have Contracts With 95% of All Providers of
Health Care in Iran:
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- 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
Administration of DHN & IHN
SSO Board
SSO Chairman
Health Deputy
31 Provincial
Hlth. Management Offices
32 Medical
Documents Offices
SSO’s Health Care
Achievements
Challenges
Achievements
1-Comprehensive and Diverse Services
DHN
2004
No. of Hospital
Admissions
689,663
No. of Surgeries
431,291
Patient Length of
Stay
Bed Occupancy
Rate
Case Flow
No. of Outpatient
visits
3.2
73.13%
80.37
41,941,648
IHN
No. of Hospital
Admissions
No. of Outpatient
visits
2004
1,484,987
182,762,519
Achievements
2-Full Geographic Coverage
Equitable Access
• The Direct and Indirect Health Networks
of the SSO cover the entire country,
including the rural and remote areas in
all 31 provinces.
DHN
Achievements
3-Continuous Quality Improvement
TQM
Improves the
Quality of
Care
Enhances
Customer
Satisfaction
Increases
Productivity
3-Continuous Quality Improvement
Provincial
Health
Management
Offices
Medical
Documents
Offices
Occupational
Health
Centers
Medical
Commissions
Certified 26 18
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6
4
2
In
20 2
Process
9
14
9
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Clinics
Centers
Status
Hospitals
Achievements
ISO 9001:2000
Achievements
3-Continuous Quality Improvement
Integrated
Management
System
ISO 9001:
2000
SA 8000
ISO 14000
ISO 18000
4-E-health
Achievements
SSO
e-health Plan
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Phase 1: Hospitals & Clinics
Phase 2: Medical Documents Offices
Phase 3: National SSO Health Portal
Phase 4: Smart Electronic Health Card
e-Care
Achievements
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.
Challenges
1-Steep Increase in Health Care Costs
Year
Growth in The SSO
Overall Expenses
Growth in Health
Care Expenses
2000-2001
24 per cent
36 per cent
2001-2002
14 per cent
2002-2003
19 per cent
30 per cent
2003-2004
24 per cent
26 per cent
2004-2005
40 per cent
32 per cent
34 per cent
1-Steep Increase in Health Care Costs
Challenges
• The major factors responsible for the
increase in health care cost :
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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
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
Good
Governance
Cost
Containment
Challenges
3-Absence of a Requisite Medical
Culture in the Society
Provider
Regulator
Consumer
Challenges
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:
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Physical fitness
Dental care
Nutritional information and eating habits
New born care
Smoking
Blood pressure
Diabetes
Medication misuse
Breast feeding
Sexually transmitted diseases
Challenges
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
A
3As
10As
Demographic Indicators:
World and Asia
Indicator
Total Population (Million)
2000
2025
2050
World
6056.7
( 100 )
Asia
3772.3
( 62.3 )
World
7936.7
( 100 )
Asia
4776.6
( 60.2 )
World
9322.3
( 100 )
Asia
5428.2
( 58.2 )
605.8
( 100 )
322.2
( 53.2 )
1186.9
( 100 )
703.4
( 59.3 )
1963.8
( 100 )
1226.7
( 62.5 )
18.8
18.1
21.0
20.5
22.2
21.8
19.9
27.2
18.8
24.5
17.9
22.3
Population above 60 (Million)
Life Expectancy at 60 (yrs.)
Labor Force Participation (65+) (%)
Source: WWW.UN.Org
Challenges
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 inpatient budget of the Capital city.
• An American study indicates population over 65:
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13% of the population
36% of hospital stays
49% of all hospital care
50% of all physician work hours
40% of healthcare dollars
4-Population Ageing
• People over 65 account for:
Challenges
• 40% of surgical procedures
• 50% of emergency operations
• 75% of surgery-related deaths
• The Iranian population above 60 will double
in ten years and reach to more than 12
millions.
Challenges
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.
Awareness
Activities
Social Security: Welfare and Social Justice for All
Thank you