Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach

Shahabi et al. Health Research Policy and Systems (2023) 21:94 https://doi.org/10.1186/s12961-023-01041-2 Health Research Policy and Systems Open Access RESEARCH Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach Saeed Shahabi1, Manal Etemadi2,3* , Maryam Hedayati4, Kamran Bagheri Lankarani1 and Mihajlo Jakovljevic5,6,7 Abstract Introduction Iran is host to one of the world’s largest and longest-standing refugee populations. Although Iran has initiated a basic health insurance scheme for refugees throughout the country since September 2015, the population coverage of this scheme is very low, and various factors have caused a significant percentage of refugees to still lack insurance coverage and often face financial hardships when receiving health services. In response, this study aimed to understand barriers to insurance coverage among refugees in Iran and propose effective policies that can address persistent gaps in financial protection. Methods This qualitative study was conducted in two phases. First, a review of policy documents and interviews with participants were conducted to investigate the common barriers and facilitators of effective insurance coverage for refugees in Iran. Then, a systems thinking approach was applied to visualize the common variables and interactions on the path to achieving financial protection for refugees. Results Findings showed that various factors, such as (1) household-based premium for refugees, (2) considering a waiting time to be eligible for insurance benefits, (3) determining high premiums for non-vulnerable groups and (4) a deep difference between the health services tariffs of the public and private service delivery sectors in Iran, have caused the coverage of health insurance for non-vulnerable refugees to be challenging. Furthermore, some policy solutions were found to improve the health insurance coverage of refugees in Iran. These included removing household size from premium calculations, lowering current premium rates and getting monthly premiums from nonvulnerable refugees. Conclusions A number of factors have caused health insurance coverage to be inaccessible for refugees, especially non-vulnerable refugees in Iran. Therefore, it is necessary to adopt effective policies to improve the health financing for the refugee with the aim of ensuring financial protection, taking into account the different actors and the interactions between them. Keywords Refugees, Healthcare financing, Humanitarian, Systems thinking, Iran *Correspondence: Manal Etemadi Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Shahabi et al. Health Research Policy and Systems (2023) 21:94 Introduction According to the United Nations High Commissioner for Refugees (UNHCR), by the end of 2019, 26 million people worldwide had become refugees due to war, violence, human rights violations or other persecutory events [1]. Refugees often present with significant and complex health needs and poorer health outcomes compared with the general population [2]. Several factors during their migration, such as transport in closed containers, accidental injuries, malnutrition and accommodation in detention centres and refugee camps, have a major influence on the health of refugees [3]. Poor access to healthcare services interacts with discrimination and limited social rights, thereby reinforcing exclusion as a root cause of ill health among refugees [4]. This profound change also impacts the sensitive demographic equilibrium between societies in the advanced population ageing stage such as Europe and far younger Arabic, Persian and other Middle Eastern nations [5]. In a universal health system, refugees should be entitled to the same basic benefits as non-migrants, as well as some level of financial protection [6]. Despite equitable aspirations, inequalities between migrants and nonmigrants in health and in access to healthcare services persist. Inequalities are the results of the economic situation of migrants, who may lack the means to pay for health services [7]. Given immigrant communities’ vulnerability and barriers to accessing care, it is possible that some of their healthcare needs are not being met [8]. Lack of awareness of one’s rights to healthcare, communication, cultural differences and financial difficulties were reported as the barriers faced by the refugees in accessing healthcare in Asian host countries such as Iran [9]. Furthermore, dynamics of investment in healthcare capacities and infrastructure will be largely influenced by Chinese Belt and Road initiative in decades to come [10]. The WHO emphasizes that on the path to universal health coverage, all people should have access to quality health services without financial hardships. Nonetheless, nearly 2 billion people continue to face catastrophic and impoverishing healthcare expenditures [11]. Financial barriers to healthcare access are significant, owing primarily to a lack of livelihoods, a lack of healthcare insurance, and increased foreigner charges [12]. Notably, financial barriers make it more difficult for vulnerable groups such as immigrants and refugees to benefit from health services than other groups in society. Lack of or insufficient health insurance and delays in obtaining health insurance, which resulted in a medical coverage gap during a critical time, were key barriers that limited refugees’ access to the healthcare system [13]. On the basis of syndemic theory, the synergistic nature of stressors [14], chronic diseases and environmental Page 2 of 13 impacts on immigrant and refugee populations living in vulnerable conditions, we should consider the immigrant experience including migration pathways, poverty, cultural distance and lack of social support [15]. According to the Internation (...truncated)