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Recommendations to improve insurance coverage for physiotherapy services in Iran: a multi criteria decision-making approach

Abstract

Background

High toll of traffic-related injuries, climate change, natural disasters, population aging, as well as chronic diseases have all made considerable demands on receiving physiotherapy services in Iran. Nevertheless, there is an assortment of complications facing utilization of such services, particularly poor insurance coverage. Therefore, the present study investigated and identified gaps in insurance coverage in order to inform future policy reforms and the design of a more comprehensive and universal benefits package for physiotherapy services in Iran.

Methods

This project was carried out in Iran, using a mix-methods (viz. qualitative-quantitative) approach. Within the first phase, a qualitative study was completed to find policy recommendations. Such recommendations were then prioritized through the Analytical Hierarchy Process (AHP), in the second phase, based on effectiveness, acceptability, cost, fairness, feasibility, and time.

Results

Within the first phase, a total number of 30 semi-structured interviews with health policy-makers, health insurers, faculty members, rehabilitation experts, and physiotherapists were completed. Several policy recommendations were also proposed by the study participants. Following the second phase, prioritized recommendations were provided to promote stewardship (e.g., informing policy-makers about physiotherapy services), collection of funds (e.g., placing value-added taxes on luxury goods and services), pooling of funds (e.g., moving allocated resources towards insurance (viz. third-party) mechanism), purchasing (e.g., using strategic purchasing), and benefit package (e.g., considering preventive interventions) as the main components of insurance coverage.

Conclusion

The study findings provided a favorable ground to improve insurance coverage for physiotherapy services in Iran. As well, decision- and policy-makers can place these recommendations on the agenda in the health sector to protect population health status, especially that of groups with disabilities.

Background

Approximately 15% of people worldwide are living with disabilities, predicted to deteriorate in the future years due to high prevalence rates of chronic diseases, population aging, traffic-related injuries, and number of survivors of traumatic events [1]. In this respect, a study in 2019, had further established that the burden of musculoskeletal disorders (MSDs) had significantly multiplied over the past decades, and such problems had been introduced as the second cause of years lived with disability (YLD) [2]. In addition, the growing incidence of neurological disorders such as tetanus, meningitis, encephalitis, stroke, traumatic brain injury (TBI), and spinal cord injury (SCI) in recent years has remained as the main cause of disability-adjusted life years (DALYs) [3]. Low-back pain (LBP), neck pain, osteoarthritis (OA), and rheumatoid arthritis (RA) are also among the leading MSDs, indicating a high burden especially in the Eastern Mediterranean region (EMR) including Iran [4]. Therefore, in accordance with the current global trends, the need for physical rehabilitation services including physiotherapy interventions is on the rise [5].

Given the high rate of traffic-related injuries (e.g., head trauma, fractures, and SCI), climate change, natural disasters, population aging, and chronic diseases, demands for receiving physiotherapy services is also considerable in Iran [6,7,8]. Therefore, appropriate funding and delivery of these services are of utmost importance. However, physiotherapy services are often regarded as luxury and tertiary ones in Iran's health care system [9]. Most of such services are provided by private centers, and out-of-pocket (OOP) payments are the leading reimbursement mechanisms attributable to insufficient insurance coverage. As a result, a major proportion of households are suffering from catastrophic expenditures (CEs) [10].

Different countries, principally developed ones, have adopted various approaches to cover physiotherapy services within health insurance programs. For instance, physiotherapy services for children up to the age of 18 years are included in the basic health insurance package in the Netherlands; however, there are limitations to utilizing such services for other groups [11]. Furthermore, physiotherapy services are among those covered by statutory health insurance (SHI), consisting of a variety of insurance schemes for the population living in France [12]. Nonetheless, reimbursement is subject to the doctors' prescriptions as well as approval of consulting doctors in the SHI Medical Service Office [12]. In Norway, physiotherapy services are provided at both primary and secondary levels, respectively funded by municipalities and the Norwegian Health Economics Administration (Helseøkonomiforvaltningen: HELFO) [13]. In general, a share of the costs is paid directly by service recipients.

The World Health Organization (WHO) has further introduced rehabilitation services as one of the main dimensions of the universal health coverage (UHC) [14]. Recently, the “WHO Global Disability Action Plan 2014–2021” has been also initiated to meet the increased demands for these interventions [1]. In addition, “Rehabilitation 2030: A Call for Action” has been started to enhance the accessibility of rehabilitation services such as physiotherapy [15]. Integrating rehabilitation services in health care systems and improving insurance coverage for such services are the main goals of this guidance. However, in many countries (especially undeveloped and developing ones), no specific funding has been thus far allotted to the rehabilitation sector [16].

Besides, the UHC aims to provide all populations with the interventions they need at a cost level protecting them from financial hardships [17]. Consequently, financing is one of the key functions in health care systems including physiotherapy services. To secure financial protection, a number of strategies such as pre-payment and pooling are being recommended [18]. Indeed, evidence shows that insurance mechanisms (as a pre-payment approach) facilitate sharing and pooling risks, and ultimately reduce direct payments [19]. Therefore, moving towards an insurance mechanism is the inevitable option to finance health care services such as physiotherapy. Even if preventive, curative, and rehabilitative effects of physiotherapy interventions have been so far confirmed by relevant evidence [20,21,22,23], their insurance coverage still low in Iran like many other countries [10]. Nowadays, fragmentation in financing and provision of physiotherapy services, like other Iranian health sub-systems, is leading to unnecessary duplication. In fact, different actors and stakeholders (including the Ministry of Health and Medical Education: MoHME, Social Security Organization: SSO, Iran Health Insurance Organization: IHIO, Armed Forces Social Security Organization: AFSSO, the Iranian Red Crescent Society: IRCS, the State Welfare Organization of Iran, and the Iranian Physiotherapy Association, etc.) are involved in this process [24, 25].

In response to the aforementioned situation, a study was conducted to identify gaps in insurance coverage in order to inform future policy reforms and the design of a more comprehensive and universal benefits package for physiotherapy services in Iran.

Methods

The present project was carried out in two phases using a mix-methods approach in Iran encompassing both qualitative and quantitative data collection methods. An overview of the study methodology is outlined in Fig. 1.

Fig. 1
figure 1

Overview of study methods

Phase 1

Firstly, an interview study was carried out to obtain the views of key stakeholders on how to improve insurance coverage for physiotherapy services in Iran. The face-to-face semi-structured interviews were accordingly conducted by the first author (a male PhD and health policy-maker experienced in rehabilitation research) in the city of Tehran, the capital of Iran. Besides, Skype and telephone calls were employed to interview those living in other areas. The study participants were also recruited using purposive and snowball sampling methods, and the sampling continued until saturation was achieved. Two interviews with duplicate data were further considered to confirm saturation. It should be noted that the first researcher contacted each participant (via phone calls or e-mails) to set a date and time for the interview session. The study population included health policy-makers, health insurers, faculty members, rehabilitation experts, and physiotherapists (Table 1). Interview guides also consisted of open-ended questions developed based on the conceptual framework components (stewardship, collection of funds, pooling of funds, purchasing, and benefit package) (Additional file 1: Fig. S1) [19]. The interviews also lasted between 20 and 55 min and recorded digitally. Verbatim transcription was further done after each session and the participants were allowed to review their interview transcripts, and if required, they had the opportunity to correct them. Framework analysis was similarly adopted to analyze the collected data. In accordance with this approach, five stages including: (1) familiarizing with collected data; (2) recognizing thematic framework; (3) indexing; (4) charting; and (5) mapping and interpreting were considered [26]. In addition, peer debriefing, triangulation, as well as prolonged engagement of the first author, were taken into account to enhance rigor and trustworthiness [27]. To ensure the participants' anonymity, a series of ID numbers were used throughout the transcriptions.

Table 1 Demographic characteristics of participants

Phase 2

In the second phase, the analytical hierarchy process (AHP), developed by Dr. Saaty in 1977, was employed to prioritize the policy recommendations obtained [28]. AHP is a multi criteria decision-making (MCDM) approach that uses pairwise comparisons to compare available alternatives with relevant criteria and to determine the best ones (Fig. 2). Based on the WHO priority-setting guideline, six criteria were selected as most significant for the study: effectiveness, acceptability, cost, fairness, feasibility, and time [29]. The relative importance of these six criteria was also obtained from 11 experts (by S.Sh), either via e-mails or at their workplace. The experts who participated in the weighting of the criteria had diverse academic and professional backgrounds, specifically experts included three university professors, three licensed physiotherapists, two health policy-makers, and three health financing officers. Regarding the sample size, there are no pre-defined guidelines as to how many experts should participate in the AHP. The sample size will largely depend on the study aim, and in general, this approach does not need a large sample [30]. In fact, one expert's viewpoint may suffice, in accordance with the aims of the study, unless several experts from different backgrounds are necessary, and so, various experts are needed if they are accessible [31]. With reference to the pairwise comparison matrix, experts were asked to express their viewpoints using Saaty’s nine-point rating scale (Table 2). Then, the final value for each pairwise comparison was calculated based on the geometric-logarithmic mean. These weighted values revealed the relative importance of each criterion, and these values were utilized to determine relative preferences for the recommendations. Furthermore, the inconsistency rate (IR) of the experts' viewpoints was calculated for each pairwise comparison. In accordance with the evidence, an IR less than or equal to 0.1 (IR  =   < 0.10) could be accepted [32]. The AHP analysis was also conducted using the Expert Choice (EC) 11 software (Arlington, Virginia, USA).

Fig. 2
figure 2

AHP hierarchy which represents the main goal, interested criteria, and potential alternatives (recommendations)

Table 2 Saaty’s pairwise comparison rating

The study received ethical approval by the Ethics Committee of the National Institute for Medical Research Development (NIMAD), Tehran, Iran (IR.NIMAD.REC.1398.337).

Results

All through the qualitative study, the participants expressed a number of policy recommendations for each component of the conceptual framework, as shown in Table 3. Stewardship including inter-sectoral leadership and intra-sectoral governance was thus highlighted by most of the participants. Accordingly, they proposed several options to improve this domain such as moving towards united stewardship, informing policy-makers about physiotherapy services and their effects, involving rehabilitation experts in decision- and policy-making processes, etc. (Table 3a). Enhancing funds or revenue collection was another main component of the financing process with various policy solutions recommended by the study participants especially policy-makers and faculty members such as levying value-added taxes on luxury goods and services, considering higher insurance contributions (i.e., premiums) for childless families, earmarking allocated resources, etc. (Table 3b). Other policy recommendations to boost insurance coverage for physiotherapy services such as pooling of funds, purchasing, and benefit package are respectively illustrated in Table 3c–e.

Table 3 Recommendations to improve the insurance coverage for physiotherapy services

Regarding the AHP session, the findings of the pairwise comparisons of the six criteria are presented in Table 4. In this respect, the relative importance of the criteria included feasibility with a ratio of 0.258, which had the highest importance as well as acceptability, fairness, cost, effectiveness respectively with ratio of 0.178, 0.171, 0.138, and 0.131. Moreover, time with a ratio of 0.124 was given the lowest importance. In the pairwise comparison of the six criteria compared with the goals, the IR was 0.09.

Table 4 Matrix of pairwise comparisons

Afterwards, policy recommendations of each component were paired and compared in accordance with the six criteria. Additional file 1: Fig. S2 presents the prioritization of the recommendations for stewardship based on each criterion. According to Fig. 3, informing policy-makers about physiotherapy services and their effects (0.128) obtained the highest priority. It was then followed by involving rehabilitation experts in decision- and policy-making process (0.115), promoting interactions between scientific associations and insurers (0.098), conducting regular supervisions and accreditations (0.098), strengthening referral systems (0.095), as well as establishing accurate information systems (0.084). Moreover, conducting comprehensive needs assessments (0.080), prioritizing and rationing (0.080), improving health technology assessment (HTA) process (0.078), facilitating interdisciplinary collaborations (0.073), and finally moving towards united stewardship (0.071), received the lowest priority. Performance sensitivity analysis of these recommendations also demonstrated in Fig. 3.

Fig. 3
figure 3

Performance sensitivity analysis of policy recommendations for stewardship based on the six criteria and overall priority

Prioritization of policy recommendations for collection of funds based on the six criteria are shown in Additional file 1: Fig. S3. In addition, Fig. 4 depicts performance sensitivity analysis and overall prioritization of the recommendations in accordance with the criteria for this component. Accordingly, levying value-added taxes on luxury goods and services (0.158) as well as harmful substances such as tobacco, sugar, etc., (0.144), using a separate premium for rehabilitation services (including physiotherapy) (0.140), earmarking allocated resources (0.140), placing taxes on chemical and toxic industries (0.135), considering higher insurance contributions for childless families (0.127), obligating complementary health insurance for employed groups (0.086), and promoting rehabilitation funding proportion from public budget (0.069), were ranked from the highest to the lowest priority.

Fig. 4
figure 4

Performance sensitivity analysis of policy recommendations for collection of funds based on the six criteria and overall priority

Prioritization of policy recommendations for pooling of funds based on the six criteria are also demonstrated in Additional file 1: Fig. S4. As presented in Fig. 5, moving allocated resources towards insurance (i.e., third-party) mechanisms (0.294), had the highest priority, followed by cross-subsiding across different groups at the national level (0.199), integrating insurance funds (0.180), consolidating small insurance funds (0.173), and finally, exploiting individual medical saving accounts (0.154), which had the lowest priority. In addition, performance sensitivity analysis based on each criterion is illustrated in Fig. 5.

Fig. 5
figure 5

Performance sensitivity analysis of policy recommendations for pooling of funds based on the six criteria and overall priority

Purchasing was among other components of financing, receiving a number of policy recommendations to improve it. Additional file 1: Fig. S5 shows the prioritization of the obtained alternatives based on the six criteria mentioned. Furthermore, performance sensitivity analysis and overall prioritization are demonstrated in Fig. 6. As shown, using strategic purchasing (0.162), correcting tariffs based on economic situation (0.130), and considering quality indicators in purchasing process (0.127) were the top three priorities. In addition, limiting induced demands by payments and punishing mechanisms (0.111), using rehabilitation experts in purchasing process (0.104), considering performance- or outcome-based payment systems (0.097), reducing co-payment rates (0.093), and exploiting capitation payment mechanisms to control expenditures (0.093), were ranked from four to eight. Finally, separation between provider and purchaser (0.084) had the lowest priority; however, it was one of the top priorities with reference to effectiveness.

Fig. 6
figure 6

Performance sensitivity analysis of policy recommendations for purchasing based on the six criteria and overall priority

The last component was benefit package, whose policy recommendations were prioritized based on each criterion (Additional file 1: Fig. S6). Like other components, performance sensitivity analysis and overall prioritization of benefit package are described in Fig. 7. The analyses revealed that considering preventive interventions (0.207) had obtained the first rank, which was notable. Furthermore, coverage for physiotherapy services up to the age of 18 years (0.195) and considering interventions required in golden time treatment after diseases (such as stroke) (0.188) were the second and third priorities. Finally, coverage for physiotherapy services required for children up to the age of six years (0.162) along with considering inpatient (0.147) and cost-effectiveness interventions (0.101) were other alternatives to improve the benefit package offered by insurance institutes.

Fig. 7
figure 7

Performance sensitivity analysis of policy recommendations for benefits package based on the six criteria and overall priority

Discussion

Stewardship

As a result, raising policy-makers’ awareness may be a significant policy recommendation to strengthen stewardship of financing. Indeed, most of health policy-makers are unaware of these services in Iran [9, 33]. Furthermore, participation of patients and rehabilitation experts in policy processes is another option, which has been noted by recent evidence [34]. Unfortunately, disabled individuals and other relevant groups do not have enough power or influence to get involved in decision- and policy-making processes in Iran [24]. Collaboration between scientific associations and health insurers can be accordingly an alternative to improve insurance coverage for physiotherapy service. Scientific associations can thus provide a list of interventions with lower costs and prevent many future complications. Furthermore, improving the HTA can play an important role in this domain [35]. Even so, weaknesses in HTA process are among common problems facing the Iranian health care system [36]. Therefore, further economic evaluation (i.e., cost-effectiveness, cost-utility, and cost–benefit) should be conducted to demonstrate the effects and the costs of physiotherapy services. Another proposed policy is improving supervision and accreditation systems. Like many other countries, there are unfortunately no transparent and regular supervision systems in the health-related rehabilitation sector including physiotherapy in Iran [24]. In addition, lack of comprehensive accreditation is one other feature of the physiotherapy sector in this country [37]. Despite this fact, providers' accreditation is assumed as a standard tool to assure the quality of services that are very important for insurers [38]. Therefore, developing effective supervisions and accreditations is necessary for the physiotherapy sector. Evidence-based prioritizing and rationing in the health system is thus a proposed recommendation, which can promote the physiotherapy status in benefit packages. However, current health care rationing does not follow any convincing rationales [39, 40]. Fragmentation in stewardship of financing is always shown as one of the significant barriers to universal insurance coverage for health services including physiotherapy in Iran. Consequently, moving towards united stewardship may be a potential policy recommendation [17]. Although the study findings prioritized united stewardship as one of the best alternatives based on effectiveness criterion, it surprisingly had no high priority based on other criteria. Indeed, in accordance with the current situation of Iran, this policy fails to be a feasible and acceptable recommendation.

Collection of funds

With regard to collection of funds, several recommendations were presented in this study. In this line, the WHO always laid focus on innovative ways such as levying taxes on chemical and toxic industries, placing value-added taxes on luxury goods and services, and imposing taxes on harmful substances such as tobacco, sugar [18, 19] which was accordance with the study findings. These policy options can thus provide new funding resources of insurance coverage for physiotherapy services. Earmarked taxes, also known as hypothecated ones, can be accordingly developed for particular plans [18]. Most of the policy-makers also believed that earmarked taxes could be a considerable fund source for rehabilitation services such as physiotherapy. The ministries of health are often favoring these taxes since they secure financing, especially for health promotion and prevention. Furthermore, the study participants highlighted that approximately all the funds to physiotherapy and other rehabilitation services, should be earmarked. Based on the Fourth Economic, Social, and Cultural Development Plan Act (Article 92) in Iran, 10% of third-party insurance must be allotted to cover medical expenditures of traffic-related injuries [41]. Therefore, as many traffic-related injuries require physiotherapy services, a part of this fund can be also earmarked for physiotherapy services. Considering higher insurance contributions by childless families was another notable policy recommendation for collection of funds. Policy-makers also believed that individuals without any children needed more rehabilitation services such as physiotherapy. Therefore, this premium could provide expedient financial resources.

Pooling of funds

Pre-payment is the only way to reduce direct payments and financial hardships. In this approach, premiums are collected through insurance mechanisms and then risks are shared and pooled [42]. In agreement with evidence, the study findings concluded that moving the allocated resources for rehabilitation services towards insurance (viz. third party) mechanisms was essential. However, the current funding for rehabilitation services was highly dispersed and each organization was receiving a separate budget [24, 43]. Additionally, using effective third-party mechanisms at the national level facilitates cross-subsidization. This policy is possible wherein multiple funds and different insured groups (namely, poor and rich or young and old) are available [18]. Nevertheless, fragmented funds are one of the key challenges of health care financing in Iran, which work against equity goals [42]. Therefore, integrating insurance funds or consolidating small insurance ones can be among policy options to improve this situation. The participants also discussed that the current fragmentation had reduced efficiency and capacity for cross-subsidization, as mentioned in previous evidence [44, 45].

Purchasing

Concerning the purchases, several policy recommendations were proposed. Based on prioritization, using strategic purchasing had the highest rank. These results were consistent with the relevant evidence [46, 47]. However, a major proportion of health care services such as physiotherapy are provided by financers. Indeed, there is no actual purchaser-provider split. Therefore, considering strategic purchasing principals such as focus on quality indicators in purchasing process and using performance- or outcome-based payment system can be one of the best alternatives to improve insurance coverage for physiotherapy services. In line with these findings, a recent study in Sweden, England, and the Netherlands had reflected on the importance of strategic purchasing in managing chronic care processes [48]. Furthermore, the study participants believed that current tariffs were not real and needed to be corrected in accordance with economic changes. Recent studies had correspondingly confirmed this problem in financing within Iran's health care system [49, 50]. Therefore, setting real tariffs could increase utilization and prevent informal payments.

Benefit package

In Iran, basic and complementary health benefit packages are being developed by the High Council of Health Insurance (HCHI) and all health insurance schemes are obligated to follow it [49]. Unfortunately, health-related rehabilitation services including physiotherapy have not been so far well considered. As a result, the number of interventions and the depth of insurance coverage for physiotherapy services are very poor. Despite this, the present study recommended significant policy options to improve this situation. Preventive physiotherapy interventions can be also an attractive alternative for decision- and policy-makers. In fact, many physiotherapy services have preventive effects, which can put a stop to expensive interventions such as surgeries in future [20, 22, 51]. Additionally, some physiotherapy interventions if prescribed until the age of 18 years, can be very effective [52, 53]. In this regard, the Netherlands has included physiotherapy services needed by children up to the age of 18 years in its basic health benefit package [11]. Therefore, considering these interventions and cost-effectiveness strategies can be added to benefit packages [54]. During the interviews, providers and faculty-members also underlined the importance of physiotherapy services after stroke and traumatic events. As shown by evidence, if physiotherapy interventions are provided at golden time (6 months after stroke or 12 months after traumatic injuries), many side effects are thwarted [21, 55]. Therefore, these services may be other potential interventions to be considered by health insurers.

Study strengths and limitations

The selected face-to-face interview sites in this study were mainly in metropolitan areas, which may limit the generalizability of the findings. However, there were attempts to interview other experts using Skype and telephone calls to deal with this problem. As well, some participants especially health policy-makers had no willingness to participate in this study. Nevertheless, a broad and diverse sample of the participants was selected to minimize this limitation. Lack of participation of patients among included individuals was another limitation of this study. The strength was the participatory and multi-stakeholder approach used which helped elicit the diverse perspectives of clinical professionals and health policy makers was the main strength of the present study.

Conclusions

In this study, the research team tried to obtain the perspectives of the key stakeholders on how insurance coverage for PT services in Iran can be improved. The findings of this study provide a preliminary evidence base to guide future decisions and reforms aiming to improve insurance coverage for physiotherapy services. Furthermore, decision- and policy-makers may consider including the study's recommendations on current and future health policy in an effort to accelerate progress towards Sustainable Development Goal 3 and UHC, especially for the most vulnerable segments of the population that are frequent users of physiotherapy and rehabilitation services such as people with disabilities.

Availability of data and materials

The data collected and analyzed during the study are available from the corresponding author on reasonable request.

Abbreviations

MSK:

Musculoskeletal

YLDs:

Years lived with disability

DALYs:

Disability-adjusted life years

LBP:

Low-back pain

OA:

Osteoarthritis

AR:

Arthritis rheumatoid

EMR:

Eastern Mediterranean Region

OOP:

Out-of-pocket

CEs:

Catastrophic expenditures

WHO:

World Health Organization

UHC:

Universal health coverage

SSO:

Social Security Organization

IHIO:

Iran Health Insurance Organization

AFSSO:

Armed Forces Social Security Organization

AHP:

Analytical hierarchy process

MCDM:

Multi-criteria decision making

HCHI:

High Council of Health Insurance

References

  1. World Health Organization. WHO global disability action plan 2014–2021: better health for all people with disability. Geneva: World Health Organization; 2015.

    Google Scholar 

  2. Sebbag E, Felten R, Sagez F, Sibilia J, Devilliers H, Arnaud L. The world-wide burden of musculoskeletal diseases: a systematic analysis of the World Health Organization Burden of Diseases Database. Ann Rheum Dis. 2019;78(6):844–8.

    PubMed  Google Scholar 

  3. Feigin VL, Nichols E, Alam T, Bannick MS, Beghi E, Blake N, Culpepper WJ, Dorsey ER, Elbaz A, Ellenbogen RG. Global, regional, and national burden of neurological disorders, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):459–80.

    Google Scholar 

  4. Moradi-Lakeh M, Forouzanfar MH, Vollset SE, El Bcheraoui C, Daoud F, Afshin A, Charara R, Khalil I, Higashi H, El Razek MMA. Burden of musculoskeletal disorders in the Eastern Mediterranean Region, 1990–2013: findings from the Global Burden of Disease Study 2013. Ann Rheum Dis. 2017;76(8):1365–73.

    PubMed  Google Scholar 

  5. Heinemann AW, Feuerstein M, Frontera WR, Gard SA, Kaminsky LA, Negrini S, Richards LG, Vallée C. Rehabilitation is a global health priority. Berlin: Springer; 2020. https://doi.org/10.1177/0008417420907804.

    Book  Google Scholar 

  6. Shirazikhah M, Mirabzadeh A, Sajadi H, Joghataei MT, Biglarian A, Mousavi T, Shahboulaghi FM. National survey of availability of physical rehabilitation services in Iran: a mixed methods study. Electron Phys. 2017;9(11):5778.

    Google Scholar 

  7. Farzadfard MT, Sheikh Andalibi MS, Thrift AG, Morovatdar N, Stranges S, Amiri A, Kapral MK, Behrouz R, Juibary AG, Mokhber N. Long-term disability after stroke in Iran: evidence from the Mashhad Stroke Incidence Study. Int J Stroke. 2019;14(1):44–7.

    PubMed  Google Scholar 

  8. Foroutaghe MD, Moghaddam AM, Fakoor V. Time trends in gender-specific incidence rates of road traffic injuries in Iran. PloS ONE. 2019. https://doi.org/10.1371/journal.pone.0216462.

    Article  Google Scholar 

  9. Soltani S, Takian A, Sari AA, Majdzadeh R, Kamali M. Cultural barriers in access to healthcare services for people with disability in Iran: a qualitative study. Med J Islam Repub Iran. 2017;31:51.

    PubMed  PubMed Central  Google Scholar 

  10. Zarei E, Nikkhah A, Pouragha B. Utilization and out of pocket (OOP) payment for physiotherapy services in public hospitals of Shahid Beheshti University of Medical Sciences. Med J Islam Repub Iran. 2018;32:19.

    PubMed  PubMed Central  Google Scholar 

  11. Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. Netherlands: health system review. Geneva: WHO; 2016.

    Google Scholar 

  12. Chevreul K, Brigham B, Durand-Zaleski I, Hernández-Quevedo C. France: health system review. London: LSE; 2015.

    Google Scholar 

  13. Ringard Å, Sagan A, Saunes I, Lindahl A. Norway: health system review. Geneva: WHO; 2013.

    Google Scholar 

  14. Reich MR, Harris J, Ikegami N, Maeda A, Cashin C, Araujo EC, Takemi K, Evans TG. Moving towards universal health coverage: lessons from 11 country studies. Lancet. 2016;387(10020):811–6.

    PubMed  Google Scholar 

  15. World Health Organization. Rehabilitation in health systems: guide for action. Geneva: World Health Organization; 2019.

    Google Scholar 

  16. Stucki G, Bickenbach J, Gutenbrunner C, Melvin J. Rehabilitation: the health strategy of the 21st century. J Rehabil Med. 2018;50(4):309–16.

    PubMed  Google Scholar 

  17. Mehrolhassani M, Najafi B, Yazdi Feyzabadi V, Abolhallaje M, Ramezanian M, Dehnavieh R, Emami M. A review of the health financing policies towards universal health coverage in Iran. Iran J Epidemiol. 2017;12:74–84.

    Google Scholar 

  18. Evans DB, Etienne C. Health systems financing and the path to universal coverage. Bull World Health Organ. 2010;88:402.

    PubMed  PubMed Central  Google Scholar 

  19. Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91:602–11.

    PubMed  PubMed Central  Google Scholar 

  20. Wang M-Y, Pan L, Hu X-J. Chest physiotherapy for the prevention of ventilator-associated pneumonia: a meta-analysis. Am J Infect Control. 2019;47(7):755–60.

    PubMed  Google Scholar 

  21. Shahabi S, Shabaninejad H, Kamali M, Jalali M, Ahmadi Teymourlouy A. The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2019. https://doi.org/10.1177/0269215519887784.

    Article  PubMed  Google Scholar 

  22. Boden I, Skinner EH, Browning L, Reeve J, Anderson L, Hill C, Robertson IK, Story D, Denehy L. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial. BMJ. 2018;360:j5916.

    PubMed  PubMed Central  Google Scholar 

  23. Henderson KG, Wallis JA, Snowdon DA. Active physiotherapy interventions following total knee arthroplasty in the hospital and inpatient rehabilitation settings: a systematic review and meta-analysis. Physiotherapy. 2018;104(1):25–35.

    PubMed  Google Scholar 

  24. Abdi K, Arab M, Khankeh HR, Kamali M, Rashidian A, Farahani FK, Shemshadi H. Challenges in providing rehabilitation services for people with disabilities in Iran: a qualitative study. J Adv Med Med Res. 2016. https://doi.org/10.9734/BJMMR/2016/23337.

    Article  Google Scholar 

  25. Shahabi S, Teymourlouy AA, Shabaninejad H, Kamali M, Lankarani KB. Financing of physical rehabilitation services in Iran: a stakeholder and social network analysis. BMC Health Serv Res. 2020;20(1):1–11.

    Google Scholar 

  26. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):1–8.

    Google Scholar 

  27. Kyngäs H, Kääriäinen M, Elo S. The trustworthiness of content analysis. In: The application of content analysis in nursing science research. Berlin: Springer; 2020. p. 41–8.

    Google Scholar 

  28. Saaty TL. Decision making with the analytic hierarchy process. Int J Serv Sci. 2008;1(1):83–98.

    Google Scholar 

  29. Terwindt F, Rajan D, Soucat A. Priority-setting for national health policies, strategies and plans. Strategizing national health in the 21st century: a handbook. Geneva: WHO; 2016. p. 71.

    Google Scholar 

  30. Schmidt K, Aumann I, Hollander I, Damm K. von der Schulenburg J-MG: Applying the Analytic Hierarchy Process in healthcare research: a systematic literature review and evaluation of reporting. BMC Med Inform Decis Mak. 2015;15(1):1–27.

    Google Scholar 

  31. Saaty TL, Özdemir MS. How many judges should there be in a group? Ann Data Sci. 2014;1(3–4):359–68.

    Google Scholar 

  32. Boroushaki S, Malczewski J. Implementing an extension of the analytical hierarchy process using ordered weighted averaging operators with fuzzy quantifiers in ArcGIS. Comput Geosci. 2008;34(4):399–410.

    Google Scholar 

  33. Shahabi S, Skempes D, Mojgani P, Bagheri Lankarani K, Heydari ST. Stewardship of physiotherapy services in Iran: common pitfalls and policy solutions. Physiother Theory Pract. 2021. https://doi.org/10.1080/09593985.2021.1898705.

    Article  PubMed  Google Scholar 

  34. McVeigh J, MacLachlan M, Gilmore B, McClean C, Eide AH, Mannan H, Geiser P, Duttine A, Mji G, McAuliffe E. Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis. Global Health. 2016;12(1):49.

    PubMed  PubMed Central  Google Scholar 

  35. Hollingworth S, Gyansa-Lutterodt M, Dsane-Selby L, Nonvignon J, Lopert R, Gad M, Ruiz F, Tunis S, Chalkidou K. Implementing health technology assessment in Ghana to support universal health coverage: building relationships that focus on people, policy, and process. Int J Technol Assess Health Care. 2019. https://doi.org/10.1017/S0266462319000795.

    Article  PubMed  Google Scholar 

  36. Olyaeemanesh A, Majdzadeh R. Health technology assessment: a necessity in post-sanctions Iran while implementing the health transformation plan. Med J Islam Repub Iran. 2016;30:436.

    PubMed  PubMed Central  Google Scholar 

  37. Nekoei-Moghadam M, Amiresmaili M, Iranemansh M, Iranmanesh M. Hospital accreditation in Iran: a qualitative case study of Kerman hospitals. Int J Health Plann Manage. 2018;33(2):426–33.

    PubMed  Google Scholar 

  38. Lamptey AA, Nsiah-Boateng E, Agyemang SA, Aikins M. National health insurance accreditation pattern among private healthcare providers in Ghana. Arch Public Health. 2017;75(1):36.

    PubMed  PubMed Central  Google Scholar 

  39. Rooddehghan Z, Parsa Yekta Z. Patient favoritism as a barrier to justice in health care: a qualitative study. Health Spirit Med Ethics J. 2019;6(4):29–35.

    Google Scholar 

  40. Yaghoubi M, Bahadori M, Ravangard R. Factors affecting income inequity among healthcare workers in Iran: a commentary. Shiraz E Med J. 2019. https://doi.org/10.5812/semj.67208.

    Article  Google Scholar 

  41. Aderyani MR, Naeeni MS, Musavi F, Salehnia E, Dehghani A, Barati M, Babaeeian K. Exploring the status of executing traffic accidents insurance (article 92 of Islamic Republic of Iran’s fourth budget plan) according to the Financial Scale of Special Incomes and Non-Settled Traffic Accidents Files at Kashani Hospital of Isfahan. Iran J Med Law. 2016;9(35):185–204.

    Google Scholar 

  42. Bazyar M, Rashidian A, Kane S, Mahdavi MRV, Sari AA, Doshmangir L. Policy options to reduce fragmentation in the pooling of health insurance funds in Iran. Int J Health Policy Manag. 2016;5(4):253.

    PubMed  PubMed Central  Google Scholar 

  43. Shahabi S, Bagheri Lankarani K, Heydari ST, Jalali M, Ghahramani S, Kamyab M, Tabrizi R, Hosseinabadi M. The effects of counterforce brace on pain in subjects with lateral elbow tendinopathy: a systematic review and meta-analysis of randomized controlled trials. Prosthet Orthot Int. 2020. https://doi.org/10.1177/0309364620930618.

    Article  PubMed  Google Scholar 

  44. Chu A, Kwon S, Cowley P. Health financing reforms for moving towards universal health coverage in the western pacific region. Health Syst Reform. 2019;5(1):32–47.

    PubMed  Google Scholar 

  45. Mathauer I, Torres LV, Kutzin J, Jakab M, Hanson K. Pooling financial resources for universal health coverage: options for reform. Bull World Health Org. 2020;98(2):132.

    PubMed  Google Scholar 

  46. Klasa K, Greer SL, van Ginneken E. Strategic purchasing in practice: comparing ten European countries. Health Policy. 2018;122(5):457–72.

    PubMed  Google Scholar 

  47. Witter S, Chirwa Y, Chandiwana P, Munyati S, Pepukai M, Bertone MP, Banda S. Results-based financing as a strategic purchasing intervention: some progress but much further to go in Zimbabwe? BMC Health Serv Res. 2020. https://doi.org/10.1186/s12913-020-5037-6.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Noort BA, Ahaus K, van der Vaart T, Chambers N, Sheaff R. How healthcare systems shape a purchaser’s strategies and actions when managing chronic care. Health Policy. 2020. https://doi.org/10.1016/j.healthpol.2020.03.009.

    Article  PubMed  Google Scholar 

  49. Bazyar M, Rashidian A, Sakha MA, Mahdavi MRV, Doshmangir L. Combining health insurance funds in a fragmented context: what kind of challenges should be considered? BMC Health Serv Res. 2020;20(1):1–14.

    Google Scholar 

  50. Doshmangir L, Bazyar M, Najafi B, Haghparast-Bidgoli H. Health financing consequences of implementing health transformation plan in Iran: achievements and challenges. Int J Health Policy Manag. 2019;8(6):384.

    PubMed  PubMed Central  Google Scholar 

  51. Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, Teixeira-Salmela LF, Hancock MJ. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199–208.

    PubMed  Google Scholar 

  52. Chaves GS, Freitas DA, Santino TA, Nogueira PAM, Fregonezi GA, Mendonca KM. Chest physiotherapy for pneumonia in children. Cochrane Database Syst Rev. 2019. https://doi.org/10.1002/14651858.CD010277.pub3.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Sebban S, Evenou D, Jung C, Fausser C, Jeulin S, Durand S, Bibal M, Geninasca V, Saux M, Leclerc M. Symptomatic effects of chest physiotherapy with increased exhalation technique in outpatient care for infant bronchiolitis: a multicentre, randomised, controlled study. Bronkilib 2. J Clin Res Med. 2019;2(4):1.

    Google Scholar 

  54. Shahabi S, Rezapour A, Arabloo J. Economic evaluations of physical rehabilitation interventions in older adults with hip and/or knee osteoarthritis: a systematic review. Eur J Physiother. 2019. https://doi.org/10.1080/21679169.2019.1672785.

    Article  Google Scholar 

  55. Dubey L, Karthikbabu S, Mohan D. Effects of pelvic stability training on movement control, hip muscles strength, walking speed and daily activities after stroke: a randomized controlled trial. Ann Neurosci. 2018;25(2):80–9.

    PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to express our sincere gratitude to Dr. Hannah Kuper for the valuable comments.

Funding

This work was supported by the National Institute for Medical Research Development (NIMAD), Tehran, Iran (No. 987627).

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Authors and Affiliations

Authors

Contributions

SSH and STH contributed to the conception and design of the study. SSH conducted the interviews, and STH and BN were co-moderators. SSH, MB, and MKGH conducted most of the analysis, which RT, STH, KBL, and LZ discussed regularly. SSH wrote the initial draft, and MB, RT, MKGH, STH, KBL, DS and LZ contributed to manuscript revisions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Seyed Taghi Heydari.

Ethics declarations

Ethics approval and consent to participate

This study was confirmed by the Ethics Committee of the National Institute for Medical Research Development (NIMAD), Tehran, Iran (IR.NIMAD.REC.1398.337). All participants were provided written consent form, and then provided verbal consent prior to interview sessions. Also, participants were free to leave the study freely at any stage of the study.

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Not applicable.

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The authors declare that they have no competing interests to share.

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Supplementary Information

Additional file 1: Figure S1.

Conceptual framework. Figure S2. Prioritization of recommendations for stewardship based on six criteria. Figure S3. Prioritization of recommendations for collection of funds based on six criteria. Figure S4. Prioritization of recommendations for pooling of funds based on six criteria. Figure S5. Prioritization of recommendations for purchasing based on six criteria. Figure S6. Prioritization of recommendations for benefit package on six criteria.

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Shahabi, S., Skempes, D., Behzadifar, M. et al. Recommendations to improve insurance coverage for physiotherapy services in Iran: a multi criteria decision-making approach. Cost Eff Resour Alloc 19, 80 (2021). https://doi.org/10.1186/s12962-021-00333-0

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Keywords

  • Insurance coverage
  • Physiotherapy
  • Health policy
  • Rehabilitation
  • Analytical hierarchy process