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

Background: High toll of trac-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 prioritized potential policy recommendations to improve insurance coverage for physiotherapy services in Iran. Methods: This project was carried out in Iran, using a mix-methods (viz. qualitative-quantitative) approach. Within the rst phase, a qualitative study was completed to nd 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 rst 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 benet package (e.g. considering preventive interventions) as the main components of insurance coverage. Conclusion: The study ndings 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.

Given the high rate of tra c-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 insu cient 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 O ce [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 speci c 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 nancial hardships [17]. Consequently, nancing is one of the key functions in health care systems including physiotherapy services. To secure nancial 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 nance health care services such as physiotherapy. Even if preventive, curative, and rehabilitative effects of physiotherapy interventions have been so far con rmed by relevant evidence [20][21][22][23], their insurance coverage still low in Iran like many other countries [10]. Nowadays, fragmentation in nancing 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 [9,24].
In response to the aforementioned situation, a comprehensive study was conducted to nd policy recommendations to improve insurance coverage for physiotherapy services in Iran. It could be also applied as a case study for insurance and health care systems in other countries.

Methods
The present project was carried out using a mix-methods (viz. qualitative-quantitative) approach in Iran. An overview of the study is outlined in Fig 1. Firstly, a qualitative study was completed to obtain the policy recommendations to improve insurance coverage for physiotherapy services in Iran. The face-to-face semi-structured interviews were accordingly conducted by S.Sh (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 con rm saturation. It should be noted that the rst 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 bene t package) (Supplemental Fig 1) [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, ve stages including: 1) familiarizing with collected data; 2) recognizing thematic framework; 3) indexing; 4) charting; and 5) mapping and interpreting were considered [25]. In addition, peer debrie ng, triangulation, as well as prolonged engagement by the rst author (S.Sh), were taken into account to enhance rigor and trustworthiness [26]. To ensure the participants' anonymity, a series of ID numbers were used throughout the transcriptions.
Secondly, the analytical hierarchy process (AHP), developed by Dr. Saaty in 1977, was employed to prioritize the policy recommendations obtained [27]. It should be noted that AHP is a multi-criteria decision-making (MCDM) approach using pairwise comparisons to compare available alternatives with relevant criteria and to determine the best ones (Fig 2). Based on the WHO priority-setting guideline, effectiveness, acceptability, cost, fairness, feasibility, and time were selected as the signi cant criteria [28]. The relative importance of these six criteria was also obtained from 11 experts (by S.Sh), either via emails or at their workplace. The given experts with different academic and executive backgrounds included three university professors, three physiotherapists, two health policy-makers, and three health nanciers. There were no pre-de ned principals to ascertain an adequate sample size of experts for AHPbased studies including the present one. In fact, one expert's viewpoint may su ce, 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 [29]. 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 nal 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 [30]. The AHP analysis was also conducted using the Expert Choice (EC) 11 software (Arlington, Virginia, USA).
This study was con rmed 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 nancing 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 bene t package are respectively illustrated in Tables 3c, d, and e.
Regarding the AHP session, the ndings 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. , 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.
The last component was bene t package, whose policy recommendations were prioritized based on each criterion (Supplemental Fig 6). Like other components, performance sensitivity analysis and overall prioritization of bene t package are described in Fig 7. The analyses revealed that considering preventive interventions (0.207) had obtained the rst 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 bene t package offered by insurance institutes.

Discussion
Stewardship As a result, raising policy-makers' awareness may be a signi cant policy recommendation to strengthen stewardship of nancing. Indeed, most of health policy-makers are unaware of these services in Iran [9]. Furthermore, participation of patients and rehabilitation experts in policy processes is another option, which has been noted by recent evidence [31]. Unfortunately, disabled individuals and other relevant groups do not have enough power or in uence to get involved in decision-and policy-making processes in Iran [24]. Collaboration between scienti c associations and health insurers can be accordingly an alternative to improve insurance coverage for physiotherapy service. Scienti c 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 [32]. Even so, weaknesses in HTA process are among common problems facing the Iranian health care system [33]. Therefore, further economic evaluation (i.e., cost-effectiveness, cost-utility, and cost-bene t) 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 [34]. Despite this fact, providers' accreditation is assumed as a standard tool to assure the quality of services that are very important for insurers [35]. 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 bene t packages. However, current health care rationing does not follow any convincing rationales [36,37]. Fragmentation in stewardship of nancing is always shown as one of the signi cant 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 ndings 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 ndings. 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 nancing, 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 tra c-related injuries [38].
Therefore, as many tra c-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 nancial resources.

Pooling of funds
Pre-payment is the only way to reduce direct payments and nancial hardships. In this approach, premiums are collected through insurance mechanisms and then risks are shared and pooled [39]. In agreement with evidence, the study ndings 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 [24,40]. 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 nancing in Iran, which work against equity goals [39]. 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 e ciency and capacity for cross-subsidization, as mentioned in previous evidence [41,42].

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 [43,44]. However, a major proportion of health care services such as physiotherapy are provided by nancers. 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 ndings, a recent study in Sweden, England, and the Netherlands had re ected on the importance of strategic purchasing in managing chronic care processes [45]. 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 con rmed this problem in nancing within Iran's health care system [46,47]. Therefore, setting real tariffs could increase utilization and prevent informal payments.

Bene t package
In Iran, basic and complementary health bene t packages are being developed by the High Council of Health Insurance (HCHI) and all health insurance schemes are obligated to follow it [46]. 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 signi cant 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 [20,22,48]. Additionally, some physiotherapy interventions if prescribed until the age of 18 years, can be very effective [49,50]. In this regard, the Netherlands has included physiotherapy services needed by children up to the age of 18 years in its basic health bene t package [11]. Therefore, considering these interventions and cost-effectiveness strategies can be added to bene t packages [51]. 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 [21,52]. 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 ndings. 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. Accurate design and methodology was the main strength of the present study.

Conclusions
In this study, several policy recommendations were proposed and prioritized to improve insurance coverage for physiotherapy services in Iran. It is expected that the ndings of this study provide a favorable ground to improve insurance coverage for physiotherapy services, and even decision-and policy-makers place these recommendations on the agenda in the health sector to protect population health status of population, especially that of groups with disabilities.

Declarations Ethics approval and consent to participate
This study was con rmed 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.

Consent for publication
Not applicable.

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

Competing interests
The authors declare that they have no competing interest to share. Authors' contributions SSH and STH contributed to the conception and design of the study. SSH conducted the interviews, and STH and KBL were co-moderators. SSH conducted most of the analysis, which STH, KBL, and LZ discussed regularly. SSH wrote the initial draft, and STH, KBL, and LZ contributed to manuscript revisions. All authors read and con rmed the nal manuscript.    . "Rehabilitation services are expensive and that is why many insurance companies are reluctant to cover them. One solution would be to set a separate premium for these services." [UP3] .
Pooling of funds