Overview
In collaboration with national stakeholders, we developed and applied an EDP to support the revision of the national health insurance benefit package, using multiple sclerosis (MS) as a test case for structured priority setting. Rising costs of MS treatments and growing budget pressure made this condition a politically and financially salient example for reform.
Rather than redesigning the entire package, the initiative focused on introducing a transparent and evidence-informed process for revising coverage decisions within the existing health insurance system. The MS case served as a concrete entry point for institutional reform.
Context & Objectives
Iran’s social health insurance system covers a large share of the population, but benefit package expansion over time had not always followed explicit criteria or systematic assessment. High-cost MS medicines, increasing demand and fiscal pressure highlighted the need for clearer and more consistent decision-making.
The objectives of the reform were to:
- Apply structured priority setting to coverage decisions for MS treatments
- Define explicit decision criteria for reimbursement
- Integrate economic evaluation into appraisal processes
- Improve transparency and legitimacy of benefit revision
- Strengthen institutional arrangements for future technology assessments
The MS case provided an opportunity to test structured appraisal within existing governance frameworks.
Approach & Methods Used
- Application of Evidence-Informed Deliberative Processes (EDPs) as overarching framework
- Explicit definition of decision criteria (effectiveness, cost-effectiveness, budget impact, severity, equity and social values)
- Systematic review of clinical and economic evidence for MS treatments
- Structured stakeholder deliberation within advisory committees
- Documentation and clarification of committee roles and decision pathways
Integration of economic evaluation into coverage discussions
Outcomes
The MS appraisal process introduced greater structure and transparency into benefit package revision. Explicit criteria and documented deliberation reduced arbitrariness and improved clarity in reimbursement decisions.
Key lessons include:
- Disease-specific cases can catalyse broader institutional reform
- Clear procedural rules improve predictability of coverage decisions
- Economic evaluation can be integrated incrementally
- Deliberative processes strengthen legitimacy in politically sensitive areas
Iran’s experience demonstrates how EDPs can support systematic benefit package revision within established social insurance systems.
Collaborating Partners
- WHO Regional Office for the Eastern Mediterranean (WHO EMRO)
- High Council for Health Insurance (HCHI)