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. 2025 Aug 12;21(1):46.
doi: 10.1186/s12992-025-01143-2.

Universal public health insurance for Afghan refugees in Iran: a contextual analysis

Sahar Amuzadeh-Araei  1 , Amirhossein Takian  2   3   4 , Alireza Jabbari  5
Affiliations

Universal public health insurance for Afghan refugees in Iran: a contextual analysis

Sahar Amuzadeh-Araei et al. Global Health. .

Abstract

Background: The right to health for all individuals, including refugees, is recognized as one of the most fundamental human rights. However, refugees continue to face numerous barriers in accessing healthcare services. Iran has not yet achieved full coverage despite implementing a health insurance scheme for refugees. Therefore, this study aims to identify the contextual factors influencing the basic universal health insurance program for Afghan refugees in Iran using the PESTEL framework.

Methods: This qualitative study was conducted between October 2024 and March 2025. Data were collected through semi-structured interviews with 22 key individuals, including managers and experts from the Health Insurance Organization, the Bureau for Aliens and Foreign Immigrants Affairs (BAFIA), the United Nations High Commissioner for Refugees (UNHCR), refugee researchers, educated Afghan refugees, and healthcare service providers. Participants were selected through purposive sampling. Data analysis was conducted using framework analysis based on the PESTEL framework. MAXQDA 20 software was used to assist with data management and analysis.

Results: The contextual determinants of the universal public health insurance policy for Afghan refugees in Iran were 61 factors that were categorized into six main themes and 17 sub-themes. The main themes identified in this study included political (four factors), economic (five factors), legal and regulatory (two factors), sociocultural (four factors), technological (one factor), and environmental factors (one factor).

Conclusion: Findings from this study, based on the PESTEL framework, revealed that the refugee health insurance policy in Iran is influenced by a range of political, economic, social, technological, legal, and environmental factors. To improve insurance coverage among refugees, policymakers-particularly senior health system managers-can create an enabling environment for equitable and sustainable access to healthcare services by strengthening information infrastructures, reforming financial and legal mechanisms, and enhancing intersectoral and international collaboration.

Clinical trial number: Not applicable.

Keywords: Health insurance; Health policy; Iran; Refugees; Universal public health insurance.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and was approved by the Research Ethics Committee of Isfahan University of Medical Sciences (ethical code: IR.MUI.NUREMA.REC.1402.153). In order to comply with the ethical issues in this study, informed consent was obtained from the participants, and individuals have the right to withdraw and leave the study at any time they want. In addition, the objectives of the study will be explained to the participants at the beginning. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
PESTEL framework
Fig. 2
Fig. 2
Analysis of the policy context of the UPHI for Afghan refugees in Iran, based on the PESTEL framework
See this image and copyright information in PMC

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