The present study analyzed the contextual factors influencing the policymaking process of the Basic Universal Health Insurance Program for Afghan refugees in Iran using the PESTEL framework. This qualitative research was conducted through semi-structured interviews with experts in the field of migrants and refugees. The contextual factors affecting refugee health insurance were identified and categorized into six main themes and seventeen sub-themes. The findings of this study indicate that the implementation of the UPHI Policy for Afghan refugees in Iran takes place within a complex context influenced by multifaceted political, economic, socio-cultural, technological, legal, and environmental factors. Among these, political factors—at both national and international levels—play a decisive role in the success or failure of the policy. Regional developments, such as the war in Ukraine and instability in Afghanistan, have led to an increase in the refugee population while simultaneously reducing international financial support for health insurance programs. This has occurred at a time when the demand for healthcare services among refugee populations is growing [22, 45].
On the other hand, instability in national policymaking, particularly as a result of governmental changes and the discontinuity in the implementation of memoranda of understanding, has led to a lack of continuity in insurance support programs and reduced the willingness of refugees to engage with these policies [46]. While international documents such as the 1951 Refugee Convention and the 2018 Astana Declaration provide potential frameworks for enhancing government accountability, the lack of effective internal mechanisms has hindered their practical implementation. Despite the emphasis of national legislation, such as the Sixth and Seventh Five-Year Development Plans, on full insurance coverage for foreign nationals, structural and operational challenges, particularly regarding undocumented migrants, have prevented the full realization of these objectives, leaving a portion of the refugee population effectively excluded from access to insurance services [47]. The exclusive concentration of policymaking authority within the Iranian government, along with the ineffective utilization of the capacities of international organizations, constitutes a significant macro-structural barrier. Nevertheless, facilitative measures—such as the removal of household requirements for pregnant women or the inclusion of patients with special conditions—can be considered part of a structural strategy aimed at ensuring sustainable access to insurance services for vulnerable groups.
The analysis of qualitative data indicates that the economic dimension constitutes one of the most fundamental barriers to Afghan refugees’ access to health insurance services in Iran. At the micro level, factors such as unemployment, unstable income, high living costs, and the requirement to insure all household members have resulted in the reprioritization of insurance premium payments among this population. In many cases, these financial constraints have rendered participation in insurance schemes practically unfeasible. Several studies, including research conducted in Massachusetts [48] and findings by Etemadi et al. in Iran [22] have emphasized the deterrent effect of high insurance premiums, particularly for non-vulnerable refugees. As a result, many of these individuals seek medical care only in emergency situations and without insurance coverage, leading to unreimbursed healthcare costs for the health system and an increase in cost-avoidant behaviors. Similar findings have been reported in the study by Asi et al. in Turkey [49].
On the other hand, financial incapacity and the lack of organized support for vulnerable groups have led to treatment avoidance and the gradual deterioration of their health status [8]. In line with the findings of this study, research on Syrian refugees in Jordan also revealed that the absence of insurance coverage constitutes a significant barrier to accessing cancer treatment services [50]. At the macro level, instability in international financial resources, reduced support from international organizations following crises such as the war in Ukraine, and fluctuations in charitable contributions have posed significant challenges to the continuity of comprehensive insurance coverage. Evidence from Jordan [51] and Iran [17] highlights the critical role of charitable organizations; however, exclusive reliance on the unstable funding of these entities presents a serious risk to the sustainability of refugees’ access to healthcare services.
Moreover, economic sanctions and currency fluctuations have diminished the government’s capacity to procure medicines and healthcare equipment, placing additional strain on Iran’s healthcare system [52]. Although the government has committed to covering half of the health insurance premiums for refugees [47], financial constraints have hindered the expansion of adequate support coverage. Meanwhile, policies such as calculating healthcare tariffs for refugees based on medical tourism rates have not only undermined financial equity in health but have also effectively diverted the insurance system from its core mission—protecting vulnerable groups against catastrophic health expenditures.
A review of international experiences indicates that financing refugee health insurance through public government budgets is an effective approach to enhancing equitable access to health services. In countries such as Colombia [53] and Poland [54,55,56], the government fully or partially covers the cost of health insurance for refugees. Colombia has taken a significant step toward social integration by funding the insurance premiums of documented refugees through public resources, although access to private health services still requires out-of-pocket payments [57, 58]. Poland has also demonstrated a successful model of financial protection by providing comprehensive health coverage through the National Health Fund (NHF) without requiring refugees’ financial contribution [55, 59]. Comparing these experiences with the situation in Iran suggests that improving health insurance coverage for refugees requires the use of public funding, reducing the financial burden on refugees, and mobilizing sustainable international support as key strategies.
Socio-cultural factors play a significant role in shaping patterns of access to and utilization of health insurance among Afghan refugees in Iran. High household size, a predominantly young age structure, and low levels of health and insurance literacy in this population are key contextual factors that contribute to reduced perceived need for insurance, increased risky behaviors, and avoidance of medical treatment. Etemadi et al. also noted that the large family sizes among Afghan refugees, combined with the requirement to pay insurance premiums in a lump sum at the time of enrollment, often result in their lack of insurance coverage [47]. This situation not only threatens the financial sustainability of insurance programs but also poses broad epidemiological consequences, particularly during outbreaks of communicable diseases, for the national health system. Concerns regarding the transmission of infectious and contagious diseases within the host community have also been documented in other studies [60,61,62]. The most significant challenge in accessing healthcare services is the low level of health and insurance literacy among refugees [63]. Nevertheless, the active involvement of certain refugee community members as “cultural mediators,” along with the use of tools such as multilingual brochures, face-to-face education, and training sessions, are considered effective strategies for improving insurance literacy.
On the other hand, many governmental institutions in Iran approach the provision of services to refugees, particularly those with special medical conditions or undocumented status, with a humanitarian and dignity-based perspective. In this regard, the study by Wong et al. emphasized that host governments should hold an ethical responsibility toward addressing the healthcare needs of migrants and refugees [64]. Supportive governmental approaches toward refugees often stand in contrast to certain negative attitudes within the host society regarding the allocation of resources to foreign nationals. This attitudinal gap—partly shaped by economic crises and media narratives—can undermine the political sustainability of insurance programs targeting refugee populations. Therefore, policymakers—especially in developing countries such as Iran—must pay equal attention to cultural and social dimensions, alongside designing and establishing financial and legal frameworks. This includes prioritizing awareness-raising, shifting public attitudes, and strengthening citizens’ social participation.
For example, Colombia’s health policies toward refugees and migrants have been designed not only with structural and economic considerations in mind but also by accounting for the cultural and social dimensions of the host society. These policies aim to facilitate the gradual integration of displaced populations into the national health system while ensuring their long-term access to healthcare services equivalent to that of Colombian citizens [65]. Drawing on Poland’s successful experience [54, 55] and adapting it to the local context, Colombia has emphasized strengthening the social and economic participation of refugees—particularly through labor market integration—as a key strategy. This approach enables refugees and migrants to contribute to the financing of their own health insurance. By fostering a sense of social belonging, improving health literacy, and reducing cultural barriers to healthcare utilization, Colombia’s inclusive and culturally sensitive health policy has enhanced both the effectiveness and sustainability of healthcare services in a multicultural setting [53, 57, 66,67,68,69].
The findings indicate that the development of health technology infrastructure in Iran has played a pivotal role in enhancing refugees’ access to insurance services. Specifically, initiatives such as replacing paper booklets with electronic systems, assigning unique identification codes, and implementing digital registration systems for refugee data represent effective steps toward reducing bureaucracy and facilitating administrative processes. This approach aligns with the recommendations of the Global Compact on Refugees and the 2021 specialized digital health technology conferences [70]. Numerous studies have also emphasized the positive impact of modern technologies on improving access to health information and welfare indicators [71]. For example, Germany’s experience in facilitating refugee access to healthcare highlights the effective use of electronic systems. Since 2016, the replacement of the Health Care Voucher (HCV) with the Electronic Health Card (EHC) has significantly streamlined access to health services for refugees, enabling direct and less bureaucratic utilization of care comparable to that of German citizens after 18 months of residence. This reform, alongside state coverage of insurance costs for the unemployed and the establishment of parallel service structures for uninsured migrants, has substantially enhanced equity in healthcare access and promoted inclusive health protection [72,73,74,75,76,77].
However, effective utilization of digital capacities faces several challenges. These include the lack of integration in identity codes, weak system interoperability among insurance, referral, and service delivery platforms, and the unstable access of refugees to smart devices and the internet. Despite the advantages of assigning a unique identity code, its inconsistent and sometimes contradictory use across various systems highlights the urgent need for a centralized and coherent platform among relevant institutions. Meanwhile, the development of electronic health records could serve as a powerful tool for care documentation, data-driven evaluation, and continuity of services. Nevertheless, the lack of technical infrastructure and failure to establish system connectivity have significantly limited its effectiveness, as also noted in other studies [78, 79].
Refugees’ access to support systems such as the 1666 hotline, which enables them to track insurance-related issues, reflects a responsive approach in health policy. Nevertheless, overcoming linguistic, cultural, and digital barriers at the service user level is essential. This can be achieved through the training of cultural mediators, the provision of multilingual content, and the design of user-centered interfaces to enhance digital equity. Overall, achieving systemic integration, intersectoral support, and technological justice can pave the way for sustainable, equitable, and efficient access to health insurance services for refugees.
It is undeniable that Iran’s high-level legal documents—such as the Sixth Five-Year Development Plan and Clause 5, Section B, Article 70 of the law—emphasize the necessity of providing health insurance coverage to foreign nationals residing in the country. However, in practice, the laws and regulations related to refugee health insurance reflect a selective implementation approach that fails to guarantee equal access for all refugee groups. Findings from several studies support this aspect of our research [47, 80, 81]. Specifically, only refugees possessing official documents, such as the “Amayesh” card or a letter of introduction from UNHCR, are eligible to receive insurance coverage and associated service packages. In contrast, individuals holding census slips or unofficial documents are excluded from this entitlement. This discriminatory approach underscores the necessity of standardizing identification processes and adopting a more comprehensive definition of insurance inclusion, one based on health needs rather than legal status. This issue has also been highlighted in the study by Vargas-Bustamante et al. (2014) in the United States [82].
In addition, policies such as the designation of “prohibited areas” for the residence of foreign nationals have led to geographic disparities in access to health insurance. Designing coverage models tailored to regional needs could be an effective strategy to address this form of discrimination. Moreover, many vulnerable groups—including housewives and individuals without work permits—are excluded from access to social insurance. However, models such as voluntary insurance, if supported by targeted financial subsidies, could provide at least minimal coverage for these populations. On the other hand, the limited participation of international organizations in the health insurance policymaking process and the lack of transparency have undermined opportunities for the technical and financial strengthening of the system. Adopting a participatory and intersectoral approach, aligned with international standards, is essential for a structural reform of the refugee health insurance system. Furthermore, strengthening the enforcement of laws and regulatory mechanisms can enhance the effectiveness of policies and the efficiency of financial provision. Overall, achieving UHC requires structural, equity-oriented, and transparent reforms within national policies that include all residents, regardless of nationality or documentation status.
One of the key challenges in the effective implementation of refugee health insurance policies is the neglect of their environmental living conditions. Findings from the present study indicate that refugees often reside in overcrowded and marginalized areas, which frequently lack basic infrastructure such as safe drinking water, proper sewage systems, and adequate ventilation. These conditions contribute to an increased burden of infectious and respiratory diseases [22]. Combined with insufficient insurance coverage for diagnostic and pharmaceutical services, this situation imposes significant out-of-pocket costs on refugee households and undermines the protective function of health insurance.
In this regard, revising the health insurance benefits package with a focus on the environmental and epidemiological needs of refugee-populated areas, such as expanding coverage for laboratory services, medications, and primary care, is an inevitable necessity. Additionally, adopting a health-oriented approach in urban and environmental policies, through intersectoral collaboration with institutions such as the Ministry of Roads and Urban Development and municipalities, can serve as a preventive intervention that effectively improves the health indicators of refugees.
Moreover, the findings indicate that geographic limitations in accessing insurance-affiliated health centers, especially in marginalized areas, constitute another barrier to benefiting from health insurance. The concentration of public healthcare facilities in urban centers and the lack of contracts with nearby private hospitals have created a geographic gap in access, an issue that has also been confirmed in previous studies [83,84,85]. In response to this challenge, policies such as expanding conditional contracts with selected private centers under adjusted tariffs, establishing community-based clinics, and deploying mobile health units in densely populated refugee areas can be employed. Overall, the environmental and spatial conditions of refugees are not only linked to their physical health but, if overlooked, can severely limit the effectiveness and feasibility of health insurance policies.