Designing a national framework for preventing fraud in Iran's health system: a sequential mixed-methods study using...

Area of Science:

• Health Policy and Governance
• Healthcare Management
• Medical Ethics and Fraud Prevention

Background:

• Fraud and misconduct in healthcare systems, including practices like false claims and informal payments, erode efficiency and public trust.
• Iran's health system faces governance challenges that necessitate targeted strategies for fraud control.

Purpose of the Study:

• To design and validate a national framework for preventing and controlling fraud and misconduct within Iran's health system.
• To address specific fraudulent practices such as overbilling, unnecessary prescriptions, and beneficiary manipulation.

Main Methods:

• A sequential mixed-methods approach was employed, starting with qualitative interviews and followed by a two-round Delphi consensus process.
• The study involved 12 experts in the qualitative phase and 31 experts in the Delphi process, all with significant experience in health management and policy.

Main Results:

• Framework analysis identified six strategic intervention categories: cultural, educational, legal, technological, insurance-related, and structural.
• The Delphi process achieved high consensus on prioritizing interventions, with unanimous agreement on legal clarity, enforceable sanctions, and electronic identity verification.
• The final framework integrates capacity building, strengthened oversight, and modernized infrastructure through six strategic pillars.

Conclusions:

• A validated, context-specific anti-fraud framework for Iran's health system has been proposed.
• The framework offers practical strategies to enhance transparency, accountability, and resilience in healthcare.
• This model can potentially guide other low- and middle-income countries in addressing similar healthcare governance challenges.