Table 2 Summary of themes and sub-themes

Challenges

High out-of-pocket payment for UIs

“Our problem is with people who are in the country illegally. They naturally do not receive [health] services because they have to pay OOP when they visit.“P6 (Male/ MOHME/14 years experiences)

High medical tariffs for UIs

“For immigrants without identity documents, we do not emphasize and define the Iranian tariff for them. The approved annual tariff is specific to Iranian nationals and we have their own circular for non-Iranian nationals.“P7(Female/ MOHME/15 years experiences)

Fear of deportation

“For instance, a diabetic illegal immigrant who could be treated with a low-cost medication in the beginning avoids going to medical facilities out of fear of being detained…” P8 (Male/ IHIO/23 years experiences)

Patient escape phenomenon

“Some of them [UIs] may escape. Because the cost of some treatments is very high. And that patient also had no way but escape.“ P6 (Male/ MOHME/14 years experiences)

Delayed referral

“In comparison to those who have an allowance and are in some way legal, those [immigrants] who are here illegally are far weaker and more vulnerable.“ P5(Male/ IHIO/20 years experiences)

Fragmented financial support

“For instance, if an undocumented Afghan worker falls down during a construction accident, breaks his arm and leg, or has his spinal cord severed, and needs to be taken to the hospital, the cost to the health system will be close to 5 billion Rials…"P15 (Male/ MOHME/15 years experiences)

Limited funding capacity

“With the sanctions and financial challenges, we encounter in our country, even the international fund which enter to the country is even not the rate we expected based on the refuges population in our country.” P4 (Male/ Ministry of Interior/20 years experiences)

Policy solutions

Creating an insurance coverage for UIs

“It should be mandatory for them to be insured, that is, if they are healthy, we should take money from them for their unhealthy ones.“ P8 (Male/ IHIO/23 years experiences)

New revenue sources for insurance coverage of UIs

Using the capacity of Afghans with adequate financial resources to support the UIs

“The Afghans who are in Iran and have very good financial resources should create an assembly like the donor assembly, a fund to help their poor countrymen…"P6 (Male/ MOHME/14 years experiences)

Earmarking a proportion of taxes paid by immigrants

“There are various taxes that this population pays for staying in the country. A part of it can be given to the health system to help with the cost of their medicine and treatment. It can be a good source of funding.“P7 (Female/ MOHME/15 years experiences)

Receiving monthly insurance premiums from immigrants

“The insurance companies can take the insurance premiums monthly. There is also an electronic system that renews them monthly. In this case, although I believe you should not work in such a way that it is an adverse selection that the sick will just come"P7(Female/ MOHME/15 years experiences)

Using the resources of international organizations such as the UNHCR

“When there are 300,000 to 350,000 UIs in a province, the UNHCR should provide a global amount as income to the Ministry of Health or health insurance so that the UIs can go to certain medical centers and be treated.“ P12 (Male/ IHIO/21 years experiences)

Considering lower premiums for UIs

“The health insurance premium for these [refugees] is about 80% higher than that of Iranians. The government should lower the insurance premium rate to encourage people to get insurance"P6 (Male/ MOHME/14 years experiences)

Accurate registering of information

“The Ministry of Interior has started the process of identifying illegal and unregistered immigrants because if you want to work in the insurance field, you must first know their identity"P16 (Female/ IHIO/11 years experiences)

Strategic purchasing

“It is possible to create a series of special clinics for immigrants in different parts of big cities. With this method, immigrants will know where to go to receive health services.“P8 (Male/ IHIO/23 years experiences)

Strengthening the governance

Taking advantage of the capacity of international and regional organizations

“International organizations such as the United Nations have huge financial resources that should be allocated to countries such as Iran that are facing limited resources in order to provide health services to vulnerable migrants…” P17(Male/ Medical University/6 years experiences)

Developing a national health map for UIs

“It is not a clear system in terms of implementation. In my opinion, the description of the national duties in this regard has not yet been formulated, which means we do not know which institution is in charge at the national level!?“ P10 (Male/ IHIO/17 years experiences)

Moving towards ex-ante financing approaches

“Now, most of the time, when the migrant crisis worsens, resources are allocated to finance their health services. While there is a need to allocate their financial resources before a crisis occurs, in addition to better risk distribution, it also provides a platform for more appropriate accumulation of collected financial resources.“ P17 (Male/ Medical University/6 years experiences)

Establishing a joint headquarters and participatory governance

“The government must form a council for this issue. The head of the council must be the first vice president so that they can move forward, because 5 million people is not a small number. If we want to think about it inter-sectoral, I think it will be simple and quick. These should be looked at comprehensively and intra sectoral"P11 (Male/ IHIO/20 years experiences)