Farmeco 2017;18(1)73-81.html Farmeconomia. Health economics and therapeutic pathways 2017; 18(1): 73-81 https://doi.org/10.7175/fe.v18i1.1273 Original Research Equilibrium between resources and expenditure of health sector of Social Security Fund: a case study of Iran Azadeh Ahmadi Dashtian 1, Mohsen Mardali 2 1 Sama Technical and Vocational Training College, Islamic Azad University, Qaemshahr Beranch, Qaemshahr, Iran 2 Department of Health Services Management, School of Management and Economics, Science and Research Branch, Islamic Azad University, Tehran, Iran Abstract In Iran, Social Security is the most important institution of social insurance fund, currently insuring more than a half of country population, and it has a significant role in fulfilling short-term and long-term commitments. Therefore investigation of the balance of resources and expenditure of health sector of the fund can be a scientific process of the funding the future and can pave the way to provide necessary revisions in this sector. Analyzing equilibrium between resources and expenditure of health sector of Social Security Fund in the past years, the present study offers recommendations for improving it in terms of parametric and structural dimensions. The methodology includes documentary library methods and statistical part is descriptive using Excel. Findings indicated that, regarding the present lack of balance of resources and expenditure of health sector, keeping on with the present conditions can lead to many crises. As a result, to escape from the present conditions of the funds where lack of balance of resources and expenditure exists, carrying out parametric and management-structural revisions seems necessary. Keywords Insurance; Social Security; Iran; Resources, Expenditure Corresponding author Azadeh Ahmadi Dashtian dashtiyan.a.a@gmail.com Disclosure The authors declare they have no competing financial interests concerning the topics of this article Introduction Social Security Fund is the main, largest and most developed institute of social security in Iran. It has been formed in a 50-year period of social and economic change and became active after the publication of the Social Security Bill in 1975. The article 1 of Social Security Law states that «For the purpose of implementing, extending and expanding various types of social insurance, and developing a consistent system appropriate to social security requirements, as well as centralizing cashes and incomes subject to the Social Security Law and investing and exploiting funds and resources, an independent Organization, affiliated with the Ministry of Social welfare, called the “Social Security Organization”, is established» [1]. Nowadays, this institute is responsible for insuring more than half of country population and it has an influential role in the insurance system of the country [2]. The investigation of the balance between resources and expenditure of health sector of this institute is fundamental to draw a trend of the Fund in the future and enable management decisions in this sector. The aim of the present study is to analyze the equilibrium between resource and expenditure in the health sector of the Social Security Fund in the past years and to suggest some recommendations for its improvement. Evolution of Social Security System in Iran With the advent of industrialization, fast economic and social growth led to creation of rules and organizations to meet health and social needs of employers and workers in different sector. The first step was the introduction of a set of methods and guidelines in 1930, followed by a precaution part in factories and institutes in 1936, the institution of a social insurance in 1968, and the launch of Social Security Fund in 1975. In 1979, the revision of 1975 Social Security Bill led to the integration of Social Security sections into an independent organization affiliated with the Ministry of Welfare. Finally, after the introduction of the “requirement act” in 1989 and its implementation in 1990, Social Security Fund was announced to be responsible for carrying out all commitments mentioned in clauses A and B of Social Security Act [3]. In the note 10 of article 4 of the 1986 implementation bylaw of single-article act announced that optional insured people and self-employers can use health services by paying only 9% of insurance fee. Article 9 of “general insurance” reduced this fee to capitation of health and the difference amount would be paid by the government. After the introduction of the “requirement act” in 1989 and its implementation bylaw in 1990, all health services would be carried out by healthcare centers, governmental sector or, if required, by private sector and related expenditure would be paid by the healthcare provider which is the subject of article 29 and other resources with some slight differences in insurance fees [4]. Social Security Organization is a non-governmental public organization and much of its funding comes from contributions and investment profits. Fund’s expenditure include legal and processing obligations. The mandatory insurance premium payment is 30% of the wage of the worker. The employer is responsible for 20% while government is responsible for 7% and 3% of it. Optional insurances range between 14 and 16% of the wage based on the services they offer. Legal obligations include long-term (retirement costs, disability pension, remained pension, secondary aids and disability compensation) and short-term commitments (wage compensation when being ill or pregnant, marriage financial aids, burial costs, etc.). Eighteen percent of 30% which is received as the insurance fee is dedicated to long-term commitments, 9% is dedicated to treatment of insured people and 3% is dedicated to short-term services [2]. The main sponsor of the fund is the triple cooperation of employers, insured people and the government in different fields such as macro-decisions and providing financial supports. The commitment of this organization equals to standards of ‘International Labor Organization’ and ‘International Organization of Social Security’ and methods of performing these services are based on fundamentals of ‘Social Security Law’ [3]. Macro-condition of Social Security Fund The ratio of overall expenditure to all the resources of Social Security Fund has been increased from 45% in 1976 to 96% in 2005 (Table I). Analyzing this ratio, it must be said that when it approaches 1, it indicates crisis of the fund. In addition, the ratio of long-term expenditure to overall expenditure was 7 to 9 in 1976 and the ratio of long-term expenditure to resources obtained from insurance fee was 65 to 78 in 2010. However, the ratio of costs of legal obligation store sources has passed its peak in 2010. Information of replacement ratio shows a normal situation in this fund; i.e. when this ratio is raised, welfare of retired people increases and it encourage employees to get retired due to lack of difference between incomes when employed or retired; in this sense, outcome and expenditure of the fund would increase [4]. Year Main insured Pensioners Sum of insured people and pensioners Employees in the insurance company Ratio of insured people and pensioners to employees 1962 206,120 12,111 218,241 2,782 112 1963 309,596 14,107 222,702 3,262 99 1964 312,416 18,232 331,046 3,228 96 1965 229,026 20,999 249,625 2,658 96 1966 294,812 23,913 418,726 2,002 105 1967 351,578 26,900 478,278 4,445 108 1968 539,862 27,738 567,700 5,207 109 1969 627,017 31,256 658,273 6,218 106 1970 683,396 33,850 717,326 7,092 101 1971 7,022,017 37,483 769,500 7,999 96 1972 722,584 41,022 874,616 9,285 94 1973 1,001,740 44,036 1,045,776 10,328 100 1974 1,122,911 49,679 1,172,586 12,074 97 1975 1,289,791 53,892 1,343,682 13,180 102 1976 1,520,951 61,201 1,582,152 3,930 404 1977 1,688,310 69,633 1,757,952 2,001 239 1978 1,765,526 79,372 1,844,898 6,500 284 1979 1,811,736 89,104 1,900,820 6,700 284 1980 1,697,978 100,903 1,798,381 6,800 263 1981 1,727,573 125,287 1,852,852 7,068 262 1982 1,746,740 153,776 1,900,516 7,013 271 1983 1,758,319 171,590 1,929,909 6,896 280 1984 1,973,615 184,661 2,158,276 6,643 225 1985 2,121,012 196,088 2,317,100 6,649 248 1986 223,397 211,149 3,434,546 7,170 339 1987 1,956,514 229,553 3,186,067 7,094 308 1988 2,180,390 238,871 2,429,211 7,102 242 1989 2,423,974 273,819 2,697,793 7,370 366 1990 2,779,138 313,638 3,092,776 7,296 420 1991 2,978,457 340,870 2,219,327 10,153 327 1992 3,318,192 365,962 3,684,156 10,822 340 1993 3,579,270 410,315 2,990,285 11,829 227 1994 3,894,654 472,254 3,368,008 13,159 332 1995 4,220,725 515,367 4,746,092 13,297 352 1996 4,819,859 554,654 9,374,514 11,697 392 1997 5,100,535 588,392 5,688,927 14,222 400 1998 5,625,038 617,830 6,242,868 14,815 221 1999 5,849,456 653,916 6,502,972 12,768 449 2000 5,943,708 692,321 6,638,029 15,082 440 2001 6,059,167 726,336 6,785,503 16,612 408 2002 6,257,913 774,794 733,277 166,655 428 2003 6,578,249 835,471 7,413,723 16,892 439 2004 6,888,154 917,569 7,805,723 16,822 464 2005 7,161,767 957,053 8,118,920 16,622 488 2006 7,373,727 1,058,853 8,533,579 17,229 495 2007 7,512,054 1,144,582 8,656,606 18,580 466 2008 8,412,492 1,237,091 9,689,583 20,872 464 2009 9,152,242 1,340,444 10,392,687 19,441 540 2010 9,917,542 1,255,166 1,272,708 19,023 598 2011 10,573,705 1,552,096 12,125,801 18,995 638 2012 11,497,089 1,726,457 12,222,546 17,942 737 Average growth 7.5 10.4 - 3.8 3.8 Table I. Some critical indexes for the functions of Social Security Fund from 1961 to 2012 [5] The average growth of the number of insured people, pensioner and ratio of insured people and pensioners to employees working in Social Security Fund was, respectively 7.5%, 10.4% and 3.8% from 1976 to 2011. This indicates an improvement of the growth rate of pensioners in this fund [5]. Ratio of correlation (for each pensioner there is a number of people who pay insurance fees) had a decreasing trend from 1976 to 2011 (from 25.8 % to 6.6%), despite attempts to perform programs to improve the number of insured people (including mandatory insurance and self-employers), and a further decrease in 2014 (6.2%) [5] Table II and Table III show the number of insured people and some statistics related to year 2014. Insured people (n.) Growth rate compared to the previous year (%) Insured people (main) 13,278,629 4.6 Insured people (dependent) 21,675,494 2.3 Insured people (main + dependent) 34,954,123 3.2 Pensioner (main) 2,738,587 8.4 Pensioner (dependent) 2,307,439 5.4 Pensioners (main + dependent) 5,046,026 7.0 Total 40,000,149 3.6 Table II. Number of insured people (December 2014) [5] Index Amount Ratio of support 6.20 Share of mandatory insured people among all insured people (%) 69.37 Share of optional insured people among all insured people (%) 5.82 Share of insured drivers among all insured people (%) 7.90 Share of insured weavers among all insured people (%) 4.10 Share of agreed insured people among all insured people (%) 1.64 Share of unemployed insured people among all insured people (%) 1.25 Share of insured workers among all insured people (%) 5.00 Share of retired people among all pensioners (%) 63.98 Share of disabled people among all pensioners (%) 30.22 Table III. Important statistics in insurance section in 2014 [5] Item Amount Direct treatment Average active bed (n.) 9,073 Used beds (%) 74 Death (n. in 1000) 8 Average patient’s stay (day) 2.7 Return period (hour) 23 Bed change (n.) 74 Hospitalized people in Tamin-e-ejtemaei Insurance (%) 79.5 Indirect treatment Contracted hospitals (%) 13.5 Treatment center and contracted policlinics (%) 28.9 Contracted D-clinics (%) 7.1 Contracted health centers 55.9 Average rate of hospitalization (Rials) 118,150 Average expense of hospitalization (Rials) 7.812.966 Table IV. Indexes related to direct and indirect treatment in 2014 [5] Health sector of Social Security Fund Khadamat-e-darmani (Healthcare Insurance Company) is an important part of social insurances which has a crucial and decisive role in providing health. Social Security Fund is responsible for Healthcare Insurance Company, most important activities of which include implementation, generalization, and development of different social insurances all over the country. Reaching this goal, which is a pre-requisite to maintenance and development of health is possible when it obviously fulfill needs. The driving force for performing activities in the health sector is its resources like in any other businesses. Employing these resources – called expenditure – would make reaching goals possible. Reaching goals of health sector is possible only when resources and expenditure are clearly defined and their applications are diagnosed in accordance with their related uses so as to make the development of their optimal utilization possible. Also, in this way, necessary information would be presented to managers and policy makers [5]. In this investigation, attempts are made to analyze resources and legal expenditure of health sector from 1980 to 2012. To this scope, resources and expenditure of health sector (Table IV) have been defined from 1980 to 2013 based on inventories of the organization in each year and change trend of them have been presented in current expenses, changes in inventories in the health sector and health expenses and their relationship with economic macro-indexes are explained. Defining concepts related to resources and expenditure Legal resources: all financial processes entering health sector in the financial period based on legal obligations and account documents or changes leading to increase of investments and debts or to decrease of property. Legal expenditure: all financial processes exiting health sector in the financial period based on legal obligations and account documents or changes leading to increase of property or to decrease of investments or debts. Treatment investment: extra income other than treatment expenses saved in an account with the title of ‘treatment investment’ (Annual yearbook of Social Security Organization, 2013). Results and Discussion Resources Treatment incomes were 212,912 million Rials (1 IRR = 0.0000252048 EUR [6]) in 1980, 171,457 million Rials in 1990, 292,576 in 1994 and 519,604 in 2001 at constant prices. Average annual growth rate of treatment incomes was 0.5% in the first period (1980-1985), 5.3% in the second period (1986-1989), 16.3% in the third period (1990 - 1993), 5.9% in the fourth period (1994 - 1997) and 11.3% in the fifth period (1998 - 2001). In order to come to a more realistic growth trend of treatment incomes, the trend of annual income inflation rate is not included. Annual treatment income was 31,524 million Rials in 1980, 13,656 million Rials in 1990, 15,626 million Rials in 1994, and 19,607 million Rials in 2001. Also, average annual growth rate was 5%, 10.4%, 6.2%, 2.1%, and 7.9% for the first, second, third, fourth, and fifth period, respectively. Treatment reserves at constant prices always had a positive growth and the annual growth in the third period was 53% (70.5% at current prices), 24.2% in the fourth period (compared to 48.8%) and 9.4% (compared to 32.4%) in the fifth period. Health sector debts at fixed prices also had a slower upward trend from 38,644 million Rials in 1991 to 67,345 million Rials in 1994 and to 161,320 million Rials in 2001. Expenditure The growth in treatment expenses at fixed prices had also an increasing trend from 185,082 million Rials in 1980, to 192,858, 207,401, and 454,427 million Rials in 1990, 1994, and 2001, respectively. Average annual growth of these expenses was -9.9% in the first period, -3.2% in the second period, +19.8 in the third period, +9.3% in the fourth period, and 12.5% in the fifth period. Annual treatment expenses were 27,403 Rials in 1980, 7,396 Rials in 1990, and 11,078 Rials in 1994 and 17,148 Rials in 2001. Average annual growth was -15.1% for the first period, 8.1% for the second period, 9% for the third period, 0.9% for the fourth and 8.8% for the fifth period. Total value of properties at fixed costs increased from 157,558 million Rials in 1980 to 359,749 million Rials in 1990 and to 859,780 in 2001. Average annual growth was 19.6%, 22.9%, and 9.8% in the third, fourth and the fifth period, respectively. Extra amount of incomes and expenses Extra incomes and expenses are functions of changes in incomes and expenses and calculation of them at fixed costs show their real changes in related years. Extra amount of income at fixed prices was 78,599 million Rials in 1990, 85,175 million Rials in 1994 and 5,177 million Rials in 2001. If extra amounts capitation is considered as a criterion for the evaluation of health sector, then extra capitation was 6,260 Rials in 1990, 4,550 Rials in 1994, 1,433 Rials in 1998 and 2,459 million Rials in 2001. Average annual growth was 29.8%, 10.8%, and 14.5% in the third, fourth, and fifth period, respectively. Due to unavailability of data about resources and expenses of the organization at fixed prices from 2002 to 2013, those information are not reported in this analysis. Since 1990 a greater portion of the treatment expenditure has been allocated to direct treatment and, as shown in Table V, the share of direct treatment expenditure increased to 30.3% in the third period (1990 - 1993), to 31.5% in the fourth period (1994 - 1997) and to 32.8% in the fifth period (1998 - 2001). Inversely, indirect treatment costs reduced from 69.6% in the third period to 68.5% in the fourth and to 67.1% in the fifth period. In 2002, the share of direct treatment expenditure was 46.7% and share of indirect treatment expenses was 53.3% of total expenditure. Year Total treatment costs (Rials) Direct treatment costs (Rials) Direct treatment costs on total costs (%) Indirect treatment costs (Rials) Indirect treatment costs on total costs (%) 1991 92,858 31,615 34 61,243 66 1992 180,600 53,681 29.7 126,919 70.3 1993 294,552 84,609 28.7 209,943 71.3 1994 386,694 112,812 29.2 273,882 70.8 1995 517,053 164,805 31.9 352,248 68.1 1996 717,941 227,222 31.6 490,719 68.4 1997 1,109,982 350,118 31.5 759,864 68.5 1998 1,560,803 485,667 31.1 1,075,136 68.9 1999 2,092,449 591,891 28.3 1,500,558 71.7 2000 2,422,064 751,388 31 1,670,676 69 2001 3,197,183 1,148,143 35.9 2,049,040 64.1 2002 4,350,686 1,575,217 36.2 2,775,469 63.8 2003 6,054,134 2,667,043 44.1 3,387,092 55.9 Table V. Share of expenditure from 1990 to 2002 [4] Table VI shows the share of direct and indirect treatment expenditure after the requirement act. A great share of treatment expenditure come from the increase of costs in related years. The omission of inflation of growth rate of expenditure shows their real growth. In the analyzed periods, treatment expenditure grew from 7.6% in the first period, to 29.4% in the fifth period (Table VII). Period (year) Indirect treatment expenditure (%) Direct treatment expenditure (%) 1991- 1994 69.6 30.3 1995- 1998 68.5 31.5 1999- 2002 67.1 32.8 2003 55.9 44.1 Table VI. Share of direct and indirect treatment expenditure in years after ‘requirement act’ [4] Growth in treatment expenditure (%) With omission of inflation from expenditure (%) First period (1980-1984) 7.6 9.9 Second period (1985-1990) 14.5 3.2 Third period (1991-1994) 44 19.8 Fourth period (1995-1998) 41.9 9.3 Fifth period (1999-2002) 29.4 12. Table VII. Growth rate in treatment expenses from 1979 to 2002 [4] Trend of resources and expenditure at current price In Appendix A resources and expenditure of health sector of Social Security Fund at current price from 1979 to 2014 are reported. Based on Authors’ calculations, between 1975-2014, resources, expenditure, and total income of the organization grew up of 9%, 13% and 28%, respectively. Figures 1 and 2 show the trend of expenditure and resources indexes of health sector of Social Security Fund between 1980-2014. Figure 1. Trend of treatment expenditure and resources, total income of the organization, and Extra amount (resources – expenditure) from 1980 to 2014 Figure 2. Ratio between resources and expenditure, treatment resources and total income, and treatment expenditure and total income of the organization from 1980 to 2014 As shown in Table VIII, the Social Security Fund ratio of participation in the health sector expenditure of the Country ranged from 9 to 11% in years 2002-2011. Year Total public expenditure of health sector (billion Rials) Total expenditure of Social Security Fund (billion Rials) Ratio of participation (%) 2003 53,351 5,047 9 2004 70,222 6,580 9 2005 90,534 9,160 10 2006 116,645 12,015 10 2007 141,667 13,154 9 2008 179,332 17,946 10 2009 224,359 24,529 11 2010 286,327 28,000 10 2011 359,286 32,948 9 2012 452,793 39,224 9 Table VIII. Social Security Fund ratio of participation in the health sector expenditure [7] Changes in resources and expenditure of health sector and price fluctuations As it can be seen, a large part of the growth of resources and expenditure is due to a constant increase of prices (inflation). If price increases are subtracted from the growth of resources and the cost of treatment is removed remove, actual prices would be available. Figure 3 shows the inflation rate in the health sector in urban and rural areas from 2003 to 2014 Without taking inflation into account, the rate of actual growth would be 0.5% for the first period (compared to 20.8%), - 5.3% for the second period (as compared to 12.3%), 16.3% for the third period (compared to 38.7), 5.9% for the fourth period (compared to 38.15%), 11.3 for the fifth period (compared to 28.4%), and finally for the sixth period (2002 - 2013) it is equal to – 3%. Average rate of actual annual growth would be 9.9% for the first period (compared to 7.6% at fixed prices), - 3.2% for the second period (as compared to 14.5%), 19.8% for the third period (compared to 44%), 9.3% for the fourth period (compared to 41.9%), 12.5% for the fifth period (compared to 29.4%), and finally for the sixth period (2002 - 2013) it is equal to 7%. Figure 3. Rate of inflation in health sector from 2003 to 2014 Conclusions As it is observed, according to the present data and statistics, the trend of resources and expenditure of health sector of Social Security Fund needs more considerations. Trend of of resources and expenditure of health sector is a function of total resources of the organization. Therefore, growth of treatment incomes has a negative status when compared to inflation and this due to 1) a reduction in organization income in recent years, 2) a little growth of resources, 3) no full allocation of legal resources to this section, 4) no payment of government debts to this sector (near 10000 milliard Rials), 5) growth of long-term commitments of this organization, and 6) reducing trend of number of years of being insured for aims of retirement. On the other hand, expenditure in the health sector would have an upward increasing trend due to many reasons including the semi-insurance (support) acts, the lack of principles of insurance calculations, increasing age of the insured people, increasing number of retired people and the need to more healthcare services, promotion of health culture in the society in requesting more healthcare services, more request for direct healthcare sector, increase of inflation in production sector, more life expectancy, and lack of investment in prevention of different levels. Now, because of the imbalance of resources and expenditure in the health sector has passed its peak in 2002 as a result of total resources and expenditure of the Organization. Since then, the gap between these has become bigger according to a 9% growth of resources and 13% growth of expenditure. On the other hand, the statistical drawback in lack of clarity in the allocation of resources in health sector leads to lack of attention to this problem and this emerges from 1) incorrect discrimination of these numbers and 2) lack of an independent official unit in health sector of Social Security Fund. If this upward trend of the ratio between expenditure and resources persists the imbalance in the health sector would lead to its bankruptcy, dysfunction in the execution of its short-term and long-term commitments, and if not supported by the government it could lead to social crisis. Recommendations Strategies to get out of the present situation to reach an equilibrium between resources and expenditure: Performing parametric reforms Increasing of retirement age Increasing of work experience and years paying insurance fee Increasing of insurance capitation Carrying out exact actuarial calculations and readjusting of insurance conditions Revising some obligations such as hard work in some occupations and early retirement Carrying out management-structural reforms Designing a multi-layer system for Social Security Fund Increasing number of insured people Saving unnecessary costs Paying pending debts Paying attention to health of insured people and concentrating on prevention of getting sick Lack of imposition of non-insurance commitments such as supportive services by the parliament and the government Actual independence of the organization as a supporting non-governmental institute Following triple principle so as to attracting cooperation of all beneficiaries in maintenance of the fund Preventing methods of escaping from being insured Receiving deductible can pave the way to better services of the fund provided to insured people so as to prevent extra costs Increasing skills and making employees competent besides reducing unemployment insurance are the best methods of making the fund out of the crisis of correct management financial resources in the organization Correct management in organizations offering health services Necessary monitor for reducing moral dangers in insurance companies Reducing treatment expenditure by prioritizing prevention services and increase of attention to health sector Clarity and discrimination of resources in health sector of Social Security Fund and of the trend and behavior of situation-sensitive variables Appendix A Year Total income of the organization (Rials) Treatment expenditure (Rials) Treatment resource (Rials) Extra amount (resources – expenditure) (Rials) Ratio between resources and expenditure (%) Growth of organization income (%) Ratio between treatment resources and total income (%) Ratio between treatment expenditure and total income 1980 - 113,673 103,455 -10,218 91.01 - - - 1981 - 185,082 212,912 27,830 115.03 - - - 1982 192,267 159,447 215,223 55,776 134.97 - 111.9396 0.8293 1983 199,359 159,447 215,223 55,776 134.98 1.036886 107.9575 0.799798 1984 223,238 145,926 210,935 65,009 144.54 1.119779 94.48884 0.653679 1985 266,077 148,565 214,994 66,429 144.71 1.191898 80.80142 0.558353 1986 275,076 166,729 226,213 59,484 135.67 1.033821 82.23655 0.60612 1987 317,993 166,128 182,301 16,173 109.73 1.156019 57.32862 0.522427 1988 319,449 131,518 169,185 37,667 128.64 1.004579 52.96151 0.411703 1989 364,317 122,694 148,594 25,900 121.10 1.140454 40.78701 0.336778 1990 427,692 115,507 148,818 33,311 128.83 1.173956 34.7956 0.270071 1991 545,478 92,858 171,457 78,599 184.64 1.275399 31.43243 0.170232 1992 787,165 149,627 202,641 53,014 135.43 1.443074 25.74314 0.190083 1993 1,099,637 196,237 226,946 30,709 115.64 1.396959 20.63827 0.178456 1994 1,622,312 209,703 272,612 62,909 129.99 1.475316 16.80392 0.129262 1995 2,570,036 210,740 292,576 81,836 138.83 1.584181 11.38412 0.081999 1996 3,269,259 192,878 273,979 81,101 142.04 1.272067 8.380462 0.058997 1997 4,711,119 241,931 303,817 61,886 125.58 1.441036 6.448935 0.051353 1998 5,887,234 290,004 340,038 50,034 117.25 1.249647 5.775853 0.04926 1999 7,212,419 324,109 358,752 34,643 110.68 1.225095 4.974087 0.044938 2000 9,370,840 311,559 381,812 70,253 122.54 1.299265 4.074469 0.033248 2001 14,228,856 371,981 460,407 88,426 123.77 1.51839 3.235789 0.026143 2002 19,460,602 454,427 519,604 65,177 114.34 1.367712 2.67003 0.023351 2003 25,502,306 588,822 568,707 -20,115 96.58 1.310458 2.23002 0.023089 2004 33,861,667 758,366 622,449 -135,917 82.07 1.327788 1.838212 0.022396 2005 47,532,902 904,388 681,271 -223,117 75.32 1.403738 1.433262 0.019027 2006 48,640,513 1,093,291 745,651 -347,640 68.20 1.023302 1.532983 0.022477 2007 67,859,550 1,335,837 816,115 -519,722 61.09 1.395124 1.202653 0.019685 2008 93,590,868 1,829,206 893,238 -935,968 48.83 1.379185 0.954407 0.019545 2009 116,616,166 2,369,470 977,649 -1,391,821 41.26 1.246021 0.838348 0.020319 2010 147,779,421 2,868,403 1,070,037 -1,798,366 37.30 1.267229 0.724077 0.01941 2011 210,393,363 3,441,652 1,171,155 -2,270,497 34.02 1.423699 0.55665 0.016358 2012 277,435,420 4,008,510 1,281,829 -2,726,681 31.97 1.318651 0.462028 0.014448 20131 356,048,834 4,549,341 1,402,962 -3,146,379 30.83 1.29 0.394036 0.012777 20141 456,937,951 5,163,141 1,535,542 -3,627,599 29.74 1.283358 0.33605 0.011299 Table IA. Resources and expenditure of health sector of Social Security Fund at current price from 1979 to 2013 [4] (Calculations of 2012 and 2013 are based on the past trend of indexes by the Author, calculations of resources in health sector of Social Security Fund from 2002 to 2013 are based on increase of expenses from 1979 to 2001 (equal to 9% annual) by the Author, resources of health sector of the organization from 2003 to 2013 are not calculated by Social Security Fund) References 1. Islamic Republic of Iran. Social Security Law 1975 2. Fazaeli A, Mehr Ara M. Examining the balance in financial provision of Iranian family `s health expenses. Health Management Journal 2010; 50: 63-70 3. Islamic Republic of Iran. Law of social security organization 1990 4. Shapourgan M. Investigation of resources and expenditure of health sector from 1975 up to now based on rules. Higher institute of Social Security Research, plan and budget: Tehran, 2013 5. Annual year book of Social Security Organization. Available at: https://www.amar.org.ir/english/Iran-Statistical-Yearbook 6. XE Currency Converter. Available at: http://www.xe.com 7. Iranian Statistics Center. National Health Account (2002 – 2011). Available at https://www.amar.org.ir/english/Statistics-by-Topic/National-accounts