Tracking socio-economic inequalities in healthcare utilization in Iran: a repeated cross-sectional analysis

Factors Explaining the Change in Socioeconomic Inequality of Disability in Iran: A Repeated Cross-sectional Study

Background

More than 15% of the world's population live with some form of disability. Assessing socioeconomic inequalities in disability and monitoring its change over time can help policymakers to design and implement targeted interventions to reduce these inequalities. This study aimed to assess the change in socioeconomic inequality in disability in Iran from 2000 to 2010.

Methods

Data for this cross-sectional study were obtained from 2 waves of Iran's demographic and health surveys (2000 and 2010). The Wagstaff normalized concentration index was used to measure the socioeconomic inequality of disability. Contributing factors to the inequality in 2000 and 2010 were investigated by concentration index decomposition. The Blinder-Oaxaca decomposition method was used to determine contributing factors of change in disability inequality. All analyses were conducted in Stata14.

Results

The negative and statistically significant concentration indices (-0.132 in 2000 and -0.165 in 2010, P < 0.001) suggested more concentration of disability among poor people. The absolute value of inequality was increased by 0.034 between the 2 points of time (P = 0.025). Level of education (123.5%), household size (12.9%), age (-35.1%), and residency (in terms of Iran's provinces) (-19.3%) were the contributing factors to the measured disability inequality in 2000. In 2010, level of education (105.8%), household size (30.5%), and urban residency (-46.3%) explained the measured inequality. Change in disability inequality was explained by household size (99.4%), province of residence (54.8%), education (36.9%), socioeconomic status (20%), urban residency (-90.3%), and age (-47.7%).

Conclusion

Iran suffers from significant socioeconomic inequality in disability, and it significantly increased over time. Interventions such as increasing health literacy and providing suitable job opportunities for people with low education level, improving the socioeconomic status of extended households, and paying more attention to the balanced development in the provinces and urban and rural areas, and attending to prevention, treatment, and mitigation of disability adversities among poor young and elderly people could be recommended to tackle increased socioeconomic inequality in disability and its unfavorable consequences in Iran.

Healthcare reform and productivity of Hospital: a DEA-based analysis from South West of Iran

BACKGROUND

Different healthcare reforms could affect the productivity of hospitals. The aim of this study was to track hospital productivity before and after the recent Iranian healthcare reform in Khuzestan province, South West of Iran.

METHODS

Hospital productivity was evaluated through data envelopment analysis (DEA) and Malmquist productivity index (MPI) from 2011 to 2015 for 17 Iranian public hospitals before and after the health sector transformation plan. We assumed an output-oriented model with variable returns to scale (VRS) to estimate the productivity and efficiency of each hospital. The DEAP V.2.1 software was used for data analysis.

RESULTS

After the transformation plan, the averages of technical efficiency, managerial efficiency and scale efficiency in the studied hospitals had negative changes, but technology efficiency had positive changes.44.4% of general hospitals, 25% of multi-specialized hospitals, and 100% of specialized hospitals had positive productivity changes after implementing the health sector evolution plan. The Malmquist productivity index (MPI) had low positive changes from 2013 to 2016 (MPI = 0.13 out of 1) but the mean productivity score had no change after the health sector evolution plan.

CONCLUSIONS

The total productivity before and after the health sector evolution plan had no change in Khuzestan province. This and the increase in the utilization of impatient services seemed to be a sign of good performance. But apart from technology efficiency, other efficiency indices had negative changes. It is suggested that in health reforms in Iran, more attention should be paid to the allocation of resources in the hospital.

Decomposed Trends of Iranian Private Health Expenditures: Should Inequality be Appreciated?

Background: Inequalities in health and health care have drawn considerable attention in social determinants of health literature. This study aims to calculate the inequality of out-of-pocket health payments (OPHP) for Iranian households during the period 1984 to 2019 and provide decomposed inequality for households with different socioeconomic status. Methods: This longitudinal study utilized the Iranian Statistics Centre data on Iranian household income and expenditures survey. The analysis includes a total of 995,300 households during a 36-year period from 1984 to 2019. The Theil index and the mean logarithmic deviation were used to decompose inequality into within-group and between-group for OPHP among Iranian households. Results: The findings indicate that the mean of the Theil index for the households covered by insurance is 1.44 (SD ± 0.34), while the index was 1.35 (SD ± 0.31) for households without insurance coverage. The mean of the Theil index for rural and urban households was 1.29 (SD ± 0.29) and 1.43 (SD ± 0.33), respectively. Regardless of the fluctuations, the trends of between- group and within group inequalities in OPHP were almost similar until 2011, but they followed a different path since then. Conclusion: Households living in cities, households with insurance coverage, and households in high income levels have experienced more inequality in OPHP than other households. This study provides a novel interpretation of inequality in health care expenditures and provides a long-term time series data to assess the effectiveness of implemented policies in health care system.

Utilization of health services among the elderly in Iran during the COVID-19 outbreak: A cross-sectional study

Background and Aims

Elderly people are potentially vulnerable with a higher need for health services, and utilization of Essential Public Health Services (EPHS) among this group is of high importance. This study aimed to examine the utilization of health services among the elderly in Iran during the coronavirus disease 2019 outbreak.

Methods

This was a cross-sectional study conducted in 21 public health centers in Sirjan, Southern Iran, from May to December 2020. A total of 420 elderly patients were selected through a systematic random sampling method. Data were collected using a questionnaire and were analyzed using SPSS v22.0. The binary logistic regression was used to examine the effect of demographic, socioeconomic and morbidity status on inpatient and outpatient healthcare utilization.

Results

Our results showed that 56% of the elderly had a history of hospitalization during the last year. Although 60% of the elderly reported they had a perceived need for outpatient services, only 49% of them reported that they utilized outpatient services. 51% and 35.5% of the elderly reported that their inpatient and outpatient costs were covered by health insurance, respectively. Others reported their health spending was financed through out-of-pocket payments. Male gender aged 80 and above, urban residents, higher socioeconomic and supplemental insurance coverage were associated with an increase in health services utilization. The elderly with Cancer, mental disorders, kidney disease, and cardiovascular diseases (CVDs) were more likely to be hospitalized.

Conclusion

There were demographic and socioeconomic inequalities in health services utilization among the elderly. Therefore, appropriate interventions and strategies are needed to reduce these inequalities in health services utilization among the elderly. In addition, given that the hospitalization rate was significantly higher among the elderly with chronic diseases than those without, it is crucial and necessary to take interventions to reduce the burden of chronic diseases in the future.

Urban and sub-urban disparities in health outcomes among patients with COVID-19; a cross-sectional study of 234 418 patients in Iran

Background

It remains crucial to understand socio-demographic determinants of COVID-19 infection to improve access to care and recovery rates from the disease. This study aimed to investigate the urban and sub-urban disparities associated with COVID-19 in patients visiting healthcare facilities in the province of Tehran, Iran.

Methods

Data from 234 418 patients who were diagnosed with COVID-19 infection from March 2020 to March 2021 in the province of Tehran were used in this analysis. Descriptive statistics were used to describe the characteristics of the study population. Chi-Squared test was applied to examine the association of study variables with residing area. Independent samples t-test was performed to compare mean age of patients in urban and sub-urban areas. Multiple Logistic Regression model was applied to examine the association of study variables with disease outcome.

Results

Overall, most patients resided in the urban settings (73%). Mean age of patients was significantly lower in sub-urban areas compared to their counterparts in urban settings (49 ± 23.1 years versus 53 ± 21.1 years, P < 0.001). Positive PCR test results were more common in urban areas (48.5% versus 41.3%, P < 0.001). Yet, sub-urban settings had higher rates of positive chest CT scan reports (62.8% versus 53.4%, P < 0.001). After accounting for age and sex covariates, residing in urban areas was associated with higher likelihood of being admitted to an ICU (OR = 1.27, CI: 1.240-1.305). Yet, a greater vulnerability to fatal outcome of COVID-19 infection was shown in patients living in sub-urban areas (OR = 1.13, CI: 1.105-1.175).

Conclusions

This study revealed a clear disparity in the health outcome of patients infected with COVID-19 between urban and sub-urban areas.

User fee removal for the poor: a qualitative study to explore policies for social health assistance in Iran

Introduction

Removal of user fee for vulnerable people reduces the financial barriers associated with healthcare payments, which, in turn, improves health outcomes and promotes health equity. This study sought to provide policy strategies to reduce user fee at the point of service delivery for the poor in Iran.

Methods

This is a qualitative study carried out in 2018. The purposive sampling method was applied, and 33 experts with relevant and valuable experiences and maximum variation to obtain representativeness and rich data were interviewed. Trustworthiness criteria were used to assure the quality of the results. The data were analyzed based on thematic analysis using the MAXQDA10 software.

Results

The most important issue regarding financial protection against user fee for the poor in Iran is policy integration and cohesion. Differences in access to financial support for user fee coverage among different groups of the poor have led to inequalities in access and financial protection among the poor. The suggested protection policies against the user fee at the point of service delivery in Iran can be categorized into three main categories: 1) basic health social insurance instruments, 2) free health services to the poor outside of the health insurance system, and 3) complementary insurance mechanisms.

Conclusion

Implementing a cohesive social assistance policy for all disadvantaged groups is needed to address inequalities in financial protection against user fee payment among the poor in Iran. Reducing user fee through mechanisms such as deductible cap, stop-loss, variable user fee and sliding fee scale can improve financial protection and enhance healthcare utilization among the poor. A user fee exemption is not enough to remove barriers to access to service for the poor, as other costs such as transportation expenditures and informal payments also put financial pressure on them. Therefore, financial support for the poor should be designed in a comprehensive protection package to reduce out-of-pocket payments for healthcare services, and indirect costs associated with healthcare utilization.

Socioeconomic inequality in congenital heart diseases in Iran

INTRODUCTION

Social-economic factors have an important role in shaping inequality in congenital heart diseases. The current study aimed to assess and decompose the socio-economic inequality in Congenital Heart Diseases (CHDs) in Iran.

METHODS

This is a cross-sectional research conducted at Shahid Rajaie Cardiovascular Medical and Research Center in Tehran, Iran, as one of the largest referral heart hospitals in Asia. Data were collected primarily from 600 mothers who attended in pediatric cardiology department in 2020. The polychoric principal component analysis (PCA) and Errygers corrected CI (ECI) were used to construct household socioeconomic status and to assess inequality in CHDs, respectively. A regression-based decomposition analysis was also applied to explain socioeconomic-related inequalities. To select the explanatory social, medical/biological, and lifestyle variables, the chi-square test was first used.

RESULTS

There was a significant pro-rich inequality in CHDs (ECI = -0.65, 95% CI, - 0.72 to - 0.58). The social, medical/biological, and lifestyle variables accounted for 51.47, 43.25, and 3.92% of inequality in CHDs, respectively. Among the social variables, family SES (about 50%) and mother's occupation (21.05%) contributed the most to CHDs' inequality. Besides, in the medical/biological group, receiving pregnancy care (22.06%) and using acid folic (15.70%) had the highest contribution.

CONCLUSION

We concluded that Iran suffers from substantial socioeconomic inequality in CHDs that can be predominantly explained by social and medical/biological variables. It seems that distributional policies aim to reduce income inequality while increasing access of prenatal care and folic acid for disadvantaged mothers could address this inequality much more strongly in Iran.

Introducing an efficient sampling method for national surveys with limited sample sizes: application to a national study to determine quality and cost of healthcare

Background

Sampling a small number of participants from an entire country is not straightforward. In this case, researchers reluctantly sample from a single setting or few settings, which limits the generalizability of findings. Therefore, there is a need to design efficient sampling method for small sample size surveys that can produce generalizable results at the country level.

Methods

Data comprised of twenty proxy variables to measure health services demands, structures, and outcomes of 413 districts of Iran. We used two data mining methods (hierarchical clustering method (HCM) and model-based clustering method (MCM)) to create homogenous groups of districts, i.e., strata based on these variables. We compared the internal and stability validity of the methods by statistical indices. An expert group checked the face validity of the methods, particularly regarding the total number of strata and the combination of districts in each stratum. The efficiency of selected method, which is measured by the inverse of variance, was compared with a simple random sampling (SRS) through simulation. The sampling design was tested in a national study in Iran, which aimed to evaluate the quality and costs of medical care for eight selected diseases by only recruiting 300 participants per disease at the country level.

Results

MCM and HCM divided the districts into eight and two clusters, respectively. The measures of internal and stability validity showed that clusters created by MCM were more separated, compact, and stable, thus forming our optimum strata. The probability of death from stroke, chronic obstructive pulmonary disease, and in-hospital mortality rate were the most important indicators that distinguished the eight strata. Based on the simulation results, MCM increased the efficiency of the sampling design up to 1.7 times compared to SRS.

Conclusions

The use of data mining improved the efficiency of sampling up to 1.7 times greater than SRS and markedly reduced the number of strata to eight in the entire country. The proposed sampling design also identified key variables that could be used to classify districts in Iran for sampling from these target populations in the future studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11441-0.

Socioeconomic determinants of unmet need for outpatient healthcare services in Iran: a national cross-sectional study

BACKGROUND

Unmet need is a critical indicator of access to healthcare services. Despite concrete evidence about unmet need in Iran's health system, no recent evidence of this negative outcome is available. This study aimed to measure the subjective unmet need (SUN), the factors associated with it and various reasons behind it in Iran.

METHODS

We used the data of 13,005 respondents over the age of 15 from the Iranian Utilization of Healthcare Services Survey in 2016. SUN was defined as citizens whose needs were not sought through formal healthcare services, while they did not show a history of self-medication. The reasons for SUN were categorized into availability, accessibility, responsibility and acceptability of the health system. The multivariable logistic regression was used to determine significant predictors of SUN and associated major reasons.

RESULTS

About 17% of the respondents (N = 2217) had unmet need for outpatient services. Nearly 40% of the respondents chose only accessibility, 4% selected only availability, 78% chose only responsibility, and 13% selected only acceptability as the main reasons for their unmet need. Higher outpatient needs was the only factor that significantly increased SUN, responsibility-related SUN and acceptability-related SUN. Low education was associated with higher SUN and responsibility-related SUN, while it could also reduce acceptability-related SUN. While SUN and responsibility-related SUN were prevalent among lower economic quintiles, having a complementary insurance was associated with decreased SUN and responsibility-related SUN. The people with basic insurance had lower chances to face with responsibility-related SUN, while employed individuals were at risk to experience SUN. Although the middle-aged group had higher odds to experience SUN, the responsibility-related SUN were prevalent among elderly, while higher age groups had significant chance to be exposed to acceptability-related SUN.

CONCLUSION

It seems that Iran is still suffering from unmet need for outpatient services, most of which emerges from its health system performance. The majority of the unmet health needs could be addressed through improving financial as well as organizational policies. Special attention is needed to address the unmet need among individuals with poor health status.

Decomposition of gendered socioeconomic-related inequality in outpatient health care utilization: A cross-sectional study from Iran

INTRODUCTION

Unequal access to required health care services could deteriorate inequality in health outcomes and increase mortality and morbidity, especially among disadvantaged groups. One of the most debated factors in shaping health care inequalities is gender. This study aimed to measure and explains gendered socioeconomic-related inequality in outpatient health care utilization in Iran.

METHODS

This is a cross-sectional research conducted at a national level in Iran. The required data was obtained from an Iranian health care utilization household survey conducted in 2015. Erreygers Concentration Index (ECI) was used to measure the socioeconomic inequality in outpatient health care utilization. A regression-based decomposition analysis was also used to explain socioeconomic-related inequalities.

RESULTS

There was a significant pro-rich inequality in outpatient health care utilization between males (ECI = 0.115, SE = 0.014) and females (ECI = 0.083 SE = 0.011) indicating that utilization of these services was concentrated on the better-offs. The decomposition analysis revealed that economic status (males = 50.58%, females = 37.42%) was the main contributor to the observed inequality. Location of residence, health insurance and education were other main driver of these inequalities.

CONCLUSIONS

Different factors have different contribution to socioeconomic-related inequality in utilization of outpatient health care services and these could be diversified considering gender. Hence, it seems that policy makers could be able to address these inequalities effectively through gender-oriented policies.