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Rezaei S, Karimi M, Soltani S, Barfar E, Gharehghani MAM, Badakhshan A, Badiee N, Pakdaman M, Brown H. Household financial burden associated with out-of-pocket payments for healthcare in Iran: insights from a cross-sectional survey. BMC Health Serv Res 2024; 24:1062. [PMID: 39272081 PMCID: PMC11396140 DOI: 10.1186/s12913-024-11477-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 08/22/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND One of the key functions and ultimate goals of health systems is to provide financial protection for individuals when using health services. This study sought to evaluate the level of financial protection and its inequality among individuals covered by the Social Security Organization (SSO) health insurance between September and December 2023 in Iran. METHODS We collected data on 1691 households in five provinces using multistage sampling to examine the prevalence of catastrophic healthcare expenditure (CHE) at four different thresholds (10%, 20%, 30%, and 40%) of the household's capacity to pay (CTP). Additionally, we explored the prevalence of impoverishment due to health costs and assessed socioeconomic-related inequality in OOP payments for healthcare using the concentration index and concentration curve. To measure equity in out-of-pocket (OOP) payments for healthcare, we utilized the Kakwani progressivity index (KPI). Furthermore, we employed multiple logistic regression to identify the main factors contributing to households experiencing CHE. FINDINGS The study revealed that households in our sample allocated approximately 11% of their budgets to healthcare services. The prevalence of CHE at the thresholds of 10%, 20%, 30%, and 40% was found to be 47.1%, 30.1%, 20.1%, and 15.7%, respectively. Additionally, we observed that about 7.9% of the households experienced impoverishment due to health costs. Multiple logistic regression analysis indicated that the age of the head of the household, place of residence, socioeconomic status, utilization of dental services, utilization of medicine, and province of residence were the main factors influencing CHE. Furthermore, the study demonstrated that while wealthy households spend more money on healthcare, poorer households spend a larger proportion of their total income to healthcare costs. The KPI showed that households with lower total expenditures had higher OOP payments relative to their CTP. CONCLUSION The study findings underscore the need for targeted interventions to improve financial protection in healthcare and mitigate inequalities among individuals covered by SSO. It is recommended that these interventions prioritize the expansion of coverage for dental services and medication expenses, particularly for lower socioeconomic status household.
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Affiliation(s)
- Satar Rezaei
- Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Maryam Karimi
- Hajar Teaching Hospital, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Shahin Soltani
- Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Eshagh Barfar
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mohammad Ali Mohammadi Gharehghani
- Social welfare Management Research Center, Social Health Research Institute, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Abbas Badakhshan
- School of Health , Golestan University of Medical Sciences, Gorgan, Iran
| | - Nasim Badiee
- Department of Health Management, Economic and Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Pakdaman
- Health Policy and Management Research Center, Department of health management and Economics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Heather Brown
- Division of Health Research, Lancaster University, Lancaster, UK
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Shaltynov A, Jamedinova U, Semenova Y, Abenova M, Myssayev A. Inequalities in Out-of-Pocket Health Expenditure Measured Using Financing Incidence Analysis (FIA): A Systematic Review. Healthcare (Basel) 2024; 12:1051. [PMID: 38786461 PMCID: PMC11121301 DOI: 10.3390/healthcare12101051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
Government efforts and reforms in health financing systems in various countries are aimed at achieving universal health coverage. Household spending on healthcare plays a very important role in achieving this goal. The aim of this systematic review was to assess out-of-pocket health expenditure inequalities measured by the FIA across different territories, in the context of achieving UHC by 2030. A comprehensive systematic search was conducted in the PubMed, Scopus, and Web of Science databases to identify original quantitative and mixed-method studies published in the English language between 2016 and 2022. A total of 336 articles were initially identified, and after the screening process, 15 articles were included in the systematic review, following the removal of duplicates and articles not meeting the inclusion criteria. Despite the overall regressivity, insurance systems have generally improved population coverage and reduced inequality in out-of-pocket health expenditures among the employed population, but regional studies highlight the importance of examining the situation at a micro level. The results of the study provide further evidence supporting the notion that healthcare financing systems relying less on public funding and direct tax financing and more on private payments are associated with a higher prevalence of catastrophic health expenditures and demonstrate a more regressive pattern in terms of healthcare financing, highlighting the need for policy interventions to address these inequities. Governments face significant challenges in achieving universal health coverage due to inequalities experienced by financially vulnerable populations, including high out-of-pocket payments for pharmaceutical goods, informal charges, and regional disparities in healthcare financing administration.
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Affiliation(s)
- Askhat Shaltynov
- Epidemiology and Biostatistics Department, Semey Medical University, Semey 071400, Kazakhstan; (U.J.); (M.A.)
| | - Ulzhan Jamedinova
- Epidemiology and Biostatistics Department, Semey Medical University, Semey 071400, Kazakhstan; (U.J.); (M.A.)
| | - Yulia Semenova
- School of Medicine, Nazarbayev University, Astana 010000, Kazakhstan;
| | - Madina Abenova
- Epidemiology and Biostatistics Department, Semey Medical University, Semey 071400, Kazakhstan; (U.J.); (M.A.)
| | - Ayan Myssayev
- Department of the Science and Human Resources, Ministry of Healthcare of the Republic of Kazakhstan, Astana 010000, Kazakhstan;
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Ezzati E, Molavynejad S, Jalali A, Cheraghi MA, Jahani S, Rokhafroz D. The challenges of the Iranian nursing system in addressing community care needs. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2023; 12:362. [PMID: 38144017 PMCID: PMC10743943 DOI: 10.4103/jehp.jehp_1398_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/07/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND The nursing system is one of the major and important fields of health and medicine in every country, responsible for providing nursing care and addressing medical and health-related community care needs. The aim of this study was to explain the challenges of the Iranian nursing system in addressing community care needs. MATERIALS AND METHODS A conventional content analysis method was performed in this exploratory qualitative study, and 27 participants were selected through a purposive sampling method based on the inclusion criteria. In-depth semi-structured interviews were conducted with the subjects, and data saturation was achieved in the 27th interview. The main interviews with the participants were individual, in person, and face-to-face, conducted at different times (morning and evening) in a peaceful environment and at the convenience of the participants. The interviews were recorded by the researcher with the participants' consent. The duration of the interviews ranged from 50 to 70 minutes, given the participants' energy and time. Data analyses were done using Graneheim and Lundman approach. RESULTS After conducting the interviews and the simultaneous analysis, three themes were extracted, including the challenging structure in the internal environment, the operating environment, and the social environment, with seven main categories and 26 subcategories. An inadequate number of nurses given the real needs of society, the unbalanced proportion of employed clinical nurses to the real needs of society, poor presence of nurses in community-based nursing services, insufficient attention to the optimization of the work environment, the gap between education and clinical practice in the nursing system, poor mutual accountability of the community, and policies in the health system were seven main categories in this study. CONCLUSION In general, the results showed that the Iranian nursing system faces many micro, meso, and macroscale challenges. It is necessary to plan properly to enhance the accountability of the nursing system to the current community care needs by improving the situation.
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Affiliation(s)
- Ebrahim Ezzati
- Student Research Committee, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Shahram Molavynejad
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Amir Jalali
- Department of Psychiatric Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad-Ali Cheraghi
- Department of Nursing Management, School of Nursing and Midwifery, Tehran University of Medical Sciences, Health Sciences Phenomenology Association, Ministry of Health and Medical Education, Tehran, Iran
| | - Simin Jahani
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Dariush Rokhafroz
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Bordbar S, Gholampoor H, Jalali FS, Delavari S. The Effect of Iran Health Transformation Plan on Equity in Health Financing: A Systematic Review. IRANIAN JOURNAL OF PUBLIC HEALTH 2023; 52:1844-1854. [PMID: 38033830 PMCID: PMC10682583 DOI: 10.18502/ijph.v52i9.13567] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 12/19/2022] [Indexed: 12/02/2023]
Abstract
Background Achieving financial goals is one of the health systems goals, especially for those in low- and middle-income countries. Since financing equity, is an objective of Health Transformation Plan (HTP) implementation in Iran, this study examined this plan toward improving equity in healthcare Financing, using four payment indices: Out-of-Pocket Payment (OOP), Catastrophic Health Expenditure (CHE), Fair financial Contribution Index (FFCI) and Impoverishing Health Expenditure (IHE). Methods Articles published in English on equity in financing related to HTP were searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between Jan 2014 and Dec 2020, following PRISMA guidelines. Overall, 1319 papers were retrieved initially, and 31 were selected for analysis. Results After implementation of HTP, OOP index has decreased between patients and households. No consistent trend was evident for CHE. HTP reforms have a limited effect on the FFCI. The one study on IHE has shown an upward trend for this index. In general, in the early years of HTP, there was a higher downward trend in equity in financing indicators than in subsequent years. Conclusion HTP has made significant accomplishments in equity, such as the financial protection of patients in healthcare centers, but fail to achieve this plan goals, significantly reduced its value. Therefore, it is necessary for managers and health policy makers around the world, with scientific and principled solutions, to prevent loss of their reform plans positive achievements.
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Affiliation(s)
- Shima Bordbar
- Student Research Committee, Department of Health Services Management, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hanie Gholampoor
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Faride Sadat Jalali
- Student Research Committee, Department of Health Services Management, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sajad Delavari
- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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Krishnamoorthy Y, Rajaa S, Sinha I, Krishnan M, Samuel G, Kanth K. Equity and extent of financial risk protection indicators during COVID-19 pandemic in rural part of Tamil Nadu, India. Heliyon 2023; 9:e18902. [PMID: 37593630 PMCID: PMC10428029 DOI: 10.1016/j.heliyon.2023.e18902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023] Open
Abstract
Catastrophic health expenditure [CHE] in India is on a rise. This situation would worsen even further when resources are disproportionately distributed across various socioeconomic classes. Hence, we conducted this study to determine the equity and extent of out-of-pocket [OOP] payments, Catastrophic health expenditure and impoverishment among rural households during COVID-19 pandemic in Tamil Nadu, India. A cross-sectional survey covering 2409 households was conducted during November 2021 across six districts in rural part of Tamil Nadu. Information on out-of-pocket payments, Catastrophic health expenditure (based on 40% capacity-to-pay [CTP] method) and impoverishment was obtained through World Health Organization standard criteria. Point estimates were reported as proportions with 95% Confidence Interval [CI]. Our results showed that the proportion of households with out-of-pocket payments on health and Catastrophic health expenditure in the month preceding the survey was 82.8% (95%CI: 81.2%-84.3%) and 26.9% (95%CI: 25.1%-28.7%) respectively. Nuclear (couple with dependent children only) and joint family type (extended family), presence of under-five children and lower socioeconomic status were significant determinants of Catastrophic health expenditure. The prevalence of impoverishment was 6.4% (95%CI: 5.4%-7.5%). To conclude, more than three fourth of the rural households in Tamil Nadu has out-of-pocket payments for health with one-fourth having Catastrophic health expenditure. Almost one in fourteen non-poor households faced impoverishment during the COVID-19 pandemic. This shows the disproportionate distribution of health expenses especially in the rural areas. Hence, appropriate financial risk protection measures should be taken in order to progress towards universal healthcare in our country.
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Affiliation(s)
- Yuvaraj Krishnamoorthy
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Sathish Rajaa
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Isha Sinha
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Murali Krishnan
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Gerald Samuel
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
| | - Krishna Kanth
- Department of Community Medicine, ESIC Medical College and PGIMSR, K.K. Nagar, Chennai, India
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Heidarzadeh A, Negari Namaghi R, Moravveji A, Farivar F, Naghshpour P, Roshan Fekr F, Mirkazemi R. Out-of-pocket and catastrophic health expenditure in Iran. J Public Health (Oxf) 2023. [DOI: 10.1007/s10389-023-01824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Aghapour E, Basakha M, Mohaqeqi Kamal SH, Pourreza A. Decomposed Trends of Iranian Private Health Expenditures: Should Inequality be Appreciated? Med J Islam Repub Iran 2022; 36:145
. [PMID: 36569397 PMCID: PMC9774990 DOI: 10.47176/mjiri.36.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ehsan Aghapour
- Department of Social Welfare Management, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mehdi Basakha
- Department of Social Welfare Management, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
, Corresponding author:
Mehdi Basakha,
| | | | - Abolghasem Pourreza
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Soltani S, Moghadam MM, Amani S, Akbari S, Shiani A, Soofi M. Socioeconomic disparities in using rehabilitation services among Iranian adults with disabilities: a decomposition analysis. BMC Health Serv Res 2022; 22:1449. [PMID: 36447232 PMCID: PMC9708139 DOI: 10.1186/s12913-022-08811-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/08/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Persons with disabilities (PWD) generally experience various barriers in using health care compared to the general population, and these problems are more worsened for those with disabilities in lower socioeconomic status. The study aimed to estimate socioeconomic inequality in using rehabilitation services (URS) in adults with disabilities in Iran. METHODS This cross-sectional study was conducted at a national level in Iran. 786 PWD (aged 18 years and older) participated in the study between September and December 2020. Socioeconomic-related inequality in URS was estimated by the Concentration Index (C). The C was decomposed to identify factors explaining the variability within the socioeconomic inequality in URS. RESULTS In the present study 8.10% (N = 61) of the study population used rehabilitation services during the past three months. In this study, the value of the C was estimated 0.25 (p-value = 0.025) that shows URS was unequally distributed, and concentrated among the higher SES groups. The results of decomposition analysis indicated that the wealth index was the largest contributor (94.22%) to the observed socioeconomic inequalities in URS among PWD. Following the wealth index, Age and marital status were the major contributors to the unequal distribution of URS among the study population. CONCLUSIONS Our findings revealed that socioeconomic inequality in using rehabilitation services was concentrated among well-off PWD. Accordingly, rehabilitation financing through appropriate mechanisms for individuals with low SES is suggested.
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Affiliation(s)
- Shahin Soltani
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Shiva Amani
- Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shahram Akbari
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Amir Shiani
- Clinical Research Development Center, Taleghani and Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Moslem Soofi
- Social Development and Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Arab M, Khosravi B, Safari H, Rahmani H, Rajabi Vasokolaei G, Mobinizadeh M, Habibi F. Reasons for informal payments from the perspective of health care providers and recipients: a qualitative study in Iran. Glob Health Res Policy 2022; 7:30. [PMID: 36045440 PMCID: PMC9434857 DOI: 10.1186/s41256-022-00263-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Informal payments are one of the major obstacles to health system reform in many developing countries, and its elimination is on the agenda of health system policymakers in many countries, including Iran. This study was conducted to identify the causes of informal payments in the Iranian health system. Methods This was a qualitative and exploratory study. The study environment included the Ministry of Health, physicians' offices, medical universities, and hospitals and health centers. The study population included health care providers (physicians and hospital staff, managers, supervisors, and nurses) and health care recipients (patients or patients who had a history of dealing with informal payments). Data were collected using open-ended questions and semi-structured interviews. Snowball sampling method was used to select managers, chief executive officers (CEOs) and nurses. Convenience sampling was used to select physicians due to their lack of participation and cooperation. Content analysis method was used to analyze the data. Results Reasons for informal payments were divided into 4 themes including: Economic factors (improper tariff valuation of services; failure to increase tariffs proportionate to inflation; lack of comprehensive participation of stakeholders in determining tariffs; tariff inconsistency in the public, private and charity sectors; etc.); socio-cultural factors (decreased social capital of the medical community among the people; improving the quality of life; incorrect comparison of providers' income levels with the income of doctors in other countries; existence of a culture of gratitude and appreciation; health as a priority for society; pride of service recipients; pride of service providers; etc.); service delivery challenges (high professional skills of the doctor; use of modern medical equipment; the monopoly of some doctors, etc.) and legal-political factors (inadequate monitoring by upstream organizations; lack of strict rules; difficulty of proving informal payments; presence of stakeholders in management and policy making processes). Conclusions Knowing the causes of informal payments can help reduce or eliminate it. The results of this study identified the causes of informal payments in the Iranian health system. Accurate knowledge of the needs and motivations of both health care providers and recipients can be effective in accurately identifying and eliminating this phenomenon.
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Affiliation(s)
- Mohammad Arab
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahman Khosravi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Safari
- Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hojat Rahmani
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghasem Rajabi Vasokolaei
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Farhad Habibi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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López-López S, Del Pozo-Rubio R, Ortega-Ortega M, Escribano-Sotos F. Catastrophic household expenditure associated with out-of-pocket payments for dental healthcare in Spain. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1187-1201. [PMID: 35066677 DOI: 10.1007/s10198-021-01420-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 12/01/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To estimate the prevalence of catastrophic health expenditure due to dental healthcare (CHED) in Spain, quantify its intensity and examine the related sociodemographic household characteristics. METHODS Data from the Spanish Household Budget Survey, which addresses more than 20,000 households each year for the period 2008-2015 were included, and the methodology proposed by Wagstaff and van Doorslaer was followed. The prevalence (number of households that devote more than a certain threshold of their income to such payments) and intensity (amount that exceeds a certain percentage of income) were estimated. Ordered logistic regression models were estimated to analyse the sociodemographic factors associated with the prevalence of catastrophic payments. RESULTS The prevalence and intensity remained stable during the period under analysis. In terms of prevalence, a mean proportion of 7.36% of the population dedicated, in terms of intensity, more than 10% of their resources to dental care payments [mean: €292.75 per year (SD €2144.14)] and 2.05% dedicated more than 40% [mean: €143.02 per year (SD €1726.42)]. This represents 36.32% and 51.34% (for the thresholds of 10% and 40%) of the total catastrophic expenditure derived from out-of-pocket payments for dental healthcare in Spain. CONCLUSION This study shows that a significant proportion of catastrophic healthcare payments correspond to dental services. Being male, aged over 40 years, unattached (single, separated, divorced or widowed), having a low level of education, a low household income, being unemployed and living in an urban area are all associated with a greater risk of CHED. This finding highlights the need to establish policies aimed at increasing dental care coverage to mitigate related financial burdens on a large part of the Spanish population.
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Affiliation(s)
- Samuel López-López
- Castilla-La Mancha Health Services, SESCAM, Hospital of Cuenca, C/ Hermandad de Donantes de Sangre, 1, 16 002, Cuenca, Spain.
| | - Raúl Del Pozo-Rubio
- Department of Economic Analysis and Finance, University of Castilla-La Mancha, Avda. Los Alfares, 44, 16 071, Cuenca, Spain
- Research Group on Food, Economy and Society, University of Castilla-La Mancha, Albacete, Spain
| | - Marta Ortega-Ortega
- Department of Applied and Public Economics, and Political Economy, Complutense University of Madrid, Campus de Somosaguas s/n, Pozuelo de Alarcón, 28 223, Madrid, Spain
| | - Francisco Escribano-Sotos
- Department of Economic Analysis and Finance, University of Castilla-La Mancha, Plaza de la Universidad s/n, 02 001, Albacete, Spain
- Research Group on Food, Economy and Society, University of Castilla-La Mancha, Albacete, Spain
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Rahman T, Gasbarro D, Alam K. Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature. Health Res Policy Syst 2022; 20:83. [PMID: 35906591 PMCID: PMC9336110 DOI: 10.1186/s12961-022-00886-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP. Results The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP. Conclusion The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00886-3.
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Affiliation(s)
- Taslima Rahman
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia. .,Institute of Health Economics, University of Dhaka, Dhaka, 1000, Bangladesh.
| | - Dominic Gasbarro
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia
| | - Khurshid Alam
- Murdoch Business School, Murdoch University, Perth, WA, 6150, Australia
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Aghapour E, Basakha M, Kamal SHM, Pourreza A. Inequality in private healthcare expenditure: A 36-year trend study of Iranian households. J Prev Med Public Health 2022; 55:379-388. [PMID: 35940193 PMCID: PMC9371783 DOI: 10.3961/jpmph.22.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/14/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives Throughout history, societies have been impacted by inequality. Many studies have been conducted on the topic more broadly, but only a few have investigated inequalities in out-of-pocket health payments (OHP). This study measures OHP inequality trends among the Iranian households. Methods This study used data from the Iranian Statistics Center on Iranian household income and expenditures. The analysis included a total of 995 300 households during the 36 years from 1984 to 2019. The Gini coefficient, Atkinson index, and Theil index were calculated for Iranian OHP. Results Average Iranian household OHP increased from 33 US dollar (USD) in 1984 to 47 USD in 2019. During this 36-year span, the average±standard deviation Gini coefficient for OHP was 0.73±0.04, and the Atkinson and Theil indexes were 0.68±0.05 and 1.14±0.29, respectively. The Gini coefficients for the subcategories of OHP of outpatient diagnostic services, medical assistant accessories, hospital inpatient services, and addiction cessation were 0.70, 0.61, 0.84, and 0.64, respectively. Conclusions In this study, we scrutinized trends of inequality in the OHP of Iranian households. Inequality in OHP decreased slightly over the past four decades. An analysis of trends among different subgroups revealed that affluent households, such as households with insurance coverage and households in higher income deciles, experienced higher inequality. Therefore, lower inequality in health care expenditures may be related to restricted access to health care services in Iran.
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Affiliation(s)
- Ehsan Aghapour
- Department of Social Welfare Management, University of Social Welfare and Rehabilitation Sciences, Tehran,
Iran
| | - Mehdi Basakha
- Department of Social Welfare Management, University of Social Welfare and Rehabilitation Sciences, Tehran,
Iran
- Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran,
Iran
| | - Seyed Hossein Mohaqeqi Kamal
- Department of Social Welfare Management, University of Social Welfare and Rehabilitation Sciences, Tehran,
Iran
- Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran,
Iran
| | - Abolghasem Pourreza
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran,
Iran
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Yousefi M, Dastan I, Alinezhad F, Ranjbar M, Hamelmann C, Ostovar A, Moghisi A, Mohammadi S, Mataria A, Hammerich A, Slama S, Pourghazian N, Hezaveh AM, Valizadeh B, Torabi P, Najmi M, Moradi M, Hodjatzadeh A, Keshvari-Shad F. Prevention and control of non-communicable diseases in iran: the case for Investment. BMC Public Health 2022; 22:1248. [PMID: 35739516 PMCID: PMC9229124 DOI: 10.1186/s12889-022-13615-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-communicable diseases are imposing a considerable burden on Iran. This study aims to assess the Return on Investment (ROI) for implementation of Non-communicable diseases (NCDs) prevention program in Iran. METHODS Four disease groups including cardiovascular diseases, diabetes, cancer, and respiratory diseases were included in our ROI analysis. The study followed four steps: 1) Estimating the total economic burden of NCDs using the Cost-of-Illness approach. 2) Estimating the total costs of implementing clinical and preventive interventions using an ingredient based costing at delivering level and a program costing method at central level.3) Calculating health impacts and economic benefits of interventions using the impact measures of avoided incidence, avoided mortality, healthy life years (HLYs) gained, and avoided direct treatment costs. 4) Calculating the ROI for each intervention in 5- and 15- year time horizons. RESULTS The total economic burden of NCDs to the Iranian economy was IRR 838.49 trillion per year (2018), which was equivalent to 5% of the country's annual Gross Domestic Product (GDP). The package of NCD will lead to 549 000 deaths averted and 2 370 000 healthy life years gained over 15 years, and, financially, Iranian economy will gain IRR 542.22 trillion over 15 years. The highest ROI was observed for the package of physical activity interventions, followed by the interventions addressing salt, tobacco package and clinical interventions. Conclusions NCDs in Iran are causing a surge in health care costs and are contributing to reduced productivity. Those actions to prevent NCDs in Iran, as well as yielding to a notable health impact, are giving a good economic return to the society. This study underscores an essential need for establishment of a national multi-sectorial NCD coordination mechanism to bring together and strengthen existing cross-agency initiatives on NCDs.
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Affiliation(s)
- Mahmood Yousefi
- Department of Health Economics, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Ilker Dastan
- Health Policy, WHO Country Office, Dushanbe, Tajikistan
| | - Farbod Alinezhad
- Bouve Colleage of Health Sciences, Northeastern University, Boston, MA, USA
| | - Mansour Ranjbar
- National Professional Officer, NCD and Mental Health Unit Head, WHO , Tehran, Iran
| | | | - Afshin Ostovar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Moghisi
- Deputy General Director for NCD Management Office, Ministry of Health and Medical Education, Tehran, IR, Iran
| | | | - Awad Mataria
- Universal Health Coverage/Health Systems (UHS), World health Organization, Regional Office for Eastern Mediterranean (WHO-EMRO), Cairo, Egypt
| | - Asmus Hammerich
- UHC/NCDs, World Health Organization, Regional Office for Eastern Mediterranean (WHO-EMRO), Cairo, Egypt
| | - Slim Slama
- Non Communicable Diseases Prevention (NCP), UHC/NCDs, World Health Organization, Regional Office for Eastern Mediterranean (WHO-EMRO), Cairo, Egypt
| | - Nasim Pourghazian
- Non Communicable Diseases Prevention (NCP), UHC/NCDs, World Health Organization, Regional Office for Eastern Mediterranean (WHO-EMRO), Cairo, Egypt
| | - Alireza Mahdavi Hezaveh
- Cardio Vascular Diseases Prevention Department, NCD Management Office, Ministry of Health and Medical Education, Tehran, IR, Iran
| | - Behzad Valizadeh
- National Tobacco Control Secretariat, Ministry of Health and Medical Education, Tehran, IR, Iran
| | - Parisa Torabi
- National Manager of Clinical Nutrition Group, Ministry of Health and Medical Education, Tehran, IR, Iran
| | - Mehdi Najmi
- Director of Respiratory Diseases Prevention Department, NCD Management Office, Ministry of Health and Medical Education, Tehran, IR, Iran
| | - Mohammad Moradi
- Expert of Cardio Vascular Diseases Prevention Department, NCD Management Office, Ministry of Health and Medical Education, Tehran, IR, Iran
| | - Alieh Hodjatzadeh
- Expert of Cardio Vascular Diseases Prevention Department, NCD Management Office, Ministry of Health and Medical Education, Tehran, IR, Iran
| | - Fatemeh Keshvari-Shad
- Department of Health Economics, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
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Xu Y, Zhou Y, Pramono A, Liu Y, Jia C. A 25-Year Trend of Catastrophic Health Expenditure and Its Inequality in China: Evidence from Longitudinal Data. Risk Manag Healthc Policy 2022; 15:969-981. [PMID: 35592442 PMCID: PMC9112452 DOI: 10.2147/rmhp.s358641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/04/2022] [Indexed: 01/26/2023] Open
Abstract
Purpose The Chinese government has carried out two major cycles of reform to improve the health system and reduce the disease burden on residents. This study aims to comprehensively track the trends in the occurrence of catastrophic health expenditure (CHE) and its inequality in the past 25 years, which may help better understand the influence of health system reforms on CHE and its inequality. Methods The study employed the subset of data from China Health and Nutrition Survey conducted from 1991 to 2015. Health payments and net household income were used to calculate CHE. Concentration index and decomposition analysis were used to measure the magnitude of income-related inequality in CHE and decompose it into determinants, respectively. Results The incidence of CHE in China increased from 3.10% in 1993 to 8.90% in 2004 and still maintained at a high level in the following years. The incidence gap of CHE between the richest and poorest became increasingly wider over year. Moreover, the values of adjusted concentration indexes were all negative in each year, decreasing from −0.202 in 1991 to −0.613 in 2015. Income was consistently the largest contributor to the inequality in CHE. The basic medical insurance did not decrease the incidence of CHE and showed the second largest contribution on its inequality before 2004. However, this contribution began to decline after 2006. Conclusion After the New Health Care Reform, despite many measures taken by the Chinese government, there was still a high incidence of CHE and an increasing inequality from 1991 to 2015. The basic medical insurance in China was not enough to protect households from CHE. The use of big data tools and techniques to effectively screen the poor households, and strengthening the social medical aid system would be helpful to decrease the inequality in CHE.
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Affiliation(s)
- Yongjian Xu
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, People’s Republic of China
- Correspondence: Yongjian Xu, School of Public Policy and Administration, Xi’an Jiaotong University, No. 28 Xianning West Road, Xi’an, 710049, People’s Republic of China, Tel +8618202985437, Email
| | - Yiting Zhou
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Andi Pramono
- Community and Aged Care Services, Hunter New EnglAnd Health, NSW, Australia
| | - Yazhuo Liu
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, People’s Republic of China
| | - Cong Jia
- School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, People’s Republic of China
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Baharin MFA, Juni MH, Abdul Manaf R. Equity in Out-of-Pocket Payments for Healthcare Services: Evidence from Malaysia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084500. [PMID: 35457364 PMCID: PMC9029138 DOI: 10.3390/ijerph19084500] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Out-of-pocket (OOP) payments are an inequitable mechanism for health financing as their high share of total health expenditures poses a risk of catastrophic healthcare expenditures. This study aimed to assess the distribution and progressivity of OOP payments made by Malaysian households for various group of healthcare services. METHODS This study utilized data from the Malaysian Household Expenditure Survey (HES) between 2014 and 2015, which involved 14,473 households. Distribution and progressivity of OOP payments were measured through their proportion of household consumption, a concentration curves plot and the Kakwani Progressivity Index (KPI). RESULTS The mean proportion of Malaysian OOP payments for healthcare of household consumption was 1.65%. The proportion increased across households' consumption quintiles, from 1.03% made by the poorest 20% to 1.86% by the richest 20%. The OOP payments in Malaysia were progressive with a positive KPI of 0.0910. The OOP payments made for hospital-based services were the most progressive (KPI 0.1756), followed by medical products, appliances and equipment (KPI 0.1192), pharmaceuticals (0.0925) and outpatient-based services (KPI 0.0394) as the least progressive. CONCLUSIONS Overall, the OOP payments for healthcare services in Malaysia were progressive and equitable as they were more concentrated among the richer households.
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Affiliation(s)
- Mohamed Fakhri Abu Baharin
- Public Health Unit, Department of Primary Health Care, Faculty of Medicine and Health Sciences, Universiti Sains Islam Malaysia, Nilai 71800, Malaysia
- Correspondence: ; Tel.: +60-6798-5024
| | - Muhamad Hanafiah Juni
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia; (M.H.J.); (R.A.M.)
| | - Rosliza Abdul Manaf
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia; (M.H.J.); (R.A.M.)
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Etemadi M, Hajizadeh M. User fee removal for the poor: a qualitative study to explore policies for social health assistance in Iran. BMC Health Serv Res 2022; 22:250. [PMID: 35209902 PMCID: PMC8867763 DOI: 10.1186/s12913-022-07629-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 02/14/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Manal Etemadi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Hajizadeh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
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Abstract
Objectives: This study aimed to systematically review the literature on the Iranian healthcare system in the time of increasing privatization. Methods: A systematic literature review was conducted using MEDLINE, CINAHL, APA PschInfo, and Cochrane databases to identify various concepts in the literature concerning the privatization of healthcare in Iran between September and November 2020. All the included articles were assessed using the John Hopkins Nursing Evidence-Based Practice Research tool. In addition, grey literature was searched using Google targeted at academic websites and key organizations and online newspapers and magazines in the Persian language. This screening resulted in a total of 70 articles, reports, and documents. The PRISMA guidelines were followed for abstracting data and assessing the quality of the studies. Results: Six health-related items were identified at the time of increased privatization in the healthcare system. These items consisted of medical establishments, accessibility, and privatization, catastrophic health expenditure (CHE), out-of-pocket payment (OOP), health inequality, privatization, and healthcare providers, and the policy and finance of privatization. Conclusions: The review identified that the process of privatization of the healthcare system in Iran occurred with poor monitoring and evaluation mechanisms. Privatization rested on neoliberal arguments, and for-profit care has worsened healthcare performance and created an unfair, expensive healthcare system of lower quality in Iran.
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