The impact of health reform in Iran on catastrophic health expenditures: Equity and policy implications

Abstract

Summary Purpose In 2014, the Islamic Republic of Iran launched the Health Transformation Plan (HTP), with the goal of achieving universal health coverage (UHC) through improved financial protection and access to high‐quality health services among Iranian households. We aimed to investigate the impact of the HTP on the level and pattern of out‐of‐pocket (OOP) payments for health care. Methods Using data from two rounds (2013 and 2016) of the Iranian Statistics Centre's Household Expenditure and Income Survey (HEIS), collected before and after implementation of the HTP, we estimate changes in the level and drivers of OOP payments, and the prevalence, intensity, and distribution of catastrophic health expenditures (CHEs) among Iranian households. Findings Our results indicate that per capita OOP payments on health remained stable during the observed period, with the largest proportion of OOP payments spent on medicines. Using thresholds of 10% and 25% of total consumption, there was a slight increase in the prevalence of CHE. The prevalence of CHE increased from 3.76% to 3.82% at threshold of 25% of total consumption. Using 40% capacity to pay threshold, prevalence diminished modestly from 2.5% to 2.37% and the intensity decreased from 13.16% to 12.32%. At all thresholds, CHE were more concentrated among wealthier households. Conclusion These results suggest that while financial protection of the poor in Iran has improved due to the HTP, more work is needed to achieve UHC in Iran. For the next phase of health reforms, more emphasis should be placed on shifting away from OOP co‐payments for health financing to progressive prepayment mechanisms to facilitate better sharing of financial risks across population groups.

<p>Incidence and Intensity of Catastrophic Health-care Expenditure for Type 2 Diabetes Mellitus Care in Iran: Determinants and Inequality</p>

“…According to the World Health Organization, when a family spends more than 40% of its income for health care after food cost deductions, this cost is regarded as high; however, countries can determine that threshold according to their own socioeconomic conditions. 11,18,19 Diabetics in low-income developing countries experience the high risk of economic burden and disastrous health costs due to frequent referral to health-care centers and high out-of-pocket payments (OOPs). 8,20 Although some countries have health-care insurance systems to cover some diabetic costs, high OOPs can still cause a lot of problems due to the existing inefficient risk division mechanisms.…”

How has sustainable development goals declaration influenced health financing reforms for universal health coverage at the country level? A scoping review of literature

“…The twelve (12) articles included for analyses related the global sustainable development agenda or SDG declaration to health financing reforms, either as part of the background statements, findings, discussion or conclusion sections and made reference to a particular country. Two articles each were from China [ 34 , 47 ], and Philippines [ 43 , 44 ], and one each from Indonesia [ 33 ], India [ 46 ], Bangladesh [ 38 ], Zambia [ 39 ], Iran [ 40 ], Republic of Korea [ 41 ], Lao People’s Democratic Republic (LPDR) [ 42 ] and Nepal [ 45 ].…”

“…Policy on benefit entitlements – Scope of services covered by capitation payment is determined by Indonesian Medical Council – Decrease in fee-for-service payment Fahim et al [ 38 ], 2018, Bangladesh, Study design: Mixed method, documentary review – The national health policy 2011–2032 updated to address contemporary issues of SDG and UHC – Health financing policy emphasizing solidarity in financing, equity of access and provision of quality care Pooling of funds – Policy emphasis on allocating a significant percent of government spending to health – Exploring ways of reducing OOP Chilufya and Kamanga [ 39 ], 2018, Zambia, Study design: Commentary Study aim: – Zambia’s transformational health agenda is in tandem with SDGs target 3.8 – Health sector strategic plan 2017–2021 was informed by the SDG agenda – Country building on the progress past health reforms during SDG era. Revenue Collection – Exploring ways of implementing sustainable health care financing – Mandatory pre-payment contribution being established Pooling of funds – Commitment to allocating sufficient government funding for health – Establishment of NHIF fund as a pooling agency Purchasing – Exploring reforming payment mechanism from inactive to active purchasing Ahmadnezhad et al [ 40 ], 2019, Iran, Study Design: Quantitative, document review – Health transformation plan recalibrated to form part of government commitment on SDG agenda Purchasing – Ministry of Health and Medical Education (MOHME) reduced co-payment Policy on benefit entitlements – Basic health insurance coverage extended from 83.2% of population to 93.2% – Aim to decrease prevalence of catastrophic expenditure to less than 1% by end of 2021 Lee et al [ 41 ], 2019, Republic of Korea, Study design: Qualitative, documentary review – In 2017, government announced NHI reform ‘Moon Jae-in care’ to increase coverage rate to 70% by 2022 and its considered a government’s commitment to health-related SDG – Reinforcing the benefits and financial coverage of national health insurance (NHI) is a core aspect of the reform – The advent of SDGs and inclusion of the President’s name in the health financing reform indicates how seriously the government has taken health financing reforms for UHC Policy on benefit entitlements – The population already covered, reform focuses on increasing the scope/depth of coverage and reducing cost-sharing – Reducing out-of-pocket (OOP) from the cost sharing component to minimize the catastrophic and impoverishing expenditure Nagpal et al [ 42 ], 2019, LPDR, ...…”

Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients : evidence from China Family Panel Studies

“…CHE intensity is estimated by overshoot and mean positive overshoot (MPO). stands for overshoot, which is the average percentage of OOP medical expenditure that exceeds a given threshold in the overall sample [26].…”