Rezaei Satar, Woldemichael Abraha, Ebrahimi Mohammad, Ahmadi Sina
Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
Department of Health Systems, School of Public Health, College of Health Sciences, Mekelle University, Tigray, Ethiopia.
J Egypt Public Health Assoc. 2020 Nov 3;95(1):29. doi: 10.1186/s42506-020-00055-w.
Equity in the distribution of health care resources and mitigating the risk of out-of-pocket (OOP) catastrophic healthcare expenditures (CHE) are the major objectives of the health system of a country. This study aims to measure equity in OOP payments for healthcare and the incidence of CHE among Iranian households over time.
This retrospective cross-sectional study utilized data extracted from the household income and expenditure survey (HIES) of Iran, collected by the Statistical Center of Iran. The analysis included a total of 174,341 households' five yearly data of 6 years starting from 1991 to 2017. Kakwani progressivity index (KPI) was used to measure the equity in OOP payment for each year and examine the households' incidence of CHE at 20%, 30%, and 40% of their capacities to pay (CTP). The trend series regression analysis was used to examine the trend in the KPI and the incidence of the CHE over time.
The findings indicated that the households' expenditure on health out of their monthly budgets for the years 1991 and 2017 were 2.1% and 10.1%, respectively. The KPI for the OOP payment was negative for all 6-year observations (1991 = - 0.680; 1996 = - 0.608; 2001 = - 0.554; 2006 = - 0.265; 2011 = - 0.225, and 2017 = - 0.207), indicating that the OOP payments for healthcare are regressive and more concentrated among the socioeconomically disadvantaged households. There was a statistically significant (p = 0.003) increase in the KPI (i.e., decline in the regressivity) over time. The incidence of the CHE (1.12, 1.93, and 3.71%) in 1991 at the CTP levels of 20%, 30%, and 40% was lower than the incidence at the corresponding levels of CTP (5.26, 10.88, and 22.16) in 2017. The findings of the time-series regression indicated a statistically significant (p < 0.05) increase in the incidence of the CHE at the 20%, 30%, and 40% levels of the households' CTP.
The current study demonstrated that OOP payment as a source of healthcare funding in Iran is inequitable. While the use of interventions such as the prepaid and publicly funded programs may contribute to the reduction of CHE and improvement of equity in healthcare financing, further inequality analyses in the incidence of the CHE among households and its main determinants can contribute to evidence-informed planning to reduce the CHE in the context.
卫生保健资源分配公平以及减轻自付灾难性医疗支出（CHE）风险是一个国家卫生系统的主要目标。本研究旨在衡量伊朗家庭医疗保健自付费用的公平性以及CHE的发生率随时间的变化情况。
这项回顾性横断面研究利用了从伊朗统计中心收集的伊朗家庭收入和支出调查（HIES）中提取的数据。分析包括从1991年到2017年共174,341户家庭的6年年度数据。使用卡克瓦尼累进指数（KPI）来衡量每年自付费用的公平性，并以家庭支付能力（CTP）的20%、30%和40%来考察家庭CHE的发生率。采用趋势序列回归分析来研究KPI和CHE发生率随时间的变化趋势。
研究结果表明，1991年和2017年家庭每月预算中用于医疗保健的支出分别为2.1%和10.1%。所有6年观察期内自付费用的KPI均为负数（1991年 = -0.680；1996年 = -0.608；2001年 = -0.554；2006年 = -0.265；2011年 = -0.225，2017年 = -0.207），这表明医疗保健自付费用具有累退性，且更多集中在社会经济弱势家庭。随着时间的推移，KPI有统计学显著增加（p = 0.003）（即累退性下降）。1991年在CTP水平为20%、30%和40%时CHE的发生率（1.12%、1.93%和3.71%）低于2017年相应CTP水平（5.26%、10.88%和22.16%）时的发生率。时间序列回归结果表明，在家庭CTP的20%、30%和40%水平上，CHE的发生率有统计学显著增加（p < 0.05）。
当前研究表明，伊朗作为医疗保健资金来源的自付费用是不公平的。虽然采用诸如预付和公共资助项目等干预措施可能有助于减少CHE并改善医疗保健融资的公平性，但对家庭中CHE发生率及其主要决定因素进行进一步的不平等分析有助于为减少CHE的循证规划提供依据。
