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Measuring and Decomposing Socioeconomic Inequality in Catastrophic Healthcare Expenditures in Iran

  • Rezaei, Satar (Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences) ;
  • Hajizadeh, Mohammad (School of Health Administration, Faculty of Health, Dalhousie University)
  • Received : 2019.02.25
  • Accepted : 2019.05.09
  • Published : 2019.07.31

Abstract

Objectives: Equity in financial protection against healthcare expenditures is one the primary functions of health systems worldwide. This study aimed to quantify socioeconomic inequality in facing catastrophic healthcare expenditures (CHE) and to identify the main factors contributing to socioeconomic inequality in CHE in Iran. Methods: A total of 37 860 households were drawn from the Households Income and Expenditure Survey, conducted by the Statistical Center of Iran in 2017. The prevalence of CHE was measured using a cut-off of spending at least 40% of the capacity to pay on healthcare services. The concentration curve and concentration index (C) were used to illustrate and measure the extent of socioeconomic inequality in CHE among Iranian households. The C was decomposed to identify the main factors explaining the observed socioeconomic inequality in CHE in Iran. Results: The prevalence of CHE among Iranian households in 2017 was 5.26% (95% confidence interval [CI], 5.04 to 5.49). The value of C was -0.17 (95% CI, -0.19 to -0.13), suggesting that CHE was mainly concentrated among socioeconomically disadvantaged households in Iran. The decomposition analysis highlighted the household wealth index as explaining 71.7% of the concentration of CHE among the poor in Iran. Conclusions: This study revealed that CHE is disproportionately concentrated among poor households in Iran. Health policies to reduce socioeconomic inequality in facing CHE in Iran should focus on socioeconomically disadvantaged households.

Acknowledgement

Supported by : Kermanshah University of Medical Sciences

References

  1. Buigut S, Ettarh R, Amendah DD. Catastrophic health expenditure and its determinants in Kenya slum communities. Int J Equity Health 2015;14:46. https://doi.org/10.1186/s12939-015-0168-9
  2. Li Y, Wu Q, Xu L, Legge D, Hao Y, Gao L, et al. Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bull World Health Organ 2012;90(9):664-671. https://doi.org/10.2471/BLT.12.102178
  3. Limwattananon S, Tangcharoensathien V, Prakongsai P. Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand. Bull World Health Organ 2007;85(8):600-606. https://doi.org/10.2471/BLT.06.033720
  4. Islam MR, Rahman MS, Islam Z, Nurs CZ, Sultana P, Rahman MM. Inequalities in financial risk protection in Bangladesh: an assessment of universal health coverage. Int J Equity Health 2017;16(1):59. https://doi.org/10.1186/s12939-017-0556-4
  5. World Health Organization. The world health report 2000:health systems-improving performance [cited 2019 Jul 10]. Available from: https://www.who.int/whr/2000/en/.
  6. Elani HW, Harper S, Allison PJ, Bedos C, Kaufman JS. Socio-economic inequalities and oral health in Canada and the United States. J Dent Res 2012;91(9):865-870. https://doi.org/10.1177/0022034512455062
  7. Wagstaff A, van Doorslaer E. Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993-1998. Health Econ 2003;12(11):921-934. https://doi.org/10.1002/hec.776
  8. Xu K, Evans DB, Carrin G, Aguilar-Rivera AM. Designing health financing systems to reduce catastrophic health expenditure; 2005 [cited 2019 Jul 10]. Available from: https://www.who.int/health_financing/documents/cov-pb_e_05_2-cata_sys/en/.
  9. Global Burden of Disease Health Financing Collaborator Network. Spending on health and HIV/AIDS: domestic health spending and development assistance in 188 countries, 1995-2015. Lancet 2018;391(10132):1799-1829. https://doi.org/10.1016/S0140-6736(18)30698-6
  10. Global Burden of Disease Health Financing Collaborator Network. Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016-40. Lancet 2018;391(10132):1783-1798. https://doi.org/10.1016/S0140-6736(18)30697-4
  11. Global Burden of Disease Health Financing Collaborator Network. Evolution and patterns of global health financing 1995-2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet 2017;389(10083):1981-2004. https://doi.org/10.1016/S0140-6736(17)30874-7
  12. Rezaei S, Woldemichael A, Hajizadeh M, Kazemi Karyani A. Catastrophic healthcare expenditures among Iranian households: a systematic review and meta-analysis. Int J Hum Rights Healthc 2019;12(2):105-115. https://doi.org/10.1108/IJHRH-02-2018-0017
  13. Hajizadeh M, Nghiem HS. Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments? Int J Health Care Finance Econ 2011;11(4):267-285. https://doi.org/10.1007/s10754-011-9099-1
  14. Ghiasvand H, Sha'baninejad H, Arab M, Rashidian A. Hospitalization and catastrophic medical payment: evidence from hospitals located in Tehran. Arch Iran Med 2014;17(7):507-513.
  15. Kavosi Z, Rashidian A, Pourreza A, Majdzadeh R, Pourmalek F, Hosseinpour AR, et al. Inequality in household catastrophic health care expenditure in a low-income society of Iran. Health Policy Plan 2012;27(7):613-623. https://doi.org/10.1093/heapol/czs001
  16. Moghadam MN, Banshi M, Javar MA, Amiresmaili M, Ganjavi S. Iranian household financial protection against catastrophic health care expenditures. Iran J Public Health 2012;41(9):62-70.
  17. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet 2003;362(9378):111-117. https://doi.org/10.1016/S0140-6736(03)13861-5
  18. Gotsadze G, Zoidze A, Rukhadze N. Household catastrophic health expenditure: evidence from Georgia and its policy implications. BMC Health Serv Res 2009;9:69. https://doi.org/10.1186/1472-6963-9-69
  19. Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff (Millwood) 2007;26(4):972-983. https://doi.org/10.1377/hlthaff.26.4.972
  20. World Health Organization. Health systems performance assessment: debates, methods and empiricism; 2003 [cited 2019 Jul 10]. Available from: https://www.who.int/health_financing/documents/cov-hspa/en/.
  21. Yardim MS, Cilingiroglu N, Yardim N. Catastrophic health expenditure and impoverishment in Turkey. Health Policy 2010;94(1):26-33. https://doi.org/10.1016/j.healthpol.2009.08.006
  22. World Health Organization. Distribution of health payments and catastrophic expenditures: methodology; 2005 [cited 2019 Jul 10]. Available from: https://www.who.int/health_financing/documents/cov-dp_05_2_health_payments/en/.
  23. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan 2006;21(6):459-468. https://doi.org/10.1093/heapol/czl029
  24. Kolenikov S, Angeles G. Socioeconomic status measurement with discrete proxy variables: is principal component analysis a reliable answer? Rev Income Wealth 2009;55(1):128-165. https://doi.org/10.1111/j.1475-4991.2008.00309.x
  25. Koolman X, van Doorslaer E. On the interpretation of a concentration index of inequality. Health Econ 2004;13(7):649-656. https://doi.org/10.1002/hec.884
  26. Wagstaff A. The concentration index of a binary outcome revisited. Health Econ 2011;20(10):1155-1160. https://doi.org/10.1002/hec.1752
  27. O'Donnell O, O'Neill S, Van Ourti T, Walsh B. Conindex: estimation of concentration indices. Stata J 2016;16(1):112-138. https://doi.org/10.1177/1536867X1601600112
  28. Wagstaff A, van Doorslaer E, Watanabe N. On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. J Econom 2003;112(1):207-223. https://doi.org/10.1016/S0304-4076(02)00161-6
  29. Yazdi-Feyzabadi V, Bahrampour M, Rashidian A, Haghdoost AA, Akbari Javar M, Mehrolhassani MH. Prevalence and intensity of catastrophic health care expenditures in Iran from 2008 to 2015: a study on Iranian household income and expenditure survey. Int J Equity Health 2018;17(1):44. https://doi.org/10.1186/s12939-018-0743-y
  30. Si Y, Zhou Z, Su M, Ma M, Xu Y, Heitner J. Catastrophic healthcare expenditure and its inequality for households with hypertension: evidence from the rural areas of Shaanxi Province in China. Int J Equity Health 2017;16(1):27. https://doi.org/10.1186/s12939-016-0506-6
  31. Boing AC, Bertoldi AD, Barros AJ, Posenato LG, Peres KG. Socioeconomic inequality in catastrophic health expenditure in Brazil. Rev Saude Publica 2014;48(4):632-641. https://doi.org/10.1590/S0034-8910.2014048005111
  32. Asefzadeh S, Alijanzadeh M, Gholamalipoor S, Farzaneh A. Households encountering with catastrophic health expenditures in Qazvin, Iran. Health Inf Manag 2013;10(1);1-8 (Persian).
  33. Soofi M, Rashidian A, Aabolhasani F, Sari AA, Bazyar M. Measuring the exposure of households to catastrophic healthcare expenditures in Iran in 2001: the World Health Organization and the World Bank's approach. Hosp J 2013;12(2):39-50 (Persian).
  34. Su TT, Kouyate B, Flessa S. Catastrophic household expenditure for health care in a low-income society: a study from Nouna District, Burkina Faso. Bull World Health Organ 2006;84(1):21-27. https://doi.org/10.2471/BLT.05.023739
  35. Wagstaff A, Lindelow M. Can insurance increase financial risk? The curious case of health insurance in China. J Health Econ 2008;27(4):990-1005. https://doi.org/10.1016/j.jhealeco.2008.02.002