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Decomposing inequality in financial protection situation in Iran after implementing the health reform plan: What does the evidence show based on national survey of households' budget?

Lookup NU author(s): Dr Heather BrownORCiD



This is the authors' accepted manuscript of an article that has been published in its final definitive form by John Wiley & Sons Ltd., 2018.

For re-use rights please refer to the publisher's terms and conditions.


Background: Assuring accessibility to health care services without facing with financial hardship is an accepted objective for health system. Utilizing the health services in an equitable way is a part of human’s right in health. Lack of well-designed health care financing mechanisms and high level of out-of-pocket payments in Iran over the last decades led to implementing Health Transformation Plan, in 2014. The initial goal of the plan was: reducing the likelihood of households suffering from catastrophic health care expenditure. There is little evidence on the impact of the plan on exposure to catastrophic health expenditures (CHE), inequality in its distribution and its determinants. Aims: This study aims to decompose inequality in financial protection of Iranian households after the implementation of the Health Transformation Plan. Methods and materials: This study was conducted using Iranian Statistics Center Survey on Rural and Urban Households Income- Expenditure in 2015-2016. First, the headcount ratio of catastrophic health expenditures was calculated using World Health Organization methodology. Then, the corrected concentration index based on approaches of Erreygers and Wagstaff was estimated. Finally, the role of different explanatory variables on inequality in the exposure to catastrophic health expenditures among poor and non-poor households was calculated using Farelie's model estimated by logistic regression. Results: The headcount ratio of the exposure to catastrophic health expenditures in urban and rural households were 4.58%, 5.65% respectively and the values of corrected concentration index based on Wagstaff's approach were -0.01, 0.0067, respectively. Values of corrected concentration index indicates that in urban households, the main burden of catastrophic health expenditures is on households with lower economic status, while among rural households, the burden is on households with higher economic status. The natural logarithm of difference in households' income levels had the highest contribution in explaining the inequality in facing catastrophic health expenditures between poor and non-poor households. Conclusion: The first goal of the plan seems has not been materialized and the headcount ratios of catastrophic health expenditure is still considerable. the results show that income is still the greatest determinant of facing catastrophic health expenditure and in urban households those in lower socioeconomic groups are more likely to face catastrophic health expenditures However, in rural areas there has been some reductions in inequalities. Overall, there is still further work that needs to be done to reduce exposure to catastrophic health expenditure.

Publication metadata

Author(s): Naghdi S, Moradi T, Brown H, Ghiasvand H, Mobinizadeh M

Publication type: Article

Publication status: Published

Journal: International Journal of Health Planning and Management

Year: 2018

Volume: 33

Issue: 3

Pages: 652-661

Print publication date: 01/07/2018

Online publication date: 24/03/2018

Acceptance date: 20/02/2018

Date deposited: 22/02/2018

ISSN (print): 0749-6753

ISSN (electronic): 1099-1751

Publisher: John Wiley & Sons Ltd.


DOI: 10.1002/hpm.2517


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