The Study of Out-of-pocket Payment and the Exposure of Households with Catastrophic Health Expenditures Following the Health Transformation Plan in Iran

Health Poverty Alleviation Project in Rural China: Impact on Poverty Vulnerability, Health Status, Healthcare Utilization, Health Expenditures

BACKGROUND

China has lead to the inception of the Health Poverty Alleviation Project (HPAP) in 2015. While the previous studies suggest that, despite its apparent reduction in patients' financial strain, the long-term poverty reduction effects are yet to be fully elucidated. This study explores HPAP's enduring impact on poverty reduction and the potential moral hazards.

METHODS

Data were obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS) spanning 2011-2018. We employed difference-in-differences (DID) models to gauge HPAP's influence on participants' poverty vulnerability, health outcomes, and healthcare utilization. The dynamic DID model is employed to test the robustness of HPAP policy effects. The mediation effect models were used to understand HPAP policy outcomes through physical examinations and inpatient care.

RESULTS

Our dataset encompassed 40,384 participants, of which 5946 (14.72%) had been exposed to HPAP and 34,438 (85.28%) had not access. Our findings reveal that HPAP decreases poverty vulnerability by 3.3% (p < 0.01) and attenuates health deterioration by 1.84% (p < 0.01). Furthermore, HPAP enhances inpatient care utilization by 9.34% (p < 0.01) and self-treatment behaviors by 4.1% (p < 0.01) while significantly slashing outpatient and inpatient expenses (p < 0.05). The implementation of HPAP has significantly reduced healthcare costs by 72.8% (p < 0.05) out-of-pocket (OOP) payments of outpatient care during the past month for the last time, and 89.39% (p < 0.05) out-of-pocket (OOP) payments of inpatient care during past the year for the last time. Mechanistic analyses have shown that the indirect effect of the HPAP policy decreases poverty vulnerability by -0.132% (p < 0.05) physical examinations and -0.309% (p < 0.05) inpatient care.

CONCLUSION

The HPAP initiative markedly attenuates poverty vulnerability and forestalls health decline among the rural populace. Moreover, HPAP bolsters healthcare service use, such as physical examinations and inpatient care, primarily attributed to the release of pent-up demand rather than moral hazards.

The Effect of Iran Health Transformation Plan on Equity in Health Financing: A Systematic Review

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.

The Variations in Catastrophic and Impoverishing Health Expenditures, and Its Determinants in Iran: A Scoping Review

Background

The high reliance on out-of-pocket (OOP) payments for health financing in Iran have been led to different inequity problems such as catastrophic health expenditure (CHE) and impoverishment. This scoping review has been conducted to understand the variations in CHE and impoverishment, the underlying determinants of CHE, and its inequality in the past 20 years.

Methods

This scoping review is guided by Arksey and O'Malley's scoping review framework. systematically PubMed, Scopus, Web of Science, ProQuest, Scientific Information Database, IranMedex, IranDoc, Magiran Science, Google Scholar, and grey literature were searched systematically from 1 January 2000 to August 2021. We included studies that reported the rate of CHE, impoverishment, inequality, and its influencing factors. Simple descriptive statistics and narrative synthesis were used to present the review findings.

Results

From 112 included articles, the average incidence of CHE was 3.19% at the 40% threshold, and about 3.21% of the households had impoverished. We found an unfavorable status of health inequality indices, including the average of fair financial contribution (0.833), concentration (-0.01), Gini coefficient (0.42), and Kakwani (-0.149). The most widely applied key drivers influencing the rate of CHE in these studies were household economic status, place of residence, health insurance status, household size, head of the household's gender, education level and employment status, having a household member under 5/ above 60 years old, with chronic diseases (in particular cancer and dialysis), disability, using inpatient and outpatient and dentistry services, medicines and equipment, and low insurance coverage.

Conclusion

The result of this review calls for intensifying health policies and financing structures in Iran to provide more equitable access to all populations, especially the poorest and vulnerable. Moreover, the government is expected to adopt effective measures in inpatient and outpatient care, dental services, medicines, and equipment.

The role of Iran's context for the development of health technology assessment: challenges and solutions

Health technology assessment (HTA) is a comprehensive and structured evaluation that aims to analyze the potential impacts of health technologies, including medical devices, diagnostic tools, pharmaceuticals, and public health interventions. Its purpose is to provide policymakers with evidence-based information to inform decisions related to the utilization and implementation of these technologies. HTA allows for the comparison of various scenarios related to a technology across a wide range of factors. This can aid in the creation of an essential drug list and health benefits package that is tailored to the actual needs of the community within a given healthcare system. In the present paper, we review the role of Iran's context for the development of HTA, in terms of challenges and solutions.

Does family medicine reduce household health expenditures: evidence from Türkiye

Türkiye introduced a family medicine-centered primary healthcare model in 2005 as part of the Health Transformation Program, which aimed to reduce household healthcare expenditures, improve access to health services, and reduce the crowding-out effect in first-stage hospital institutions. We investigate the impact of the family medicine program on household healthcare expenditures in Türkiye, focusing on doctor visits, medication prescriptions, and hospitalization expenditures. Using data from a large representative household survey, we employ a difference-in-differences approach combined with the entropy-balancing matching technique. Our robust findings show that living in a province exposed to the family medicine program reduced household doctor visit expenditures by over 40 percent. We also find a significant negative association between the family medicine program and expenditures regarding doctor visits and medication prescriptions in the long run. Greater efforts are now needed to ensure the quality of services offered by family health centers, such as improving the doctor-to-patient ratio.

Health Care Utilization and Out-of-Pocket Payments among Elderly with Cognitive Frailty in Malaysia

Background: Cognitive frailty (CF) as a potential risk factor for dementia, functional disability, poor quality of life, and mortality. The aim of this study was to explore the health care-related utilization and out-of-pocket (OOP) expenditures, sociodemographic characteristics, and comorbidities among elderly Malaysians with CF. Methods: A cross-sectional study targeting elderly Malaysian aged ≥65 years was conducted. The study included all participants of the fourth phase of the Malaysian representative Long-Term-Research-Grant-Scheme Towards-Useful-Aging (LRGS-TUA) community-based study. A structured and validated interview questionnaire was used. Results: In total, 1006 elderly were interviewed, with a 66.18% response rate. Only 730 respondents met the inclusion criteria. Of the eligible respondents, the CF prevalence was 4.5%. Around 60.6% of the participants with CF had utilized outpatient care at government clinics within the past 6 months. The estimated mean total OOP payments for CF during the past 6 months was 84 Malaysian Ringgit (RM) (SD 96.0). Conclusions: CF among elderly Malaysians is within the internationally recognized range of prevalence. The OOP payments for seeking health care among CF elderly are not different from that of other elderly categories. There is a high possibility of underutilization of the health care services of CF cases while they are still needy.

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.