Document Type : Original Article

Authors

1 Associate Professor in Health Services Management, Department of Health Services Management, Public Health School, Arak University of Medical Sciences, Arak, Iran

2 Research Center for Environmental Determinants of Health, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

3 Associate Professor, Department of Economics, Urmia University, Urmia, Iran

Abstract

INTRODUCTION: Health care is considered as a human right, and fair financial contribution to health
care plays an important role in providing effective services for all members of society. This study
aimed at investigating the effects of targeted subsidy plan (since 2010) on equality in health‑care
financing in Iran from 2004 to 2014.
MATERIALS AND METHODS: This was a descriptive‑analysis, cross‑sectional study that was
conducted using data obtained from households’ expenditure‑income survey that is performed every
year by the Statistical Center of Iran. The Lorenz curve, Gini coefficient, and  Theil index were applied
to measure inequality in  healthcare expenditures (HEs). Furthermore, the Kakwani index was used
to examine inequality in health‑care finance during the study period. The analysis was performed
using Stata version 13.
RESULTS: Kakwani index was negative for all the studied years, except 2007. The value of this
index was equal to −0.032, −0.045, and −0.046 in 2004, 2008, and 2014 for rural areas and was
equal to −0.041, −0.029, and −0.0001 for urban areas, respectively. Despite the Kakwani index has
been negative for most of the years, which reflects regressive financing in health care, there is no
significant change in the trend of this indicator after the implementation of the subsidies. In addition,
this indicator is moving toward being positive (progressive) in urban areas in 2014, which represents
increased share of the poor in health payments.
CONCLUSIONS: According to the results, the targeted subsidy plan could not reach to its purpose in
health‑care system for supporting the poor from HEs. It is recommended for policy‑makers to design
a specific plan for health‑care financing and to allocate some defined resources such as taxes or
subsidies to health‑care sector.

Keywords

  1. Chen M, Zhao Y, Si L. Who pays for health care in China? The
    case of Heilongjiang province. PLoS One 2014;9:e108867.
    2. Munge K, Briggs AH. The progressivity of health‑care financing
    in Kenya. Health Policy Plan 2014;29:912‑20.
    3. Hossein Z, Gerard A. Trends in cost sharing among selected high
    income countries‑‑2000‑2010. Health Policy 2013;112:35‑44.
    4. Sanwald A, Theurl E. Out‑of‑pocket payments in the Austrian
    healthcare system – A distributional analysis. Int J Equity Health
    2015;14:94.
    5. Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N.
    Moving towards universal health coverage: Health insurance
    reforms in nine developing countries in Africa and Asia. Lancet
    2012;380:933‑43.
    6. ZengW, Lannes L, MutasaR. Utilization of health care and burden
    of out‑of‑pocket health expenditure in Zimbabwe: Results from
    a national household survey. Health Syst Reform 2018;4:300‑12.
    7. Rijal A, Adhikari TB, Khan JA, Berg‑Beckhoff G. The economic
    impact of non‑communicable diseases among households in
    South Asia and their coping strategy: A systematic review. PLoS
    One 2018;13:e0205745.
    8. Hajimahmoudi H, Zahedi F. Justice in the healthcare system:
    Payment and reimbursement policies in Iran. Iran J Med Ethics
    History Med 2013;6:1‑16.
    9. O’donnell O, Van Doorslaer E, Wagstaff A, Lindelow M.
    Analyzing health equity using household survey data: a guide
    to techniques and their implementation. The World Bank;
    2007 Oct 27.
    10. Wamai RG. The Kenya health system – Analysis of the situation
    and enduring challenges. JMAJ 2009;52:134‑40.
    11. Amuzegar J. Iran’s 20‑year economic perspective: Promises and
    pitfalls. Middle East Policy 2009;16:41.
    12. Zare H, Trujillo AJ, Driessen J, Ghasemi M, Gallego G. Health
    inequalities and development plans in Iran; an analysis of the
    past three decades (1984‑2010). Int J Equity Health 2014;13:42.
    13. Buigut S, EttarhR, Amendah DD. Catastrophic health expenditure
    and its determinants in Kenya slum communities. Int J Equity
    Health 2015;14:46.
    14. Available from: http://www.refahi.ir.2010.(2017/10/15)
    15. Boerma T, Eozenou P, Evans D, Evans T, Kieny MP, Wagstaff A,
    et al. Monitoring progress towards universal health coverage at
    country and global levels. PLoS Med 2014;11:e1001731.
    16. Iranian Statistics. Iranian Rural Expenditure‑Income Annual
    Report. Tehran, IR Iran: Iranian Statistics Center Publications;
    2012.
  2. 17. Naghdi S, Azami SR, Naghdi A, Faghi Solouk F, Ghiasvand H.
    The Inequity of Expenditure Ratios on Health and Food among
    Different Deciles of Iranian Households. Iranian journal of health
    sciences. 2013:15; 1(3):18‑27.
    18. Brown MC. Using gini‑style indices to evaluate the spatial
    patterns of health practitioners: Theoretical considerations
    and an application based on Alberta data. Soc Sci Med
    1994;38:1243‑56.
    19. Theodorakis PN, Mantzavinis GD, Rrumbullaku L, Lionis C,
    Trell E. Measuring health inequalities in Albania: A focus on the
    distribution of general practitioners. Hum Resour Health 2006;4:5.
    20. Das RC, Ray K, Das U. Health Expenditures Across Major States
    of India: Issues of Convergence and Equality. InIssues on Health
    and Healthcare in India 2018; 293‑306.
    21. Rohde N. Derivation of Theil’s Inequality Measure from Lorenz
    Curves. University of Queensland, Working Paper; 2007.
    22. Yin C, He Q, Liu Y, Chen W, Gao Y. Inequality of public health
    and its role in spatial accessibility to medical facilities in China.
    Appl Geogr 2018;92:50‑62.
    23. Chotikapanich D, Rao D, Tang KK. Estimating income inequality
    in China using grouped data and the generalized beta distribution.
    Rev Income Wealth 2007;53:127‑47.
    24. Kakwani NC. Measurement of tax progressivity: An international
    comparison. Econ J 1977;87:71‑80.
    25. Pourasghari H, Jafari M, Bakhtiari M, Keliddar I, Irani A,
    Afshari M. Analysis of equality in Iranian household healthcare
    payments during Iran’s fourth development program. Electronic
    physician. 2016 Jul; 8 (7):2645.
    26. Zandi H. Analysis of Impact of Targeted Subsidies on Equity
    Financing Health Care, in Health Management and Health Services
    and Economic. Iran: Tehran University of Medical Sciences; 2016.
    27. Raghfar H, G.S., Households’ Health Expenditure Inequality in
    Iran: 1984‑2011. Hakim Health Systems Research Journal, 2014.
    16 (4): p. 302‑316(Persian).
    28. Soares FV, Ribas RP, Osório RG. Evaluating the impact of Brazi’s
    Bolsa Familia: Cash transfer programs in comparative perspective.
    Latin Am Res Rev 2010;45:173‑90.
    29. Behrman JR, Sengupta P, Todd P. Progressing through
    PROGRESA: An impact assessment of a school subsidy experiment
    in rural Mexico. Econ Dev Cultur Chang 2005;54:237‑75.
    30. Hoces De la Guardia F, Hojman A, Larrañaga O. Evaluating
    the chile solidario program: Results using the chile solidario
    panel and the administrative databases. Estudios de Economía,
    2011;38:129‑169.
    31. Ir P, Horemans D, Souk N, Van Damme W. Using targeted
    vouchers and health equity funds to improve access to skilled
    birth attendants for poor women: Acase study in three rural health
    districts in Cambodia. BMC Pregnancy Childbirth 2010;10:1.
    32. Available from: http://www.tahavol.sbmu.ac.ir/.2004.
    (2017/10/15)