Catastrophic Healthcare Expenditures Among Iranian Households: a Systematic Review and Meta-Analysis

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Catastrophic Healthcare Expenditures Among Iranian Households: A Systematic Review and Meta-Analysis

Article · March 2018 DOI: 10.1108/IJHRH-02-2018-0017

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The user has requested enhancement of the downloaded file. International Journal of Human Rights in Healthcare Catastrophic healthcare expenditures among Iranian households: a systematic review and meta-analysis Satar Rezaei, Abraha Woldemichael, Mohammad Hajizadeh, Ali Kazemi Karyani, Article information: To cite this document: Satar Rezaei, Abraha Woldemichael, Mohammad Hajizadeh, Ali Kazemi Karyani, (2018) "Catastrophic healthcare expenditures among Iranian households: a systematic review and meta-analysis", International Journal of Human Rights in Healthcare, https://doi.org/10.1108/IJHRH-02-2018-0017 Permanent link to this document: https://doi.org/10.1108/IJHRH-02-2018-0017 Downloaded on: 20 August 2018, At: 06:58 (PT) References: this document contains references to 59 other documents. To copy this document: [email protected] Access to this document was granted through an Emerald subscription provided by Token:Eprints:JAGWSPDIYMVMTHFSP7ND: For Authors If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information. About Emerald www.emeraldinsight.com Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services. Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation.

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Satar Rezaei, Abraha Woldemichael, Mohammad Hajizadeh and Ali Kazemi Karyani

Abstract Satar Rezaei is based at the Purpose – Protecting households against financial risks of healthcare services is one of the main functions of Research Center for health systems. The purpose of this paper is to provide a pooled estimate of the prevalence of catastrophic Environmental Determinants of healthcare expenditures (CHE) among households in Iran. Health, Kermanshah University Design/methodology/approach – Both international (PubMed, Scopus and Clarivate Analytics (previously of Medical Sciences, known as the Institute for Scientific Information)) and Iranian (Scientific Information Database, Iranmedex and Kermanshah, Iran. Magiran) scientific databases were searched for published studies on CHE among Iranian households. Abraha Woldemichael is The following keywords in Persian and English language were used as keywords for the search: “catastrophic Lecturer at the School of Public healthcare costs,”“catastrophic health costs,”“impoverishment due to health costs,”“fair financial Health, College of Health contribution,”“prevalence,”“frequency” and “Iran” with and without “health system”. The I2-test and χ2-based Q-test suggested heterogeneity in the reported prevalence among the qualified studies; thus, a Sciences, Mekelle University, random-effects model was used to estimate the overall prevalence of CHE among households in Iran. Mekelle, Ethiopia. Findings – A total of 24 studies with a cumulative sample of 301,097 households were included in the study. Mohammad Hajizadeh is The estimated pooled prevalence of CHE among households was 7 percent (95 percent confidence interval: Assistant Professor at the 6–8 percent). Meta-regression analysis indicated that the prevalence of CHE was inversely related to the School of Health sample size (po0.05). The results did not suggest a significant association between the prevalence of CHE Administration, Faculty of and the year of data collection. Health, Dalhousie University, – Originality/value The findings revealed that the prevalence of CHE among Iranian households is Halifax, Canada. significantly higher than 1 percent, which is the goal set out in Iran’s fourth five-year development plan. Ali Kazemi Karyani is based at This warrants further policy interventions to protect households from incurring CHE in Iran. the Research Center for Keywords Faith, Human rights, Healthcare, Public services Environmental Determinants of Paper type Literature review Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.

Introduction Protecting households against financial risks of healthcare services is one of the main functions of health systems (World Health Organization, 2000). The universal health coverage (UHC) strives to Downloaded by TEHRAN UNIVERSITY OF MEDICAL SCIENCES At 06:58 20 August 2018 (PT) ensure financially accessible essential healthcare services to all population groups, regardless of their socioeconomic differences. That is, people should not experience financial hardship in receiving the essential healthcare services. Thus, financial protection is considered as one of the Received 11 February 2018 most important indicators for evaluating whether a country has achieved the UHC (World Health Revised 2 March 2018 Organization, 2010). Nevertheless, the out-of-pocket payments (OOP) is one of the main sources Accepted 6 March 2018 The authors gratefully of healthcare financing in under-resourced countries (Saito et al., 2014). For example, the OOP in acknowledge the research council Iran is estimated to be more than 40 percent (World Health Organization, 2000). Available evidence of Kermanshah University of shows a strong correlation between higher levels of OOP and the incidence of catastrophic Medical Sciences for providing financial support. This study was healthcare expenditures (CHE) and impoverishing health expenditures (Xu et al.,2003). extracted from an approved project by Kermanshah University Several studies have documented the levels of CHE in different countries. In a study conducted in of Medical Sciences (KUMS) and 89 countries (Xu et al., 2007), the level of CHE was reported 3 percent in low-income countries, was funded and supported by the Research Deputy of KUMS (Grant 1.8 percent in middle-income countries and 0.6 percent in high-income countries. No. 96419).

DOI 10.1108/IJHRH-02-2018-0017 © Emerald Publishing Limited, ISSN 2056-4902 j INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE The prevalence of CHE varies across Asian and African countries. While about 4.1 percent of households experience CHE in South Korea (Choi et al., 2016), 13 percent of households face CHE in China (Li et al., 2012). The rate of CHE was 6–15 and 2.9 percent in Burkina Faso and Uganda, respectively (Su et al., 2006; Xu et al., 2006). According to the World Health Organization (WHO), CHE occurs when a household pays more than 40 percent of its capacity to pay for healthcare services. The capacity to pay is defined as total income minus spending on essential items such as food (World Health Organization, 2000). Approximately 44m households (over 150m people) experience CHE globally every year from healthcare services use. Some poor households even decide not to use healthcare services due to lack of protection from financial risks associated with healthcare expenses. In fact, financial protection of households against healthcare expenditures is one of the main concerns of policy makers (World Health Organization, 2005). Healthcare services in Iran are provided by three sectors, namely public, private and not for profit. Public sector mainly delivers all the three levels of healthcare (i.e. primary, secondary and tertiary) in rural and urban areas. The private sector provides secondary and tertiary healthcare in urban areas only. Non-governmental organizations are active in providing health services for chronic (e.g. diabetes) and severe patients such as cancer patients. Healthcare in Iran is funded through the government’s general revenue (primary raised from general tax revenue and sale of natural resources), health insurance organizations and individual OOP (Mehrdad, 2009; Hajizadeh and Connelly, 2010). In Iran, the high OOP and poor financial protection of households against CHE are among the major public health concerns. Thus, the recent economic, social and cultural development plan ( fourth five-year development plan) of Iran aimed to reduce the prevalence of CHE to less than 1 percent. To achieve the goal of reducing the OOP and CHE among Iranian households, the health sector evolution plan (HSEP) has been implemented since May 2014. One of the main objectives of this reform is to reduce OOP for inpatient services in the hospitals affiliated with Ministry of Health, Medical and Education (MoHME). Specifically, the latter reform aims to reduce total healthcare expenditures for patients admitted to MoHME to 6 percent for urban residents and 3 percent for rural and small towns (populationso20,000) residents (Moradi-Lakeh and Vosoogh-Moghaddam, 2015). Measuring and monitoring the prevalence of CHE among households is the first step toward designing and implementing effective interventions to improve financial protection of the population against healthcare costs and CHE. Several studies measured the prevalence of CHE among Iranian households. The estimated prevalence of CHE varies in different regions of Iran. While the prevalence of CHE in some studies was reported to be less than 5 percent (Homaie Rad et al., 2017; Yousefi et al., 2015; Fazaeli, Ghaderi, Fazaeli, Lotfi, Salehi and Mehrara, 2015; Nekoeimoghadam et al., 2014; Masaeli et al., 2015), others reported a prevalence of greater than 20 percent (Ghiasi et al., 2016; Ghoddoosinejad et al., 2014; Daneshkohan et al., 2011; Asefzadeh et al., 2013), and this figure was reported to be higher than 5 percent in a study conducted by Raghfar et al. in 2010 (Raghfar et al., 2013). This study aims to conduct a systematic review and meta-analysis of the available literature to measure the overall prevalence of CHE among Iranian households. In addition, the general trend of prevalence of CHE was estimated. The comprehensive knowledge gained about the prevalence and trend of CHE among Downloaded by TEHRAN UNIVERSITY OF MEDICAL SCIENCES At 06:58 20 August 2018 (PT) households in Iran is anticipated to warrant further policy attention to develop mechanisms to reduce the prevalence of CHE in Iran.

Methods and materials Search strategy We carried out literature search from June 1 to July 10, 2017 about the prevalence of CHE among Iranian households using international (PubMed, Scopus and Clarivate Analytics (previously known as the Institute for Scientific Information)) and Iranian (Scientific Information Database, Iranmedex and Magiran) scientific databases. We searched articles that published in Persian and English languages without limiting the year of publication. A combination of “catastrophic healthcare costs,”“catastrophic health costs,”“impoverishment due to health costs,”

INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE “fair financial contribution,”“prevalence,”“frequency” and “Iran” with and without “health system” were used as keywords to search published studies. The reference lists of the papers were checked for additional relevant articles.

Inclusion and exclusion criteria The studies that reported the prevalence of CHE among Iranian households, published in Persian or English regardless of the year of publication and whose quality score were between 8 and 12 were included in the study. When two or more studies reported the prevalence of CHE among households in the same setting, the latest report was included in the review. In addition, studies reported the prevalence of CHE over time; the latest year was included in the review. Brief reports, letter to the editor, working papers, editorial comments, studies with data or language duplication and studies that were conducted among other participants (e.g. hospitalized patients and retired persons) were excluded from the study. Two of the authors independently assessed the retrieved studies and any disagreement about the eligibility of a paper was resolved through discussion with a third author.

Data extraction and quality assessment The authors’ designed checklist was used to extract the required data from each eligible study. The data on first author, year of data collection, the location of the study, the language of study, sample size, cut-off point to measure CHE and prevalence of CHE were extracted from each eligible article. The quality of the manuscripts was assessed using a checklist whose validity was confirmed in previous studies (Rezaei et al., 2017; Moosazadeh et al., 2014; Haghdoost and Moosazadeh, 2013). The checklist consisted of 12 questions that included questions related to the aim of the study, the method of the study, data collection method and tool, sample size and study population. A value of 1 was assigned to each question and the total quality score was calculated for each eligible articles. Studies that obtained a quality score of 8–12 were included in the final analysis (Table I).

Data analysis In this study, the prevalence of CHE was defined as the proportion of households who faced CHE. A household was considered with CHE if the household’s spending on healthcare services was higher than 40 percent of its capacity to pay. Based on the WHO (Murray et al., 2003), the difference between a household’s income and the living expenditure is considered as the capacity to pay. For each study, we used the binomial distribution formula to calculate the standard error (SE) of the prevalence of CHE among the households. The heterogeneity among the studies was checked by using the χ2-based Q-test and I2-test. The p-valueo0.05 for the

Table I Checklist for assessing the quality of primary studies Score No. Questions

Downloaded by TEHRAN UNIVERSITY OF MEDICAL SCIENCES At 06:58 20 August 2018 (PT) Yes=1 No=0 1. Are the research questions clearly stated? 2. Is the approach appropriate for the research question? 3. Is the study context clearly described? 4. Is the role of the researcher clearly described? 5. Is the sampling method clearly described? 6. Is the sampling strategy appropriate for the research question? 7. Is the data collection method clearly described? 8. Is the data collection method appropriate to answer the research question? 9. Is the method of analysis clearly described? 10. Are the main characteristics of the population well described? 11. Is the analysis appropriate for the research question? 12. Are the claims made supported by sufficient evidence? Note: The checklist questions were obtained from Moosazadeh et al. (2014)

INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE χ2-based Q-test and I2 greater than 50 percent for the latter were used a cut-off for the heterogeneity of the studies. The random-effects model was used to measure the pooled prevalence of CHE. The forest plot with 95 percent confidence interval (95% CI) was also used to obtain the estimation of point prevalence CHE among the households. The bivariate meta-regression analysis was applied to identify the potential sources of the heterogeneity among the included studies. The Egger test was used to examine for publication bias and the p-value of the test less than 0.05 indicated publication bias among studies included in the analysis. The data analysis was performed using the Stata version 14.2 (Stata Corp, College Station, TX) and the p-value less than 0.05 was considered statistically significant.

Ethical statement The study protocol was reviewed and approved by the ethics committee of the Deputy of Research in Kermanshah University of Medical Sciences (IR.KUMS.REC. 1396.373).

Results A total of 24 eligible studies (Soofi et al., 2013; Mehrara and Fazaeli, 2010; Nekoeimoghadam et al., 2014; Moghadam et al., 2012; Kavosi et al., 2012, 2014; Daneshkohan et al., 2011; Fazaeli, Ghaderi, Fazaeli, Lotfi, Salehi and Mehrara, 2015; Fazaeli, Seyedin, Moghaddam, Delavari, Salimzadeh, Varmazyar and Fazaeli, 2015; Yousefi et al., 2015; Sabermahani et al., 2014; Asefzadeh et al., 2013; Amery, Vafaee, Alizadeh, Ghiasi, Shamaeianrazavi and Khalafi, 2013; Amery, Jafari and Panahi, 2013; Masaeli et al., 2015; Ghiasi et al., 2016; Ghoddoosinejad et al., 2014; Arab et al., 2016; Rezapour et al., 2013; Piroozi et al., 2016; Anbari et al., 2014; Hanjani and Fazaeli, 2006; Ghafoori et al., 2014; Homaie et al., 2017) were included in the review, of which 13 (54.2 percent) were published in English and the remaining 11 (45.8 percent) were in Persian. In all, 9 (37.5 percent) of the studies were published between 2006 and 2010 and the remaining 15 (62.5 percent) were published between 2014 and 2017. The cumulative sample size was 301,097 households and the lowest and highest sample sizes were 100 and 39,088, respectively. There was a wide disparity in the prevalence of the CHE based on the sample sizes. The larger the sample size, the smaller was the prevalence rate of the CHE. The average sample size of 11 (45.8 percent) eligible studies was 22,671 and the prevalence of CHE was less than 5 percent, while the mean sample size of the remaining 13 (54.2 percent) eligible studies was 3,977 and prevalence of the CHE was more than 5 percent. Of the eligible studies, 16 (66.7 percent) were conducted in different provinces and the remaining 8 (33.3 percent) studies were conducted in all the provinces of Iran. The descriptive characteristics of the 24 eligible studies are presented in Table II and the systematic reviewing process is displayed in Figure 1. The results indicated a high heterogeneity among the studies included in the analysis ( χ2-based Q ¼ 4790 with po0.001 and I2 ¼ 99.5 percent). Publication bias was observed among all the articles included in the study (see Table III). There was a high variation in the prevalence of the CHE among the eligible studies. The prevalence of CHE ranged from 1.6 percent, reported by Masaeli et al. (2015), to as high as

Downloaded by TEHRAN UNIVERSITY OF MEDICAL SCIENCES At 06:58 20 August 2018 (PT) 24 percent, reported by Ghoddoosinejad et al. (2014) and Asefzadeh et al. (2013). Based on the random effects modeling, the estimated pooled prevalence of CHE among the households was 7 percent (95% CI: 6–8 percent) (Figure 2). The results from the meta-regression, presented in Table IV, indicated that the prevalence of the CHE was inversely related to the sample size and directly to the year of data collection (i.e. trend analysis). The association between the sample size and prevalence of the CHE ( po0.05) was statistically significant.

Discussion Financial protection of households against the risk of unexpectedly high healthcare expenses is one of the main functions of health systems. Measuring the prevalence of CHE and tracking the changes over time are critical for policy makers. The CHE is believed to be one of the main

INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE Table II Characteristics of articles included in the systematic review

First author Year of data collection Language Location of study Sample size Prevalence of CHE (%)

Soofi 2001 Persian All of provinces in Iran 10,300 15.3 Alizadeh Hanjani 2002 English All of provinces in Iran 32,153 3.9 Mehrara 2007 Persian All of provinces in Iran 31,283 2.5 Nekoeimoghadam 2008 Persian Kerman 1,480 4.1 Nekoeimoghadam 2008 English All of provinces in Iran 39,088 2.8 Kavosi 2008 English Tehran 592 11.8 Daneshkohan 2008 English Kermanshah 189 22.2 Fazaeli 2010 English All of provinces in Iran 28,997 2.1 Fazaeli 2010 English All of provinces in Iran 38,170 3.1 Yousefi 2011 Persian All of provinces in Iran 36,071 3.8 Saber Mahani 2011 Persian Tehran 34,700 11.3 Kavosi 2011 English Shiraz 800 14.2 Asefzadeh 2011 Persian Qazvin 100 24 Amery 2011 Persian Yazd 400 8.3 Masaeli 2011 Persian All of provinces in Iran 38,437 1.6 Ghafoori 2012 English Tehran 792 7.2 Amery 2012 Persian Razavi Khorasan 384 6.8 Ghiasi 2013 Persian Zabol 393 20.6 Bagheri Faradonbeh 2013 Persian Tehran 625 3.8 Ghoddoosinejad 2013 English South Khorasan 100 24 Rezapour 2013 English Tehran 2,200 6.45 Anbari 2014 English Markazi 758 11.2 Piroozi 2015 English Kurdistan 663 4.8 Homaei Rad 2015 English Guilan 2,422 3.8

Notes: CHE, catastrophic healthcare expenditures. Household is the unit of observation in all studies. The cut-of point in all of the studies was 40 percent of capacity to pay

indicators that can show the financing performance of a health system. In Iran, reducing OOP by 30 percent and CHE among households by 1 percent are the two main goals set in the recent five-year development plan of Iran (Moghaddam et al., 2013). This study aimed to provide evidence about the prevalence and time trend of CHE of households in Iran. The estimated pooled prevalence of CHE was 7 percent. The results of meta-regression did not suggest a statistically significant relationship between the prevalence of CHE and the year of study (data collection). However, the results indicated that the prevalence of CHE was inversely related to the sample size ( po0.05). In other words, studies with the smaller sample sizes were more likely to report higher prevalence of CHE in Iran. For example, the reviewed studies with the sample size of less than 400 households reported the prevalence of CHE to be more than 20 percent (Ghoddoosinejad et al., 2014; Ghiasi et al., 2016). Other studies also reported a higher prevalence of CHE in Iran. For example, a review of studies Downloaded by TEHRAN UNIVERSITY OF MEDICAL SCIENCES At 06:58 20 August 2018 (PT) on both patients and households reported a prevalence of CHE ranging from 2.5 to 72.5 percent among households (Aeenparast et al., 2016). Another study reported the prevalence of CHE among households to be 24 percent (Daneshkohan et al., 2011). The findings from the existing studies indicated the lowest prevalence rate of CHE in South Khorasan province (1.6 percent) (Ghoddoosinejad et al., 2014). The highest prevalence rate of CHE was reported in Qazvin province (24 percent) (Asefzadeh et al., 2013). The prevalence of CHE in Iran is comparable to those reported in some developing countries such as Brazil, Vietnam and Georgia (Xu et al., 2003; Gotsadze et al., 2009). The estimated CHE prevalence is higher compared to what has been reported in developed countries. For example, a study in 59 developed countries found a prevalence of CHE to be less than 0.5 percent in all countries except the USA (0.55 percent), Switzerland (0.57 percent), Greece (2.17 percent) and Portugal (2.71 percent) (Xu et al., 2003). The samples of eight studies in the current review were drawn from all the provinces in Iran and the estimated prevalence of the CHE was based on surveys conducted by Statistical Center of

INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE Figure 1 Flow chart of systematic search and studies selection

Search results in PubMed, Scopus, Clarivate Analytics, SID, Iranmedex and Magiran n=163

50 excluded due to duplicated in databases

113 articles after duplication

44 articles excluded based on title

69 articles after title screening

27 articles excluded based on abstract

42 articles remained to review based on full text 2 articles were excluded due to duplication: both English and Persian versions of the studies were available 8 and 1 articles were excluded because of hospitalized patients and retirement homes were included in the study

22 articles + 2 articles entered to the 8 articles were excluded: the overall study through a reference check of prevalence of CHE was not reported included articles 1 article was excluded because the sample size was not reported

Table III Egger’s test for small-study effects to examine the publication bias

Coefficient SE p-value 95% confidence interval Downloaded by TEHRAN UNIVERSITY OF MEDICAL SCIENCES At 06:58 20 August 2018 (PT) Prevalence of CHE Slope 0.02 0.005 0.001 0.009–0.03 Bias 9.6 3.5 0.012 2.37–16.85

Notes: Test of H0: no small-study effects ( p ¼ 0.012)

Iran and other national-level data sources. The remaining studies were based on a survey that investigated the prevalence of CHE in a defined region of Iran. The average CHE reported in the regional surveys (9.42 percent) was higher than that reported from the studies which used national-level data sets (8.73 percent). The national studies could be very important in informing the level of CHE in Iran. These studies could provide a better understanding of the prevalence of CHE when they reported the CHE in different provinces (Nekoeimoghadam et al., 2014;

INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE Figure 2 Forest plot of the prevalence of CHE among households in Iran

Year of data % Author collection ES (95% CI) Weight

Soofi 2001 0.15 (0.15, 0.16) 4.95 Alizadeh Hanjani 2002 0.04 (0.04, 0.04) 5.06 Mehrara 2007 0.03 (0.02, 0.03) 5.06 Nekoeimoghadam 2008 0.04 (0.03, 0.05) 4.83 Nekoeimoghadam 2008 0.03 (0.03, 0.03) 5.06 Kavosi 2008 0.12 (0.09, 0.14) 3.82 Daneshkohan 2008 0.22 (0.16, 0.28) 1.88 Fazaeli 2010 0.03 (0.03, 0.03) 5.06 Fazaeli 2010 0.02 (0.02, 0.02) 5.06 Yousefi 2011 0.04 (0.04, 0.04) 5.06 Saber Mahani 2011 0.11 (0.11, 0.12) 5.04 Kavosi 2011 0.14 (0.12, 0.17) 3.95 Asefzadeh 2011 0.24 (0.16, 0.32) 1.15 Amery 2011 0.08 (0.06, 0.11) 3.75 Masaeli 2011 0.02 (0.01, 0.02) 5.07 Ghafoori 2012 0.07 (0.05, 0.09) 4.38 Amery 2012 0.07 (0.04, 0.09) 3.88 Ghiasi 2013 0.21 (0.17, 0.25) 2.86 Bagheri Faradonbeh 2013 0.04 (0.02, 0.05) 4.57 Ghoddoosinejad 2013 0.24 (0.16, 0.32) 1.15 Rezapour 2013 0.06 (0.05, 0.07) 4.82 Anbari 2014 0.11 (0.09, 0.13) 4.08 Piroozi 2015 0.05 (0.03, 0.06) 4.49 Homaie Rad 2015 0.04 (0.03, 0.05) 4.93 2 Overall (I = 99.5%, p = 0.000) 0.07 (0.06, 0.08) 100.00

00.5 Note: Weights are from random effects analysis

Table IV Meta-regression analysis of the prevalence of CHE among households in Iran

Coefficient SE p-value 95% confidence interval

Prevalence of CHE Year of data collection 0.00001 0.004 0.99 −0.0085 to 0.0085 Sample size −2.06e 7.5e 0.012 −3.62e to −4.69e

Ghiasvand et al., 2015). Nonetheless, most of the national studies used surveys that were not preliminary designed for measuring the prevalence of CHE. Hence, designing specific national surveys to measure the prevalence of CHE or modifying the existing national survey tools in Iran in a way that they incorporate the measurement and monitoring of the prevalence of CHE can provide a better understanding of CHE faced by households in Iran. Evidence showed that utilization of healthcare services is one of the main determinants of CHE in Iran (Arab et al., 2016; Ghoddoosinejad et al., 2014; Nekoeimoghadam et al., 2014) and other countries (Su et al., 2006; Adhikari et al., 2009; Rivero et al., 2006; Limwattananon et al., 2007).

Downloaded by TEHRAN UNIVERSITY OF MEDICAL SCIENCES At 06:58 20 August 2018 (PT) The utilization of inpatient services in the public sector and outpatient and inpatient services in the private sector also increased the chance of CHE and impoverishment (Murray et al., 2000; Su et al., 2006). Socioeconomic status, age (the presence of under five-years old children and over 65 years old) of the household members and place of residence were the main factors reported to have an influence on the prevalence of CHE in Iran (Nekoeimoghadam et al., 2014; Yousefi et al., 2015; Piroozi et al., 2016; Arab et al., 2016). There existed a significant association between having basic health insurance and lower risk of CHE (Arab et al., 2016). In contrast, others reported that health insurance did not protect individuals against impoverishment and CHE (Piroozi et al., 2016; Kavosi et al., 2014). Nonetheless, social health insurance and population-based tax-funded health systems are the best ways to improve financial protection of households and to decrease CHE (Somkotra and Lagrada, 2009; Puteh and Almualm, 2017; Sun et al., 2009). Other risk pooling schemes such as community-based health insurance can also protect poor people against CHE in areas where there is no nationwide financial risk protection scheme (Ranson, 2002).

INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE Decreasing the OOP and CHE are among the main goals of Iran’s HSPE reform. After the implementation of this plan, the prevalence of CHE in the west of Iran was reported to have been reduced to less than 5 percent (Piroozi et al., 2016). While the decision on the changes in the prevalence of CHE after the implementation of the HSPE requires baseline evidence, related studies reported a higher prevalence of CHE than the one percent goal set in the recent five-year development plan of Iran. A related study also suggested an increasing trend of CHE after the implementation of the HSEP in Iran (Yazdi Feyzabadi et al., 2017). This increasing trend might be due to improved access to healthcare services that would subsequently increase the utilization of the healthcare services, which, in turn, affected the CHE. The focus of Iran’s HSPE reform on inpatient care in the public hospitals and the relative increase in the prices of the clinical services might have led to the increased OOP and CHE in Iran. In addition, macroeconomic issues such as high inflation rate that could decrease households’ capacity to pay might have contributed to the increased prevalence of the CHE in Iran (Yazdi Feyzabadi et al., 2017; Piroozi et al., 2016). This study has some limitations and the findings should be interpreted with caution. First, the latest reported prevalence was included in the meta-analysis when more than one studies reported CHE for the same region. Second, the selected articles reported CHE in different provinces of Iran. Given the wide variation in the socioeconomic and demographic characteristics across provinces, a random effects model was used to reduce the effect of this heterogeneity in the meta-analysis. Nevertheless, the findings should be interpreted with caution due to the unexplained heterogeneity of findings across studies. Third, there was no report on the prevalence of CHE among households for some of the provinces. Thus, the findings should be interpreted in light of this limitation. Finally, this systematic and meta-analysis was limited to studies that were conducted in Iran and the results are not generalizable to other countries.

Conclusion The pooled estimated prevalence of CHE in Iran is found to be significantly higher than 1 percent, whichisthegoalsetoutinIran’s fourth five-year development plan. This result implies that the current interventions targeting the higher CHE in Iran did not have a considerable effect on the prevalence of the CHE. Thus, further interventions are required to protect households against CHE in Iran.

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