This study demonstrated the low level of PWD's access to healthcare services in rural areas of Iran. In addition, background factors and socio-financial determinants, including gender, age, marital status, education level, residence status, the income of the head of the household, financial aid, and residency area, presented a significant effect on financial access.
Concerning the availability dimension, more than 70% of PWDs evaluated this dimension as strongly low and low, with the highest-burden on health posts. PWDs also require rehabilitative services and psychological support, which are not available in health posts or other rural healthcare centers. A study conducted on caregivers of PWDs in Australia also reported similar findings, while emphasizing the necessity of addressing traveling a long distance and long waiting times, not to mention high expenditures (8). For 63% of PWDs, the utilization rate was strongly low, with general physicians as the primary provider (67.8%). As rehabilitative and psychological services are primarily providing by the private sector, particularly in small cities and counties, it can be argued that either PWDs are deprived of such services or pay high costs and wait for long hours (7, 8). Concerning families' experiences with a PWD member, Raeis-Dana et al. (14) reported shortages in psychological and supportive services as a significant barrier. Noteworthy, the WHO emphasized more equitable access of PWDs to rehabilitative and psychological services through public centers (15).
The Iran health system's extended health network has resulted in high rates of PWDs identification, particularly in rural areas. However, there is no comprehensive plan to provide affordable and in-home services to them. In this line, 68% of PWDs reported not using in-home services. On the other hand, they receive such services from the private sector while paying high costs. In addition, 80% of subjects declared unavailability of telephone or internet scheduling or telecommunication services. About 60% of participants are deprived of health services due to the lack of information, revealing a significant challenge for PWDs. Lack of appropriate communication strategies has intensified this challenge (14). Some studies mentioned that low awareness of health staff about the health needs of PWDs and lack of comprehensive training programs are major factors contributing to this issue (14). Furthermore, restrictions imposed to control the Covid-19 pandemic, including canceling several elective services, resulted in declined access of PWDs to healthcare services (5). These issues indicate the necessity of strengthening electronic systems required to provide supportive and psychological services.
Concerning affordability of healthcare services, 80% of participants mentioned moderate and low levels; meanwhile, 79% of them did not have complementary health insurance coverage. In a study on reasons for not receiving healthcare services, Rezapour et al. (16) mentioned high costs, long waiting times, self-medication, long traveling distance, not having insurance coverage, and unawareness about healthcare centers. Addressing this issue requires particular attention of policymakers to complementary health insurance coverage of PWDs, which plays a significant role in meeting their unmet health needs, translating into improved health status and living conditions.
Utilization of specialized services and obtaining prescribed medicines are other important dimensions of financial access to healthcare services. In this regard, 33% of PWDs declared borrowing money to pay their health expenditures. Similar results are reported by studies performed in South Africa and by United Nations (7). In addition, 10% of them declared selling their commodities. Meanwhile, PWDs and their caregivers or companions faced a 24–56% decline in income due to referring to healthcare centers. Two factors should be considered when interpreting this finding: (a) access to specialized services is a challenging issue in rural areas, similar to Australia (8); and (b) the price and income elasticity of drug demand is less than one in Iran, which indicates the necessity of receiving such services (17–19).
Lack of primary and complementary health insurance coverage translates into increased out-of-pocket payments (OOP) and a low tendency to utilize healthcare services. Meanwhile, primary health insurance plans of Iran do not provide appropriate coverage for services and drugs related to PWDs, which is consistent with some previous studies (20, 21). In some countries, such as Canada and United States, special benefit packages are developed for covering services related to PWDs, including medicines, medical devices, transportation, and even guide dogs (22, 23).
According to the findings of the regression model, benefiting from primary and complementary health insurance coverage has a significant impact on all three dimensions of financial access, which was not statistically significant for each of them. Similar results are reported by Rezapour et al. (18) and Sharifian-Sani (24). There are evidence indicating the positive effect of benefiting from health insurance coverage on the utilization of healthcare services among the poor (25, 26). Definitely, health insurance coverage declines OOP, leading to increased utilization. The variable of age presented a significant association with financial access. Falkingham et al. (27) showed that utilization of healthcare services differs based on age so that younger and older individuals have higher levels of utilization. In addition, education level also presented a significant effect on access to healthcare services, particularly for the dimension of availability.
Nevertheless, Rezapour et al. (16) found no significant association between the education level of the household and access to required healthcare services. Evidence show a significant association between education and utilization of healthcare services up to a Diploma and a non-significant association for those with a university degree (20). The Residency area also presented a significant effect on access to healthcare services, particularly the availability dimension, which can be attributed to the household's type of residence and economic status. This is consistent with Rezapour et al. (16), in which homeowner households had a higher chance of meeting their need (by 1.97 times) than others.
Income and financial aid positively affected access to healthcare services, particularly regarding availability dimension. In a study in China, Ma and McGhee mentioned economic status (low income) as the variable with the highest impact on health-related quality of life among all socioeconomic factors (28). Ataguba, which intended to investigate income inequality in South Africa, mentioned disappropriate concentration of good health among the rich compared to the poor (29). Income is the most important determinant of health and is the prerequisite for access to other factors affecting health, such as housing, nutrition, and education. Low-income and poor people often have low living standards, translating into the low financial ability to afford health expenditures, inadequate nutrition, and low education levels.
Low income reduces a person's searching behavior, leading to declined access to healthcare services (30). On the other hand, income, in addition to indicating social prestige, is also an indicator of access to various resources such as financial ability to obtain health insurance coverage and utilization of healthcare services (31, 32).