Fairness in Household Financial Contribution to the Healthcare System; the Evidence of Iran from 2008 to 2018

Objective: The achievement of equity in health leads to health gains and nancial risk protection and this issue was one of the important goals of Iran’s health transformation programm (HTP). The present study aimed to how the HTP achieved its objectives in terms of fair nancial protection by assessing the Fair Financial Contribution Index (FFCI) in various households of urban and rural areas before (2008-2013) and after (2014-2018) the implementation of the HTP. Results: According to the sample analyzed, 207,980 and 212,249 of households lived in urban and rural areas, respectively. The worst fair contributions to health expenditure in urban (FFCI= 0.684) and rural areas (FFCI= 0.530) were occurred in 2010 and 2009, respectively. Otherwise, the best fair contributions for urban areas (FFCI=0.858) and rural areas (FFCI= 0.836) were made in 2011. Before the HTP implementation was began (between 2008 and 2013), FFCI witnessed minor changes from 0.834 in 2008 to 0.833 in 2013. Following the HTP implementation, the FFCI values in urban and rural population declined (worsened) from 0.842 to 0.836 and 0.816 to 0.809, respectively. Overall, FFCI has been improved during years after the implementation of HTP. Such that, the improvement was shown more in rural areas.


Introduction
Equity in utilization and resource distribution is an essential intermediate objective of health nancing policy [1]. The achievement of this objective leads to health gains and nancial risk protection, especially for those in need. Since 2000, the WHO has drawn attention to ensure equitable (or fair) nancing for health care, highlighting that health systems are not just about improving health status. However, also improving fairness through health system nancing and delivery has a broader social value [2]. In the 2010 World Health Report, the fair nancial contribution was considered to be the main criterion for achieving universal health coverage. [3].
Generally, different methods have been used to nance health systems, including tax-based insurance, social insurance, private insurance, and Out-of-Pocket (OOP) payment [4]. From the viewpoint of both risk protection and equity, OOP payments is considered to be the worst possible form of health nancing [5,6]. Evidence shows that the high share of OOP payments for health services is a sign of inadequate social health coverage and can lead to economic hardship, particularly in low-and middle-income countries [7,8]. OOP imposes the most signi cant burden on the poor and carries a high risk of falling households into poverty by imposing Catastrophic Health Expenditure (CHE) [9]. To this end, WHO has more than ever emphasized the CHE and the Fair Financial Contribution Index (FFCI) as equity indicators for household nancial contributions to health systems [10,11] and recommended the universal health coverage strategy with the aim of ensuring that all people have access to the required health services without any nancial di culties at the time of receiving services.
In Iran, given the requirements of the National Five-Year Development Plans to address high OOP rates, i.e., 52.1% of total health expenditure [12], the increased contribution of the government in providing the funds for public health expenses and appropriate allocation of public resources in the health sector are of great importance. Accordingly, in May 2014, the Ministry of Health and Medical Education (MoHME) of Iran implemented a comprehensive health system transformation package called the Health Transformation Plan (HTP) [13]. The reduction in the percentage of OOP payments and the reduction in the percentage of households facing CHE were identi ed as top priorities in HTP content.
Even though various indices such as the Kakwani index, Gini coe cient, CHE, and the impoverishment index [14] can be assessed for the performance of the health system, the WHO emphasizes the FFCI as an essential measure [11,15]. Fairness in healthcare nancing is assessed by the level of inequality in the payment of health care between households of unequal Capacity to Pay (CtP) [16].
Overall, equitable nancing is a crucial objective of healthcare systems and healthcare nancial risk protection, recommended to be measured on a continuous and periodic basis every 2-5 years [5,17].
The present study aims to how the HTP achieved its objectives in terms of fair nancial protection by assessing FFCI in various households of urban and rural areas before (2008-2013) and after (2014-2018) the implementation of the HTP.

Methods
The present study is a retrospective descriptive study that was conducted using annual national repeated cross-sectional surveys on households' income and expenditure from 2008 to 2018 in Iran.
Iran's household expenditure and income survey plan have been implemented in rural areas since 1963 and urban areas since 1968 by Iran Statistical Center (ISC). In addition to household expenditure, income information has also been collected since 1974 and has been given annually to date. In this plan, information related to the average expenditures and income of an urban and rural household in the country is provided annually. Data obtained from this annual survey are collected using a questionnaire for about 38,000 Iranian households that have been sampled and entered into the survey in a step-by-step manner. The questionnaire includes three sections, including socio-economic characteristics of the household, expenses (household food and non-food expenses), and household income. The pillars studied in this survey are the educational status of the household, household assets, access to basic facilities and public goods and household expenses in various sectors such as Health [18].
The sample size of the data used in the study is presented in the form of Table 1 separately for each year and the urban and rural population. In order to calculate and compare households' fair nancial contribution in health expenditures, the distribution of household nancial contributions among them is summarized using an index called the FFCI. This index puts much weight on households that spend a high proportion of their income on health.
FFCI generally re ects inequality in the nancial contribution of households in health, although it re ects explicitly households that face catastrophic health expenditures. The mathematical cube-root is used to place more weight on households in the distribution sequence. In this study, the following equation has been used to calculate the values of health expenditures FFCI.
Where w h represents households sampling weights, oopctp h represents the ratio of OOPs to the household's CtP for health expenditures, which shows the nancial burden borne for health services. The steps and details of the calculation of CtP are presented in another study by the researchers [19,20]. Also, the value of oop 0 In the above Formula is obtained from the following equation: FFCI calculations were performed for six years before the HTP implementation and ve years after it, and its trend in these years was reviewed and analyzed. Excel 2016 and Stata 14 software were used to prepare the data and analyze the results.

Results
The total sample sizes for urban and rural areas from 2008 to 2018 are shown in Table 1. According to the sample analyzed, 207,980 and 212,249 of households lived in urban and rural areas, respectively.
The FFCI results before and after the HTP in rural areas, urban areas, and the total population are shown in Table 2 Generally and on average, fairness in health expenditure contribution has experienced 4.34%, 6.37% and 5.85% improvements following the HTP in urban areas, rural areas and total population of Iran (Table 2).

Discussion
The FFCI is one measure that can help policymakers recognize the aws in the nancial protection mechanisms embedded in the health nancing system. According to our 11-year analysis, it is clear that nancial contributions in Iranian households on average were 21% and 18% away from achieving complete fairness in rural and urban areas, respectively. As far as HTP is concerned, intending to improve the distribution of health expenditure across various socio-economic groups, the results of this study showed that more fair nancial contributions had been made after the HTP, particularly in rural areas.
Despite the decline in FFCI in 2018, the nancing contributions in health payments were generally improved at the country level following ve years after the HTP. In addition, FFCIs have shown higher inequalities in rural areas compared to urban areas both before and after the HTP.
Previous studies from different regions of Iran have been reported FFCI values ranging from 0.83 in a national study in 2016 [14] to 0.6 in a study conducted in Shiraz province in 2012 [4] [24].
Results on the trend of FFCI after HTP compared to before its implementation has shown that improvements have occurred, and average FFCI values are closer to the equity level. However, by examining this index from year to year, it is clear that the numerical values of the index did not change signi cantly in 2018 compared to 2013 and were almost constant. So, consistent with the Kheibari et al.' study [14] could be stated that fair contribution to nancing improved after the HTP but less than that expected. The reasons behind the small improvements in the FFCI could be explained as follows. First, the HTP focuses only on inpatient services delivered in hospitals a liated with medical universities under the sponsorships of the MoHME. Accordingly, outpatient and inpatient services provided in other hospitals and the private sector, which have a high proportion of services almost not considered being part of the HTP. Second, despite the existence of clinical guidelines for various medical and health services, but in practice, health and medical services are not provided based on these guidelines, which may increase the cost of treatment and increase OOP payments. Third new relative value-based scales and the relative increase of tariffs in various medical specialties and subspecialties in this plan, although the percentage of OOP in the inpatient department has decreased, the absolute amount of OOP payments has practically increased.
As part of the HTP, the relative value of health care and services has been increased to motivate healthcare providers to deliver high-quality services [25] according to the new relative value book (2016 edition) [26]. As a result, new medical tariffs ascended the absolute amounts of OOP payments irrespective of reduction in payment for inpatient services. Forth, the demand for health services delivered in the public sectors has been stimulated by the HTP and, due to human, nancial, and equipment constraints, many people in the public sector (such as public hospitals) have needlessly been referred to the private sector. This has doubled the nancial burden on households.

Conclusion
We concluded that FFCI has been improved during years after the iimplementation of HTP than before ones. Overall, the improvement was shown more in rural areas than urban ones. Another conclusion drawn from the present study is that there is still a defference between level of FFCI and the targeted level (as determined 90%) in national development plans. This necessitates the strengthen actions and interventions to reduce and achieve to desired level recommended by the WHO for the OOP spending (Up to 15-20%).

Limitations
This study had some limitations which should be addressed. First, an inherent drawback of the FFCI is that it represents both vertical and horizontal equity, without distinguishing between them, though, as Wagstaff (2002)  Availability of data and material