In total, 69.7% of the participants in the last month (the last 30 days) had perceived the need for outpatient care, of which 67.7% had sought for these services, and finally 79.5% of whom had received the services. Unmet need for outpatient services was 46.6%. Perceiving need for a doctor's visit, dental services, and para-clinical services were most prevalent. In the Iranian Utilization of Healthcare Services Survey in 2016, conducted on a population over the age of 15, unmet need for outpatient services was reported at 17% over the past two weeks. About 40% of people cited the lack of affordability as a reason for unmet need for outpatient.
In a study conducted in Iran (Kerman city) in the elderly population, the perceiving need for health services during the last two weeks was reported to be about 64%, of which about 71% of these people had referred to medical centers for outpatient services and the most required service was a visit to a specialist doctor. In this study, 29% of people did not go to any center despite the need for outpatient services, and about 68% of them had self-medication. The most important reason for not visiting, despite the need, was that their illness was not serious. In the study of Hassanzadeh et al. In Iran (Markazi Province), about 37% of people needed outpatient care during the last two weeks, of which about 66% sought outpatient care and finally about 98% had received the services. In another study in Iran, households over the age of 65 were more likely to use outpatient services. A study in Brazil found that the elderly population seeking outpatient services was about 64% in the last four months.
In our study, the most important reasons for not seeking outpatient care were; "I could not afford it" and "insurance did not cover the costs properly", respectively. In a study in Iran (Tehran), the most important reasons for not using outpatient services were the self-medication, the elimination of the problem and the lack of affordability . In Iran, unlike inpatient services, most outpatient services are provided by the private sector. In Iran, the difference between private and public sector tariffs is significant and over 100%, and basic insurance in the private sector covers only 70% of public sector tariffs, and 30% of the patient’s share and the difference between public and private sector tariffs must be paid by the patient and out of pocket [18–21]. Also, in Iran, basic insurance does not have adequate service coverage and services such as dental and rehabilitation services, which are essential services for the elderly population, are not included in the basic insurance service package [22–24]. In many studies in Iran, the use of outpatient health services and the presence of the elderly in the household were the risk factors for dealing with the catastrophic costs of health [25–28]. In one study conducted in six European countries, the most common barriers to use health services were personal beliefs (I was able to deal with my problems; my problems would be solved), practical barriers (lack of access to a doctor; lack of affordability; lack of knowledge of how to request assistance) and barriers related to stigma were identified. In this study, 29.7% of the elderly needed hospital care during the past year (last 12 months), of which 85.1% sought for these services and finally 97.5% of them received the services.
Unmet need for inpatient services was 17%. The most important reasons for not seeking hospital care were "having the medication at home and taking it," "being away from the hospital," and "maybe I will refer in the future," respectively. In a study in Iran, about 25% of the elderly had been hospitalized in the past six months. A study in India reported a behavior seeking for health problems of about 84%, and the most important reasons for not referring were "lack of money" and "lack of perceiving the need to see a doctor due to problems related to age".
In Iran, most hospital beds are in public sector hospitals and most inpatient services are provided by this sector. In addition, basic insurance covers over 90% of hospital costs in this sector, so financial barriers to the use of inpatient services in the public sector is less common. There is only one private hospital in Kurdistan Province, which provides most of the services related to elective surgery and childbirth. In the study of Borhaninejad et al, in Iran, the highest number of hospitalizations was public hospitals and the most important reason was the lower cost of public hospitals compared to other hospitals. In many studies in Iran, the prevalence of self-medication in the public and the elderly population has been reported and one of the reasons has been reported as not timely visiting health centers and service providers [32–35]. Based on the results of multivariate logistical regression, having health insurance and middle economic status, and having a 65–70 age group increased the chances of seeking inpatient care. According to Anderson's behavioral model, age as "predisposing factors" and insurance status and economic status as "enabling or impeding factors" are the factors influencing the utilization of health services.
In various studies in Iran and the world, having insurance and better economic status are the factors influencing the seeking and the use of inpatient services in the elderly and general population [14, 17, 36–42].
In this study, having a younger age reduced the chances of seeking outpatient care. This may be less severe in young elderly. In the study in Iran, no significant relationship was found between outpatient seeking and marital status, age group, private insurance, job status and place of residence.
In this study, based on the results of the concentration index, there was inequality in using outpatient services and it was significantly concentrated among the rich. These findings are consistent with various studies [1, 14, 43, 44].
The private sector provides most outpatient services in Iran, and basic insurance in this sector does not provide adequate financial protection against health expenditures[25, 26]. Besides, several outpatient services, such as rehabilitation and dental services, which are also essential services for the elderly, are not covered by insurance [45–47].