Universal health coverage means that everyone has access to health services they need without facing financial barriers[21].According to the World Health Organization, the CHE value should be less than 1%[4]. Achieving universal health coverage is one of the commitments of the Islamic Republic of Iran. In this regard, reducing the CHE index to 1% has been stated as a goal in the fourth, fifth and sixth five-year development plans of the country[13].
In this study, in total, the rate of exposure to catastrophic health expenditures in Iran was reported 8.3%. The highest percentage of exposure was seen among users of rehabilitation services (35%), households with poor socioeconomic status (27%), households with a disabled member (22%), dental services users (20%), female head of the household (17%) and housewives (17%). The difference in the percentage of CHE between provinces was not significant.Based on the findings of this study, in the last year of the sixth five-year development plan (2017–2021) as a strategic document, like the two previous development plans,Iran not only did not achieve the goal of reducing the percentage of households exposed to CHE to 1% and there is still a big gap to reach that goal, but also, based on the findings of previous studies, this gap seems to have become deeper[15–17]. According to the findings of another systematic and meta-analysis study in Iran (2017) conducted by Ghorbaian et al., the prevalence of households faced with CHE was reported to be 3.9% (95% CI, 3.26–11.07)[22].. Also, in the latest systematic and meta-analysis study in Iran (2018) conducted by Aryankhesal et al., in total, the percentage of households exposed to CHE was 7.5% (95% CI, 6.2–9.1) and for inpatient services was 35.9% (95% CI, 23.5–54.3)[15].Based on a national study in Iran (2020) conducted by Moradi et al. on households with disabled children, 32.7% of households were exposed to CHE[23]. Also, according to the report of the research center of the Iranian parliament, the value of the CHE index for the country at the end of 2015 (end of the fifth development plan) was reported 6%[18].A comparison of the findings of our study with the findings of the above studies conducted in recent years shows that the status of the financial protection index against CHE in Iran not only did not reach the 1% target but rather the gap between the status quo with a predetermined goal and the desired status seems to have widened[15, 17, 22]. Due to the situation caused by the Corona virus in the world and in Iran, on the one hand, it seems that the use of elective health services has decreased, which in turn can lead to an increase in unmet health needs and a false decrease in the percentage of exposure to CHE because of not using health services. On the other hand, the current situation can weaken the economic situation of households and thus reduce households' capacity to pay and increase the prevalence of households facing CHE. Designing appropriate and targeted interventions to move towards achieving universal health coverage and more financial protection should be on the agenda of policy makers in the Iranian health system.
According to our study, in final models, variables of female head of household, use of inpatient, outpatient, dental, and rehabilitation services, families with disabled members and households with low socioeconomic status, were significantly associated with increased odds of facing CHE.
In most similar studies conducted in Iran, these variables have been reported as variables affecting the CHE[6, 24, 25]. In Iran, despite the fact that a high percentage of population is covered by basic health insurance, service coverage and depth of coverage of health costs are not in a good situation and these insurance companies have not been able to provide adequate financial protection of people against health costs and a significant part of the costs is paid out of the pockets[26]. In Iran, dental and rehabilitation services and equipment are not covered by basic health insurance and most of these services are provided by the private sector. In most studies, the use of rehabilitation and dental services have been reported as determinants of exposure to CHE[6]. The results of a systematic and meta-analysis study in Iran (2021) conducted by Soofi et al. showed that health insurance companies do not provide effective financial protection against CHE[26]. Based on the results of the study, the expansion of prepayment mechanisms, integration of insurance funds and designing insurance service packages to cover chronic diseases have been proposed as appropriate solutions for financial protection against CHE[26]. Findings of another systematic and meta-analysis study in Iran (2019) indicated that the variables of using inpatient, outpatient, and dental services, low education, rural life and low household income are the factors that determine CHE in Iran, and these variables increase the odds of encountering CHE[22, 23]. In another study in Iran (2020) on households with children with disabilities, the variables of female head of household, poor economic status of the household, lack of supplementary insurance and type of basic health insurance significantly increased the chances of facing CHE. According to a study by Kavosi et al. in Iran (Tehran), exposure to CHE was significantly associated with consumption of inpatient and dental services, the presence of a person over 65 in the household and low economic status[6].
According to our study, having supplementary insurance did not lead to greater financial protection and nor reduced the chance of facing CHE, which contradicts the findings of a number of previous studies[8, 10, 12].
Strengths Of The Study
This study was conducted at the national level and is the first study at this level to evaluate the goal related to the financial protection of citizens in the sixth five-year development plan of the Islamic Republic of Iran.