Out-of-Pocket and Informal Payment Before and After the Health Transformation Plan in Iran: Evidence from Hospitals Located in Kurdistan, Iran

Abstract

Background: One of the objectives of the health transformation plan (HTP) in Iran is to reduce out-of-pocket (OOP) payments for inpatient services and eradicate informal payments. The HTP has three phases: the first phase (launched in May 5, 2014) is focused on reducing OOP payments for inpatient services; the second phase (launched in May 22, 2014) is focused on primary healthcare (PHC) and the third phase utilizes an updated relative value units for health services (launched in September 29, 2014) and is focused on the elimination of informal payments. This aim of this study was to determine the OOP payments and the frequency of informal cash payments to physicians for inpatient services before and after the HTP in Kurdistan province, Iran. Methods: This quasi-experimental study used multistage sampling method to select and evaluate 265 patients ischarged from hospitals in Kurdistan province. The study covered 3 phases (before the HTP, after the first, and third phases of the HTP). Part of the data was collected using a hospital information system form and the rest were collected using a questionnaire. Data were analyzed using Fisher exact test, logistic regression, and independent samples t test. Results: The mean OOP payments before the HTP and after the first and third phases, respectively, were US$59.4, US$17.6, and US$14.3 in hospital affiliated to the Ministry of Health and Medical Education (MoHME), US$39.6, US$33.7, and US$13.7 in hospitals affiliated to Social Security Organization (SSO), and US$153.3, US$188.7, and US$66.4 in private hospitals. In hospitals affiliated to SSO and MoHME there was a significant difference between the mean OOP payments before the HTP and after the third phase (P<.05). The percentage of informal payments to physicians in hospitals affiliated to MoHME, SSO, and private sector, respectively, were 4.5%, 8.1%, and 12.5% before the HTP, and 0.0%, 7.1%, and 10.0% after the first phase. Contrary to the time before the HTP, no informal payment was reported after the third phase. Conclusion: It seems that the implementation of the HTP has reduced the OOP payments for inpatient services and eradicated informal payments to physician in Kurdistan province.

Decomposing inequality in financial protection situation in Iran after implementing the health reform plan: What does the evidence show based on national survey of households' budget?

“…Some reasons for this can be because of targeting of the mentioned plan, so that the plan has covered only services provided in hospitals affiliated to the Ministry of Health while the role of private sector, as a key player in providing services in outpatient setting, has not been significantly considered. Because outpatient services such as diagnostic services, dentistry, rehabilitation, outpatient consultations, medicines, and equipment are mainly provided by the private sector, they were found to be the key determinants of health expenditures in Iranian households in previous studies …”

“…Results of some studies showed that lower income households are more likely to face catastrophic health expenditures. Some reasons for these findings are if health services are expensive than consequently households have to spend considerable amount of their income, wealth, and savings or to borrow or sell their productive assets …”

Health informal payments and their main determinants: The case of Iran

“…21,27 In such a situation, the problem of patients' informal payments may persist even after implementing reforms. 21,28,29 This study aimed to identify the most important factors affecting health informal payments in Iran.…”

The burden of preventable hospitalizations before and after implementation of the health transformation plan in a hospital in west of Iran

“…It shows that people without health insurance utilized hospitalization services less than those with insurance (Piroozi et al , 2017). In a number of studies, the impact of continuity on PHs has been measured as one of the features of primary health care, and their results indicated the negative effect of the continuity of primary care on burden of PHs (Menec et al , 2006; Ionescu-Ittu et al , 2007).…”

“…This decline is due to the implementation of the package ‘Reducing payment rates for hospitalized patients in university hospitals’ in the form of HTP. According to this package, hospitalized patients who live in cities are required to pay a maximum of 6% of hospitalization costs, and patients who live in villages and cities under 20 000 population, if referred through the referral system, are required to pay a maximum of 3% of total hospitalization costs (Piroozi et al , 2017). An increase in the hospitalization costs is due to the introduction of a new book with updated relative value units, which resulted in using real and high medical tariffs.…”