Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments?

  • Mohammad HajizadehEmail author
  • Hong Son Nghiem


Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian—regardless of their employment status—can better protect households from catastrophic health spending.


Out-of-pocket expenditures Catastrophic expenditures Heckman selection model Hospital care Iran 

JEL Classification

D63 H51 I18 


  1. Amaya Lara J., Ruiz Gomez F. (2011) Determining factors of catastrophic health spending in Bogota, Colombia. International Journal of Health Care Finance and Economics 11(2): 83–100PubMedCrossRefGoogle Scholar
  2. Asadi-Lari M., Sayyari A., Akbari M., Gray D. (2004) Public health improvement in Iran: Lessons from the last 20 years. Public Health 118(6): 395–402PubMedCrossRefGoogle Scholar
  3. Berman P. (1995) Health sector reform: Making health development sustainable. Health Policy 32(1–3): 13–28PubMedCrossRefGoogle Scholar
  4. Castano-Yepes R. A., Arbelaez J. J., Giedion U. B., Morales L. G. (2002) Equitable financing, out-of-pocket payments and the role of health care reform in Colombia. Health Policy and Planning 17: 5–11CrossRefGoogle Scholar
  5. Greene W. H. (2003) Econometrics analysis. Prentice Hall, Upper Saddle River, NJGoogle Scholar
  6. Habibov N. (2010) Hospitalisation in Tajikistan: Determinants of admission, length of stay, and out-of-pocket expenditures. Results of a national survey. International Journal of Health Planning Management 25: 251–269Google Scholar
  7. Hajizadeh M., Connelly L. B. (2010) Equity of health care financing in Iran: The effect of extending health insurance to the uninsured. Oxford Development Studies 38(4): 461–476CrossRefGoogle Scholar
  8. Holahan J., Zedlewski S. (1992) Who pays for health care in the United States? Implications for health system reform. Inquiry 29: 231–248PubMedGoogle Scholar
  9. Hosseinpoor A. R., Naghavi M., Alavian S. M., Speybroeck N., Jamshidi H., Vega J. (2007) Determinants of seeking needed outpatient care in Iran: Results from a national health services utilisation survey. Archive of Iranian Medicine 10(4): 439–445Google Scholar
  10. Janssen R., van Doorslaer E., Wagstaff A. (1994) Health insurance reform in the Netherlands: Assessing the progressivity consequences. Economic and Social Review 25: 302–320Google Scholar
  11. Kakwani N., Wagstaff A., van Doorslaer E. (1997) Socioeconomic inequalities in health: Measurement, computation, and statistical inference. Journal of Econometrics 77(1): 87–103CrossRefGoogle Scholar
  12. Lairson D. R., Hindson P., Hauquitz A. (1995) Equity of health care in Australia. Social Science and Medicine 41(4): 475–482PubMedCrossRefGoogle Scholar
  13. Limwattananon S., Tangcharoensathien V., Prakongsai P. (2007) Catastrophic and poverty impacts of health payments: Results from national household surveys in Thailand. Bulletin of the World Health Organisation 85: 600–606CrossRefGoogle Scholar
  14. Londono J., Frenk J. (1997) Structured pluralism: Towards an innovative model for health system reform in Latin America. Health Policy 41(1): 1–36PubMedCrossRefGoogle Scholar
  15. Management and Planning Organisation. (2005). Iran’s fourth socio-economic development act: Government of Iran. Tehran: Management and Planning OrganisationGoogle Scholar
  16. Mehrdad R. (2009) Health system in Iran. Japan Medical Association Journal 52(1): 69–73Google Scholar
  17. Natawa K. (1993) A note on the estimation of models with sample selection biases. Economic Letters 42: 15–24CrossRefGoogle Scholar
  18. O’Donnell O., van Doorslaer E., Wagstaff A., Lindelow M. (2007) Analysing health equity using household survey data—A guide to techniques and their implementation. The World Bank, GenevaCrossRefGoogle Scholar
  19. O’Donnell O., van Doorslaer E., Rannan-Eliya R. P., Somanathan A., Adhikari S. R., Akkazieva S. R. B. et al (2008) Who pays for health care in Asia?. Journal of Health Economics 27(2): 460–475PubMedGoogle Scholar
  20. Okunade A. A., Suraratdecha C., Benson D. A. (2010) Determinants of Thailand household healthcare expenditure: The relevance of permanent resources and other correlates. Health Economics 19: 365–376PubMedCrossRefGoogle Scholar
  21. Roodman, D. (2009). Mixed-process models with cmp. Technical Report 11, Center for Global Development.Google Scholar
  22. Sesma-Vazquez S., Perez-Rico R., Sosa-Manzano C. L., Gomez-Dantes O. (2005) Catastrophic health expenditures in Mexico: Magnitude, distribution and determinants. Salud Publica de Mexico 47: S37–S46PubMedGoogle Scholar
  23. Shen Y. C., McFeeters J. (2006) Out-of-pocket health spending between low-and higher-income populations: who is at risk of having high expenses and high burdens?. Medical Care 44: 200–209PubMedCrossRefGoogle Scholar
  24. Smith S. (2010) Equity in Irish health care financing: Measurement issues. Health Economics, Policy Law 5(April): 149–169CrossRefGoogle Scholar
  25. Somkotra T., Lagrada L. P. (2008) Payments for health care and its effect on catastrophe and impoverishment: Experience from the transition to Universal Coverage in Thailand. Social Science and Medicine 67: 2027–2035PubMedCrossRefGoogle Scholar
  26. Sun X., Jackson S., Carmichael G., Sleigh A. C. (2009) Catastrophic medical payment and financial protection in rural China: Evidence from the New Cooperative Medical Scheme in Shandong Province. Health Economics 18: 103–119PubMedCrossRefGoogle Scholar
  27. Van Doorslaer E., O’Donnell O., Rannan-Eliya R. P., Somanathan A., Adhikari S. R., Garg C. C. et al (2007) Catastrophic payments for health care in Asia. Health Economics 16: 1159–1184PubMedCrossRefGoogle Scholar
  28. Vyas S., Kumaranayake L. (2006) Constructing socio-economic status indices: How to use principal components analysis. Health Policy and Planning 21(6): 459–468PubMedCrossRefGoogle Scholar
  29. Wagstaff A., van Doorslaer E., Calonge S., Christiansen T., Gerfin M., Gottschalk P. et al (1992) Equity in the finance of health care: Some international comparisons. Journal of Health Economics 11(4): 361–387PubMedCrossRefGoogle Scholar
  30. Wagstaff A., van Doorslaer E., VanDer Burg H., Calonge S., Christiansen T., Citoni G. et al (1999) Equity in the finance of health care: Some further international comparisons. Journal of Health Economics 18(3): 263–290PubMedCrossRefGoogle Scholar
  31. Wagstaff A., van Doorslaer E. (2003) Catastrophe and impoverishment in paying for health care: With applications to Vietnam 1993–1998. Health Economics 12: 921–934PubMedCrossRefGoogle Scholar
  32. Waters H. R., Anderson G. F., Mays J. (2004) Measuring financial protection in health in the United States. Health Policy 69: 339–349PubMedCrossRefGoogle Scholar
  33. World Bank. (2010). Iran National Health Accounts. Accessed 20 March 2010.
  34. World Health Organisation. (2000). The World Health Report 2000: health systems: improving performance. World Health Organisation, Geneva, SwitzerlandGoogle Scholar
  35. World Health Organisation. (2010). National Health Accounts. Geneva, Switzerland. Accessed 26 July 2010.
  36. Xu K., Evans D. B., Kawabata K., Zeramdini R., Klavus J., Murray C. J. L. (2003) Household catastrophic health expenditure: A multicounty analysis. Lancet 362: 111–117PubMedCrossRefGoogle Scholar
  37. Yardim M. S., Cilingiroglu N., Yardim N. (2010) Catastrophic health expenditure and impoverishment in Turkey. Health Policy 94: 26–33PubMedCrossRefGoogle Scholar
  38. Yi Y., Maynard A., Liu G., Xiong X., Lin F. (2005) Equity in health care financing: Evaluation of the current Urban Employee Health Insurance reform in China. Journal of the Asia Pacific Economy 10: 506–527CrossRefGoogle Scholar
  39. Yu C. P., Whynes D. K., Sach T. (2006) Assessing progressivity of out-of-pocket payments: With illustration to Malaysia. International Journal for Health Planning and Management 21: 193–210CrossRefGoogle Scholar
  40. Yu C. P., Whynes D. K., Sach T. (2008) Equity in health care financing: The case of Malaysia. International Journal for Equity in Health 7: 15PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Australian Centre for Economic Research on Health (ACERH) and School of EconomicsThe University of QueenslandHerstonAustralia
  2. 2.Centre of National Research on Disability and Rehabilitation Medicine (CONROD)The University of QueenslandBrisbaneAustralia

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