Equity in Out-of-Pocket Payments for Healthcare Service Delivery in Urban and Rural Households: Evidence from Iran

Abstract

Background: Out-of-pocket payments for medical services may undermine access to medical services and equity in healthcare financing. Objectives: The present study aimed to determine the distribution of the burden of out-of-pocket payments for healthcare services among the households in Qazvin province, Iran. Methods: This descriptive-analytical study was conducted on the urban and rural households in Qazvin province, Iran during 2019 - 2020. Data were obtained from the Statistics Center of Iran (2019 - 2020). The optimal sample size was calculated to be 992 households, and the households were selected via three-stage random cluster sampling. Data were collected using a valid questionnaire and via face-to-face interviews with the household owners. The fair financial contribution index (FFCI), concentration index, and Kakwani index were estimated in the Stata software. Results: The estimated parameters indicated that during the study period (March 21, 2019-March 20, 2020), the FFCI value of the rural and urban households was 0.782 and 0.854, respectively. The out-of-pocket payment concentration index based on income rank was estimated at 0.188 in rural households (P < 0.05) and 0.031 in the urban households. In addition, the Kakwani index of the urban and rural households was calculated to be -0.165 and -0.84, respectively. Conclusions: According to the results, out-of-pocket payments were unequally distributed among the households in Qazvin province in 2019 - 2020. These payments were mostly concentrated on the 5th - 7th deciles of urban households. On the other hand, the out-of-pocket payments during the study period were regressive. To promote financial equity, Qazvin health policymakers must run payment exemptions for low-income groups and also expand the medical insurance coverage and universal coverage of healthcare services.