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.
Highlights
The share of out-of-pocket (OOP) health payments in total health expenditures and the subsequent catastrophic health expenditures (CHEs) are the 2 important factors that should be taken into account while planning and designing health policies.[1,2] Too much reliance on OOP payments prevents countries from reaching universal health coverage (UHC).[3,4,5,6] Heavy reliance on OOP payments deprives millions of people from receiving healthcare services when they are in need of such services.[3]
Since 2003, Turkey has brought about a series of reforms in the health sector which are managed under the health transformation program (HTP); this program is aimed at achieving UHC, reducing OOP payment, decreasing health inequalities in cofinancing healthcare expenditures, increasing people’s access to health services, and improving health outcomes.[36]
The reduction of OOP can be attributed to different factors including increased coverage of inpatient expenditures by health insurances schemes, reduction of informal payments, providing free-of-charge natural childbirth services in hospitals affiliated to the Ministry of Health and Medical Education (MoHME), utilization of the health transformation fund for paying part of hospitalization costs, and not referring patients hospitalized in the hospitals affiliated to the MoHME to purchase medicines, medical supplies, and diagnostic services out of the supply chain.[44,45,46]
Summary
The share of out-of-pocket (OOP) health payments in total health expenditures and the subsequent catastrophic health expenditures (CHEs) are the 2 important factors that should be taken into account while planning and designing health policies.[1,2] Too much reliance on OOP payments prevents countries from reaching universal health coverage (UHC).[3,4,5,6] Heavy reliance on OOP payments deprives millions of people from receiving healthcare services when they are in need of such services.[3] OOP payment is the most unfair and inefficient method of financing in the health sector and could lead to an increase in poverty.[4] Globally, about 150 million people are faced with CHE because of OOP payments to the health sector, of whom about 100 million people are pushed below the poverty line.[7] OOP payments are common in most of developing countries for different reasons such as the lack or inefficiency of health insurance system, low share of health budget from the total budget of governments, and low government budgets As a consequence, these types of payments are the main source of financing of the health sector for 33 countries. Some countries have had some achievements to solve this problem.[31,35] Since 2003, Turkey has brought about a series of reforms in the health sector which are managed under the health transformation program (HTP); this program is aimed at achieving UHC, reducing OOP payment, decreasing health inequalities in cofinancing healthcare expenditures, increasing people’s access to health services, and improving health outcomes.[36]
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