Iranian Journal of Public Health 2018. 47(3):390-396.

Iran’s Health Reform Plan: Measuring Changes in Equity Indices



Background: Two years after the implementation of the Health Sector Evolution Plan (HSEP), this study evaluated the effects of the plan on health equity indices.

Methods: The main indices assessed by the study were the Out-of-Pocket (OOP) health expenditures, the Fairness in Financial Contribution (FFC) to the health system index, the index of households’ Catastrophic Health Expenditure (CHE) and the headcount ratio of Impoverishing Health Expenditure (IHE).

Results: The per capita share of costs for total health services has been decreased. The lowered costs have been more felt in rural areas, generally due to sharp decrease in inpatient costs. Per capita pay for outpatient services is almost constant or has slightly increased. The reform plan has managed to improve households’ Catastrophic Health Expenditure (CHE) index from an average of 2.9% before the implementation of the plan to 2.3% after the plan. The Fairness in Financial Contribution (FFC) to the health system index has worsened from 0.79 to 0.76, and the headcount ratio of Impoverishing Health Expenditure (IHE) index deteriorated after the implementation of plan from 0.34 to 0.50.

Conclusion: Considerable improvement, in decreasing the burden of catastrophic hospital costs in low income strata which is about 26% relative to the time before the implementation of the plan can be regarded as the main achievement of the plan, whereas the worsening in the headcount ratio of IHE and FFC are the equity bottlenecks of the plan.




Health policy, Policy evaluation, Health equity, FFC, CHE, IHE, Health sector reform

Full Text:



Ministry of health and medical education (MHME) (2014). “Collection of executive guidelines of Health reform plan”, 1st edition, Tehran.

Ministry of Health and Medical education portal for Health Reform Programs (2013).

United Nations (1989). National Household Survey Capability Programme: Household Income and Expenditure Surveys: A Technical Study. DP/UN/INT-88-X01/6E. Department of Technical Co-operation for Development and Statistical Office.

United Nations. (1993). System of National Accounts 1993. New York: United Nations.

United Nations. (2008). System of National Accounts 2008. New York: United Nations.

World Health Organization. The world health report 2000: health systems: improving performance.

Tandon A, Murray CJ, Lauer JA, Evans DB. Measuring overall health system performance for 191 countries Geneva:

CJ M, Knaul F, Musgrove P, Xu K, Kawabata K. Defining and measuring fairness in financial contribution to the health system. Global Programme on Evidence for Health Policy Discussion Paper Series. 2000

Murray C, Frenk J (2001). World Health Report 2000: a step towards evidence-based health policy. Lancet, 357(9269):1698-700.

Wagstaff A (2002). Reflections on and alternatives to WHO's fairness of financial contribution index. Health Econ, 11(2):103-15.

Xu K, Klavus J, Kawabata K et al (2003). Household health system contributions and capacity to pay: Definitional, empirical and technical challenges. In: Murray, CJL; Evans, DB, (eds.) Health system performance assessment: Debates, methods and empiricism. WHO, Geneva, pp. 533-563.

Kerssens JJ, Groenewegen PP, Sixma HJ et al (2004). Comparison of patient evaluations of health care quality in relation to WHO measures of achievement in 12 European countries. Bull World Health Organ, 82(2):106-14.

Galárraga O, Sosa-Rubí S, Salinas A, Sesma S (2008). The impact of universal health insurance on catastrophic and out-of-pocket health expenditures in Mexico: A model with an endogenous treatment variable. HEDG Working Paper, 8(12).

Akinkugbe O, Chama-Chiliba C, Tlotlego N (2012). Health Financing and Catastrophic Payments for Health Care: Evidence from Household-level Survey Data in Botswana and Lesotho. Afr Dev Rev, 24(4):358-370.

Yardim MS, Cilingiroglu N, Yardim N (2014). Financial protection in health in Turkey: the effects of the Health Transformation Programme. Health Policy Plan, 29(2):177-92.

Etezadi M, Ranjbar H (2016). Review of Meta-Frontier Efficiency of the Health Systems in the World. Int Business Manage, 10(20): 5025-32.

Ferreira F (2015). Let's Talk Development. [Online].

Xu K (2005). Distribution of health payments and catastrophic expenditures methodology.

World Health Organization (2015). Global Reference List of 100 Core Health Indicators, 2015.


  • There are currently no refbacks.

Creative Commons Attribution-NonCommercial 3.0

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.