Out of Pocket Payment and Affordability of Medication for Geriatric Patients in Tehran, Iran

  • Morvarid ZARIF-YEGANEH Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran AND Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
  • Mona KARGAR Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
  • Arash RASHIDIAN Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Aarefeh JAFARZADEH KOHNELOO Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  • Kheirollah GHOLAMI Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
Keywords: Out-of-pocket, Affordability, Geriatric patients, Elderly, Medication cost


Background: Considering the importance of high out-of-pocket (OOP) payment (OOPP), as a marker of health system performance, and affordability of medications in the elderly, this study was conducted to determine these issues. Methods: In this cross-sectional study, prescriptions of patients aged 65 yr or older from 5 university-affiliated pharmacies in Tehran, Iran were evaluated from Jan to Mar 2014. Prescriptions were selected from four insurance organizations. We used the prescriptions data regarding patients’ demographics and the prescribers as well as the sales data for OOP. Affordability was calculated by considering the daily salary of an unskilled worker. Results: Totally, 1467 prescriptions were analyzed. Mean age of patients was 73.89(6.66) yr. Mean (SE) of reimbursable and OOPP of the prescriptions were 203820 (10831) and 230252 (10634) IRR (Iranian Rials) respectively (equivalent to 81.6 (4.33) and 92.17 (4.33) US$ respectively). Subspecialists imposed higher expenditures for patients and insurance organizations. Patients referred to the ophthalmologists paid less OOP. Nearly 50% of the total prescription costs was paid as OOP. The mean OOPP was averagely equal to 1.41(0.065) daily salary. These prescriptions were unaffordable for 36.2% of patients. Conclusion: The OOPP was higher than the insurance goal of 30% for outpatients in Iran. More than one-third of elderly patients could not afford their single prescription. Due to the health consequences of the unaffordability of medications, corrective actions are needed by the insurance organizations and the health system.  


1. He W, Goodkind D, Kowal PR (2016). U.S. Census Bureau, International Population Reports, An Aging World: 2015, U.S. Government Publishing Office Inc, Washington, DC, P95/16-1.
2. United Nations Population Fund (UNFPA) Asia & the Pacific. Ageing. Available from: http://asiapacific.unfpa.org/en/node/1520
3. Afshar PF, Asgari P, Shiri M, Bahramnezhad F (2016). A Review of the Iran's elderly status according to the census records. Galen Medical Journal, 5(1):1-6.
4. Park E-J, Kwon J-W, Lee E-K, Jung Y-H, Park S (2015). Out-of-pocket Medication Expenditure Burden of Elderly Koreans with Chronic Conditions. Int J Gerontol, 9(3):166-71.
5. Lehnert T, Heider D, Leicht H, et al (2011). Health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev, 68(4):387-420.
6. Marzban S, Rajaee R, Gholami S, Keykale MS, Najafi M (2015). Study of Out-of-Pocket Expenditures for Outpatient Imaging Services in Imam-Khomeini Hospital in 2014. Electron Physician, 7(4):1183-89.
7. Paez KA, Zhao L, Hwang W (2009). Rising out-of-pocket spending for chronic conditions: a ten-year trend. Health Aff (Millwood), 28(1):15-25.
8. Zhang J, Lee U, Meltzer DO (2015). The effect of functional limitations and hospitalization on out-of-pocket medical payments in older adults. Ann Community Med Pract, 1(1):1004.
9. Klein D, Turvey C, Wallace R (2004). Elders who delay medication because of cost: health insurance, demographic, health, and financial correlates. Gerontologist, 44(6):779-87.
10. Lynch T (2006). Medication costs as a primary cause of nonadherence in the elderly. Consult Pharm, 21(2):143-6.
11. Piette JD, Heisler M, Wagner TH (2004). Problems paying out-of-pocket medication costs among older adults with diabetes. Diabetes Care, 27(2):384-91.
12. Yamada T, Chen C-C, Murata C, Hirai H, Ojima T, Kondo K (2015). Access Disparity and Health Inequality of the Elderly: Unmet Needs and Delayed Healthcare. Int J Environ Res Public Health, 12(2):1745-72.
13. Keshavarzian M, Mofidian S (2015). An Overview on Iran Health Care Financing System: Challenges and Solutions. JHPSH, 1(4):131-6.
14. Davari M, Haycox A, Walley T (2012). The Iranian health insurance system; past experiences, present challenges and future strategies. Iran J Public Health, 41(9):1-9.
15. World Health Organization, Regional Office for the Eastern Mediterranean (‎2010)‎. Islamic Republic of Iran: Medicine prices, availability, affordability and price components. http://www.who.int/iris/handle/10665/116636
16. Pouragha B, Pourreza A, Hasanzadeh A, Sadrollahi MM, Ahvazi Kh, KhabiriR (2013). Pharmaceutical costs in social security organization and components influencing its utilization. HIM, 10 (2):1-11.
17. Kemp A, Preen DB, Glover J, Semmens J, Roughead EE (2011). How much do we spend on prescription medicines? Out-of-pocket costs for patients in Australia and other OECD countries. Aust Health Rev, 35(3):341-9.
18. Christensen Sethi R (2004). Prescription drugs: recent trends in utilization, expenditures, and coverage. EBRI Issue Brief, (265):1-36.
19. Carpenter A, Islam MM, Yen L, McRae I (2015). Affordability of out-of-pocket health care expenses among older Australians. Health Policy, 119(7):907-14.
20. Mehrdad R (2009). Health system in Iran. JMAJ, 52(1):69-73.
21. Abolhallaje M, Hasani S, Bastani P, Ramezanian M, Kazemian M (2013). Determinants of catastrophic health expenditure in Iran. Iran J Public Health, 42(Supple1):155-160.
22. Callander EJ, Corscadden L, Levesque J-F (2017). Out-of-pocket healthcare expenditure and chronic disease–do Australians forgo care because of the cost? Aust J Prim Health, 23(1):15-22.
23. Brinda E, Rajkumar A, Enemark U, Prince M, Jacob K (2012). Nature and determinants of out-of-pocket health expenditure among older people in a rural Indian community. Int Psychogeriatr, 24(10):1664-73.
24. Wei W, Akincigil A, Crystal S, Sambamoorthi U (2006). Gender differences in out-of-pocket prescription drug expenditures among the elderly. ROA, 28(4):427-53.
25. Crystal S, Johnson RW, Harman J, Sambamoorthi U, Kumar R (2000). Out-of-pocket health care costs among older Americans. J Gerontol B Psychol Sci Soc Sci, 55(1):S51-S62.
26. Onder G, Marengoni A, Russo P, Degli Esposti L, Fini M, Monaco A, et al (2016). Advanced age and medication prescription: more years, less medications? A nationwide report from the Italian Medicines Agency. J Am Med Dir Assoc,17(2):168-72.
27. Babar ZUD, Ibrahim MIM, Singh H, Bukahri NI, Creese A (2007). Evaluating drug prices, availability, affordability, and price components: implications for access to drugs in Malaysia. PLoS Med, 4(3):e82.
28. Cheraghali AM, Idries AM (2009). Availability, affordability, and prescribing pattern of medicines in Sudan. Pharm World Sci, 31(2):209-15.
How to Cite
ZARIF-YEGANEH M, KARGAR M, RASHIDIAN A, JAFARZADEH KOHNELOO A, GHOLAMI K. Out of Pocket Payment and Affordability of Medication for Geriatric Patients in Tehran, Iran. Iran J Public Health. 48(6):1124-1132.
Original Article(s)