Review Article

Catastrophic Health Expenditure in Iran: A Review Article


Background: One of the main challenges of healthcare systems is to protect people from consequences of health expenditures. Such expenditures may lead to catastrophic financial loss in families so that many people deny demanding necessary healthcare services, which results in harms to their health status. The aim of this systematic review was to investigate the catastrophic health expenditures trend and its related factors in Iran.

Methods: This systematic review and meta-analysis was conducted on studies conducted between 1984 and 2014. Data were collected through searching electronic databases and searching engines of PubMed, Scopus, EconLit, Google Scholar, Science Direct, MagIran, and Scientific Information Database (SID). The random effects were used with 95% confidence interval for the meta-analysis.

Results: Out of 561 initially retrieved articles, finally 42 were included in the final analysis. The studies were conducted between 1984 and 2014. The overall proportion of exposure to catastrophic health expenditure in Iran was 7.5% (95% CI, 6.2 – 9.1). In the urban and rural areas, the proportion was 2.3% (95% CI, 1.8 – 2.9) and 3.4% (95% CI, 2.8 – 4.1) respectively. The overall proportion of exposure to the catastrophic health expenditure in hospitals was 35.9% (95% CI, 23.5 – 54.3).

Conclusion: The catastrophic expenditures proportion of healthcare is relatively high in Iran and the government is expected to adopt effective measures in this regard, especially for the inpatient care. There are needs for special supporting policies for the financial protection of specific patients, the poor and villagers.



Mooney G (1993). Equity in the finance and delivery of health care, an international perspective. J Epidemiol Community Health, 47(4): 338-39.

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

Rezapour A, Ghaderi H, Azar FE, Larijani B, Gohari MR (2013). Effects of Health Out-of-Pocket Payment on HouseHolds in Iran; Catastrophic and Impoverishment: Population Based Study in Tehran (2012). Life Sci J, 10(3): 1457-69.

Jan S, Lee SW, Sawhney JP et al (2016). Catastrophic health expenditure on acute coronary events in Asia: a prospective study. Bull World Health Organ, 94(3): 193-200.

Cotlear D, Nagpal S, Smith O, Tandon A, Cortez R (2015). Going Universal: How 24 developing countries are implementing Universal Health Coverage Reforms. Washington DC, World Bank.

Xu K, Ravndal F, Evans DB, Carrin G (2009). Assessing the reliability of household expenditure data: results of the World Health Survey. Health Policy, 91(3): 297-305.

Onoka CA, Onwujekwe OE, Hanson K, Uzochukwu BS (2011). Examining catastrophic health expenditures at variable thresholds using household consumption expenditure diaries. Trop Med Int Health, 16(10): 1334-41.

O'Donnell O, Van Doorslaer E, Wagstaff A, Lindelow M (2008). Catastrophic payments for health care. Analyzing Health Equity Using Household Survey Data. Washington, DC: The World Bank.

World Health Organization (2012). Spending on health: A global overview. Fact sheet. Geneva, 319.

Buigut S, Ettarh R, Amendah DD (2015). Catastrophic health expenditure and its determinants in Kenya slum communities. Int J Equity Health, 14;14:46.

Kavosi Z, Rashidian A, Pourreza A et al (2012). Inequality in household catastrophic health care expenditure in a low-income society of Iran. Health Policy Plan, 27(7): 613-23.

World Health Organization (2015). Tracking universal health coverage: first global monitoring report. ed. World Health Organization.

Ghosh S (2010).Catastrophic payments and Impoverishment due to Out-of-Pocket health spending: The effects of recent health sector reforms in India. Econ Polit Wkly, 46(47): 63-70.

World Health Organization (2014). WHO Global Health Expenditure Atlas. ed. World Health Organization, Switzerland, 224-224.

Murray CJ, Evans D (2006). Health systems performance assessment. Office of Health Economics.

Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T (2007). Protecting households from catastrophic health spending. Health Aff (Millwood), 26(4): 972-83.

Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ (2003). Household catastrophic health expenditure: a multicountry analysis. Lancet, 362(9378): 111-7.

Barros AJ, Bertoldi AD (2008). Out-of-pocket health expenditure in a population covered by the Family Health Program in Brazil. Int J Epidemiol, 37(4): 758-65.

Su TT, Kouyaté B, Flessa S (2006). Catastrophic household expenditure for health care in a low-income society: a study from Nouna District, Burkina Faso. Bull World Health Organ, 84(1): 21-7.

Ghiasvand H, Gorji HA, Maleki M, Hadian M (2015). Catastrophic Health Expenditure Among Iranian Rural and Urban Households, 2013-2014. Iran Red Crescent Med J, 17(9): e30974.

Masaeli A, Sadeghih H, Ghanbari A (2011). High Health Costs, Financial Catastrophic and Impoverishment Expenditures: Concepts for Policy Formation. Health Inf Manage, 12(2):254-61

Sadeghiyehahari S, Amani F, Salehi M (2013). Investigation of Exposure to Catastrophic Expenditures in Patients with End Stage Renal Disease Refering to Ardebil Dialysis Centers Ardabil University of Medical Science.Master of Sciences Thesis.Ardabil University of Medical Science.

Ameri H, Vafayi H, Alizadeh H, Ghiyasi A, Razavi NS, Khalfi A (2013). Estimates of Catastrophic Health Care Expenditures on Families Supported by Torbat Heydariyeh University of Medical Sciences in 1391. JTHUMS, 1(2): 46-54.

Tofighi S, Asefzadeh S, Mamikhani J, Sadeghifar J (2014). The Impact of Rural Health Insurance on Reduction of Catastrophic Health Expenditure (CHE). JAEBS, 4(5): 154-60.

Asefzadeh S, Alijanzadeh M, Gholamalipoor S, Farzaneh A (2013). Households Encountering with Catastrophic Health Expenditures in Qazvin, Iran. Health Inf Manage, 10(1): 1-8.

Wells G, Shea B, O’connell D, Peterson J, Welch V, Losos M, Tugwell P (2000). The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute.

Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003). Measuring inconsistency in meta-analyses. BMJ, 327 (7414): 557-560.

Abolhallaje M, Hasani SA, Bastani P, Ramezanian M, Kazemian M (2013). Determinants of catastrophic health expenditure in Iran. Iran J Public Health, 155-160.

Ameri H, Jafari A, Panahi M (2013). Determining the Rate of Catastrophic Health Expenditure and Its Influential Factors on Families in Yazd Province. J Health Adm, 16(52): 51-60.

Anbari Z, Mohammadbeigi A, Mohammadsalehi N, Ebrazeh A (2014). Health expenditure and catastrophic costs for inpatient- and out-patient care in Iran. Int J Prev Med, 5 (8): 1023-1028.

AsadiLari M, Vaez-Mahdavi MR (2008). An overview on Urban-HEART Tehran experience. World Health Organization.

Bagherifaradonbeh S, Arab M, Roodbari M, Rezapoor A, Bagherifaradonbeh H, azar FE (2016). Catastrophic and Impoverishing Health Expenditure in Tehran Urban Population. J Health Adm, 19 (63): 55-67.

Daneshkohan A, Karami M, Najafi F, Karami Matin B (2011). Household catastrophic health expenditure. Iran J Public Health, 40(1): 94-99.

Fazaeli AA, Ghaderi H, Fazaeli AA, Lotfi F, Salehi M, Mehrara M (2015). Main Determinants of Catastrophic Health Expenditures: A Bayesian Logit Approach on Iranian Household Survey Data (2010). Glob J Health Sci, 7(4): 335-40.

Fazaeli AA, Seyedin H, Moghaddam AV, Delavari A, Salimzadeh H, Varmazyar H, Fazaeli AA (2015). Fairness of Financial Contribution in Iranian Health System: Trend Analysis of National Household Income and Expenditure, 2003-2010. Glob J Health Sci, 7(5): 260-5

Ghafoori MH, Ebadifard Azar F, Arab M, Mahmoodi M, Yusef zadeh N, Rezapour A (2014). The Distribution of Health Expenditures in Tehran’s Districts. JCHR, 3(2): 132-44.

Ghiasi A, Baghi A, Rezapour A, Alipour V, Ahadinezhad B, Mahmoudi M, Veysinasab F (2016). Health insurance, medicine expenses and catastrophic health expenditures. J Health Adm, 18(62): 64-73.

Ghiasvand H, Hadian M, Maleki M, Shabaninejad H (2010). Determinants of Catastrophic Medical Payments in Hospitals Affiliated to Iran University of Medical Sciences; 2009. Hakim Health Sys Res, 13(3): 145-54.

Ghiasvand H, Sha'baninejad H, Arab M, Rashidian A (2014). Hospitalization and catastrophic medical payment: Evidence from hospitals located in Tehran. Arch Iran Med, 17(7): 507-13.

Ghoddoosinejad J, Jannati A, Gholipour K, Baghestan EB (2014). Households encountering with catastrophic health expenditures in Ferdows, Iran. J Egypt Public Health Assoc, 89(2): 81-4.

Hajizadeh M, Nghiem HS (2011). Out-of-pocket expenditures for hospital care in Iran: Who is at risk of incurring catastrophic payments? Int J Health Care Finance Econ, 11(4): 267-85.

Hanjani Hm, Fazaeli A (2005). Estimation of Fair Financial Contribution in Health System of Iran. Social walfare, 5(19): 279-300.

Hatam N, Orejlu PH, Jafari A, Kavosi Z (2015). Catastrophic Healthcare Expenditures of Hospitalized Patients in the Hospitals of Shiraz in 2013. Shiraz E-Med J, 16(5): e22231

Juyani Y, Hamedi D, Jebeli SSH, Qasham M (2016). Multiple Sclerosis and Catastrophic Health Expenditure in Iran. Glob J Health Sci, 8(9): 194-199.

Karami M, Najafi F, Karami Matin B (2009). Catastrophic health expenditures in Kermanshah, West of Iran: Magnitude and distribution. J Res Health Sci, 9(2): 36-40.

Kavosi Z, Delavari H, Keshtkaran A, Setoudehzadeh F (2014). Catastrophic health expenditures and coping strategies in households with cancer patients in Shiraz Namazi Hospital. Middle East J Cancer, 5(1): 13-22.

Kavosi Z, Keshtkaran A, Hayati R, Ravangard R, Khammarnia M (2014). Household financial contribution to the health System in Shiraz, Iran in 2012. Int J Health Policy Manag, 3(5): 243-249.

Mehrara M, Fazaeli A (2010). Health finance equity in Iran: an analysis of household survey data (1382-1386). J Health Adm, 13(40):51-62.

Moghimi M, Zanjani SV, Zamiri RE, Feizi A, Rostamkhani MH, Ghahramani R (2008). Performance of Government Rule in Supprting and Decreasing Catastrophic Expenditures of Cancer Patients in Zanjan Province in 2007-2008. Health System, 1(2):41-46.

Nekoei Moghadam M, Akbari-Javar M, Amiresmaili M, Baneshi M, Ganjavai S (2013). Households Exposure to Catastrophic Health Expenditures and the Affecting Factors in Kerman Province, Iran. J Manage Med Inform Sch, 101-90.

Moghadam MN, Baneshi M,Javar MA, Amiresmaili M, Ganjavi S (2012). Iranian household financial protection against catastrophic health care expenditures. Iran J Public Health, 41(9):62-70.

Panahi H, Janati A, Narimani M et al (2014). Catastrophic Expenditure for Hospitalized Patients in Tabriz, Iran. Payesh, 13(6): 655-663.

Piroozi B, Moradi G, Nouri B, Mohamadi Bolbanabad A, Safari H (2016). Catastrophic health expenditure after the implementation of health sector evolution plan: a case study in the west of Iran. Int J Health Policy Manag, 5(7):417-423.

Raghfar H, AtrkarRoshan S, Atefi M (2013). Measurement of the Fair Financial Contribution Index and Catastrophic Expenditures in Different Regions of Iran, 1984-2010. Hakim Health Sys Res, 16(3): 182-191.

Razavi SM (2011). Impact of Structural Adjustment Programs on Health Care Financing in Iran. Brandeis University, The Heller School for Social Policy and Management.

Rezapour A, Arabloo J, Tofighi S, Alipour V, Sepandy M, Mokhtari P, Ghanbary A (2016). Determining Equity in Household's Health Care Payments in Hamedan Province, Iran. Arch Iran Med, 19(7): 480-87.

Rezapour A, Azar AE, Asadi S, Faradonbeh SB, Toofan F (2016). Estimating the Odd-Ratio of Factors Affecting Households’ Exposure to Catastrophic and Impoverishing Health Expenditures. J Mil Med, 18(1): 355-61.

Sabermahani A, Noranimotlagh S, Vaezmahdavi M, Hadian M, Asadilari M (2014). Catastrophic Health Expenditures and its Determinants among Households in Tehran in 2011 , Urban HEART-2 study. RJMS, 21(126): 15-26.

Soofi M, Rashidian A, Aabolhasani F, Sari AA, Bazyar M (2013). Measuring the Exposure of Households to Catastrophic Healthcare Expenditures in Iran in 2001: the World Health Organization and the World Bank's Approach. Hospital, 12(2): 39-50.

Tofighi S, Zaboli R, Mahdavi MRV et al (2015). The Healthcare Costs in the Aging Based on Data from the Urban Health Equity Assessment and Response Tool Project in Tehran, Iran (UHEART-2). IJMR, 2(1): 201-207.

Yavangi M, Sohrabi MR, Riazi S (2013). Out of pocket payment for obstetrical complications: a cost analysis study in iran. Int J Prev Med, 4(11): 1296–1303.

Yousefi M, Assari Arani A, Sahabi B, Kazemnejad A, Fazaeli S (2015). The Financial Contribution Of Households Using By Health Services. Payavard Salamat, 8(6): 517-27

Zare H, Trujillo AJ, Driessen J, Ghasemi M, Gallego G (2014). Health inequalities and development plans in Iran; an analysis of the past three decades (1984–2010). Int J Equity Health,13(1): 42

Aryankhesal A, Etemadi M, Agharahimi Z, Rostami E, Mohseni M (2016). Analysis of social functions in Iran’s public hospitals: pattern of offering discounts to poor patients. Int J Hum Rights Healthc, 9(4): 242-53.

Mahdavi M, Parsaeian M, Jaafaripooyan E, Ghaffari E (2018). Recent iranian health system reform: an operational perspective to improve health services quality. Int J Health Policy Manag, 7(1): 70-74.

Khosravi M, Kazemian M (2013). The Evaluation of rural health insurance plan based on horizontal and vertical equities situation. IJHIE, 1(1):1-6.

Zandian H, Olyaeemanesh A, Takian A, Hosseini M (2016). Contribution of Targeted Subsidies Law to the Equity in Healthcare Financing in Iran: Exploring the Challenges of Policy Process. Electronic Physician, 8(2): 1892–1903.

Doshmangir L, Doshmangir P, Abolhassani N, Moshiri E, Jafari M (2015). Effects of Targeted Subsidies Policy on Health Behavior in Iranian Households: A Qualitative Study. Iran J Public Health,44(4):570-9.

Abolhallaje M, Mousavi SM, Anjomshoa M et al (2014). Assessing health inequalities in Iran: a focus on the distribution of health care facilities. Glob J Health Sci, 6(4):285-91.

Sabermahani A, Barouni M, Seyedin H, Aryankhesal A (2013). Provincial human development index, a guide for efficiency level analysis: the case of iran. Iran J Public Health, 42(2):149-57

Lankarani KB, Ghahramani S, Zakeri M, Joulaei H (2015). Lessons learned from national health accounts in Iran: highlighted evidence for policymakers. Shiraz E Med J, 16(4): 1-3

Weraphong J, Pannarunothai S, Luxananun T, Junsri N, Deesawatsripetch S (2013). Catastrophic health expenditure in an urban city: seven years after universal coverage policy in Thailand. Southeast Asian J Trop Med Public Health, 44(1):124-36.

Van Doorslaer E, O'Donnell O, Rannan‐Eliya RP et al (2007). Catastrophic payments for health care in Asia. Health Econ, 16(11):1159-84.

Onwujekwe O, Hanson K, Uzochukwu B (2012). Examining inequities in incidence of catastrophic health expenditures on different healthcare services and health facilities in Nigeria. PLoS One, 7(7): e40811.

Essue BM, Kimman M, Svenstrup N, Kjoege KL, Laba TL, Hackett ML, Jan S (2015). The effectiveness of interventions to reduce the household economic burden of illness and injury: A systematic review. Bull World Health Organ, 93(2):102-12B.

Jaspers L, Colpani V, Chaker L et al (2014). The global impact of non-communicable diseases on households and impoverishment: a systematic review. Eur J Epidemiol, 30(3):163-88.

Wagstaff A, Lindelow M (2008). Can insurance increase financial risk?: The curious case of health insurance in China. J Health Econ, 27(4):990-1005.

Daivadanam M, Thankappan K, Sarma P, Harikrishnan S (2012). Catastrophic health expenditure & coping strategies associated with acute coronary syndrome in Kerala, India. Indian J Med Res, 136(4):585-92.

IssueVol 47 No 2 (2018) QRcode
SectionReview Article(s)
Catastrophic payments Health economics Financially vulnerable people Iran

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
ARYANKHESAL A, ETEMADI M, MOHSENI M, AZAMI-AGHDASH S, NAKHAEI M. Catastrophic Health Expenditure in Iran: A Review Article. Iran J Public Health. 2018;47(2):166-177.