Impacts of Health Reform Plan in Iran on Health Payments Distributions and Catastrophic Expenditure

  • Morteza JOSHANI KHEIBARI Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
  • Reza ESMAEILI Department of Public Health, School of Health, Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
  • Mahmood KAZEMIAN Department of Health Economics, School of Medicine, Shahed University, Tehran, Iran
Health care reform, Health expenditures, Poverty


Background: Health reform in Iran began in 2014, aimed at improving financing pattern of health services. We assessed the reform by changes in variables representing distribution of health payments and catastrophic expenditures.
Methods: Using data from households’ income-expenditure survey, this study computed the financial variables, representing poverty line and households at poor state, household’s catastrophic health expenditure, fairness in financial contribution (FFC) index, and household’s impoverishment state, in the years 2010-2016, in urban and rural areas. The variables were computed by special software designed for this study, based on C-Sharp(C#) programming language, with yearly data on more than 38000 households, each with 1072 information sources.

Results: The food share-based poverty line after sharp rise in 2010-2013, in 2014-2016 raised slowly, and the average percent of households facing catastrophic health expenditure, after sharp rise in 2011-2013, left at 3.25 in 2014-2015 and raised to 3.45 in 2016. The average FFC index remained at 0.839 to 0.837 in 2013-2016. However, interestingly, the average percent of households impoverished after out-of-pocket payments improved from 1.36 to 0.912 in 2013-2016.
Conclusion: In three years of health reform, the major impact of reform was considerable improvements in the rate of the impoverished after out-of-pocket payments. The reform had limited impacts on the rates of households facing catastrophic health expenditure, and on FFC indexes, for the rural and urban residents.


1. Frenk J, González-Pier E, Gómez-Dantés O et al (2006). Comprehensive reform to improve health system performance in Mexico. Lancet, 368 (9546): 1524-34.
2. Evans DB, Etienne C (2010). Health sys-tems financing and the path to universal coverage. Bull World Health Organ, 88 (6): 402-3.
3. Zhou XD, Li L, Hesketh T (2014). Health system reform in rural China: voices of healthworkers and service-users. Soc Sci Med, 117:134-41.
4. McDonough JE (2014). Health system re-form in the United States. Int J Health Pol-icy Manag, 2 (1):5-8.
5. Lambert MF, Sowden S (2016). Revisiting the risks associated with health and healthcare reform in England: perspective of Faculty of Public Health members. J Public Health (Oxf), 38 (4): e438-e445.
6. Mossialos E, Wenzl M, Osborn R, Ander-son C (2015). International Profiles of Health Care Systems, 2014. The Com-monwealth Fund. New York.
7. Eggleston K (2012). Health care for 1.3 bil-lion: An overview of China’s health sys-tem. Stanford Asia Health Policy Program Working Paper No. 28. Available at SSRN:
8. Yip WC-M, Hsiao WC, Chen W et al (2012). Early appraisal of China's huge and complex health-care reforms. Lancet, 379 (9818): 833-42.
9. Berman P, Bossert T (2000). A decade of health sector reform in developing coun-tries: what have we learned? UNAID. Washington.
10. Rajabi F, Esmailzadeh H, Rostamigooran N, Majdzadeh R, Doshmangir L (2013). Fu-ture of health care delivery in Iran, op-portunities and threats. Iran J Public Health, 42: 23–30.
11. Iran Ministry of Health (2014). The manual of Health Reform Plan.
12. Iran Fifth Five Development Plan (2010). Deputy President for Planning. Tehran
13. Moghaddam AV, Damari B, Alikhani S et al. (2013). Health in the 5th 5-years Devel-opment Plan of Iran: main challenges, general policies and strategies. Iran J Public Health, 42: 42–49.
14. World Health Organization. (‎2000)‎. The World health report: 2000: Health sys-tems: improving performance. World Health Organization.
15. World Health Organization (2012). Strategy on health policy and systems research: changing the mindset. World Health Or-ganization. Geneva.
16. Raghfar H, Zargari N, Sangari Mk (2013). Measuring inequality in households ‘health care expenditures in Iran. Hakim Research Journal, 16 (2): 89-97.
17. Yousefi M, Assari Arani A, Sahabi B, Kazemnejad A, Fazaeli S (2015). The Fi-nancial Contribution of Households Us-ing By Health Services. Payavard Salamat, 8 (6): 517-527
18. Gakidou, Emmanuela E, Murray et al (‎2001)‎. Measuring preferences on health system performance assessment / Emmanuela Gakidou, Christopher J. L. Murray, Julio Frenk. World Health Organization.
19. World Health Organization. (‎2005)‎. Distri-bution of health payments and cata-strophic expenditures Methodology / by Ke Xu. World Health Organization.
20. Wagstaff A, Doorslaer Ev (2003). Catastro-phe and impoverishment in paying for health care: with applications to Vietnam 1993–1998. Health Econ, 12 (11): 921-34.
21. Yardim MS, Cilingiroglu N, Yardim N (2014). Financial protection in health in Turkey: the effects of the Health Trans-formation Programme. Health Policy Plan, 29 (2): 177-92.
22. Rao KD, Arora R, Ghaffar A (2014). Health systems research in the time of health system reform in India: a review. Health Res Policy Syst, 12 (1): 37.
23. Xu K, Evans DB, Kawabata K et al (2003). Household catastrophic health expendi-ture: a multicountry analysis. Lancet, 362 (9378): 111-7.
24. Choi J-W, Choi J-W, Kim J-H et al (2015). Association between chronic disease and catastrophic health expenditure in Korea. BMC Health Serv Res, 15: 26.
25. Zhou C, Long Q, Chen J et al (2016). The effect of NCMS on catastrophic health expenditure and impoverishment from tuberculosis care in China. Int J Equity Health, 15 (1): 172.
26. Kimani DN, maina t. Catastrophic Health Expenditures and Impoverishment in Kenya. 2015.
27. Yardim MS, Cilingiroglu N, Yardim N (2010). Catastrophic health expenditure and impoverishment in Turkey. Health policy, 94 (1): 26-33.
28. Lara JLA, Gómez FR (2011). Determining factors of catastrophic health spending in Bogota, Colombia. Int J Health Care Fi-nance Econ, 11 (2): 83-100.
29. Fazaeli AA, Seyedin H, Delavari A, Salimza-deh H, Varmazyar H (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.
30. Raghfar H, Atrkar Roshan S, Atefi M (2013). Measurement of the Fair Financial Con-tribution Index and Catastrophic Ex-penditures in Different Regions of Iran, 1984-2010. Hakim Research Journal, 16 (3): 182-191.
31. Mehrara M, Fazaeli A (2010). Health finance equity in Iran: an analysis of household survey data 1382-1386. Journal of Health Administration, 13 (40): 51-62.
32. Hanjani H, Fazaeli A (2006). Estimation of Fair Financial Contribution in Health Sys-tem of IRAN. Social Welfare Quarterly, 5 (19): 279-300.
33. Arab M, Roodbari M, Rezapoor A (2016). Catastrophic and impoverishing health expenditure in Tehran urban population. Journal of Health Administration, 19 (63): 55-67.
How to Cite
JOSHANI KHEIBARI M, ESMAEILI R, KAZEMIAN M. Impacts of Health Reform Plan in Iran on Health Payments Distributions and Catastrophic Expenditure. Iran J Public Health. 48(10):1861-1869.
Original Article(s)