Causes and consequences of quack medicine in health care: a scoping review of global experience.

BACKGROUND: The field of health has been facing challenges with fraudulent practices and the prevalence of "quack medicine". Many cases have given rise to this issue. Therefore, this study aims to comprehensively investigate and categorize the causes and consequences of quack medicine in the healthcare. METHODS: A scoping review, using the 5 stages of Arksey and O'Malley's framework, was conducted to retrieve and analyze the literature. International databases including the PubMed, Scopus, Embase and Web of Science and also national Iranian databases were searched to find peer reviewed published literature in English and Persian languages. Grey literature was also included. Meta-Synthesis was applied to analyze the findings through an inductive approach. RESULTS: Out of 3794 initially identified studies, 30 were selected for this study. Based on the findings of this research, the causes of quackery in the health were divided into six categories: political, economic, socio-cultural, technical-organizational, legal and psychological. Additionally, the consequences of this issue were classified into three categories: health, economic and social. Economic and social factors were found to have a more significant impact on the prevalence of quackery in the health sector. Legal and technical-organizational factors played a crucial role in facilitating fraudulent practices, resulting in severe health consequences. CONCLUSION: It is evident that governing bodies and health systems must prioritize addressing economic and social factors in combating quackery in the health sector. Special attention should be paid to the issue of cultural development and community education to strengthen the mechanisms that lead to the society access to standard affordable services. Efforts should be made also to improve the efficiency of legislation, implementation and evaluation systems to effectively tackle this issue.

Ethical soundness of health technology assessment reports in Islamic Republic of Iran.

Background: Health technology assessment (HTA) is a conventional method for evaluating reasonable use of health technologies in many countries. Aims: To investigate the ethical soundness of HTA studies in Islamic Republic of Iran. Methods: All HTA reports published by the HTA office until 2020 were reviewed using the HTA Core Model and the Q-SEA questionnaires. Results: We evaluated 91 reports for ethical soundness. The research question, literature search and inclusion/exclusion criteria were included in 91.2%, 83.5% and 82.4% of the HTA reports, respectively. Only 13.2% of the reports explicitly stated the objective of the analysis and 6.6% stated the ethics framework. Only 2.2%, 4.4%, 9.9%, 9.9%, 14.3%, and 2.2%, respectively, of the reports, complied with the completeness, bias, policy implications, other implications, conceptual clarification, and conflicting values. Conclusions: HTA reports in the Islamic Republic of Iran require coordinated and integrated framework acceptable to all stakeholders to ensure their compliance with sound ethical requirements.

Evaluating the quality of health technology assessment reports in a developing country.

Background: No single method of health technology assessment (HTA) can meet all the policy- and decision-making needs in a country. However, there should be minimum criteria for performing HTA worldwide, and many HTA agencies have reached a consensus on this. Aim: This study aimed to assess the quality of HTA reports in the Islamic Republic of Iran. Method: We examined all the HTA research reports published by the Iranian HTA office up to 2020, using the International Network of Agencies for Health Technology Assessment checklist for quality assessment. Results: A total of 97 reports were examined, of which only 10.0% provided complete and appropriate contact details for further information and 5.6% clearly stated a conflict of interest. In 87.78% of the reports, the scope of assessment was clearly determined. The quality of the reports was relatively appropriate as well as details of the sources of information and text search strategies. Some 7.8%, 74.4%, 11.1%, 8.9%, and 4.4%, respectively, of the reports considered legal aspects, economic analysis, ethical implications, social implications, and other stakeholder perspectives. Conclusion: We recommend that minimum standards be established for the HTA process so that healthcare policy- and decision-makers can make reliable decisions on the basis of the HTA reports.

Strategies of drugs cost containment in hospital: A systematic literature review.

BACKGROUND: In recent years, the world's health system faces with increasing trend of costs. In this regard, Hospital is one of the environments that consumes a large share of the total expenditure of the health system. Medications are one of the most expensive components in hospitals, which require appropriate measurements to control and reduce costs. The present systematic review was conducted to identify strategies and actions for cost containment in hospital. METHOD: Using the PRISMA protocol, a systematic review of the texts was performed to identify strategies and actions for reducing drug cost. In this systematic review, the selected keywords were searched in the following databases: web of sciences, Scopus, PubMed, Google Scholar, and Embase. The inclusion criteria included English-language articles, hospital-level studies, and those studies performed on reducing and controlling hospital costs. The exclusion criteria also included the followings: primary health care studies, non-English language studies, health system studies, and studies solely focussed on the cost-effectiveness of a particular drug. The quality of these articles was investigated using the checklist adapted and modified in the present study. RESULTS: A total of 4696 articles were identified from the reviewed databases and 26 articles were identified from some other sources. After removing duplicate studies and reviewing the title, summary, and full text of articles using reference check and supplemental search, 21 articles were finally included. A number of strategies or managerial actions were extracted from the final articles. According to the qualitative results, qualitative meta-synthesis was used and after eliminating duplicate solutions, the data were classified into five groups: procurement, storage, distribution, prescription, and use. CONCLUSION: According to the increasing cost of medicines, some hospital managers now attempt to reduce hospital costs using drug chain management. Drug cost reduction strategies can be applied for any component of drug chain management such as procurement, storage, distribution, prescription, and use. Also, proper implementation of these strategies and rationalisation of drug use will result in more efficiency of the hospital.

Drivers, uncertainties, and future scenarios of the Iranian health system.

BACKGROUND: Health promotion is an essential dimension of sustainable development in any country. It has a high degree of complexity, with numerous components interacting both inside and outside of the system, so having a systemic and forward-looking approach is essential to planning for the future. METHODS: The research has been designed based on scenario-based planning in three main stages. The data gathering was qualitative by working group meetings and compiling an importance-uncertainty questionnaire to complete the cross-impact analysis matrix. The MicMac and scenario Wizard has been used for data analysis. RESULTS: The scoping review and upstream document evaluation lead to 54 key variables for analyzing the Iranian health system (HS). The MicMac analysis ends by determining seven key variables: power, politics, and communication network; lifestyle and behavioral factors; quality of human resources training and education; environmental and occupational risk factors, payment and tariff system, and allocation pattern; support society / individuals health; and services effectiveness, especially para-clinical and outpatient ones. Finally, six main scenario spaces are depicted using Scenario Wizard. collective equity was the priority of the HS vision in the desirable scenario, consisting of the most favorable state of the uncertainties. The second, third, and fourth scenarios are also considered desirable. In the disaster scenario, which is the most pessimistic type of consistent scenario in this study, health and equity are not significant either in the social or individual dimensions. In the sixth scenario, the individual dimension of health and equity is the most critical perspective of the HS. CONCLUSIONS: Due to the unsustainability and high complexity of the Iran's HS, the development and excellence of the HS governance based on the Iran context and health advocacy improvement (applying good governance); creating sustainable financial resources and rational consumption; and human resources training and education are three main principles leading the HS to the images of the desired scenarios.

Health protection challenges of slums residents during the COVID-19 pandemic, according to the social determinants of health framework: A case study of Kerman city in Iran.

BACKGROUND: Coronavirus disease-2019 (COVID-19) pandemic can aggravate the health problems in slum areas. The present study intends to examine the challenges of health protection of slum's residences during the COVID-19 pandemic with the Social Determinants of Health perspective, in Kerman city in Iran. MATERIALS AND METHODS: The present study was a qualitative content analysis. Data were collected by purposeful sampling in-depth and semi-structured interviews with 16 people. The interviews were conducted (from October to December 2020) with the local representatives of the slum's residents, health-care workers, managers of facilitation offices, and welfare social service centers that are located in slum areas (Interview's guide is attached). The textual material from the interviews was entered into the MAXQDA software and directed content analysis was used to analyze the data. RESULTS: Data analysis led to the identification of 4 categories (Sociocultural, Situational, Economical, and Physical environment) and 12 subcategories: Sociocultural: lack of awareness, begging culture, low trust in disease control programs, low bottom-up planning, and increasing violence; Situational: decreasing donors' activities and canceling important meetings; Economical: unemployment, decreasing in income, and increasing limitations of many institutions in providing resources; and Physical environment: inadequate space and inappropriate conditions in some houses and alleys for people protection against Corona viruses. CONCLUSIONS: Slum residents have faced many challenges during the COVID-19 pandemic. These challenges can affect the health of slum and other urban dwellers. Multidisciplinary thinking and actions are needed. Increase awareness and engagement slum residents in control disease programs should be considered.

District health network policy in Iran: the role of ideas, interests, and institutions (3i framework) in a nutshell.

BACKGROUND: District Health Network (DHN), one of Iran's most successful health reforms, was launched in 1985 to provide primary health care (PHC), in response to health inequities in Iran. The present study aims to use interrelated elements of the 3i framework: ideas (e.g., beliefs and values, culture, knowledge, research evidence and solutions), interests (e.g., civil servants, pressure groups, elected parties, academians and researchers, and policy entrepreneurs), and institutions (e.g., rules, precedents, and organizational, government structures, policy network, and policy legacies) to explain retrospectively how (DHN) policy in Iran, as a developing country, was initiated and formed. METHODS: A historical narrative approach with a case study perspective was employed to focus on the formation and framing process of DHN. For this purpose, the 3i framework was used as a guideline for data analysis. This study mainly searched and extracted secondary sources, including online news, reports, books, dissertations, and published articles in the scientific databases. Primary interviews as a supplementary source were also carried out to meet cross-validation of the data. Data were analyzed using a deductive and inductive approach. RESULTS: According to the 3i framework, the following factors contributed to the formation of DHN policy in Iran: previous national efforts (for instance Rezaieh plan) and international events aiming to provide public health services for peripheral regions; dominant social discourses and values at the beginning of the Iranian revolution such as addressing the needs of disadvantaged and marginalized groups, which were embedded in the goals of DHN policy aiming to provide basic health services for deprived people especially living in rural and remote areas. Besides, the remarkable social cohesion and solidarity among people reinforced by the Iran-Iraq war were among other factors which contributed to the formation of participatory plans such as DHN (ideas). Main policy entrepreneurs including Minister of Health, his public health deputy and two planners of DHN with similar and rich background in the public health field and sharing the same beliefs (interests) which subsequently led to creation of tight-knit policy community network between them (institutions) also accelerated the creation of DHN in Iran to great extent. Political support of parliamentary representatives (interests), and formal laws such as principles of Iran Constitution (institutions) were also influential in passing the DHN in Iran. CONCLUSIONS: The 3i framework constituents would be insightful in explaining the creation of public health policies. This framework showed that the alignment of laws, structures, and interests of the main actors of the policy with the dominant ideas and beliefs in the society, opened the opportunity to form DHN in Iran.

Community empowerment for health promotion in slums areas: A narrative review with emphasis on challenges and interventions.

Community empowerment has been proposed since the 1980s as a way to increase people's power to influence social determinants of health. However, community empowerment for health promotion in urban slums still faces challenges. The present study examined interventions, challenges, actors, scopes, and the consequences mentioned in various studies and with emphasizing interventions and executive challenges tried to create a clear understanding of empowerment programs in slums and improving their health. Narrative review method was used to conduct the study. Databases including PubMed, Scopus, Embase, Web of Science, and Cochrane were searched. The selection of studies was done according to the "community empowerment" defined by the World Health Organization, the concept of bottom-up approach for health promotion of Laverack and Labonte's study and definition of slums by UN-HABITAT. Finally, Hare and Noblit's meta-synthesis was used to analyze the studies. From 15 selected studies, the most intervention proposed for empowerment was identified to be "residents' participation in expressing problems and solutions." The challenge of "creating a sense of trust and changing some attitudes among residents" was the greatest challenge in the studies. Moreover, "improving living conditions and health services" were the most important outcomes, "slum residents" and "governments" were the most important actors, and "sanitation" was the most important scope among the studies. Having a comprehensive view to the health and its determinants and attention to the factors beyond neighborhood and health sector would lead to fewer implementation challenges and better intervention choices to health promotion of slum dwellers.

How Much Money Should be Paid for a Patient to Isolate During the COVID-19 Outbreak? A Discrete Choice Experiment in Iran.

INTRODUCTION: Isolation of COVID-19 patients is a vital strategy for preventing the spread of the virus. Isolation without any incentive or compensation for the patients cannot be effective. We sought to find the monetary value of the willingness to accept (WTA) being isolated for COVID-19 in Iran. METHODS: In this discrete choice experiment, scenarios were designed by reviewing the literature and semi-structural interviews. Fourteen choice sets with two scenarios were included in an internet-based questionnaire that was sent to the Telegram Social Network. A total of 617 individuals completed the questionnaire. A random-effects logistic regression model was used for the main analysis. RESULTS: The average monetary value of a WTA 7 days of isolation was US$51.71 (95% confidence interval [CI] 43.09-60.33). The WTA for one day of isolation was US$1.48 (95% CI 1.11-1.85) for unemployed groups, US$1.49 (95% CI 1.18-1.79) for office employees and US$1.36 (95% CI 0.73-2.01) for manual workers. The WTA was 0.44 (95% CI 0.35-0.53) US$ for low-income groups, US$0.68 (95% CI 0.52-0.84) for middle-income groups and US$0.77 (95% CI 0.35-1.18) for high-income groups. CONCLUSIONS: Our findings suggested that financial preferences for being isolated vary widely across individuals within different socioeconomic groups. Policymakers should consider these differences when designing effective intervention to increase compliance with the isolation protocols during infectious disease outbreaks.

Prevalence of food insecurity and related factors among slum households in Kerman, south of Iran.

INTRODUCTION: Household food insecurity (FI) is defined as limited or uncertain access to nutritionally adequate and safe food or limited ability to obtain foods in socially acceptable ways has become a global issue in recent decades. METHODS: This cross-sectional study was conducted in Kerman, southeast of Iran in 2019, covering 559 marginalised households. United States Department of Agriculture food security measure was used for data collection. Finally, data were analysed using t-test, χ2 , Mann-Whitney tests and logistic regression. RESULTS: The prevalence of FI was 82% among slums households. The most important experience of FI in households was reliance on low-cost foods. There was a significant relationship between slums FI and gender of head of household, household size, household income, household education level and marital status (p Ë‚ 0.05). According to the results of the multivariate regression the variables of education, household income level and household size significantly determined FI (p Ë‚ 0.05). CONCLUSION: The most important determinant of FI was low socioeconomic status (income, education, household size). Hence, public policies targeting socioeconomic factors should be made to improve the socioeconomic status of slum dwellers.

Fairness in household financial contribution to the Iran's healthcare system from 2008 to 2018.

OBJECTIVE: Enhancing financial protection in health is one of the main goals of Iran's health transformation program (HTP), a recent reform conducted in early 2014. This study aimed to measure financial protection using the fair financial contribution index (FFCI) in urban and rural areas before (2008-2013) and after (2014-2018) the HTP implementation. Using a retrospective study on annual national cross-sectional surveys of households' income and expenditure, FFCI was measured. The total sample sizes for urban and rural areas from 2008 to 2018 were 207,980 and 212,249 households, respectively. RESULTS: The worst fair contributions to health expenditure in urban (FFCI = 0.684) and rural areas (FFCI = 0.530) were related to 2010 and 2009, respectively. Otherwise, the best fair contributions for urban (FFCI = 0.858) and rural (FFCI = 0.836) areas were made in 2011. Before the HTP implementation began, FFCI showed minor changes from 0.834 in 2008 to 0.833 in 2013. Following the HTP implementation, the FFCI values in urban and rural populations declined (worsened) from 0.842 to 0.836 and 0.816 to 0.809, respectively.On average more fair financial contributions had been made following five years after the HTP, especially in rural areas, but less than that expected in upstream documents (as determined 0.9).

The experiences of merging health insurance funds in South Korea, Turkey, Thailand, and Indonesia: a cross-country comparative study.

BACKGROUND: Fragmentation in health insurance system may lead to inequity in financial access to and utilization of health care services. One possible option to overcome this challenge is merging the existing health insurance funds together. This article aims to review and compare the experience of South Korea, Turkey, Thailand and Indonesia regarding merging their health insurance funds. METHODS: This was a cross-country comparative study. The countries of the study were selected purposefully based on the availability of data to review their experience regarding merging health insurance funds. To find the most relevant documents about the subject, different sources of information including books, scientific papers, dissertations, reports, and policy documents were studied. Research databases including PubMed, Scopus, Google Scholar, Science Direct and ProQuest were used to find relevant articles. Documents released by international organizations such as WHO and World Bank were analyzed as well. The content of documents was analyzed using a data-driven conventional content analysis approach and all details regarding the subject were extracted. The extracted information was reviewed by all authors several times and nine themes emerged. RESULTS: The findings show that improving equity in health financing and access to health care services among different groups of population was one of the main triggers to merge health insurance funds. Resistance by groups enjoying better benefit package and concerns of workers and employers about increasing the contribution rates were among challenges ahead of merging health insurance funds. Improving equity in the health care financing; reducing inequity in access to and utilization of health care services; boosting risk pooling; reducing administrative costs; higher chance to control total health care expenditures; and enhancing strategic purchasing were the main advantages of merging health insurance funds. The experience of these countries also emphasizes that political commitment and experiencing a reliable economic growth to enhance benefit package and support the single national insurance scheme financially after merging are required to facilitate implementation of merging health insurance funds. CONCLUSIONS: Other contributing health reforms should be implemented simultaneously or sequentially in both supply side and demand side of the health system if merging is going to pave the way reaching universal health coverage.

Economic burden of cardiovascular diseases before and after Iran's health transformation plan: evidence from a referral hospital of Iran.

BACKGROUND: Different countries have set different policies to control and decrease the costs of cardiovascular diseases (CVDs). Iran was aiming to reduce the economic burden of different disease by a recent reform from named as health transformation plan (HTP). This study aimed to examine the economic burden of CVDs before and after of HTP. METHODS: This cross-sectional study was conducted on 600 patients with CVDs, who were randomly selected from a specialized cardiovascular hospital in the north-west of Iran. Direct and indirect costs of CVDs were calculated using the cost of illness and human capital approaches. Data were collected using a researcher-made checklist obtained from several sources including structured interviews, the Statistical Center of Iran, Iran's Ministry of Cooperatives, Labor, and Social Welfare, the central bank of Iran, and the data of global burden of disease obtained from the Institute for Health Metrics and Evaluation to estimate direct and mortality costs. All costs were calculated in Iranian Rials (IRR). RESULTS: Total costs of CVDs were about 5571 and 6700 billion IRR before and after the HTP, respectively. More than 62% of the total costs of CVDs accounted for premature death before (64.89%) and after (62.01%) the HTP. The total hospitalization costs of CVDs was significantly increased after the HTP (p = 0.038). In both times, surgical services and visiting had the highest and lowest share of hospitalization costs, respectively. The OOP expenditure decreased significantly and reached from 54.2 to 36.7%. All hospitalization costs, except patients' OOP expenditure, were significantly increased after the HTP about 1.3 times. Direct non-medical costs reached from 2.4 to 3.3 billion before and after the HTP, respectively. CONCLUSION: Economic burden of CVDs increased in the north-west of Iran after the HTP due to the increase of all direct and indirect costs, except the OOP expenditure. Non-allocation of defined resources, which coincided with the international and national political and economic challenges in Iran, led to unsustainable resources of the HTP. So, no results of this study can be attributed solely to the HTP. Therefore, more detailed studies should be carried out on the reasons for the significant increase in CVDs costs in the region.

'Poverty's scar: A qualitative inquiry of financing shortcomings in specialized burn hospitals.

BACKGROUND: Victims of burn have particular characteristics such as high vulnerability, expensive treatment, and cost of burn services. Thus, the financing of burn services is crucially important. The purpose of the present work is to recognize the financing challenges in Iranian specialized burn hospitals (SBHs). METHODS: In the present qualitative descriptive research, purposive sampling was used for selecting key informants with maximum variation at local, provincial, and national levels. Semi-structured interviews were used for data collection. Interviews were continued as long as the saturation point was achieved at the 21 st interview. We employed conventional content analysis using an inductive data-driven coding process and theme development for the analysis of the transcribed documents by MAXQDA Analytics Pro 2018 (VERBI GmbH Release 18.2.0 Berlin). RESULTS: We extracted 3 themes and 12 sub-themes, including resource mobilization (the poor burnt victims, unique feature of the single- SBH, high direct and indirect costs, and poor intra-sectoral advocacy), insurance coverage for burn care (incomplete breadth of population coverage, inadequate depth of benefits package and coverage of costs, and reimbursements of burn care) and mechanism of financial resource allocation (unsuitable payment system, less sustainable budgeting, inappropriate tariffing for burning services, top-down budgeting approach, and politicized budget process). CONCLUSIONS: We suggest that health policy-makers in Iran could modify the SBHs financing system by improving resource mobilization, scaling up insurance coverage for burns, and optimizing the allocation of financial resources. Besides, we propose several points for policy entry to address SBHs financial difficulties. These points are serious attention to vulnerable and the poor burn patients, provision of burn care in multi-specialized hospitals, strengthening intra-collaboration, revision of tariffs, and payments for burn services, and preservation and realization of burn budgeting.

What are the potential advantages and disadvantages of merging health insurance funds? A qualitative policy analysis from Iran.

BACKGROUND: In countries with health insurance systems, the number and size of insurance funds along with the amount of risk distribution among them are a major concern. One possible solution to overcome problems resulting from fragmentation is to combine risk pools to create a single pool. This study aimed to investigate the potential advantages and disadvantages of merging health insurance funds in Iran. METHODS: In this qualitative study, a purposeful sampling with maximum variation was used to obtain representativeness and rich data. To this end, sixty-seven face-to-face interviews were conducted. Moreover, a documentary review was used as a supplementary source of data collection. Content analysis using the 'framework method' was used to analyze the data. Four trustworthiness criteria, including credibility, transferability, dependability, and confirmability, were used to assure the quality of results. RESULTS: The potential consequences were grouped into seven categories, including stewardship, financing, population, benefit package, structure, operational procedures, and interaction with providers. According to the interviewees, controlling total health care expenditures; improving strategic purchasing; removing duplication in population coverage; centralizing the profile of providers in a single database; controlling the volume of provided health care services; making hospitals interact with single insurance with a single set of instructions for contracting, claiming review, and reimbursement; and reducing administrative costs were among the main benefits of merging health insurance funds. The interviewees enumerated the following drawbacks as well: the social security organization's unwillingness to collect insurance premiums from private workers actively as before; increased dissatisfaction among population groups enjoying a generous basic benefits package; risk of financial fraud and corruption due to gathering all premiums in a single bank; and risk of putting more financial pressure on providers in case of delay in reimbursement with a single-payer system. CONCLUSION: Merging health insurance schemes in Iran is influenced by a wide range of potential merits and drawbacks. Thus, to facilitate the process and lessen opponents' objection, policy makers should act as brokers by taking into account contextual factors and adopting tailored policies to respectively maximize and minimize the potential benefits and drawbacks of consolidation in Iran.

Measuring inequalities in the selected indicators of National Health Accounts from 2008 to 2016: evidence from Iran.

BACKGROUND: Increase in total health expenditures is one of the main challenges of health systems worldwide, and its inequality is considered as a concern in global arena especially developing countries. This study aims to measure inequality in the distribution of selected indicators of national health accounts across the Iranian provinces. METHODS: In this study, the data on health financing agents from provincial health accounts from 2008 to 2016 were collected. Gini coefficient (GC) was used to measure inequality. The population and the number of service providers in each province were the bases to measure the GC. The Coefficient of Variation (CV) and the Rate Ratio (RR) were used to determine the dispersion and variation across the provinces. Disparity index was employed to measure the average deviation of the out-of-pocket (OOP) proportion from the desired OOP proportion presented in national development plans (NDPs) of Iran. RESULTS: The distribution of resources using both bases were unequal, especially in OOP, with the highest rate over the years studied, ranging from 0.50 to 0.59. The inequality in public resources was lower, with Health Insurance Organization dropping from 0.42 to 0.40 over the years. CV and RR also confirmed the inequality in health resources distribution. In the years 2014 and 2015, the lowest and highest levels were 0.22 and 0.39, respectively. The values of disparity index for OOP had a fluctuating trend ranging from 37.01 to 65.85%. CONCLUSION: Inequality in the distribution of public health expenditures was moderate to high. Moreover, inequality in private health expenditures was higher than public one. Distribution of OOP spent by households at provincial level showed a high inequality. It is suggested that inequality measures to be considered in NDPs to illustrate how resources are distributed at the geographical level. NHA framework can help to provide robust evidence base for policymaking.

Tracking socio-economic inequalities in healthcare utilization in Iran: a repeated cross-sectional analysis.

BACKGROUND: Although some healthcare reforms such as Health Transformation Plan (HTP) were implemented in Iran to provide required healthcare services, few studies have been conducted to track the impacts of these reforms on socio-economic inequality in healthcare utilization. This study aims to track socio-economic inequalities in healthcare utilization and their changes between 2008 and 2016 in Iran. METHODS: Required data were obtained from two of Iran's utilization of healthcare services survey conducted in 2008 and 2016. Erreygers concentration index (EI) was used to measure inequality in the utilization of outpatient and inpatient healthcare services (UOH and UIH). The decomposition of EI (DEI) was used to explain healthcare utilization inequality. Oaxaca decomposition (OD) was also employed to track the changes in EI in this period. RESULT: Inequality in UOH increased from 0.105 to 0.133 in the studied years, indicating the pro-rich distribution of UOH. Inequality in UIH decreased from 0.0558 to - 0.006. DEI showed that economic status was the main factor that contributed to inequality in the UOH and UIH. OD showed that residence in rural areas and supplementary insurance were the main contributing factors in the increased inequality of UOH. Moreover, OD also showed that economic status was the main contributing factor in the reduced inequality of UIH. CONCLUSION: While Iran still suffers from significant socio-economic inequalities in UOH, it seems that healthcare reforms, especially HTP, have reduced UIH inequality. Expanding healthcare reforms into the outpatient sector and also implementing effective health financing policies could be recommended as a remedy against UOH inequality.

Health services utilization among slum dwellers: An experience from Iran.

INTRODUCTION: Health services utilization is a complex behavioral phenomenon affected by multiple factors including availability, distance, cost and quality of health services as well as personal attitudes, cultural beliefs, and socioeconomic characteristics. This study aimed to assess the status of health-care utilization among dwellers of slums in one of the Iran's big cities. METHODS: This was a cross-sectional study in which 559 slums people were selected using a random clustered sampling method. Data on health services utilization were collected using health equity assessment and response tool questionnaire. Data analysis was performed using descriptive statistics and logistic regression analysis through SPSS ver. 22. RESULTS: In this study, 42.5% (238) people who required outpatient services. 21% (118) of them were able to use them. Furthermore, among the families, who needed outpatient services during the past month, 15% (38) were able to use the services for at least once. Regarding inpatient services, 62% (349) of people needed hospitalization, of which 31% (175) were able to be hospitalized. Age (P = 0.2), gender (P = 0 <001), marital status (P = 0 <001), income status (P = 0.1), and education (P = 0.21) determined utilization of outpatient services; however, inpatient services utilization was affected by age (P = 0.03), gender (P = 0.02), marital status (P = 0 <001), and income status (P = 0.32). The final model of multiple regression showed that, there was a relationship between age (odds ratio [OR] =1.7, confidence interval [CI] 95% = 0.47-0.88), marital status (OR = 2.78, CI 95% = 0.64-1.2), and the use of inpatient services. CONCLUSION: The utilization of health services in slum areas is not desirable. As it was showed that the utilization of health services in slums people is a multifactorial event; thus, proper planning and policy for this increasingly demand are essential.