Informal Payments for Outpatient Health Care: Country-Wide Evidence from Iran.

Background: Reliance heavily on out-of-pocket (OOP) payments, including informal payments (IPs), has undesired effects on financial risk protection and access to care. While a significant share of total health expenditure is spent on outpatient services, there is scant evidence of the patient's amount paid informally in outpatient services. Such evidence is available for inpatient services, showing the high prevalence of informal payments, ranging from 14 to 48% in the whole hospital. This study aimed to investigate the extent of OOP and IPs for outpatient services in Iran. Methods: A secondary data analysis of the 2015 IR Iran's Utilization of Healthcare Services (IrUHS) survey was conducted. A sample of 11,782 individuals with basic health insurance who were visited at least once by a physician in two private and public health care centers was included in this analysis. The percentage of OOP was determined and compared with the defined copayment (30%). The frequency of IPs was determined regarding the number of individuals who paid more than the defined copayments. The Mann-Whitney test also investigated the relationships between OOP percentage and IPs frequency with demographic variables. Results: The share that insured patients in Iran pay for a general practitioner (GP) visit was 38% in public versus 61% in the private sector, while for a specialist practitioner visit, the figures were 80% and 96%, respectively, which is higher than defined copayment (30%). This share was significantly higher in females, urban areas, highly educated people, private service providers, and specialist visits. The frequency of IPs, who paid more than the defined copayments, was 73% for a GP in public versus 86% in the private sector, while for a specialist practitioner visit, these were 90% and 93%, respectively. Conclusion: Informal patient payments for outpatient services are prevalent in Iran. Hence, more interventions are required to eliminate or control the IPs in outpatient services, particularly in the private sector. In this regard, making a well-regulated market, reinforcing the referral system, and developing an equity-oriented essential health services package would be fundamental.

On bias reduction estimators of skew-normal and skew-t distributions.

A particular concerns of researchers in statistical inference is bias in parameters estimation. Maximum likelihood estimators are often biased and for small sample size, the first order bias of them can be large and so it may influence the efficiency of the estimator. There are different methods for reduction of this bias. In this paper, we proposed a modified maximum likelihood estimator for the shape parameter of two popular skew distributions, namely skew-normal and skew-t, by offering a new method. We show that this estimator has lower asymptotic bias than the maximum likelihood estimator and is more efficient than those based on the existing methods.

The comparison of hospitals' performance indicators before and after the Iran's hospital care transformations plan.

INTRODUCTION: Hospital care transformation plan (HCTP) was implemented, in 2014, with the aim of ensuring all Iranians have fair access to hospital care, mainly in the public sector. It was assumed that HCTP would lead to increased quality and effectiveness of health care in public hospitals. To explore whether HCTP has achieved its aim, this study has investigated the impact of this plan on performance indicators (PIs) of the public hospitals. MATERIALS AND METHODS: This cross-sectional descriptive study was conducted in 2016. The study population included all hospitals in the Isfahan City. Data (10 selected PIs) were collected through formal reports which were available at the Isfahan University of Medical Sciences and analyzed using Statistical Package for Social Sciences (version 17). The statistical significant level analysis was 0.05. RESULTS: After HCTP, it was shown an increase of (1) Bed occupancy, bed turnover, occupied bed-days, inpatients visits, and number of surgeries in all types of hospitals, (2) Outpatients' visits in all hospitals except private ones, (3) Emergency visits in public and social security hospitals, and (4) Natural deliveries in public and semi-public hospitals. Furthermore, the average length of stay and hospital mortality rate has decreased in all types of hospitals after HCTP implementation. DISCUSSION AND CONCLUSION: Although, improving PIs of hospitals were not directly stated and known objectives of HCTP implementation, it seems HCTP could improve the performance of all hospitals, including involved and noninvolved ones.