Mohammad Hajizadeh

Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments?

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian—regardless of their employment status—can better protect households from catastrophic health spending.

Socioeconomic inequalities in HIV/AIDS prevalence in sub-Saharan African countries: evidence from the Demographic Health Surveys

IntroductionExtant studies universally document a positive gradient between socioeconomic status (SES) and health. A notable exception is the apparent concentration of HIV/AIDS among wealthier individuals. This paper uses data from the Demographic Health Surveys and AIDS Indicator Surveys to examine socioeconomic inequalities in HIV/AIDS prevalence in 24 sub-Saharan African (SSA) countries, the region that accounts for two-thirds of the global HIV/AIDS burden.MethodsThe relative and generalized concentration indices (RC and GC) were used to quantify wealth-based socioeconomic inequalities in HIV/AIDS prevalence for the total adult population (aged 15-49), for men and women, and in urban and rural areas in each country. Further, we decomposed the RC and GC indices to identify the determinants of socioeconomic inequalities in HIV/AIDS prevalence in each country.ResultsOur findings demonstrated that HIV/AIDS was concentrated among higher SES individuals in the majority of SSA countries. Swaziland and Senegal were the only countries in the region where HIV/AIDS was concentrated among individuals living in poorer households. Stratified analyses by gender showed HIV/AIDS was generally concentrated among wealthier men and women. In some countries, including Kenya, Lesotho Uganda, and Zambia, HIV/AIDS was concentrated among the poor in urban areas but among wealthier adults in rural areas. Decomposition analyses indicated that, besides wealth itself (median = 49%, interquartile range [IQR] = 90%), urban residence (median = 54%, IQR = 81%) was the most important factor contributing to the concentration of HIV/AIDS among wealthier participants in SSA countries.ConclusionsFurther work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in SSA. Higher prevalence of HIV/AIDS could be indicative of better care and survival among wealthier individuals and urban adults, or reflect greater risk behaviour and incidence. Moreover, differential findings across countries suggest that effective intervention efforts for reducing the burden of HIV/AIDS in the SSA should be country specific.

Social inequalities in the utilization of maternal care in Bangladesh: Have they widened or narrowed in recent years?

BackgroundNotwithstanding the significant progress in reducing maternal mortality in recent years, social inequalities in the utilization of maternal care continue to be a challenge in Bangladesh. In this study, we aim to provide a comprehensive analysis of trends in social inequalities in utilization of antenatal care (ANC), facility based delivery (FBD), and skilled birth attendance (SBA) in Bangladesh between 1995 and 2010.MethodsData were extracted from the five latest rounds of Bangladesh Demographic Health Surveys (BDHS). The Theil index (T) and between-group variance (BGV) were used to calculate relative and absolute disparities in the utilization of three measures (ANC, FBD, and SBA) of maternal care across six administrative regions. The relative and slope indices of inequality (RII and SII, respectively) were also used to calculate wealth- and education-based inequality in the utilization of maternal care.ResultsThe results of the T-index suggest that relative inequality in SBA has declined by 0.2% per year. Nevertheless, the estimated BGV demonstrated that absolute inequalities in all three measures of maternal care have increased across administrative divisions. For all three measures of maternal care, the RII and SII indicated consistent socioeconomic inequalities favouring wealthier and more educated women. The adjusted RII suggested that wealth- and education-related inequalities for ANC declined by 9% and 6%, respectively, per year during the study period. The adjusted SII, however, showed that wealth- and education-related inequalities for FBD increased by 0.6% per year.ConclusionsAlthough socially disadvantaged mothers increased their utilization of care relative to mothers of higher socioeconomic status, the absolute gap in utilization of care between socioeconomic groups has increased over time. Our findings indicate that wealthier and more educated women, as well as those living in urban areas, are the major users of ANC, FBD and SBA in Bangladesh. Thus, priority focus should be given to implementing and evaluating interventions that benefit women who are poorer, less educated and live in rural areas.

Inequalities in maternal health care utilization in sub-Saharan African countries : a multiyear and multi-country analysis

To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.

Equity of health care financing in Iran: the effect of extending health insurance to the uninsured.

This paper examines the progressivity of health insurance premiums and consumer co-payments in Iran by calculating Kakwani Progressivity Indices using data from annual national household surveys between 1995/96 and 2006/07. During this period, the Urban Inpatient Insurance Scheme in 2000 and the Rural Health Insurance Scheme in 2005 extended health insurance coverage in urban and rural areas. Unexpectedly, the results suggest that both of these initiatives had regressive impacts on the distribution of health care financing in Iran, which could be explained by public sector activity having crowded out private sector charitable activity. Although this study does not address changes in the distribution of health care utilization, these results for health care financing suggest the need for caution in the implementation of such programmes in low-income and middle-income countries. If charitable activity already results in the provision of health care to the poor at zero or low prices, public intervention may not improve the progressivity of health care financing.

Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low- and Middle-Income Countries: A Quasi-Experimental Study

Background Maternity leave reduces neonatal and infant mortality rates in high-income countries. However, the impact of maternity leave on infant health has not been rigorously evaluated in low- and middle-income countries (LMICs). In this study, we utilized a difference-in-differences approach to evaluate whether paid maternity leave policies affect infant mortality in LMICs. Methods and Findings We used birth history data collected via the Demographic and Health Surveys to assemble a panel of approximately 300,000 live births in 20 countries from 2000 to 2008; these observational data were merged with longitudinal information on the duration of paid maternity leave provided by each country. We estimated the effect of an increase in maternity leave in the prior year on the probability of infant (<1 y), neonatal (<28 d), and post-neonatal (between 28 d and 1 y after birth) mortality. Fixed effects for country and year were included to control for, respectively, unobserved time-invariant confounders that varied across countries and temporal trends in mortality that were shared across countries. Average rates of infant, neonatal, and post-neonatal mortality over the study period were 55.2, 30.7, and 23.0 per 1,000 live births, respectively. Each additional month of paid maternity was associated with 7.9 fewer infant deaths per 1,000 live births (95% CI 3.7, 12.0), reflecting a 13% relative reduction. Reductions in infant mortality associated with increases in the duration of paid maternity leave were concentrated in the post-neonatal period. Estimates were robust to adjustment for individual, household, and country-level characteristics, although there may be residual confounding by unmeasured time-varying confounders, such as coincident policy changes. Conclusions More generous paid maternity leave policies represent a potential instrument for facilitating early-life interventions and reducing infant mortality in LMICs and warrant further discussion in the post-2015 sustainable development agenda. From a policy planning perspective, further work is needed to elucidate the mechanisms that explain the benefits of paid maternity leave for infant mortality.

Addiction Relapse and Its Predictors: A Prospective Study

Drug addiction has been recognized as a chronic, relapsing illness for several years. This study aims to estimate relapse rate and determine its predictors in Iran. In this prospective study, we studied 436 patients referring voluntarily to an addiction treatment center in Maragheh, Iran. We completed two questionnaires at the beginning of study and six months after cessation by conducting interviews with patients by trained interviewers. Logistic regression model was used in order to identify the predictors of relapse in our sample. After six months follow-up, we found that the relapse rate was 64.0% (CI 95%: 59.3-68.4). The results of logistic model indicate that smoking (OR=12.15), having a drug user in the family (OR=2.54), having lower hope to quit (OR=2.61), unemployment (OR=2.78) and stay connected with drug user friends after quitting (OR=46.7) were factors associated with relapse. This study similar to other studies showed a high relapse rate and determined some of its risk factors among addicts.

Health policy and horizontal inequities of health-care utilization in Australia: 1983-2005

We used five National Health Surveys (NHSs) in order to measure horizontal inequity (equal health care for equal need) in health-care utilization in Australia over five time points from 1983 to 2005. The direct standardization method was used to estimate the horizontal inequity indices for six measures of health-care utilization. The results suggest that the distributions of General Practitioner (GP) services and any physician visits in Australia were generally pro-poor, whereas the distributions of specialist visits, dentist visits and any ambulatory visits were pro-rich. The computed indices demonstrate that the introduction of Medicare in 1984 had a pro-poor effect on the utilization of GPs, any physician visits and any ambulatory visits. In contrast, the implementation of Private Health Insurance (PHI) policies over the period 1997 to 2000 had a pro-rich effect on the distribution of health-care utilization in recent years, but this finding is based on the assumption that PHI policies affected health-care consumption in the long term.

The socioeconomic gradient of secondhand smoke exposure in children: evidence from 26 low-income and middle-income countries

Objective To provide the first analysis of socioeconomic inequalities in childrens daily exposure to indoor smoking in households in 26 low-income and middle-income countries (LMICs). Methods We used nationally representative household samples (n=369 654) collected through the Demographic Health Surveys between 2010 and 2014 to calculate daily exposure to secondhand smoke (ESHS) among children aged 0–5 years. The relative and absolute concentration (RC and AC) indices were used to quantify wealth-based inequalities in daily ESHS in each country and in urban and rural areas in each country. We decomposed total socioeconomic inequalities in ESHS into within-group and between-group (rural–urban) inequalities to identify the sources of wealth-based inequality in ESHS in LMICs. Findings We observed substantial variation across countries in the prevalence of daily ESHS among children. Childrens ESHS was higher in rural areas compared to urban areas in the majority of the countries. The RC and AC demonstrated that daily ESHS was concentrated among poorer children in almost all countries (RC, median=−0.179, IQR=0.186 and AC, median=−0.040, IQR=0.055). The concentration of ESHS among poorer children was greater in urban relative to rural areas. The decomposition of the overall socioeconomic inequality in daily ESHS revealed that wealth-based differences in ESHS within urban and rural areas were the main contributor to socioeconomic inequalities in most countries (median=46%, IQR=32%). Conclusions Special attention should be given to reduce ESHS among children from rural and socioeconomically disadvantaged households as social inequalities in ESHS might contribute to social inequalities in health over the life course.

Socioeconomic gradient in health in Canada: Is the gap widening or narrowing?

BACKGROUND Notwithstanding a general improvement in health status, the socioeconomic gradient in health remains a public health challenge worldwide. OBJECTIVE Using longitudinal data from the National Population Health Survey (NPHS, n=17,276), we examined trends in socioeconomic gradients in two health indicators, viz. the Health Utility Index (HUI) and the Frailty Index (FI), among Canadian adults (25 years and older) between 1998/9-2010/11. METHODS The relative and slope indices of inequality (RII and SII, respectively) were employed to summarize income- and education-based inequality in the FI and the HUI in Canada as whole, and in five regions: the Atlantic provinces, Quebec, Ontario, the Prairies and British Columbia. RESULTS We found that education- and income-related inequalities in health were present in all five regions of Canada. The estimated RIIs and SIIs suggested that education-related inequalities in the FI and the HUI increased among women. The results also revealed that relative and absolute income-related inequalities in the HUI increased in Canada, especially among women. Both absolute and relative inequalities indicated that income-related inequalities in the HUI increased in Quebec and in the Prairies over time. CONCLUSION Persistent and growing socioeconomic inequalities in health in Canada over the past one and half decades should warrant more attention. The mechanisms underlying socioeconomic-related inequalities in Canada are less clear. Therefore, further studies are required to identify effective polices to reduce the socioeconomic gradient in health in Canada.