Ghobad Moradi

Background: One of the main objectives of health systems is the financial protection against out-of-pocket (OOP)
health expenditures. OOP health expenditures can lead to catastrophic payments, impoverishment or poverty among
households. In Iran, health sector evolution plan (HSEP) has been implemented since 2014 in order to achieve
universal health coverage and reduce the OOP health expenditures as a percentage of total health expenditures.
This study aimed to explore the percentage of households facing catastrophic health expenditures (CHE) after the
implementation of HSEP and the factors that determine CHE.
Methods:A total of 663 households were selected through a cluster sampling based on the census framework of
Sanandaj Health Center in July 2015. Data were gathered using face-to-face interviews based on the household
section of the World Health Survey questionnaire. In this study, according to the World Health Organization
(WHO) definition, if household health expenditures were equal to or more than 40% of the household capacity to
pay, household was considered to be facing CHE. The determinants of CHE were analyzed using logistic regression
model.
Results:The rates of households facing CHE were 4.8%. The key determinants of CHE were household economic
status, presence of elderly or disabled members in the household and utilization of inpatient or rehabilitation
services.
Conclusion:The comparison of our findings and those of other studies carried out using a methodology
comparable with ours in different parts of Iran before the implementation of HSEP suggests that the
implementation of recent reforms has reduced CHE at the household level. Utilization of inpatient and rehabilitation
services, the presence of elderly or disabled members in the household and the low economic status of the household
would increase the likelihood of facing CHE. These variables should be considered by health policy-makers in order
to review and revise content of recent reform, thus financially protecting public against CHE.

Background: One of the objectives of the health transformation plan (HTP) in Iran is to reduce out-of-pocket (OOP) payments for inpatient services and eradicate informal payments. The HTP has three phases: the first phase (launched in May 5, 2014) is focused on reducing OOP payments for inpatient services; the second phase (launched in May 22, 2014) is focused on primary healthcare (PHC) and the third phase utilizes an updated relative value units for health services (launched in September 29, 2014) and is focused on the elimination of informal payments. This aim of this study was to determine the OOP payments and the frequency of informal cash payments to physicians for inpatient services before and after the HTP in Kurdistan province, Iran. Methods: This quasi-experimental study used multistage sampling method to select and evaluate 265 patients discharged from hospitals in Kurdistan province. The study covered 3 phases (before the HTP, after the first, and third phases of the HTP). Part of the data was collected using a hospital information system form and the rest were collected using a questionnaire. Data were analyzed using Fisher exact test, logistic regression, and independent samples t test..4 in private hospitals. In hospitals affiliated to SSO and MoHME there was a significant difference between the mean OOP payments before the HTP and after the third phase (P < .05). The percentage of informal payments to physicians in hospitals affiliated to MoHME, SSO, and private sector, respectively, were 4.5%, 8.1%, and 12.5% before the HTP, and 0.0%, 7.1%, and 10.0% after the first phase. Contrary to the time before the HTP, no informal payment was reported after the third phase. Conclusion: It seems that the implementation of the HTP has reduced the OOP payments for inpatient services and eradicated informal payments to physician in Kurdistan province. Implications for policy makers • It seems that the implementation of the health transformation plan (HTP) reduced the mean out-of-pocket (OOP) payments for inpatient services in Kurdistan province, Iran. • After the implementation of the third phase of the HTP, during the study period, we did not found any informal cash payments to physicians for inpatient services. • Several factors significantly increased the probability of informal payments to physician including the followings: being discharged from private sector and social security hospitals, being discharged from hospitals before the implementation of the HTP, living in rural areas, being visited by an ophthalmologist, urologist or otolaryngologists. • Health policy-makers should pay attention to patients' payments for " bought and brought health care goods " purchased from out-of-hospital supply chain. Implications for the public After the implementation of the health transformation plan (HTP), the amount of out-of-pocket (OOP) payments for inpatient services was reduced. Reduction of OOP payments for inpatient services improves people's access to such services and enhances the equity. After the implementation of the third phase of the HTP no informal cash payments to physician was reported. The elimination of informal payments reduces the probability of corruption in the health system.