Catastrophic Health Expenditure among Iranian Households: Evidence from the COVID-19 Era.

Background: Monitoring households' exposure to catastrophic health expenditure (CHE) based on out-of-pocket (OOP) health payments is a critical tool for evaluating the equitable financial protection status within the health system. The COVID-19 pandemic has brought unprecedented global change and potentially affected the mentioned protection indicators. This study aimed to assess the prevalence of CHE among households in Iran during the COVID-19 period.

Methods: The present study employed a retrospective-descriptive design utilizing data derived from two consecutive cross-sectional Annual Household Income and Expenditure Surveys (HIES) undertaken by the Statistical Centre of Iran (SCI) in 2020 and 2021. The average annual OOP health payments and the prevalence of households facing CHE were estimated separately for rural and urban areas, as well as at the national level. Based on the standard method recommended by the World Health Organization (WHO), CHE was identified as situations in which OOP health payments surpass 40% of a household's capacity to pay (CTP). The intensity of CHE was also calculated using the overshoot measure. All statistical analyses were carried out using Excel-2016 and Stata-14 software.

Results: The average OOP health payments increased in 2021, compared to 2020, across rural and urban areas as well as at the national level. Urban residents consistently experienced higher OOP health payments than rural residents and the national level in both years. At the national level, the prevalence of CHE was 2.92% in 2020 and increased to 3.18% in 2021. In addition, rural residents faced a higher prevalence of CHE based on total health services OOP, outpatient services OOP, and inpatient services OOP compared to urban residents and the national level. Regarding the intensity of CHE using overshoot, the results for 2020 and 2021 revealed that the overshoot ranged between 0.60% and 0.65% in rural areas, between 0.30% and 0.33% in urban areas, and between 0.38% and 0.41% at the national level.

Conclusion: A considerable percentage of households in Iran still incur CHE. This trend has increased in the second year of COVID-19 compared to the first year, as households received more healthcare services. The situation is even more severe for rural residents. There is an urgent need for targeted interventions in the health system, such as strengthening prepayment mechanisms, to reduce OOP and ensure equitable protection for healthcare recipients.