Epidemiol Health.  2017;39:e2017029. 10.4178/epih.e2017029.

Pros and cons of the health transformation program in Iran: evidence from financial outcomes at the household level

  • 1Social Determinants of Health Research Center, Guilan University of Medical Sciences, Rasht, Iran. hasanafkar@yahoo.com
  • 2School of Management and Medical Informatics, Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
  • 3Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran.
  • 4Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran.


The health transformation program was a recent reform in the health system of Iran that was implemented in early 2014. Some of the program's important goals were to improve the equity of payments and to reduce out-of-pocket (OOP) payments and catastrophic health expenditures (CHE). In this study, these goals were evaluated using a before-and-after analysis.
Data on household income and expenditures in Guilan Province were gathered for the years 2013 and 2015. OOP payments for outpatient, inpatient, and drug services were calculated, and the results were compared using the propensity score matching technique after adjusting for confounding variables. Concentration indices and curves were added to quantify changes in inequity before and after the reform. The incidence of catastrophic expenditures was then calculated.
Overall and outpatient service OOP payments increased by approximately 10 dollars, while for other types of services, no significant changes were found. Inequity and utilization of services did not change after the reform. However, a significant reduction was observed in CHE incidence (5.75 to 3.82%).
The reform was successful in decreasing the incidence of CHE, but not in reducing the monetary amount of OOP payments or affecting the frequency of health service utilization.


Health care reform; Health expenditures; Health equity; Financial statements; Catastrophic illnesses; Iran's health transformation program

MeSH Terms

Catastrophic Illness
Confounding Factors (Epidemiology)
Family Characteristics*
Financial Statements
Health Care Reform
Health Equity
Health Expenditures
Health Services
Propensity Score
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