Today, with the rising costs of health care, there is growing concern about the economic impact of health spending on households facing diseases [33], so that in most political circles and parties there is a discussion about health costs and protecting households from facing CHEs [32]. The present study aimed to measure the percentage of households facing CHEs and its effective factors in Shiraz, Iran in 2018.
Taking account of excluding households living below the poverty line before paying for health services from the study, the results showed that the percentage of households in Shiraz facing CHEs was 16.48%, which is higher than the goal of the Sixth Development Plan of the country, i.e. reducing the rate of facing CHEs to less than 1% [34]. This large gap can be due to the increasing costs of medical services, including pharmaceutical costs and costs of using new technologies, which put a lot of upward pressure on the health expenditure, and as a result, it places a heavy financial burden on households. Another important reason could be the financing of health care in developing countries largely through out-of-pocket payments, combined with the relative lack of adequate health insurance coverage [35]. Different rates of CHEs have been reported in previous studies in different health systems, both in Iran and other countries. For example, in a study by Rezaei et al. [36] in 2019, 4.12% of households in western Iran were exposed to CHEs. This rate was reported 11.80% by Kavousi et al. [28], 3.14% by Yazdi et al. [37], and 3.91% by Ghorbanian et al. [38] in the years 1995–2015 in Iran.
Also, in Zhen et al. in China [39], the percentage of households facing CHEs was 17.50% and in the study of Barasa et al. [40] in Kenya in East Africa was 6.58%.
The results of the multiple logistic regression in the current study showed that facing CHEs was significantly associated with living in rented houses, having disabled family members, not having supplementary health insurance coverage, and having children under 5 years old.
In other words, households living in rented houses had higher odds of facing CHEs (3.4 times) than those who owned a house, which is consistent with the results of the studies conducted by Mohammadzadeh et al. and Ghiasvand et al. [41, 42] in Iran. According to the Statistical Center of Iran, in 2018, 34% of the budget of urban households has been spent on renting a house, which has been the highest cost among household expenditures [43]. Therefore, the costs of renting a house and transporting home appliances when moving from house to house may impose an additional burden on household income, thereby lowering households' capacity to pay for healthcare.
However, Mobaraki et al. and Khammarnia et al. [2, 44] showed there were no significant associations between homeownership and facing CHEs.
In the present study, households with disabled family members were more likely to face CHEs (27.98 times). These households are more likely to be in need of care services and, consequently, because of the high costs of care services, they have fewer financial resources to meet other family needs. Also, such households have higher direct non-medical costs, including the costs of purchasing a wheelchair, changing the home environment to adapt to the situation of the disabled person, etc. Therefore, if there is no effective protection mechanism, these households face increased risks of financial problems and catastrophic expenditures. The results of the present study are similar to those of Hatam et al. and Kavosi et al.’s [28, 45] studies in Iran. Moreover, Somkotra and Lagrada, Gotsadze et al., and Su et al. [14, 46, 47] in their studies concluded that the presence of people with physical or mental disabilities in the household could increase the household health care costs over its total costs, increasing the risk of facing CHEs.
Furthermore, there was a significant association between supplementary health insurance coverage and facing CHEs in the current study, so that households that were not covered by supplementary health insurance had higher odds of facing CHEs (1.87 times) than those covered by supplementary health insurance. It can be due to that households covered by the supplementary health insurance schemes pay less to the health system, and the supplementary health insurance organizations provide services and cover costs that basic insurers do not provide and cover. In line with the results of the present study, Mobaraki et al. [44] demonstrated a significant negative association between supplementary insurance coverage and facing CHEs. Rezapour et al. [48] showed that having health insurance coverage could protect households from facing CHEs, similar to the results of the present study. Yardim et al. and Xu et al. [11, 49] showed that having basic and supplementary health insurance coverage had a positive effect on reducing the exposure to CHEs, which are consistent with the results of the present study. However, Mobaraki et al. [44] didn’t find any significant association between having basic and supplementary health insurance coverage and facing CHEs. On the other hand, the results of Wagstaff and Lindelow [50] in China showed that having health insurance coverage had increased the risk of households' exposure to CHEs by encouraging people to use more health services, especially more advanced services.
Moreover, the results of the current study showed that households with children under 5 years old were more likely to face CHEs. In other words, the higher the number of children under 5 years old in the household, the greater the risk of the financial burden on the household [51]. With the increase in the number of children under 5 years old, because of the greater need of this age group for health care and services as well as the high costs of childcare in healthy and suitable kindergarten and nursery school and buying food and dietary supplements needed by children, the households are more likely to face rising health costs and CHEs. These results are similar to those of the Mohammadzadeh et al., Sabermahani et al., and Amery et al.’s [4, 41, 52]. However, Hatam et al. and Kavosi et al. [28, 45] didn’t show any statistically significant association between having children under 5 years old and facing CHEs.
The results of the present study showed no significant associations between facing CHEs and household income and size as well as having a family member over 65 years of age, which are consistent with the results of Soofi et al. [53] and Kavousi et al.’s [28] studies, and inconsistent with those of the Mobaraki et al. [44], Emamgholipour et al. [54], Amery et al. [55], Ghiasvand et al. [42], Yardim et al. [49], Somkotra and Lagrada [56], and Su et al.’s [14] studies.
Overall, the reasons for the observed differences between the results of the current study and those of other studies mentioned can be due to the differences in the sources of data used, population and samples studied, sampling methods, data collection instruments and measuring tools used, how to determine the households’ total income (for example, asking the households or the use of expenditures as a proxy), and the year of study and therefore differences in the inflation rates and out-of-pocket payments.
Like other studies, the present study had some limitations such as recall bias, self-report and lower or higher cost reporting. Also, because this study was conducted only in one city of Iran, although the fifth-most-populous one, it is necessary to be cautious in generalizing the results of the present study to other Iran cities and provinces, as well as to other similar countries.
According to the result of the current study, policymakers should pay special attention to the poor and socioeconomically disadvantaged households to reduce their exposure to CHEs in Iran through measures such as making reforms in the basic health insurance service packages, supplementary insurance premiums, cost-sharing policies, and earmarked taxes allocated to the health system.