Strategies for reducing out of pocket payments in the health system: a scoping review

Background Direct out-of-pocket payments (OOP) are among the most important financing mechanisms in many health systems, especially in developing countries, adversely affecting equality and leading vulnerable groups to poverty. Therefore, this scoping review study was conducted to identify the strategies involving OOP reduction in health systems. Methods Articles published in English on strategies related to out-of-pocket payments were Searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between January 2000 and November 2020, following PRISMA guidelines. As a result, 3710 papers were retrieved initially, and 40 were selected for full-text assessment. Results Out of 40 papers included, 22 (55%) and 18 (45%) of the study were conducted in developing and developed countries, respectively. The strategies were divided into four categories based on health system functions: health system stewardship, creating resources, health financing mechanisms, and delivering health services.As well, developing and developed countries applied different types of strategies to reduce OOP. Conclusion The present review identified some strategies that affect the OOP payments According to the health system functions framework. Considering the importance of stewardship, creating resources, the health financing mechanisms, and delivering health services in reducing OOP, this study could help policymakers make better decisions for reducing OOP expenditures.


Introduction
Nowadays, spending on health is rising, accounting for 10% of global gross domestic product (GDP). Government expenditures, out-of-pocket payments (OOPs), and sources like voluntary health insurance, employer-provided health programs, and activities by non-governmental organizations are all included in health spending [1].
As defined by the World Health Organization (WHO), OOP expenses are the individuals' direct payments to healthcare providers at the time of service use [2]. OOPs, include purely private transactions (payments made by individuals to private doctors and pharmacies), official patient cost-sharing (user fees/copayments) within defined public or private benefit packages, and informal payments (payments beyond the prescriptions entitled as benefits, both in cash and in-kind). Therefore, OOPs may be explicitly some part of a policy or can occur through market transactions, or both [3].
OOP health expenditures may increase whenever households opt to access and receive health services but are not protected against high payments since medical

Open Access
Cost Effectiveness and Resource Allocation  19:47 costs are high. They do not have access to insurance coverage and other safeguards against OOPs [4]. The following factors significantly affect OOP health care costs: increased patient cost-sharing, development of high-deductible health care plans, and more use of costly biologic or designer drugs. OOP payments are not an efficient way of financing health care and may negatively affect equity and cause vulnerable groups to experience poverty [5]. High OOP medical costs can use up financial savings and damage credits and have a negative impact on the quality of life, medication adherence, and different health outcomes [6]. A new report by the World Bank Group stated that OOP payments accounted for a non-negligible part of total health care expenditures in Central and Eastern European countries. Also, Patients in developing countries spent half a trillion dollars each year (over $80 per person) out of their own pockets to receive health services [7]. Unfortunately, such expenses significantly harmed the poor [8]. The more the health sector grew, the less reliant it would be on OOP spending. The total OOP spending increased at least twice as much in lowand middle-income countries during 2000-2017 and reached 46% in high-income ones. However, its growth was slower than that of public spending in all income groups [9]. According to Adam Wagstaf (2020), OOP expenditures changed significantly within income groups, ranging from $32 in Sweden to $1200 in Switzerland in the high-income groups, and from six dollars in Madagascar to $100 in Cambodia, Haiti, and Nepal in the low-income ones [10].
There have been health financing policy reforms and measures in several countries recently to deal with the concerns over high OOP payments. While there is no remedy, available information suggests that having well-designed policies and strategies can help countries reduce OOP and its adverse effects successfully [2,11]. In general, reforms can apply some key strategies to abolish user fees or charges in public health facilities and exempt specific community groups such as the poor and the vulnerable, and pregnant women and children from official payments. They should also exempt some health services such as maternal and child care from official payments and deliver them free of charge [12].
Due to the lack of resources, implementing effective policies can protect households against the common and high costs of the health system. To date, no known study has reviewed the proposed appreciate strategies for reducing OOP health payments worldwide. So, the present study aims to investigate strategies of reducing OOP payments in the health system through scoping review studies between 2000 and 2020. This review can help decision-makers learn from the effective experiences of other countries in reducing OOP health payments.

Materials and methods
This study was carried out based on the Joanna Briggs Institute scoping review method as a framework [13], and a comprehensive systematic scoping review was performed to explain the strategies that could effectively reduce OOP health expenditures around the world. A defined question based on the PCC (Population, Concept, and Context) elements was raised at the first stage. All the countries in the world (Population), strategies and policies that affected OOP health expenditures (Concept), and all health systems having OOP payments (Context) were included in the question.
The second stage dealt with the target population, which comprised all the studies related to "Out-of-Pocket Expenditures" in various countries. To this end, all related studies conducted since 2000 were retrieved through the research strategy (Table 1).
Thus, the original English keywords appropriate to the research objective were first selected based on the comments of the research team and the keywords used in available related studies. Then, PubMed, Scopus, ISI Web of Science, and Embase databases were searched. It was decided to identify all the articles with at least an English abstract indexed in one database. "Out-of-Pocket Expenditure" OR "Out-of-Pocket Payment" OR "Out-of-Pocket Cost" OR "Out-of-Pocket Spending" OR "Out-of-pocket health spending" OR "Out of Pocket Expenditures" OR "Out-of-Pocket Expenses" OR "OOP" OR "Out of pocket" #2 Strategy OR intervention OR policy The selection of the relevant studies was carried out in the third stage. First, 3710 articles were indexed in all databases. After deleting duplicates, 1474 Englishlanguage articles were selected for review. Then, 223 articles were excluded from the list after reviewing the titles and abstracts, and 108 were chosen to review the full-text, and finally, the research team chooses 40 papers (Fig. 1). It is worth mentioning that all of the research processes and selection of the papers were conducted by two researchers independently (FSJ and PB), and a third researcher was responsible for reaching consensus if necessary (SD). Also, the protocols and review studies were not included in the present research. Finally, the Critical Appraisal Skills Program (CASP) tool was used to evaluate the quality of the original articles since it worked as a guide to cover the essential areas for critical appraisal of articles effectively.
In the last stage, the data were extracted from each study using the data-charting form (Appendix Table 4) and were collated and classified according to the thematic analysis provided.
In stage four, the data-charting form was used to extract data from each study (Appendix Table 4 the collected data were collated and classified according to the thematic analysis in the last stage.
Other findings show that four main factors have been emphasized as the effective factors on reducing OOP payments in the health systems, including Health system stewardship, creating resources, the health financing mechanisms, and delivering health services ( Table 2).
As it derives from Table 2, 31 (77.5%) articles pointed to the "role of the healthcare system stewardship" as one of the main components in reducing OOP payments. The three subcomponents under the tutelage include legislation (40.5%), legislation implementation (42.5%), and effective monitoring (17%).
The second most referred main component belonged to the "health financing mechanisms " with 18 articles (45%) and three subcomponents, namely revenue collection (19%), pooling and Resource management (57%), payment and purchasing (24%). -Pro-poor health financing policy focusing on financial protection not only for those close to the poverty line, but also those who are already below it in both rural and urban areas [5] -Inclusion of private providers in the system [29] Implement regulations [15, 16, 18-20, 22, 23, 30-42] -Broadly implement DRGs and refine payment systems [33] -Universal health insurance coverage programs [28] -Create patient transport system in remote locations [38] Regulatory monitoring [15,18,27,29,[36][37][38]43] -A need for federal and state policymakers to reexamine how state agencies are applying the cost-sharing protections for contraception under Medicaid and Medicaid managed care plans [27] -Ensuring more investment for health from social health insurance and/or tax-based government funding [36] Creating resources Facilities [5,15,32,39,44] -The need for availability of drugs and medical supplies at the public facility [15] -Improving access to healthcare facilities like diagnostic test [32] -Telehealth (on-line video consultation) [44] Personnel [17,20,27,45,46] -Training the physicians [17] -Physicians should develop the habit of using brief just-in-time interventions at the point of prescription ordering [45] Financing Revenue collection [5,19,29,42] -Innovative financing mechanisms on the collection side to reduce the intensity of poverty [5] -Exemption process of fees for the poor, disabled, and disadvantaged [19] Pooling [5,20,21,24,30,31,37,42,43,[46][47][48] -Mobilizing OOP payments on a pre-paid basis through formal or community-based risk-pooling schemes [24] -Enrolment into health insurance [37] -Basic Insurance Scheme (BIS) (Retired workers are exempt from premium contributions, and the cost of their contributions is to be borne by their former employers) [48] Purchasing [5,14,18,33,49] -Diagnosis-related group (DRG)-based payment system [49] -Performance-based payment [14] Delivering services Prevention [5,16,24,27,28 The number of article on "delivering health services" were 15 (37.5%). It has two sub-components of preventive services (50%), and treatment (50%) have been considered as one of the main components affecting the reduction of OOP payments in health systems.
"Creating Resource" with ten articles (25%) and two sub-components, namely the physical resources (50%), human capital investment, and training (50%), also have the least referred in the articles.
As Table 3 shows, developed and developing countries have implemented various strategies to reduce OOP. Developed Asian countries have applied medical subsidy, universal health coverage, Choosing the right pharmacy, requesting inexpensive generic drugs by patients, the inclusion of dental care coverage in health insurance packages, control strategies drug price, performancebased payment, eliminating OOP costs for methods of contraception, choose a brand-name drug with a generic equivalent, free screening, drug coupons, promoting the quality of primary care services, ordering by physicians and telehealth as effective strategies in reducing OOP payments. Government support of public health insurance program, subsidy program for diseases with high economic burden, prevent and control chronic diseases, training the physicians, developing clinical guidelines, universal health coverage, diagnosis-related group (DRG) based payment system, expanding the dental health reform, providing care closer to home, Insurance for children, students, the elderly, the disabled, and other unemployed populations in urban regions groups not covered by basic health insurance catastrophic disease insurance, increase the efficiency and quality of care, free treatment to the vulnerable segment of the population, clear the system from informal payment, -innovative financing mechanisms on the collection, pooling and purchasing side, free gynecologic screening and discharging patients earlier are some strategies that Asian developing countries such as Iran, India, China, Bangladesh and the Philippines and African countries such as Ethiopia and Ghana have implemented to reduce their OOP payments.

Discussion
Overall, the results showed that four main componentshealth system stewardship, financing mechanisms, service delivery, and creating resources-have been effective in reducing OOP payments in health systems of different countries. This category is similar to the functions introduced by the WHO report in 2000 [52].
Legislation, legislation implementation, and effective monitoring are considered as proposed subcomponents of the stewardship. The results of many studies have shown that health care governance around the world can reduce household health expenditures by legislation. For example, Rahman et al. (2020), in their research in Bangladesh, stated that health care governance, strengthening the rules and regulations related to care subsidies by public health centers, counseling and planning clinics for parents, and Community-based health centers for low-income consumers and patients with high economic burden can play an important role in reducing OOP healthcare costs [31]. Sarnak et al. (2017) cited federal government negotiations and legislation on the announcement of centralized prices. They approved drug ceiling rates in the United States as one factor in reducing OOP payments [22].
Ensuring implementation and monitoring the correctness of the laws by health system governance can also help reduce OOP payments. Several studies have identified the implementation of laws and programs related to global health care coverage as a way to protect households from these expenditures [22,23,28,35,36].
Control on the efficiency and quality of care and payment systems [18], Careful monitoring to clear the informal payments [29,37] and ensuring the supply and availability of essential medicines [38] is also helpful in this regard.
According to the present study results, by investing in human capital investment and training and physical facilities, OOP payments can also be reduced. Providing the infrastructure for online video consultation in Australia [44], improving access to health facilities in India [32], physicians' training on various fields in Iran [17] and the United States [45], had been reported as effective strategies in reducing OOP.
On the other hand, the lack of financial protection has been recognized as a health system disease. OOP payments are one of the major financing mechanisms in many developing countries and put the poor's greatest pressure. Adequate financing and its functions, including revenue collection, risk pooling and purchasing, are introduced as the most important mechanisms in reducing the share of direct OOP payment [53]. For example, Aryeetey et al. (2016), in their study in Ghana, stated that enrolment into health insurance would reduce OOP payments by 80% [37].
Several studies have also expanded the intensity and health insurance coverage for dental services [21]، rare and incurable diseases treatment [31], and mentioned the support for vulnerable groups as effective factors in this regard [42]. A study in India found that using new methods of health financing to collect, pooling and purchasing would reduce the severity of poverty and OOP payments [5], including pay for performances [14] and diagnosisrelated groups (DRGs) payments [18,33,49].
Also in this research, the provision of prevention and treatment services have been included as two  Changing logistics of care, --Facilitating co-pay assistance or coupons, Providing free samples, changing or adding insurance plans -Innovation in drug pricing to include value, the introduction of performance-based payment -Removal of consumer cost-sharing for contraceptives -Federal coverage in eliminating OOP costs among privately insured women for at least some methods of contraception -Improve private health plans -Choose a brand-name drug with a generic equivalent -Free breast cancer screening -Drug coupons for multiple sclerosis -Adults individual insurance -The Medicare insurance -Prioritize public financing of services for the poor -Promoting the quality of primary care services; -Mobilizing OOP payments on a pre-paid basis through formal or community-based risk-pooling schemes -Using brief just-in-time interventions at the point of prescription ordering by physicians -Discontinuing nonessential medicines -Use of an over-the-counter medicine as a substitute -Refer the patient to a public aid agency or social worker Oceania -Telehealth (on-line video consultation) Europe -Inclusion of dental care coverage in health insurance packages -Integrating the prevention and control of oral diseases into universal health insurance coverage programs sub-components of providing health services. Some studies have shown that taking precautionary measures can prevent many OOP payments in the future. Meda et al.
(2019) stated that the implementation of screening programs for gynecological diseases in reproductive age would prevent cancer in later years and thus will lead to individual financial protection [16].
The results of a study by Kastor et al. Showed that launching national prevent and control cancer, diabetes, cardiovascular disease, and stroke programs in India significantly reduces OOP payment [31].
It is worth mentioning that the studies obtained from the present study showed that in addition to preventive services, the providers' behaviors and actions are also effective in reducing OOP payments. physicians can

Interventions in developing countries
Asia -Government support of public health insurance program -Subsidy program for diseases with a high economic burden -Prevent and control chronic diseases -Training the physicians -Developing clinical guidelines -Universal health coverage -Diagnosis-related group (DRG)-based payment system -Expanding the dental health reform -Providing care closer to home -Improve the effectiveness of services -Regularly updating the essential list of drugs according to need of patients -Mandatory social insurance program for urban employees -Insurance for children, students, the elderly, the disabled, and other unemployed populations in urban regions groups not covered by basic health insurance -Catastrophic Disease Insurance -Increase the efficiency and quality of care -National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke -Free treatment to the vulnerable segment of the population for the treatment of cancer and heart diseases -Create patient transport system in remote locations -Fees exemption for the poor, disabled, and disadvantaged -Public and private insurance -More investment for health from social health insurance and tax-based government funding -Inclusion of private providers in the system -Decrease and even eliminate the copayments for those at low-income levels -Clear the system from informal payments -Innovative financing mechanisms on the collection, pooling, and purchasing side replace generic drugs with brand drugs in their prescriptions [20,39,45] Limiting diagnostic-therapeutic tests and surgeries and preventing unnecessary admissions in special intensive care wards and alternative interventions, discharge patients quickly [50] And improve the quality and effectiveness of services [15,18], play an effective role in reducing OOP payments.
Also, as this study shows, employing cost-effectiveness research for determining price ceilings, dental care coverage in health insurance packages, control strategies drug price, and on-line video consultation are some strategies implemented in developed countries. But developing countries have implemented strategies, such as government support of public health insurance programs, subsidy programs for diseases with high economic burdens, training the physicians, eliminate informal payments, and discharging patients earlier.
Strategies such as free screening programs, universal health coverage, pay for performance, promoting the quality of care services and replacing the brand drug with generic have been common in both developed and developing countries. The reason for these differences can be sought in factors such as the medical capacity of countries, per capita government funding, different patterns of disease, the governing system, and the health financing system. A study in Iran cited economic factors, policy factors, social support organizations, insurance, cost of health services, tariffs, health services organizations, providers and consumers' behaviors, and epidemiological conditions as factors influencing OOP health payments [54].
It should be noted that this study by a research team has reviewed articles related to effective solutions to reduce OOP payments in the health systems of different countries. The search strategy consisted of four electronic databases, and two independent researchers evaluated each article.
This study faces several limitations including limitations related to databases and search strategies by researchers. As well the suggested strategies were not surveyed regarding to effectiveness or cost. Therefore, more studies are needed to check the cost and effectiveness of suggested strategies for reducing OOP.

Conclusion
One of the most important characteristics of successful countries in providing maximum health for their communities is the rationality of the financing method and maximizing the share of the public sector in the share of OOP payments in health services so that people feel comfortable when the disease occurs. In case of disability and poverty, do not give up health services.
The present review identified the importance of each health system's functions that affect the reduction of OOP payments. Given that OOP payments are the worst form of financing in any health system, the strategies proposed and successfully implemented worldwide must be considered by policymakers when making future decisions to target health systems. Approach their goals, which include promoting health, increasing accountability, and equitable financial participation.

Appendix 1
See Tables 4 and 5.             -Give the patient office samples -Critically review medication list and discontinue nonessential medicines -Switch to a different brand-name drug within the same drug class -Prescribe a higher dose of medicine and tell the patient to split the tablets -Refer the patient to a pharmaceutical company assistance program -Recommend the use of an over-thecounter medicine as a substitute -Refer the patient to a public aid agency or social worker