aliakbar fazaeli

Cancer is considered one of the most common causes of mortality, in today’s world. A growing body of evidence has demonstrated that the global cancer burden is expected to rise significantly in the years to come. Cancer is characterized by the uncontrollable rate of cells growth, ultimately proving fatal if not treated. Both genetic and environmental contributing factors have proven critical in developing differential cancers. Chemotherapy is the most common form of treatment used for cancers all around the world. Despite a high efficiency in treating malignancies, toxicity and targeting of normal healthy tissues are considered the most common side effects of chemotherapeutic agents. Thus, reducing the aforementioned side effects with complementary treatments can prove critical through maximizing therapeutic efficiency while also minimizing unwanted side effects at the same time. Doxorubicin (DOX) is a common chemotherapy drug that, has limitations on its use due to severe side effects such as hepatotoxicity, nephrotoxicity, as well as cardiotoxicity. Metformin is one of the most common drugs originally used for the treatment of type II diabetes. Additionally, coenzyme Q10 is naturally produced by the body and can also be obtained from diet and supplements. Both metformin and coenzyme Q10 have demonstrated protective effects against toxicity and oxidative stress and are attractive candidates for the treatment of diseases with the basis of inflammation and oxidative stress as demonstrated by various studies investigating the effect of metformin as well as coenzyme Q10 against toxicities. This study investigates the protective effects of metformin and coenzyme Q10 alone and in combination against doxorubicin-induced oxidative damage in rats.

In this experiment, 36 male Wistar rats were divided into six groups (n=6). The groups consisted of a normal control group (distilled water), metformin and coenzyme Q10 control group: (metformin+coenzyme Q10), doxorubicin control group (doxorubicin), Metformin pre-treatment group (metformin+ doxorubicin), coenzyme Q10 pre-treatment group (coenzyme Q10+doxorubicin), as well as metformin and coenzyme Q10 pre-treatment group  (metformin + coenzyme Q10+doxorubicin). Metformin (200 mg/kg) and coenzyme Q10 (15 mg/kg) were administered orally daily for one week, and doxorubicin (25 mg/kg), was injected on the eighth day. 24 hours after the last injection, blood and liver tissue samples were collected to analyze liver enzymes (i.e. ALT, AST, ALP), oxidative stress parameters (i.e. malondialdehyde, total antioxidant capacity, catalase, superoxide dismutase, glutathione peroxidase), and histological changes.

The results showed that doxorubicin significantly elevates the activity of liver enzymes, concentration of malondialdehyde, and tissue damage and decreases total antioxidant capacity, catalase, superoxide dismutase, and glutathione peroxidase activity (P<0.001). Treatment with metformin, coenzyme Q10, and their combination significantly reduced liver enzymes' activity, improved antioxidant parameters, and significantly contributed to histomorphological amelioration compared to the doxorubicin control group.

These findings showed that metformin and coenzyme Q10, alone or in combination, can significantly reduce and protect against the liver complications of doxorubicin injection in rats. This effect is likely, through mitigating oxidative stress and bolstering antioxidant defense mechanisms.

The impact of population aging on health expenditure is inevitable. It affects health expenditure by causing changes in people’s health status and the demand for health care services. In this study, we aim to investigate the age-related and gender-related differences in hospital admission rate, length of stay, and hospital costs of people in Iran.

This is a quantitative, descriptive-analytical study with a cross-sectional design conducted on data of 41 million Iranian people covered by the Iran Health Insurance Organization in 2020. Hospital admission rate, length of stay, and hospital costs were dependent variables. Hospital costs included insurance payments, patients’ out-of-pocket spending, and government subsidies. Age and sex of the patients, ownership of the hospital, type of patients’ medical files were descriptive variables. The Mann-Whitney U test was used to compare hospital costs between elderly (>60 years of age) and non-elderly (<60 years of age) groups and between females and males. Spearman’s correlation test was used to find the correlation between age and dependent variables. 

During the study period, there were about 3,800,000 hospital admissions. The rate of hospital admission in the elderly was 3.7 times higher than that of non-elderly groups. The average length of stay was 1.3 days for the elderly, and 2.2 days for the non-elderly. In the elderly group, men had a higher hospital admission rate than women, while in non-elderly groups, women had a higher admission rate. The average hospital cost was 28 million IRR for the non-elderly and 45 million IRR for the elderly. The average cost of surgery, hospitalization, medicine and medical consumables for the elderly was 1.5 times more than that of the non-elderly. There was a positive and significant relationship between the hospital admission rate and age of the patients (r=0.879, P<0.001). As the age of the patients increased, the length of stay in the hospital increased significantly (r=0.582, P<0.001). The relationship between patients’ age and the average hospital cost was also positive and significant (r=0.582, P=0.006).

Hospital admission rate, length of stay, and average hospital costs are significantly higher for the elderly in Iran.

Economists have always sought to discover the factors that cause poverty, because by understanding these factors, they can plan to reduce poverty. The purpose of this study is to determine the poverty line and the factors affecting it in the year 2021.

In the present study, only the line and its indicators were estimated by the data of urban and rural households' expenditure and income plan in the year 1400 and using the linear expenditure system (LES), and the determining factors of poverty were investigated. Also, the impact of the probability of poverty on the characteristics of the households was investigated using the probit model with Stata17 software.

The poverty line for a household in 2021 was calculated as 73,980,000 Rials. The highest reduction in the probability of household poverty is related to the level of education of the head of the household. With the increase of each unit of education level, the probability of facing poverty in the household will decrease by 23.1%. After that, the number of working people in the household has the highest effect in reducing the probability of household poverty with a decrease of 19.9 percent. Among these variables, in terms of the household, having health insurance has the least effect in preventing the household from becoming poor.

The gender of the head of the household is effective in reducing poverty. Also, in households where the head is younger, the probability of poverty increases. More support for young people and creating more favorable conditions for their employment is necessary to reduce poverty. Increasing the level and depth of insurance coverage will also be effective in reducing poverty.

The high reliance on out-of-pocket (OOP) payments for health financing in Iran have been led to different inequity problems such as catastrophic health expenditure (CHE) and impoverishment. This scoping review has been conducted to understand the variations in CHE and impoverishment, the underlying determinants of CHE, and its inequality in the past 20 years.  

This scoping review is guided by Arksey and O’Malley’s scoping review framework. systematically PubMed, Scopus, Web of Science, ProQuest, Scientific Information Database, IranMedex, IranDoc, Magiran Science, Google Scholar, and grey literature were searched systematically from 1 January 2000 to August 2021. We included studies that reported the rate of CHE, impoverishment, inequality, and its influencing factors. Simple descriptive statistics and narrative synthesis were used to present the review findings.  

From 112 included articles, the average incidence of CHE was 3.19% at the 40% threshold, and about 3.21% of the households had impoverished. We found an unfavorable status of health inequality indices, including the average of fair financial contribution (0.833), concentration (-0.01), Gini coefficient (0.42), and Kakwani (-0.149). The most widely applied key drivers influencing the rate of CHE in these studies were household economic status, place of residence, health insurance status, household size, head of the household’s gender, education level and employment status, having a household member under 5/ above 60 years old, with chronic diseases (in particular cancer and dialysis), disability, using inpatient and outpatient and dentistry services, medicines and equipment, and low insurance coverage.  

The result of this review calls for intensifying health policies and financing structures in Iran to provide more equitable access to all populations, especially the poorest and vulnerable. Moreover, the government is expected to adopt effective measures in inpatient and outpatient care, dental services, medicines, and equipment.

Equitable financing is an important goal of health systems and protecting the financial risks of health care. Also, equitable financing of health is important both for improving the state of health systems and for achieving universal health coverage (UHC). In this study, with an overview has introduced the indicators of justice in health and the results of the indicators in this field have been examined in the country. The search for articles in the present study is of a review type that was conducted through search engines and databases within the range of 2002-2022. In order to identify the advantages and disadvantages of indicators showing justice in health financing, including out-of-pocket payment indicators, catastrophic health expenditures index, Kakwani index, concentration index and fair financial contribution index, a review of studies was used and the limitations and advantages of each index were extracted and compared. The results of this study showed that in terms of health equity index, the index of back-breaking health costs had the highest frequency in the studies. Each of the indicators had advantages and problems. Also, according to the numerous studies on the calculation of the health justice index, the existence of a health watchdog is necessary to monitor these indicators.

Catastrophic health expenditure (CHE) has been explained as a growth in spending for health care services that exceeds 40% of total household income. Therefore, devoting a large portion of household resources to health care services can greatly threaten to standards of living in the short and long term. The present study was an attempt to evaluate the financial contribution of Iranian households in health care services system in Hamadan Province in 2017. This cross-sectional study reflected on spending for health care services. For this purpose, the data were extracted from the household expenditure statistics published in the database of the Statistical Center of Iran. Accordingly, among the common econometric models associated with the subject matter, the logit model was employed, and the data were then analyzed using the Stata 14 software. The study findings revealed that 8.9% of the total household costs had been allocated to health care services. The results also showed that 3.5% of the households faced catastrophic cost among all the studied households. Upon examining the factors, significant relationship was further observed between the probability of exposure to CHE and living in rural areas, income decile group, number of employees, and marital status in the households concerned. It was concluded that poor distribution of health care services, unequal distribution of income and wealth among jobs, as well as socioeconomic conditions could influence CHE. Therefore, there is a need to plan and develop policies for better access to health care services.

The financing function within a health system is considered inherently complex, so it is of utmost importance to design a suitable future for this system given uncertainties and complexities of the environment. With regard to the current and future complicated conditions, health system financing is also likely to succeed if it can anticipate the impacts of effective factors in the future and further plan appropriate interventions ahead of time. Thus, the purpose of this study was to develop scenarios for the health system financing in Iran.

This mixed-design research of exploratory future studies type was conducted using the scenario method. In this respect, the key variables were evaluated using a questionnaire from two aspects of importance and uncertainty as well as formation of a future studies group (focus group). Finally, sensitivity analysis was carried out through cross-impact balance (CIB) analysis using the Scenario Wizard (Version 4.31) software.

A total of 25 factors were selected based on the type and the position of the variables (driving force, bi-dimensional, risk, secondary leverage or modifiable-to-secondary leverage) over the diameter of the MICMAC chart. Considering the degree of significance and uncertainty, eight variables including all four driving force variables (oil sales and economic blockade, leadership and advocacy, bureaucracy and corruption, and possibility of using information technology in providing services), as well as the variables of resource sustainability, natural disasters, regional security, and specialization culture were chosen. Then, five variables were finalized as the key changes that would create the scenario based on sensitivity analysis and final expert opinions. According to the defined conditions, 270 scenarios were developed, of which fourteen scenarios were identified as poorly adaptable and five cases as highly adaptable.

The best scenario identified in this study based on the degree of adaptation included the use of massive technology and oil sales, mediocre economic conditions with high probability of occurrence, strong leadership and advocacy, high regional security, as well as bureaucracy and low corruption with medium probability of occurrence.

The present study was carried out to analyze the costs involved with COVID-19 in one of the largest hospitals in Iran. In this descriptive study, the total costs of hospitalization in Imam Khomeini Hospital affiliated to Tehran University of Medical Sciences for COVID-19 confirmed patients were analyzed until April 17, 2020. Data were extracted by reviewing patient record bills, and analyzed using descriptive and analytical statistics in SPSS 21. Data related to 1324 patients with COVID-19 were analyzed. Totally, 32.4% of all hospitalized patients had comorbidities, and 13.7% required intensive care and were admitted to the ICU. The average cost per hospitalized patient was 33,121,029 Rials (US $ 209.22), but this average had a high standard deviation (66,936,158 Rials, US $ 422.82). There was a significant difference in costs based on the length of stay (P-value = 0.000), ICU hospitalization (P-value = 0.000), presence of comorbidities (P-value = 0.002), age (P-value = 0.002) and gender (P-value = 0.002), but the results of path analysis showed that only the variables of length of stay and hospitalization in the ICU had a direct effect on the costs and other factors had indirect effects. COVID-19 is imposing significant costs on the health system, a significant proportion of which belongs to the length of hospital stay and the need to intensive care units. Directing resources to expand timely diagnostic capacity and manage disease in the early stages can both reduce the financial burden of providing highly costly inpatient services.

Inappropriate admission and inappropriate hospital days are two undesirable indicators in terms of controlling hospital costs. This study was conducted to determine the rate of inappropriate admission and hospital days and related factors in Shohada Hospital in Kermanshah.

This is descriptive-analytical study.The statistical population included patients admitted of Kermanshah shohada Hospital in 1397. 245 Inpatient records were selected using Cochran's formula and stratified random sampling. Appropriateness evaluation protocol was used to evaluate the inappropriate admission and inappropriate hospital days. The relationship between age, sex, type of admission, type of ward, type of treatment, coverage of cost hospitalization, place of residence, with rate of inappropriate admissions and inappropriate hospital days was assessed using spss16 software.

5.7% of admissions and 21.4% of hospital days were inappropriate. Inadequate admission was significantly related to gender, type of surgical or medical treatment, type of hospital ward in chi-square test in contingency tables with 95% confidence.  Inappropriate hospital days were related to the type of hospitalization ward in kruskal-Wallis test , type of treatment and place of residence in Mann-Whitney test.

By determining the amount of inappropriate admissions and inappropriate hospital days and related factors for policy makers and managers of hospitals and insurance organizations, it is possible to avoid unnecessary costs without reducing the quality of hospital services.

Out-of-Pocket (OOP) payment is categorized among the critical indicators of health system financing. Given the high hospitalization costs of the hospitals, the ministry of health has attempted to implement Health Transformation Plan (HTP) in Iran to reduce OOP. The purpose of this paper is to show the effects of HTP on OOP payments of the hospitalized patients in Hamedan, Iran.

This descriptive-analytical study was carried out on 587 patients in the educational hospitals of Hamedan. The data obtained before and after implementing the HTP was from 2013 to 2015. Data analysis was performed using SPSS16.

In this study, each patient's expenditures increased by 32.2 % in 2015, compared to before the implementation of the HTP. Therefore, the health insurance organization's coverage of OOP payments decreased to 8.3 % of the total costs by a 20.2 % reduction in 2015, compared to before the implementation of the plan.

According to the study, HTP and government health subsidies were adequate, but the total hospitalization costs had an upward trend in all funds.

Urban health centers are one of the most important centers for providing primary health services. According to the wide range of health centers and the number of services provided by these centers, a significant portion of the community health system resources are allocated to these centers; therefore, the determination and continuous monitoring of the effectiveness of these centers can play a significant role in improving the efficiency of health resources and preventing waste of resources. The purpose of this study Assessment of Technical Efficiency of Comprehensive Health Services Centers of Hamadan by Data Envelopment Analysis (DEA) in 2019.

This descriptive-analytic study evaluates the effectiveness of Hamedan comprehensive health centers services using the data envelopment analysis method. Inputs include: number of physicians and number of employees (midwife, specialist in the fight against diseases.). Outputs include: number of examinations by physician, midwifery services, vaccinations, injections and dressings.

In 2018 the average technical efficiency of the comprehensive health services centers was 0.751, the mean management efficiency was 0.85 and the mean efficiency of the scale was 0.88. Of the total centers of comprehensive health services surveyed, 6 centers have technical capacity of 1 and 13 centers with a technical efficiency of less than 1.

In centers with efficiency less than 1, there were initial and optimal values of the same and different inputs. Therefore, it is suggested that these centers reduce their inputs as much as possible so that they can achieve maximum efficiency.

Diagnosis-related group payment system is highly valuable for developing countries and governments that are seeking to appropriately control health costs and expanding public health coverage due to its impact on managing costs and increasing efficiency of hospitals. The present study aimed to investigate the implementation of this payment sysvem.

This cross-sectional descriptive-analytical study was performed on 34 hospital managers, Iranian health insurance managers, and clinical and financial experts of Hamadan province. In the first part, a researcher-developed questionnaire was used to assess the level of knowledge and attitude. In the second part, a checklist was used to assess how to record patients’ clinical-financial information in five public hospitals in the Hamadan province. Data were analyzed using descriptive statistics by Stata version 11.

Various factors were identified, including pros and cons, barriers and prerequisites of implementation, increasing the efficiency and quality of provided services after implementation, synchronization with insurance organizations, the use of this payment system for outpatients were mentioned. All public hospitals in the Hamadan province recorded financial and clinical information completely and appropriately using the International Classification of Diseases, versions 9 and 10.

Considering the limitation of resources and diversity of health staff, changing the payment system is difficult in all countries. However, preparing the executive staff and managerial support pave the way for changes in the payment system and help to address the resulting problems. According to the findings, it seems that the DRG payment system can be implemented after establishing necessary measures and providing appropriate infrastructure.

Organizational health is a competitive advantage and an important factor with regard to the effectiveness of hospitals. Therefore, this study was conducted to investigate the relationship between organizational health and the degree of accreditation of hospitals in Kermanshah University of Medical Sciences.

This descriptive-analytical study was conducted cross-sectionally in 2019. The statistical population included the staff of selected hospitals affiliated to Kermanshah University of Medical Sciences. The sample size was estimated as 382 people and sampling was performed using multi-stage method. The data collection tool was the Standard Organizational Health Questionnaire. The validity of the administered questionnaire was confirmed using the experts’ opinions and reliability of these tools was calculated by Cronbachchr('39')s alpha (0. 88). The hospitals’ accreditation status was obtained from the Accreditation Office of Kermanshah University of Medical Sciences and analyzed using the descriptive and inferential statistics (independent t-test and Pearson correlation coefficient) by SPSS 16 software.

Findings showed a significant relationship between the organizational health and the degree of accreditation (one and two) )p < 0.05(. Meanwhile, the highest mean of organizational health was related to Mohammad Kermanshahi Hospital with an average of 170.40, but the lowest mean was related to Dr. Moaven Sahneh Hospital with an average of 123.61).

Given the significant relationship between organizational health and the degree of accreditation of hospitals, managers are recommended to make serious revisions in the accreditation process of health centers and take corrective actions regarding the points that can be improved, standard criteria, evaluation methods, and evaluators’ training.

High salt intake is considered as one of the most important causes of hypertension and cardiovascular diseases. Measuring and identifying factors contributing to people's salt intake behaviors is important to evaluate effectiveness of interventions focusing on salt reduction behaviors. The purpose of this study was to develop and test a new theory of planned behavior (TPB)- based instrument to measure factors influencing three different salt intake behaviors (adding salt during cooking, at the table, purchasing salty food) among women. Study design: A mixed-method study.

After the face and content validity of developed instrument were established, a representative sample of women (N= 300, age (SD):42.82(12.10)) were recruited to assess the construct validity using Partial Least Square confirmatory factor analysis. Coefficient alpha and composite reliability (CR) were used to establish reliability of instrument. The content validity index (CVI) and content validity ratio (CVR) were used to assess the content validity.

Assessing validity and reliability of instrument led to 56-item questionnaire. CVI was more than 0.70 and CVR more than 0.56. Internal consistency as assessed by Cronbach's alpha was acceptable. Convergent and discriminant validity were established. The GOF index for behavior one was 0.250, for behavior two was 0.414 and behavior three was 0.374. The results of confirmatory factor analysis indicate that TPB model has an acceptable fit with data.

Our instrument provides a validated and reliable tool for assessing different aspects of salt intake behaviors in women to evaluate effectiveness of interventions focusing on salt reduction behaviors.

Tuberculosis is an infectious disease and is the leading cause of death from single-agent infectious diseases. The purpose of this study was to estimate the economic costs of this disease and its effective factors in Hamadan province.

This descriptive-analytical study was conducted on a cross-sectional (two-year time scale) study in 2014 and 2015. The population of this study is tuberculosis patients in Hamadan province. Data extraction was performed by examining the file of patients with tuberculosis in urban and rural health centers and patients of hospital in Hamadan. Also, using a logistic model and Stata 15, social factors and households that are more likely to be exposed to this disease were studied.

A total of 173 tuberculosis patients were identified, with an estimated cost of treatment of 8307 million IRR. Also, the results of the Logit model showed that people living in the city over 65, low educated, and people with HIV The order of 22, 14, 18, and 6 percent would be greater than the likelihood of exposure to tuberculosis.

The cost of tuberculosis, in addition to allocating a significant amount of health resources in the province, also imposes a high burden on households. The social and economic consequences of these costs lead to many abnormalities such as the exclusion of women with a family or the abandonment of the children of affected people.

Sustainable development is human-centered and deserves health and safety. The rapid growth of industrialization, coupled with insufficient attention to safety principles, has led to an increase in the rate of accidents in developing countries. The purpose of this study was to estimate the years of life lost due to work-related accidents among workers covered by the National Social Security Organization from 2007 to 2017.

This is a descriptive cross-sectional study and was carried out on the statistics of accidents related to the work of the Social Security Organization using the Dali index. Disability percentiles were used to estimate disability burden. The number of years lost due to early death (YLL) and years lost due to disability (YLD) and Disability-Adjusted Life Years (DALY) were calculated using Excel software.

The results showed that the number of years lost (DALY) due to work accidents is 181900 years, with 15.8% share of the number of years lost due to early death and 84.2% share of years lost due to disability. Most of the years lost due to work-related accidents are related to construction activities with 39860 years (21.9%).

The results of this study highlight the inadequate supervision of construction activities and the need for early training in construction workers and contractors.
Keywords: DALY, work-related accidents, Social Security Organization, Years of Life Lost, Death, Disability

Increase of healthcare costs has become a major challenge worldwide. In order to ensure the security of treatment for all people, resiliency is necessary for the country’s health economy and must promote in the country. The aim of this article is to introduce the macro-axes and specific issues of each axis.

In this study, concurrent-nested mixed method was used. After discussing in focus group meeting and qualitative content analysis, the macro- axes priority of the resistance economy and specific issues were extracted. Studies in the field of health and resistance economics were identified as the complementary role by searching the databases of sid, magiran and Google scholar and with the keywords health, resistance economy, health system and Iran and the final list was obtained.

Twelve macro-priority areas and specific issues of each axis were identified. The macro-axes are: "Conceptualism", "Basis, Principles, Values, Goals", "Policies and Strategies”, “Pathologic barriers and Challenges of the Health Economics", "Indices", " Intersectoral dimensions of the Health Economics and the Resistance Economics", "Requirements", Examples/Objective Examples in Contemporary History”, “Culture and Culture-Building”, “Dimensions of Health Economics Management”,  and “Implementation Strategies" in each macro-axis, a number of specific issues were introduced.

Strengthening the countrychr('39')s health system in normal conditions, crisis and disaster, war and bioterrorism, and economic sanctions, requires the implementation of health resistance economy. An excellent, efficient and responsive health system is possible with comprehensive implementation of the general health policies, related clauses of the resistance economy general policies, and other upstream documents in the field of health. Monitoring, evaluating and macro observation of health are also necessary for dynamism and prosperity of health economy and the achievement of affect and defense capabilities.

Accurate economic forecast has important effects on governmental policy and economic planning, and it can help policymakers to make decisions for future and create new infrastructures for the development of new forecasting methods. This study calculated total health expenditure, public health expenditure and out of pocket (OOP) payment for 2016-2020. 

Autoregressive Integrated Moving Average Process (ARIMA) is one of the most important forecasting models. In this study, five-year values were forecasted using EViews8 software according to health expenditures in Iran from 1971 to 2015.

Applying annual data for total health expenditure, resulted in the ARIMA (1,1,1) model being the most appropriate to predict these costs. The results of this study indicate that total health expenditures will reach from about 1228338 billion IRR in 2016 to 2698346 billion IRR in 2020 and the amount of out of pocket (OOP) will become more than 41% of total health expenditure in 2020.

Total health expenditures in 2020 will become more than two halves in 2016. These expenditures indicated there is a need for continued governmental support of this sector during the upcoming years.

Hospitals with high performance and optimal use of resources are among the ultimate goals of healthcare policy makers. The current study aimed at assessing the efficiency of hospitals affiliated to Hamadan University of Medical Sciences, Hamadan, Iran, using data envelopment analysis and Tobit regression in 2017.

In the current descriptive study, the statistical population included all hospitals affiliated to Hamedan University of Medical Sciences (n = 15). The required information and statistics were collected from the Deputy of Treatment at the university in two stages using the standard checklist provided by the Iranian Ministry of Health and Medical Education. The efficiency of data envelopment analysis was assessed in the first stage. The input variables of data envelopment analysis included the number of staff (physicians, paramedics, etc.) and the number of active beds, and the output variables included the number of patients (outpatients and admissions) and the number of surgeries and occupied beds. In the second stage, efficiency as a dependent variable, and hospital size and population were considered as independent variables in Tobit regression. Deep2.1 software was used to estimate the data envelopment analysis and Stata 15 software was used for Tobit regression.

The average technical efficiency of the hospitals was 0.933. The average management efficiency was 0.951, and the average efficiency of the scale was 977.0. Of the total hospitals surveyed, six hospitals had a capacity of < 1, and nine hospitals have an efficiency of 1. Also, hospital size and population size were significant as an environmental variable in Tobit regression.

In hospitals with < 1 efficiency there is a surplus in the number of input variables. It is recommended that the hospitals shift toward maximum efficacy by optimizing the number of staff and active beds

The status of financial participation of individuals in health financing is one of the challenging issues in assessing the performance of health systems in the world. The concern about the financing of the health system and its consequences on Iranian households from about a decade ago is a turning point in attracting the attention of researchers and policymakers to this area. This study has been calculated financial contribution of people in Iran health system in 2015.
Using cost-income information of 38252 Iranian households collected by the Statistical Center of Iran in 2015, the distribution of health expenditures of households based on the income approach is calculated and factors influencing the concentration index are measured.
The results showed that the concentration index of health care expenditures in Iran was 0.3318. This is indicative of the progressive status of household participation in financing the health system. Also, dental expenditures with the index of 0.496 have the highest inequality in the distribution of health care expenditures. Payment for hospital services and dental care services had the highest share in increasing the coefficient index.
Having insurance coverage as one of the most important policy tools to achieve the desired model of household financial participation has a significant effect on the distribution of financial participation of households and the most important factor in reducing the coefficient of concentration index