Volume 28, Issue 4 (3-2026)
jha 2026, 28(4): 16-23 |
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Aeenparast A, Bayati M, Farzadi F, Maftoon F, Haeri-Mehrizi A A, Ayoubian A et al . Brief report: Iranian household exposure to catastrophic expenditures of dental care. jha 2026; 28 (4) :16-23
URL: http://jha.iums.ac.ir/article-1-4759-en.html
URL: http://jha.iums.ac.ir/article-1-4759-en.html
Afsoon Aeenparast1 
, Mohsen Bayati2 , Faranak Farzadi3 , Farzaneh Maftoon1 , Ali Asghar Haeri-Mehrizi1 , Ali Ayoubian4 , Fatemeh Riazi1
, Mohsen Bayati2 , Faranak Farzadi3 , Farzaneh Maftoon1 , Ali Asghar Haeri-Mehrizi1 , Ali Ayoubian4 , Fatemeh Riazi1
1- Health Metrics Research Center, Iranian Institute for Health Sciences Research, Academic Center for Education, Culture, and Research, Tehran, Iran.
2- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
3- Department of Women's Health, Academy of Medical Sciences of the Islamic Republic of Iran, Tehran, Iran.
4- National Center for Health Insurance Research, Tehran, Iran. ,ayoubian@ihio.gov.ir
2- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
3- Department of Women's Health, Academy of Medical Sciences of the Islamic Republic of Iran, Tehran, Iran.
4- National Center for Health Insurance Research, Tehran, Iran. ,
Keywords: Catastrophic health expenditures, Out-of-pocket payments, Financial protection, Dental services, Insurance coverage
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Results
In this study, 20,764 households covered by the Iran Health Insurance Organization were analyzed. The demographic characteristics of the insured households are presented in Table 1.
The results showed that 3.7% of the study population had utilized dental services in 2019, while approximately 96% had not utilized such services. The incidence of CHE was higher among households that utilized dental services compared to those that did not, indicating that dental care use increases the likelihood of experiencing CHE, with the incidence rising from 4.8% to 6.3% (Table 2).
Discussion
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Introduction
Health, as one of the key pillars of sustainable development, plays a decisive role in ensuring and enhancing individuals’ quality of life. Health expenditures impose a substantial financial burden on households worldwide. Catastrophic health expenditure (CHE) is one of the indicators commonly used to assess households’ financial protection against costs incurred through the utilization of health services [1]. CHE occurs when out-of-pocket payments for healthcare services exceed a certain proportion of a household’s financial resources, thereby exposing households to financial hardship. The incidence of CHE is influenced by population characteristics and geographical context. Additionally, insurance coverage, along with socioeconomic indicators, is considered a key determinant of CHE [2]. In Iran, financial protection of households against health expenditures has been a key focus of health policymakers, with the aim of reducing out-of-pocket payments and limiting households’ exposure to CHE. Accordingly, the Seventh Development Plan sets targets to reduce the incidence of CHE to 2% and to lower the share of out-of-pocket payments to 30% of total health expenditures [3].
Oral and dental care services are considered among the highest-cost healthcare services worldwide. Even in high-income countries, 5% to 10% of public health expenditures are allocated to dental care [4]. According to Listl et al. [5], approximately USD 298 billion is spent annually on dental care worldwide, accounting for 4.6% of total health expenditures. Based on the 2021 Household Income and Expenditure Survey in Iran, dental services account for 21.14% of households’ out-of-pocket payments for health services. Thus, after pharmaceuticals (31.84%), dental care ranks second in terms of the share of out-of-pocket health expenditures [6]. Despite the significant share of dental services in household health expenditures and their role in exposure to CHE, few studies in Iran have examined this issue quantitatively. Accordingly, this study aimed to assess Iranian households’ exposure to CHE.
Methods
This descriptive–analytical study was conducted using data from households participating in the 2019 Household Income and Expenditure Survey of Iran. This survey is conducted annually by the Statistical Center of Iran, using a random cluster sampling method to collect data from approximately 38,000 households residing in urban and rural areas. For the present study, based on insurance coverage information, 20,764 households covered by the Iran Health Insurance Organization were selected, and the analysis was conducted on this subset of households. To measure CHE, the capacity-to-pay approach proposed by the World Health Organization was applied. According to Equation 1, CHE occurs when the ratio of out-of-pocket health payments to a household’s capacity to pay exceeds 40% [7]:
.PNG)
In the equation, CHE represents catastrophic health expenditure,oop i ctp i
Health, as one of the key pillars of sustainable development, plays a decisive role in ensuring and enhancing individuals’ quality of life. Health expenditures impose a substantial financial burden on households worldwide. Catastrophic health expenditure (CHE) is one of the indicators commonly used to assess households’ financial protection against costs incurred through the utilization of health services [1]. CHE occurs when out-of-pocket payments for healthcare services exceed a certain proportion of a household’s financial resources, thereby exposing households to financial hardship. The incidence of CHE is influenced by population characteristics and geographical context. Additionally, insurance coverage, along with socioeconomic indicators, is considered a key determinant of CHE [2]. In Iran, financial protection of households against health expenditures has been a key focus of health policymakers, with the aim of reducing out-of-pocket payments and limiting households’ exposure to CHE. Accordingly, the Seventh Development Plan sets targets to reduce the incidence of CHE to 2% and to lower the share of out-of-pocket payments to 30% of total health expenditures [3].
Oral and dental care services are considered among the highest-cost healthcare services worldwide. Even in high-income countries, 5% to 10% of public health expenditures are allocated to dental care [4]. According to Listl et al. [5], approximately USD 298 billion is spent annually on dental care worldwide, accounting for 4.6% of total health expenditures. Based on the 2021 Household Income and Expenditure Survey in Iran, dental services account for 21.14% of households’ out-of-pocket payments for health services. Thus, after pharmaceuticals (31.84%), dental care ranks second in terms of the share of out-of-pocket health expenditures [6]. Despite the significant share of dental services in household health expenditures and their role in exposure to CHE, few studies in Iran have examined this issue quantitatively. Accordingly, this study aimed to assess Iranian households’ exposure to CHE.
Methods
This descriptive–analytical study was conducted using data from households participating in the 2019 Household Income and Expenditure Survey of Iran. This survey is conducted annually by the Statistical Center of Iran, using a random cluster sampling method to collect data from approximately 38,000 households residing in urban and rural areas. For the present study, based on insurance coverage information, 20,764 households covered by the Iran Health Insurance Organization were selected, and the analysis was conducted on this subset of households. To measure CHE, the capacity-to-pay approach proposed by the World Health Organization was applied. According to Equation 1, CHE occurs when the ratio of out-of-pocket health payments to a household’s capacity to pay exceeds 40% [7]:
In the equation, CHE represents catastrophic health expenditure,
Results
In this study, 20,764 households covered by the Iran Health Insurance Organization were analyzed. The demographic characteristics of the insured households are presented in Table 1.
The results showed that 3.7% of the study population had utilized dental services in 2019, while approximately 96% had not utilized such services. The incidence of CHE was higher among households that utilized dental services compared to those that did not, indicating that dental care use increases the likelihood of experiencing CHE, with the incidence rising from 4.8% to 6.3% (Table 2).
Discussion
The study indicates that households utilizing dental services are more likely to be exposed to catastrophic health expenditure. Dental services involve higher out-of-pocket payments compared to other health services; therefore, increases in out-of-pocket health expenditures contribute to the incidence of catastrophic health expenditure [5, 6].
According to a study conducted in 41 low- and middle-income countries, dental services increased the likelihood of households experiencing catastrophic health expenditure. Therefore, financing policies in these countries have not been successful in protecting households against the economic consequences of dental care expenditures [8]. A study by Kavosi et al. [9] in Iran also showed that dental expenditures are an important driver of CHE among Iranian households. Households that utilized dental services were four times more likely to experience catastrophic health expenditure compared to those that did not. Additionally, lower-income households were less exposed to catastrophic dental expenditures due to their lower utilization of dental services. Furthermore, Farhadi et al. [10] demonstrated that there was a significant association between dental service insurance coverage, oral health status, and out-of-pocket payments for dental services and individuals’ oral health outcomes. Therefore, given the high out-of-pocket payments for dental services and the resulting increased likelihood of households experiencing catastrophic health expenditure, expanding insurance coverage for these services through both basic and supplementary insurance packages is essential.
According to a study conducted in 41 low- and middle-income countries, dental services increased the likelihood of households experiencing catastrophic health expenditure. Therefore, financing policies in these countries have not been successful in protecting households against the economic consequences of dental care expenditures [8]. A study by Kavosi et al. [9] in Iran also showed that dental expenditures are an important driver of CHE among Iranian households. Households that utilized dental services were four times more likely to experience catastrophic health expenditure compared to those that did not. Additionally, lower-income households were less exposed to catastrophic dental expenditures due to their lower utilization of dental services. Furthermore, Farhadi et al. [10] demonstrated that there was a significant association between dental service insurance coverage, oral health status, and out-of-pocket payments for dental services and individuals’ oral health outcomes. Therefore, given the high out-of-pocket payments for dental services and the resulting increased likelihood of households experiencing catastrophic health expenditure, expanding insurance coverage for these services through both basic and supplementary insurance packages is essential.
Table 1. Demographic characteristics of households
.PNG)
Table 2. Percentage of health insurance covered households experiencing catastrophic health expenditure by dental service utilization
.PNG)
Limitations
Table 2. Percentage of health insurance covered households experiencing catastrophic health expenditure by dental service utilization
Financial limitations in low-income households may lead them to delay or avoid high-cost healthcare services. As a result, these households may appear to face lower catastrophic health expenditures in the short term, although this does not indicate improved financial protection. Additionally, the data used in this study, which were collected through a self-reported household income and expenditure survey, may be subject to recall bias or reporting errors. Furthermore, the study sample included only households covered by the Iran Health Insurance Organization, and uninsured households, who are likely more vulnerable, were not included in the analysis. In addition, data from households participating in the 2019 Household Income and Expenditure Survey of Iran were analyzed.
Conclusion
This study indicates that utilization of dental services increases the likelihood of households experiencing catastrophic health expenditure. The lack of insurance coverage for many dental services and the high costs of these services, driven by rising prices of dental materials and equipment, play a significant role in this regard. Expanding oral health and preventive dental care services can play a crucial role in reducing the need for costly dental treatments and may help lower the risk of catastrophic health expenditures.
Declarations
Ethical considerations: The study was approved by Academic Center for Education, Culture, and Research ( ACECR ) under the code IR.ACECR.IBCRC.REC.1399.012.
Funding: This study was financially supported by the National Center for Health Insurance Research. Funder had no roles in data collection and analysis, and preparation of the manuscript.
Conflict of interest: The authors declare no conflicts of interest.
Author Contributions: A.A: Conceptualization, study design, data management, writing-review and editing, supervision and final approval; M.B: Methodology, data analysis, data management, final approval; F.F: Conceptualization, study design, data analysis, final approval; F.M: Data analysis, writing-drafting and final approval; A.H: Methodology, data curation, software, final approval; A.A: Conceptualization, study design, data analysis, software, validation, writing-review and editing final approval; F.R: Data curation, writing-drafting and final approval. All authors have read and approved the final version of the article.
Consent for publication: Not applicable.
Data availability: Data from this study are available from the corresponding author upon request, with a valid justification.
AI deceleration: The authors used ChatGPT artificial intelligence for editing the English section of this article. All AI-edited content was reviewed and approved by the authors.
Acknowledgments: This study was commissioned and financially supported by the National Center for Health Insurance Research and conducted by the Health Measurement Research Center, Research Institute for Health Sciences, ACECR. The authors sincerely thank all colleagues who contributed to various stages of the study design and implementation.
Conclusion
This study indicates that utilization of dental services increases the likelihood of households experiencing catastrophic health expenditure. The lack of insurance coverage for many dental services and the high costs of these services, driven by rising prices of dental materials and equipment, play a significant role in this regard. Expanding oral health and preventive dental care services can play a crucial role in reducing the need for costly dental treatments and may help lower the risk of catastrophic health expenditures.
Declarations
Ethical considerations: The study was approved by Academic Center for Education, Culture, and Research ( ACECR ) under the code IR.ACECR.IBCRC.REC.1399.012.
Funding: This study was financially supported by the National Center for Health Insurance Research. Funder had no roles in data collection and analysis, and preparation of the manuscript.
Conflict of interest: The authors declare no conflicts of interest.
Author Contributions: A.A: Conceptualization, study design, data management, writing-review and editing, supervision and final approval; M.B: Methodology, data analysis, data management, final approval; F.F: Conceptualization, study design, data analysis, final approval; F.M: Data analysis, writing-drafting and final approval; A.H: Methodology, data curation, software, final approval; A.A: Conceptualization, study design, data analysis, software, validation, writing-review and editing final approval; F.R: Data curation, writing-drafting and final approval. All authors have read and approved the final version of the article.
Consent for publication: Not applicable.
Data availability: Data from this study are available from the corresponding author upon request, with a valid justification.
AI deceleration: The authors used ChatGPT artificial intelligence for editing the English section of this article. All AI-edited content was reviewed and approved by the authors.
Acknowledgments: This study was commissioned and financially supported by the National Center for Health Insurance Research and conducted by the Health Measurement Research Center, Research Institute for Health Sciences, ACECR. The authors sincerely thank all colleagues who contributed to various stages of the study design and implementation.
Type of Study: Short Communication |
Subject:
Health Economics
Received: 2025/11/10 | Accepted: 2026/02/17 | Published: 2026/02/25
Received: 2025/11/10 | Accepted: 2026/02/17 | Published: 2026/02/25
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