The barriers to achieve financial protection in Iranian health system: a qualitative study in a developing country

Background: The move to universal health coverage and consequently health promotion is influenced by political, socio-economic and other contextual factors in a country. Iran, as a developing country with an upper-middle national income, has developed policies to achieve universal health coverage through financial protection. This study aims to investigate barriers to develop financial protection as a requirement to achieve universal health coverage.Materials and Methods: This qualitative study was conducted using 20 in-depth interviews with experts in social welfare, health insurance and financing. The framework analysis method was used to analyze the data.Results: The results have been categorized in three major themes that were extracted from ten sub-themes. The major themes included the political, social and economic context of the country, the context and structure of healthcare system and dimensions of UHC.Conclusion: Achieving financial protection as a long-term objective should be considered as a priority among Iranian policy makers that requires an inter-sectoral collaboration with a defined in-charge body. Health policy makers in Iran should develop a more comprehensive benefits package for diseases and health conditions with catastrophic consequences. They also should develop a plan to cover the poor people.Keywords: Universal Health Coverage, Financial Protection, Catastrophic Health Expenditures, Impoverishing Health Expenditure

Competing treatments for migraine : a headache for decision-makers

Background: Migraine is the world’s second most common disabling disorder, affecting 15% of UK adults and costing the UK over £1.5 billion per year. Several costly new drugs have been approved by National Institute for Health and Care Excellence. Aim: To assess the cost-effectiveness of drugs used to treat adults with chronic migraine. Methods: We did a systematic review of placebo-controlled trials of preventive drugs for chronic migraine. We then assessed the cost-effectiveness of the currently prescribable drugs included in the review: Onabotulinum toxin A (BTA), Eptinezumab (100mg or 300mg), Fremanezumab (monthly or quarterly dose), Galcanezumab or Topiramate, each compared to placebo, and we evaluated them jointly. We developed a Markov (state-transition) model with a three-month cycle length to estimate the costs and quality-adjusted life years (QALYs) for the different medications from a UK NHS and Personal Social Services perspective. We used a two-year time horizon with a starting age of 30 years for the patient cohort. We estimated transition probabilities based on monthly headache days using a network meta-analysis (NMA) developed by us, and from published literature. We obtained costs from published sources and applied discount rates of 3.5% to both costs and outcomes. Results: Deterministic results suggest Topiramate was the least costly option and generated slightly more QALYs than the placebo, whereas Eptinezumab 300mg was the more costly option and generated the most QALYs. After excluding dominated options, the incremental cost-effectiveness ratio (ICER) between BTA and Topiramate was £68,000 per QALY gained and the ICER between Eptinezumab 300mg and BTA was not within plausible cost-effectiveness thresholds. The cost-effectiveness acceptability frontier showed that Topiramate is the most cost-effective medication for any amount the decision maker is willing-to-pay per QALY. Conclusions: Among the various prophylactic medications for managing chronic migraine, only Topiramate was within typical cost-effectiveness threshold ranges. Further research is needed, ideally an economic evaluation alongside a randomised trial, to compare these newer, expensive CGRP MAbs with the cheaper oral medications

Decomposing disparity in adult individual’s mental health in Tehran among lower and higher economic groups; an Oaxaca- Blinder analysis on urban HEART Survey- round 2

Background: Mental health is one of the main aspects of social well-being. Tehran -capital of Iran- is metropolitan, where the mental health status of citizens is not prioritized effectively. Objectives: The purpose of this study was identifying contributors of mental health inequality between lower and higher economic groups in Tehran through Oaxaca- Blinder method. Methods: The study was conducted by the data of Tehran’s Urban Heart Survey- Round 2 (2012). Through a three- stage stratified and clustered sampling method, 34,700 were selected  as samples. The mental health status was measured by the General Health Questionnaire 28- items (GHQ- 28) and the quantity of the inequality in mental health was measured by corrected concentration index. The Fairlie’s decomposition approach was performed in STATA 14.Results: The corrected concentration index were: -0.0967 and -0.1004 by Erreyger’s and Wagstaff’s approaches. Being of the Iranian origin, disability conditions, employment status and smoking were identified as the main contributors of inequality in mental health among lower and higher economic groups.Conclusion: Thus, re-organizing strategies and plans on promoting the socio- economic status of non-Iranian residents, improving employment opportunities, developing well-designed environment for disabled individuals and supporting plans to reduce smoking is recommended to the urban policy makers. Keywords: Mental health, decomposing inequality, urban heart survey, Tehran

Research priorities for randomised controlled trials in chronic migraine preventive medication : a stakeholder consensus workshop [version 1; peer review: awaiting peer review]

Background Chronic migraine is a disabling condition that can substantially impact on quality of life. People with chronic migraine have headaches on at least 15 days of every month. Preventative medications aiming to reduce number of days with migraine are available, but high-quality randomised evidence is lacking for many drugs, and it is unclear which medications should be prioritised for research. There is also no existing evidence about patient and clinicians’ priorities for research. Methods We undertook a consensus workshop with patient and healthcare professional stakeholders, using nominal group technique, to understand these stakeholders’ priorities for future randomised controlled trials. We reached a consensus on a set of research recommendations for the field. Results Eight people with chronic migraine and eleven healthcare professionals took part in an online workshop. Comparisons of calcitonin gene-related peptide monoclonal antibodies (CGRP MAbs) and OnabotulinumtoxinA (BTA) were a top priority for our group. Candesartan and Flunarizine were the top drugs the group wanted to compare against placebo. Conclusions These research recommendations should guide researchers in the field, and funders when prioritising commissioned research and assessing funding applications. Particular areas to explore further are Candesartan or Flunarizine versus placebo, and comparing and combining CGRP MAbs with other medications

A systematic review of economic evaluations of pharmacological treatments for adults with chronic migraine

Background and aims: Chronic migraine is a common neurovascular brain disorder with substantial economic costs. We performed a systematic review to identify economic evaluations of pharmacological treatments for adults with chronic migraine. Methods: We undertook systematic literature searches using terms for migraine/headache and prophylactic drug interventions, combined with economic/cost terms where appropriate. Using inclusion and exclusion criteria, two reviewers independently assessed the citations and abstracts, and full-text articles were retrieved. A review of study characteristics and methodological quality was assessed. Results: Sixteen citations met the inclusion criteria and were model-based cost-utility studies evaluating: Botox (n = 6); Erenumab (n = 8); Fremanezumab (n = 2); and Galcanezumab (n = 1) as the main treatment. They varied in their use of comparators, perspective, and model type. Botox was cost-effective compared to placebo with an incremental cost-effectiveness ratio (ICER) ranging between £15,028 (€17,720) and £16,598 (€19,572). Erenumab, Fremanezumab and Galcanezumab when compared to Botox, was associated with ICERs ranging between £59,712 ($81,080) and £182,128 (€218,870), with the ICERs above the most common willingness-to-pay thresholds (WTPs). But they were cost-effective within the commonly used WTPs among the population for whom the previous treatments including Botox were failed. Three studies compared the cost-effectiveness of Erenumab against the placebo and found that Erenumab was dominant. All studies performed sensitivity analyses to check the robustness of their results. None of the findings from the included articles were generalisable and none of the included studies fulfilled all the criteria mentioned in the CHEERS 2022 reporting checklist and Phillips’s checklist for economic models. Conclusions: Evidence to support the cost-effectiveness of pharmacological treatments of chronic migraine in the adult population using Botox and Erenumab were identified. Our findings suggest that both Botox and Erenumab, are cost-effective compared to placebo; although Erenumab had more incremental economic benefits compared to Botox, the ICERs were above the most common willingness-to-pay thresholds. Hence, Erenumab might be an acceptable treatment for chronic migraine for patients whom other treatments such as Botox do not work. Further research is needed to help characterise the data to adequately structure and parameterise an economic model to support decision-making for chronic migraine therapies

Decomposing disparity in adult individual\u2019s mental health in Tehran among lower and higher economic groups; an Oaxaca- Blinder analysis on urban HEART Survey- round 2

Background: Mental health is one of the main aspects of social well-being. Tehran -capital of Iran- is metropolitan, where the mental health status of citizens is not prioritized effectively. Objectives: The purpose of this study was identifying contributors of mental health inequality between lower and higher economic groups in Tehran through Oaxaca- Blinder method. Methods: The study was conducted by the data of Tehran\u2019s Urban Heart Survey- Round 2 (2012). Through a three- stage stratified and clustered sampling method, 34,700 were selected as samples. The mental health status was measured by the General Health Questionnaire 28- items (GHQ- 28) and the quantity of the inequality in mental health was measured by corrected concentration index. The Fairlie\u2019s decomposition approach was performed in STATA 14. Results: The corrected concentration index were: -0.0967 and -0.1004 by Erreyger\u2019s and Wagstaff \u2019s approaches. Being of the Iranian origin, disability conditions, employment status and smoking were identified as the main contributors of inequality in mental health among lower and higher economic groups. Conclusion: Thus, re-organizing strategies and plans on promoting the socio- economic status of non-Iranian residents, improving employment opportunities, developing well-designed environment for disabled individuals and supporting plans to reduce smoking is recommended to the urban policy makers

Clinical effectiveness of pharmacological interventions for managing chronic migraine in adults : a systematic review and network meta-analysis

Background: Chronic migraine can be a profoundly disabling disorder that may be treated with preventive medications. However, uncertainty remains as to which preventive medication is the most effective. We present a network meta-analysis to determine the effectiveness and rank of preventive drugs for chronic migraine in adults. Methods: We identified, reviewed, and extracted data from randomised controlled trials (RCTs) of preventive drugs for chronic migraine with at least 200 participants. Data were analysed using network meta-analysis. Findings: We included 12 RCTs of six medications (Eptinezumab, Erenumab, Fremanezumab, Galcanezumab, Onabotulinumtoxin A, and Topiramate) compared to placebo or each other. All drugs effectively reduced monthly headache and migraine days compared with placebo. The most effective drug for monthly headache days was Eptinezumab 300mg, with a mean difference of -2.46 days, 95% Credible Interval (CrI): -3.23 to -1.69. On the Surface Under the Cumulative Ranking Area (SUCRA) analysis, the probability that Eptinezumab 300mg was ranked highest was 0.82. For monthly migraine days, the most effective medication was Fremanezumab-monthly, with a mean difference: -2.77 days, 95% CrI: -3.36 to -2.17, and 0.98 probability of being ranked the highest. All included drugs, except Topiramate, improved headache-related quality of life. No eligible studies were identified for the other common preventive oral medications such as Amitriptyline, Candesartan, and Propranolol. The main reasons were that the studies did not define chronic migraine, were undertaken before the definition of chronic migraine, or were too small. Interpretation: All six medications were more effective than the placebo on monthly headache and migraine days. The absolute differences in the number of headache/migraine days are, at best, modest. No evidence was found to determine the relative effectiveness of the six included drugs with other oral preventive medications. Registration: PROSPERO (number CRD42021265990)

The Inequity of Expenditure Ratios on Health and Food among Different Deciles of Iranian Households

Background and purpose: Utilization of health care services and food influence the health status. The food and health care expenditure ratios determine the importance level of them in household's consumption expenditures. We aimed to investigate the Iranian rural and urban food and health expenditure ratios inequality during 1998 to 2012. Materials and Methods: This is a descriptive longitudinal study, which conducted based on Iranian Statistics Centre and Central Bank annual surveys. Firstly we calculated the households food and health expenditure ratios. Then we calculated the Gini coefficients and Atkinson index by using STATA version 12. Results: The mean of rural households food and health expenditure ratios were 0.53 and 0.37 respectively. Also these were 0.53 and 0.22 for urban households. All above inequality levels are based on Gini coefficients. Conclusion: There is a high level of inequality between Iranian rural and urban income deciles for health expenditure ratio, but the food expenditure ratio inequality were less and lower

The Inequity of Expenditure Ratios on Health and Food among Different Deciles of Iranian Households IJHS 2013;1(3):18 The Inequity of Expenditure Ratios on Health and Food

Abstract Background and purpose: Utilization of health care services and food influence the health status. The food and health care expenditure ratios determine the importance level of them in household's consumption expenditures. We aimed to investigate the Iranian rural and urban food and health expenditure ratios inequality during 1998 to 2012. Materials and Methods: This is a descriptive longitudinal study, which was conducted based on Iranian Statistics Centre and Central Bank annual surveys. Firstly we calculated the households food and health expenditure ratios. Then we calculated the Gini coefficients and Atkinson index by using STATA version 12. Results: The mean of rural households food and health expenditure ratios were 0.53 and 0.37 respectively. Also these were 0.53 and 0.22 for urban households. All above inequality levels are based on Gini coefficients. Conclusion: There is a high level of inequality between Iranian rural and urban income deciles for health expenditure ratio, but the food expenditure ratio inequality were less and lower

Making orphan drugs and services available and accessible for people who live with rare diseases : what has been done? A systematic scoping review

Objectives: Rare diseases are recognized as non-prevalent health disorders. Availability, accessibility, and affordability of Orphan Drugs (ODs), alongside genetic testing, are the major contributors to ensuring no patient is excluded by the health system. Therefore, making ODs available and accessible has been a challenge even for high-income nations. This review aims to summarize the evidence on the availability and accessibility of orphan drugs and other required resources for managing rare diseases. Methods: The Joanna Briggs Institute scoping review method was used as the analytical framework. We searched Medline, and Embase through Ovid, and Web of Science. We used Guilford et al. definition and classification of accessibility and its dimensions to synthesize the evidence. Results: The majority of the final included evidence is about the financial, and then availability and physical accessibility to ODs. Furthermore, almost all the evidence comes from high-income countries. Conclusion: The principal hurdles to the availability and accessibility of ODs and other related services are very high prices, lack of a legal framework, and budgetary impact on public funding. A lack of reimbursement mechanisms and lower availability of other resources are among other problems