Introduction

Type 2 diabetes (T2D) is one of the world’s most prevalent non-communicable diseases (NCDs).1 T2D is the ninth-leading cause of death in the world and accounts for 11.5% of global healthcare expenditures for people.2 3 T2D is a long-life disease that requires continuous care and management4 otherwise, the complications of diabetes occur resulting in social and economic outcomes. International Diabetes Federation (IDF) estimated that the total cost related to T2D will increase to US$1.03 trillion by 2030 and US$1.05 trillion by 2045. IDF projected that the number of those with T2D increase from 537 million in 2021 to 640 million by 2030 and 783 million by 2045, an increase of 46%. Over three in four will be living in low-income and middle-income countries.5 Iran as a developing country is located in the Middle East/North Africa (MENA) region which faced the highest prevalence of T2D with 12.2% in 2019. There is an expected 96% increase in diabetes prevalence between 2019 and 2045 in MENA.6 73 million people in MENA have diabetes and the prevalence of diabetes in Iran is 9.5%.7 The costs related to T2D per person were reported to be US$1354.8 in Iran in 2021. It is estimated that these costs increase to US$1663.5 by 2030 and US$1839.2 by 2045.8

Slums are the epitome of deprivation and are specified by poor access to basic services, inadequate houses and overcrowding.9 Slum dwelling has negative consequences on health so in the United Nations’ Sustainable Development Goals health of slum dwellers has been considered a priority.10 Due to social and environmental factors as well as some behaviours from slum dwellers, they are more likely to develop T2D and its complications.11 12 A study in Brazil indicated that the prevalence of T2D among slum dwellers is twofold compared with the rest of the population (10.1% vs 5.2%).13 The results of a study in Dhaka, Bangladesh indicated risk factors to develop NCDs among slum dwellers include insufficient fruit and vegetable intake (95.6%), poor physical activity (15.3%), hypertension (13.7%), overweight/obesity (22.7%), smoking (36%) and self-reported diabetes (5%).14

For decades, Iran has experienced the expansion of slums in its metropolises. In Iran, slums are known as informal settlements located around cities. Those living in Iran slums are poor, unskilled and unemployed people who moved from small towns or rural areas to metropolises in search of employment and welfare services. The uneven distribution of facilities and jobs within the country, as well as the lack of support for native jobs in small towns and villages, has caused these people to migrate to metropolises. Migrants are forced to live in marginalised areas due to poor living conditions. Tabriz is one of Iran’s major metropolises with a large number of slum dwellers. A study in Tabriz slums showed that despite attempts to achieve universal health coverage (UHC), underutilisation of health services among those with T2D is notably high because of lower income levels, Iran Health Insurance insufficiency and a lack of supplemental insurance.15 Another study in Tabriz showed that because of high costs, underutilisation of medication is nearly twofold among slum dwellers compared with the rest of the population (7.2% vs 3.3%).16

T2D is one of the most expensive chronic illnesses, demanding the financial support of patients, especially disadvantaged ones, including slum dwellers. Unsuitable cost-coping strategies vis-à-vis T2D expenditures may result in impoverishment. However, health systems fail to protect poor and near-poor people from the financial consequences of illness.17 Identifying cost-coping strategies for T2D care can be helpful for appropriate planning in slums, to increase healthcare utilisation. Therefore, this study was conducted to assess financial protection and equity in healthcare financing system among slum dwellers with T2D in Tabriz slums, Iran in 2022.

MethodsStudy design and setting

We report here a cross-sectional study conducted among slum dwellers in Tabriz, Iran in 2022. As the healthcare system in Iran is primarily centralised, and the Ministry of Health and Medical Education plays a key role in stewardship, governance, management and administration,18 Tabriz has purposely been chosen as a representative of Iranian slums so the results can be generalised. In recent years, slum populations in Tabriz have increased significantly. Compared with the general population, Tabriz has the largest number of slum dwellers in Iran.

Patient and public involvement

The public and patients were not involved in any stage of the study.

Inclusion criteria, sample size and sampling method

Over 400 000 people live in slums in Tabriz out of its 1 600 000 population. 13 155 people with T2D live in Tabriz slums.19 Based on Cochran’s Sample Size Formula,20 with a 95% CI, 0.05 marginal error and 0.50 possible prevalence, we need 374 people. Therefore, we included 400 patients with T2D who lived over 5 consecutive years in slums, were over 18 years old and were without intellectual disability. Other types of diabetes were excluded. The information of those with T2D is recorded at an integrated health system known as SIB. An SIB was established by the Iranian Ministry of Health to maintain and update electronic health records of Iranian citizens. By using the SIB, doctors and health experts are able to monitor patients’ conditions and facilitate referrals. At SIB, the primary characteristics of patients are recorded, such as their age, gender, phone number and address. The method of sampling was systematic random sampling. Each patient at SIB is assigned a code. After extracting the eligible patients from SIB, their codes were sent to an Excel spreadsheet. In the next stage, each slum area’s population was divided by the desired sample size. Patients were selected based on this fixed interval. There are four slum areas in Tabriz. To avoid selection bias, we included 100 patients in any area. As we were unable to interview 100 people in each area during the first round of sampling, a second round was conducted.

Data collection and data analysis

For data collection, a questionnaire was developed. The questionnaire consisted of two parts. The first one involved sociodemographic information. The second enveloped cost-coping strategies for T2D care and forgone care of outpatient and inpatient services (online supplemental questionnaire). Cost-coping strategies were identified by a meeting with 30 patients from different slum areas. Patients were asked what strategies they use to cope with diabetes care costs. All comments were taken into consideration. Five different strategies were identified in the end. Face validity was confirmed by 10 experts in the field. Data were collected by two trained researchers at patients’ homes. Researchers called the patients’ SIB-registered phone numbers before visiting the homes. The researchers visited the homes of patients who agreed to participate in the study. A paper questionnaire was used to collect data. The people of Tabriz speak Turkish, and illiterate people often cannot speak Persian. The questionnaire was originally written in Persian, but two researchers translated it into Turkish for the illiterate people. The data collection process took 2 months. For illiterate people, two researchers read out the questionnaire and filled it out. Data were analysed by SPSS V.22. The descriptive analysis involved frequency and per cent. In interpretative analysis, the χ2 test was used to determine the association between sociodemographic as well as forgone care and cost-coping strategies for T2D care. Univariate and multiple logistic regression models were used to examine sociodemographic variables on cost-coping strategies. As a result of the low probability of losing data, we applied a pairwise excluding approach to deal with missing data.

ResultsSociodemographic characteristics of the study population and cost-coping strategies for T2D care

400 of the 600 people who were contacted participated in the study, which is about 66.7%. Of the 400 persons who participated, more than half of the participants were women and the majority of the population was over 30 years old. A total of 27.8% of participants were illiterate while 30.3% were capable of reading and writing. 82.3% were covered by basic insurance while only 15% had supplemental insurance. The level of income for a majority of the population (75.8%) was below 40 million Rial (online supplemental table 1). A bit over 90 million rial was the median income in Iran during the study period.

184 (46%), 89 (22.3%), 87 (21.8%), 14 (3.5%) and 8 (2%) of participants used health insurance, the combination of health insurance and personal savings, personal savings, borrowing and sale of personal assets vis-à-vis T2D expenditures respectively (figure 1). 336 (84%) and 64 (16%) of patients refer to the public sector and private sector for receiving services, respectively.

Figure 1

Percentage of cost-coping strategies for T2D care. T2D, type 2 diabetes.

Association between sociodemographic factors and cost-coping strategies for T2D care

The results of the χ2 test indicated that there is no significant association between gender and cost-coping strategies for T2D care. There is a significant association between age and cost-coping strategies (p<0.001). 62.5% of those under 30 years old used health insurance to cover the costs of T2D care while the use of other strategies among those over 60 years old was 60%. Cost-coping strategies were significantly associated with education (p<0.001). 88.2% of those with first university degree used insurance and 34% of illiterate people used personal savings. Furthermore, having a lower level of education is associated with being older (χ2=188.580, p<0.0001).

There are significant associations between cost-coping strategies and marital status, income level, basic insurance, type of insurance, supplemental insurance and disease duration. 79.8% of people with income over 4 million Rial used insurance to cope with costs while 55% of those with income under 4 million Rial used personal savings and a combination of insurance and personal savings. 56.6% of those who were covered by basic insurance used insurance to cope with T2D costs while 67.7 of uncovered patients used personal savings. 65.2% of people who were covered by social insurance used health insurance to cope with costs and 55% of those who were covered by Iran health insurance used personal savings and a combination of health insurance and personal savings. 82.5% of those who were covered by supplemental insurance and 42.2% of those who were uncovered used health insurance to cope with costs (online supplemental table 1).

Association between forgone care and cost-coping strategies

Foregone care of outpatient services and inpatient services were 59 (14.8%) and 35 (8.8%), respectively. Forgone care of outpatient services and inpatient services among those who used non-insurance strategies to cope with costs were nearly 79.5% and 93.9%, respectively. Forgone care of outpatient services and inpatient services among those who used health insurance were 19.6% and 6.1%, respectively (table 1).

Table 1

Forgone care in cost-coping strategies for T2D care

Factors affecting cost-coping strategies

Univariate and multiple logistic regression models were applied to the dependent variables (other types of cost-coping strategies=0, health insurance=1). The Hosmer and Lemeshow goodness of fit showed that the fitted model is correct (χ2=3.436, p=0.881) for univariate regression and (χ2=6.173, p=0.628) for multivariate regression. It was found that illiterate people (adjusted OR=16, p<0.001), those with limited reading and writing abilities (OR=4.80, p=0.039), those with low incomes (OR=5.024, p<0.001), those without supplemental insurance (OR=1.885, p<0.001) and those over 60 years old (OR=1.557, p=0.02) were, respectively, 16, 4.8, 5.024, 1.885 and 1.557 times more likely to use other forms of cost-coping strategies than health insurance. As a result of including several explanatory variables in the equation and performing multiple logistic regression, illiterate people and people over 60 were, respectively, 34.43 and 10.97 times more likely to use other types of cost-coping strategies than health insurance (table 2).

Table 2

Univariate and multiple logistic regression models for factors impacting cost-coping strategies

Discussion

The purpose of the study was to assess financial protection and equity in the healthcare financing system among slum dwellers with T2D in Iran. According to the results, 47.62% of slum dwellers use strategies to cope with T2D expenditures that do not protect them from financial risks. The results showed that sociodemographic factors are significantly associated with cost-coping strategies. Additionally, forgone care of outpatient and inpatient services, although less common among those who use insurance, are not nevertheless satisfactory.

Iran has committed to the achievement of UHC for many years. Some goals of UHC are financial protection of illness costs for whole people in a given country and equal access to quality healthcare without sacrificing those who are not able to pay.21 The health transformation plan (HTP) was an important attempt towards the achievement of UHC goals in Iran in 2014. A key objective of the HTP was to improve access to and utilisation of healthcare among slum dwellers. Despite the achievement of good results in a short period of time, because of financial instability, this plan failed. The clear message from the study is that the goals of UHC have not been achieved in slums. Even though slum dwellers are disadvantaged, they often use cost-coping strategies to cope with T2D care, which does not protect them from financial risks. The out-of-pocket payment not only impoverishes households but also prevents them from availing of healthcare services, which leads to inefficiency and unfair resource allocations.22 Uninsured and poor people are more likely to incur impoverishing and catastrophic spending.23 The results of a study in Nigeria among people with T2D revealed that poor people had the highest incidence of catastrophic expenditures.24 Considering T2D is a chronic disease, it has greater negative consequences for disadvantaged people. Results of a study in the USA showed that those with T2D are vulnerable to rising costs of care and may adopt cost-coping strategies that could have negative outcomes on health.25 Therefore, it is imperative to cover slum dwellers with a minimum out-of-pocket expense to avoid further impoverishment and negative outcomes related to T2D.

Iran’s government is the most important provider of healthcare.26 Attempts have been made by the government to increase the coverage of vulnerable people through Iran Health Insurance. 22.30% of participants in the study use a combination of health insurance and personal savings to cope with T2D costs. These findings indicate that the insurance system in Iran is not adequately efficient. The insurance system does not cover the whole population of slums. Moreover, cover of costs and benefits package is not sufficient.27 According to Xu et al, poorer countries and nations with limited prepayment systems have a higher rate of catastrophic expenditures.28 29 Considering that slum dwellers are socioeconomically poor, the insurance system should consider special measures in slums. Therefore, first of all, the insurance system needs to be reformed.

Delivery of healthcare services is cheaper in the public sector than in the private sector. It seems logical if the majority of the slum dwellers (84%) refer to the public sector for receiving care. According to a systematic review, however, patients in low-income and middle-income countries frequently lack timeliness and hospitality when it comes to the public sector.30 Therefore, there is a need to improve the quality of health services in the public sector.

Education is an affecting factor in coping with costs. We found that a high percentage of slum dwellers are undereducated. It is clear that higher education affects the use of health services and better self-care31 and for diabetes care, health literacy makes it better.32 Low education was found to be associated with negative attitudes towards self-care among elderly patients with T2D in Recife, northeastern Brazil.33 Also, it has been confirmed by a study in Poland that the level of education is associated with income inequality.34 In fact, higher education increases the chances of finding a job and receiving income, so they can obtain basic as well as supplemental insurance coverage. Therefore, there is a need to eliminate income inequalities in coverage by insurance and take bigger steps towards UHC.

An influencing factor associated with cost-coping strategies is age. Elderly patients are less likely to use insurance to cope with costs. A study in Bangladesh slums showed that health-seeking behaviour among older people is influenced by age, education, marital status and satisfaction with domains of life.35 According to a study in Delhi, even though T2D is common in slums, it fails to be adequately understood, treated and controlled among the elderly.36 The results of a systematic review showed that there are five themes for diabetes self-management among elderly patients including the need for information on T2D care, support from the health system and social, functional decline, attitude of persons with T2D and challenges of adopting a healthy lifestyle.37 As a result, elderly patients need more financial, social and informational support from the health system, society and government. Moreover, elderly people typically have poor education, so health insurance inequalities related to the elderly must be eliminated to ensure universal coverage.

It seems that marital status affects cost-coping strategies so the sale of personal assets and borrowing is more common among single people. Because a study did not identify marital status as a significant predictor of diabetes care,38 we prefer to interpret this with some caution. Maybe lower liability or lower income leads to this behaviour.

Income level plays an important role in adopting a cost-coping strategy. Although the whole population of the study was disadvantaged, a small increase in income can change cost-coping strategies vis-à-vis T2D care expenditures. The use of insurance among those who have an income over 4 million Rial is nearly twofold compared with those who have an income under 4 million Rial. An explanation can be that people with higher incomes are more able to receive basic and supplemental insurance. A public non-governmental organisation, for instance, Social Security Insurance, covers employees from the formal private sector and self-employed people.39 People covered by this organisation have a specific income source, so they can use cost-coping strategies such as insurance. Additionally, Iranians with higher incomes are more likely to receive supplemental insurance.40 As a result, financial support for slum dwellers with T2D is necessary.

People who are not covered by basic insurance mostly use personal savings as a cost-coping strategy for T2D care and have more forgone care. Results of a study indicated that people with T2D who are uninsured have less healthcare utilisation.41 In order to manage diabetes and prevent complications from occurring, people with diabetes need affordable and adequate health insurance to cover the costs of supplies, medications, education and healthcare.42 According to a study conducted on the Texas-Mexico border, those without health insurance were twice as likely to develop diabetic complications as patients with health insurance.43 Thus, it is imperative that the Iranian government commits to providing coverage to slum dwellers and achieving the UHC goals.

The type of insurance affects cost-coping strategies. People with Social Security Insurance more use health insurance as a cost-coping strategy and the combination of health insurance and personal savings is more used by those with Iran Health Insurance. An explanation can be the difference in benefits packages between insurance types. Social Security Insurance has more benefits packages than Iran Health Insurance. Social Security Insurance has several hospitals and clinics that provide free healthcare, although the number of these centres is not sufficient. By contrast, Iran Health Insurance has fewer cover of costs and mostly covers vulnerable people. Having supplemental insurance is significantly associated with adopting health insurance as a cost-coping strategy. The use of personal savings and a combination of health insurance and personal savings as cost-coping strategies are more common among those without supplemental insurance. As previously mentioned in Iran most people with higher income are being covered by supplemental insurance, suggesting that there are fewer constraints for adopting cost-coping strategies that lead to impoverishment. Supplemental insurance covers costs and services that are not covered by basic insurance.44 Attempting for coverage of slum dwellers with supplemental insurance is a rational solution, given that slum dwellers are poor.45 Disease duration is associated with adopting cost-coping strategies. It is clear that with ageing disease duration increases. Therefore, as previously mentioned older people are more likely to adopt cost-coping strategies that lead to much more poverty.