Introduction
ealth and its sub-sectors are one of the most important service areas, and the share of health expenditures in the Gross Domestic Product (GDP) of countries has become one of the most challenging issues in the field of policy-making and resource allocation. The share of health expenditures in the world economy reached more than 9.9% in 2017 [1]. This shows that on average, one-tenth of the world’s total annual economic output is spent on health. The share of the health sector in the economy varies greatly from country to country, with Venezuela at 1.2% and the United States at 17.1 % having the lowest and highest share of the economy in health care, respectively [1].
 One of the most important economic issues related to health is how to finance health services. These activities are mainly funded by various institutions, such as social insurance, private insurance, government, companies, and institutions or direct payments of individuals. The greater the dependence of financing on direct payments of individuals, the greater the financial pressures on individuals and the lower the sustainability of health care activities. The average share of direct payments of the total health expenditures in the world is equal to 18.2% and the countries of Armenia (with a share of 84.4%) and Botswana (with a share of 2.3%) have the highest and lowest dependence on direct payments, respectively [1].
 Of all the functions of the health system, rehabilitation services are by far the most dependent on the costs paid by households (out-of-pocket payments) [2], which puts the sustainability of activities and services in this area at high risk. This high dependence has led to these costs turning into catastrophic costs in households in high need of rehabilitation services [4, 3]. It should be borne in mind that the presence of the elderly or people with disabilities in the family will be a very important factor in the need for rehabilitation services and thus face catastrophic costs [4, 5, 6, 7, 8].
 The occurrence of catastrophic costs has been directly related to insurance coverage (including basic insurance and supplementary insurance) [3, 8, 9, 10]. The lack of serious presence of social insurance and private insurance in the field of rehabilitation services has made the vulnerability of those in need of these services more than other functional areas of the country’s health system. The combination of these two issues, namely the risk factor of “need for rehabilitation services” and the protective factor of “insurance coverage”, highlights the serious issue that rehabilitation services are among the most important health needs in the country, and applicants for these services are among the groups most at risk of catastrophic costs and even impoverishing costs. Therefore, examining the composition of national health expenditures and recognizing its importance in national health planning can be the first step in reducing the risks to households in need of services. This necessity becomes doubly important with the implementation of the health system transformation plan and the injection of new financial resources into this sector [11, 12, 13]. Due to the importance of the subject, the present study sought to investigate the share of rehabilitation services in the health system and economy of Iran from 2002-2017.
Materials and Methods
 The present research was a descriptive study of longitudinal data trend analysis. Process analysis is the process of reviewing different information at different time intervals to review policies and achieve an appropriate pattern in macro decisions. This type of research is mainly done to achieve the two goals of identifying contradictions and resolving them [14]. This longitudinal study examined the share of rehabilitation services in the health system and economy of Iran. The data used in this study are extracted from the report of national health accounts from 2002-2017, which are reported to the current figures [2]. It should be noted that information on national health accounts in 2016 was not reported. This secondary data is only available for the mentioned period and all available data were included in the study.
 For the preparation of national health accounts based on the most reputable databases related to health activities in Iran, with the help of the Statistics Center, separate letters were sent to collect information related to health expenditures to organizations, institutions, and other domestic institutions and the information obtained was entered in these accounts. Therefore, the information obtained from these accounts can be considered as the most reliable information available in Iran, which is collected and published to support better governance and more principled decision-making in the health system [2]. These accounts report the financing process and expenditures in the field of healthcare as input-output tables. These tables classify the costs incurred in the country’s health system based on the type of financial suppliers, funding source, operation, and provider. Therefore, they make it possible to determine the contribution of each of the financing agents and financial resources in financing the various functions of the health system and health service providers. Classification of national health accounts of health financing agents in Iran, including the domestic governmental (Ministry of Health, universities of medical sciences, armed forces, Petroleum Industry Medical Services Organization, Radio, Municipality, Martyr Foundation, Relief Committee, Pastor institute, and other central government agencies), social security funds (health services organization and social security organization), private sector (supplementary insurance, households, banks, free universities, other private companies, non-profit institutions), and other parts of the world (foreign aid), and the total cost of these sectors can be considered as the total costs incurred in different sectors. Health costs, both in terms of the share of these costs in GDP and terms of the combination of costs incurred, are strongly influenced by the health system and economic and social factors of each country [15]. Various studies have shown that there is a very strong relationship between health expenditures and the level of national income [16, 17]. Therefore, to more accurately compare health expenditures between different countries and regions, the ratio of health expenditures to GDP or gross domestic product is often used. Despite some weaknesses in the data of these accounts, this information was trusted because better information about rehabilitation services was not found in the country’s health system.
Results
 According to the World Bank, Iran’s health expenditures are among the highest in the region in terms of GDP. According to these statistics, in 2017, the share of health expenditures in Iran’s GDP was more than 8.1%. In the same year, Pakistan (2.7%) and Qatar (3.08%) were the countries with the lowest share of GDP in the health sector. The average share of health expenditures in GDP in the Middle East and North Africa in 2016 was 6.13% [1]. It should be noted that high health costs do not always mean better results in the performance indicators of the health system and the high share of costs can be a sign of inefficient use of resources in this area [18, 19, 20].
 According to the information in the national health accounts, the costs related to rehabilitation services have increased from 884 billion Rials in 2002 to more than 6389 billion Rials in 2015 and with a sharp decline in 2015 and 2016 to 2967 billion Rials [2]. This shows that these costs have grown by an average of 7.9% per year. Despite this increase, the share of economic activities in the field of rehabilitation in the Iranian economy has decreased over the past 16 years. Although Iran’s economy has fluctuated a lot in recent years, the average annual growth of Iran’s nominal GDP from 2002-2017 was equal to 16 %. Comparing this rate with the growth rate of rehabilitation costs (7.9% per year) shows the reason for the decline in the share of rehabilitation services in the country’s economy. The share of rehabilitation expenditures in Iran’s GDP in the highest situation was about 0.17% of Iran’s GDP (in 2007), which in the last decade, its volume has decreased and reached 0.02% in 2017 (Figure 1). Examining the combination of health costs over different years can be a good criterion for assessing the importance of different health functions. The costs incurred by consumers of rehabilitation services have been in return for receiving services from its providers. Therefore, the costs of this section can be considered equivalent to the provision of rehabilitation services. Figure 2 shows that costs related to “health care” have always played a dominant role among the components of health costs. Expenditures related to “medical services” in 2017 were equal to 811 thousand billion Rials, which accounted for more than 59.1% of total health expenditures. The share of this sector in health expenditures had been declining since 2011 and the implementation of the health system transformation plan and the injection of financial resources into this sector has led to the reversal of this trend. Expenses related to “long-term nursing services” and expenses related to “ancillary medical care” have been being replaced by medical expenses since 2011, but the process has stopped with the implementation of this plan in 2014. A similar trend has occurred for the costs of public health and prevention services.
 The lowest share of health expenditures in recent years has been in “rehabilitation services”. The share of these costs in 2007 was at its highest rate (3.07% of total health costs). In the following years, this figure has always had a decreasing trend, reaching 0.59% in 2015 and less than 0.22% in 2017, which was the lowest value during the last 16 years.
According to the health services financing model, the three main paths of insurance, government expenditures, and out-of-pocket payments are considered as the main sources of health system financing. The statistics related to national health accounts show that in 2017, about 18.7% of total rehabilitation expenditures have been supplied by the government, 24.6% by social insurance, 18.7% by private insurance, and 37.6% by households, and the rest (4.0%) by non-profit organizations and companies. This was while in 2015, the government’s share of rehabilitation costs was about 8.1%, the share of private insurance was 4.3%, the share of social insurance was 8.7% and the share of households was 78.9%. To investigate the contribution of various institutions in financing these costs before the start of the health system transformation plan, the mentioned ratios for 2013 have also been extracted. In 2013, the government’s share of total rehabilitation expenditures was more than 60.7%. In addition to the government, 8.1% of expenditures were covered by social insurance and 31.2% by households, with private insurance and other institutions and companies playing no role. However, after the implementation of the health system transformation plan, the burden of rehabilitation costs initially fell on households, and this has caused the use of these services to be severely affected. Along with these developments, it can also be seen that rehabilitation services are heavily dependent on out-of-pocket payments for households, and this has jeopardized the sustainability of activities in this area.
 Considering the financial responsibility of insurance companies and non-profit organizations and companies in providing rehabilitation services shows that these resources have never played a significant role in this sector and whenever the government has reduced their costs, the financial burden of providing these costs is directly on the shoulders of individuals and households. This is not the case for other functional areas of health, and various intermediaries, including social insurance and non-profit organizations and companies, have co-financed them with the government.
Discussion and Conclussion
 Today, more than ever, the benefits of rehabilitation services are recognized around the world. More than 74% of the years of the life of people with disabilities have been affected by factors that could provide better conditions for them to use rehabilitation services. For every one million people, there are 10 specialists in various fields of rehabilitation in low- and middle-income countries [21]. Understanding this importance can lead to the development of the rehabilitation services market and increase the share of these activities in the economies of different countries.
 The Organization for Economic Co-operation and Development (OECD) Statistics Center on Health-Related Accounts shows that among these countries, Mexico has accounted for less than 0.04% of GDP and Turkey with 0.43% of GDP for disability support services, have the lowest value. Sweden, Norway, and Denmark accounted for 4.41%, 4.31%, and 4.14% of GDP in support of the disabled, respectively, in 2016 [22].
 In addition to developed countries, the World Health Organization has collected data on health expenditures for a limited group of countries around the world. Based on the available information, it can be seen that the share of rehabilitation expenditures in the GDP of countries is significantly different. India accounted for less than 0.002% of its gross domestic product in rehabilitation services, while Bosnia and Herzegovina with 0.25% had the most attention to the services provided in the field.
Despite the differences in the method of calculating national health accounts, a comparison of the share of rehabilitation services in the Iranian economy with different countries shows that the position of this sector is by no means comparable to developed countries and even lower than many developing countries.
 Despite the challenges caused by chronic diseases in the present century, the increase in the elderly population, and the significant relationship between the need for rehabilitation services and exorbitant costs in Iran, the study of the share of rehabilitation services in the Iranian health system shows that these services are still considered insignificant. The insignificant role of the government and, more importantly, social insurance in financing rehabilitation services and its increasing decline is evidence of this claim. Despite the implementation of the health system transformation plan, it can be seen that the volume of rehabilitation services has decreased during the implementation of this program.
 Some studies on health expenditures show that due to the participation of government and insurance in financing this sector, there is a possibility of moral hazard and excessive consumption of health services [23, 24]. That is why different countries have reconsidered the cost of health services as well as rehabilitation costs [25] and implemented various laws to reduce the use of these services. However, many studies addressing this issue have overlooked the subsequent positive effects of these costs. In other words, if shifting the burden of health care costs to households leads to less use of health services, this need may be more severe and costly with a little pause. Experimental studies have also shown that increasing the cost of visits and essential medicines will reduce their use, but will rapidly increase the cost of outpatient and inpatient services [25, 26]. This is also true of the use of rehabilitation services, and because these services are used to restore power lost as a result of an accident, illness, or injury, rehabilitation should be considered inherently a form of prevention (of loss of efficiency) [27]. Therefore, it can be said that the benefits that people with disabilities get from rehabilitation services are very high compared with the costs incurred for these services [28].
 Now is not the time to refer to the population of one billion people with disabilities in the world or their population of 1.4 million in Iran; rather, we need to talk about the growth of people in need of rehabilitation services as a result of the aging population, the shift in the burden of disease to chronic disease, and the inequality of people with disabilities in accessing health care.
The costs of using rehabilitation services have always been mentioned as one of the factors limiting access to these services [29]. Therefore, the development of financial resources to provide rehabilitation services will be one of the most important needs of the health system. This restriction will be doubly important given that non-governmental organizations and social insurance in Iran do not have an acceptable share of these costs. People with disabilities are in low-income groups and often do not have a job [30]; thus, the ability to provide private insurance will not be beyond the reach of these people (or their families). The lack of financial resources to provide new assistive devices is difficult for many people, and it is also difficult for families with disabled members. These factors will go hand in hand to make these individuals more constrained in their activities and social participation [31].
Data from national health accounts in Iran also revealed that rehabilitation costs account for a very small share of total health expenditures in Iran and have steadily declined in importance in recent years. In addition, households have been responsible for a large part of the financing of these services, which has led to a sharp decline in demand for rehabilitation services in Iran. This situation has been exacerbated by the implementation of the health system transformation plan and the government’s expenditures on these activities have been drastically reduced. Given the low contribution of social and private insurance to the financing of rehabilitation services, the government is expected to provide other alternative sources of funding for these activities and supportive policies in this area before reducing its responsibilities and costs for rehabilitation services. Otherwise, the total cost of using rehabilitation services will be borne by households and many of their needs will remain unmet. In addition, these costs can be catastrophic or even impoverishing if they relate to low-income households with disabled members.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.195) 

Funding
This research was supported by the research project (No. 00-T-2680), Funded by the University of Social Welfare and Rehabilitation Sciences.

Conflict of interest
The author declared no conflict of interest.


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