Healthcare Inequity in Spinal Cord Injury: Out of Pocket and Access Barriers in Paraplegic and Tetraplegic Patients in Iran.

OBJECTIVE: Spinal cord injury (SCI) imposes substantial long-term physical, psychological, as well as financial burdens on patients in Iran, where high out-of-pocket (OOP) payments remain a major barrier to care. This study examined inequalities in healthcare utilization and OOP expenditures among patients with paraplegia and tetraplegia. METHODS: This cross-sectional analyzed data from the 2023 International Spinal Cord Injury Survey for Iran, including 191 patients from the Guilan Province. Data on healthcare utilization and OOP spending for consultations, rehabilitation, medications, diagnostics, mental health, and inpatient services were analyzed. Inequality was assessed using Gini and concentration indices, and further explored through decomposition analysis and recentered influence function regression. RESULTS: Inpatient care accounted for the highest OOP cost (US$516.27/month), followed by rehabilitation (US$178.65/month). Mental health services were the least utilized and most inequitable, with a concentration index of 0.49, indicating pro-rich access. Education, marital status, and place of residence significantly influenced the disparities, with rural and less-educated patients experiencing greater barriers. CONCLUSION: Patients with SCI in Iran face substantial financial inequities, and wealthier groups enjoy greater access to essential services. Policy reforms aimed at expanding insurance coverage, decentralizing rehabilitation, and subsidizing high-cost care are urgently required to promote equitable healthcare access and improve outcomes.