EUROHEALTH

Moving towards universal health coverage
19
Figure 1: Three dimensions of health coverage
Source: Adapted from Ref 1
Universal coverage of needed
services and financial protection
Reduce co‐payments and
other out‐of‐pocket
payments
Extend to
non‐covered
Pooled funds
Population: who is covered?
health care and increased use of publicly
financed treatment may put pressure on
publicly financed health services
• reductions in public spending on health
and restrictions of health coverage are
likely to shift health care costs onto
households, increasing the out-of-pocket
share of total spending on health and
leading to financial hardship, access
barriers and unmet need, particularly
among vulnerable groups of people.
Evidence from previous shocks indicates
that countercyclical public spending
on health and other social services
during an economic downturn – that
is, public spending that rises as gross
domestic product (GDP) is falling – is
important for protecting health and health
system performance.
The impact of the crisis on UHC:
practice
To assess the impact of the crisis on
UHC in EU countries, we look first at
trends in public spending on health and
trends in out-of-pocket payments, to see
if reductions in public spending shifted
health care costs onto households. We
then review health system responses to
the crisis, focusing on changes to the
three dimensions of health coverage.
Include
cost‐effective
services
Services:
which services
are covered, of
what quality?
Costs:
how much do
people have to
pay out‐ofpocket?
Note: In almost every country in the world, the vast majority of pooled funds are considered to be public because they are
generated through compulsory forms of pre-payment and are not linked to individual risk of ill health.
Finally, we consider data on two key
UHC outcome indicators: unmet need and
financial protection.
The information we draw on comes from a
study on the impact of the crisis on health
and health systems in Europe carried out
jointly by the European Observatory on
Health Systems and Policies and the WHO
Regional Office for Europe. 3 4 5 The study
looked at policy responses to the crisis
between the end of 2008 and the beginning
of 2013.
Many countries shifted health care
costs onto households
Changes in public spending on health
and out-of-pocket payments can be
used as simple proxy indicators of
potentially negative effects on UHC.
Evidence from previous economic
shocks clearly highlights the importance
of countercyclical public spending in
minimising risks to health and health
system performance.
Figure 2 shows how public spending
on health has been pro-cyclical – that
is, falling as GDP falls – rather than
countercyclical in nearly half of all EU
countries in the years since the crisis, with
several countries experiencing substantial
and sustained declines. Public spending
on health fell to such an extent that the
level of spending per person in 2013/14
was around the level of 2007/08 in Croatia,
Cyprus, Italy, Latvia, Luxembourg,
Slovenia and Spain, and around the
level of 2003/04 in Greece, Ireland
and Portugal.
Between 2008 and 2014, out-of-pocket
payments per person rose steadily in all
except a handful of countries (Croatia,
Cyprus, France, Greece and Slovakia,
where they were lower in 2014 than
they had been in 2008). Out-of-pocket
payments rose as a share of total spending
on health in just over half of all EU
countries (Figure 3). In several countries
heavily affected by reductions in public
spending on health, the increase in the
out-of-pocket share has been large. For
example, in Ireland, Portugal and Spain,
the out-of-pocket share in 2014 was higher
than in any year since 1995. In Greece,
the out-of-pocket share fell dramatically
in 2009, but grew rapidly in 2013 and 2014.
Changes of this magnitude indicate a
substantial shifting of health care costs
from governments to households at a
time when many households were facing
‘‘
additional financial pressure.
spending cuts
were large
enough to limit
access
Relatively vulnerable people lost
entitlement to publicly financed health
coverage
People who are not entitled to publicly
financed health coverage will face
significant barriers to access unless
they are able to buy private insurance.
Extending population entitlement is
therefore a critical first step in moving
towards UHC. The decade before the
crisis saw important changes to population
entitlement in EU countries – for example,
coverage expansions in Belgium for
self-employed people, in Ireland for older
Eurohealth — Vol.22 | No.2 | 2016