EUROHEALTH

Moving towards universal health coverage
21
Figure 4: Unmet need for health care due to cost, distance or waiting time,
2005 – 2014, EU28
12
10
%
8
6
4
2
Unemployed
Poorest quintile
2nd quintile
Whole population
3rd quintile
4th quintile
Richest quintile
0
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Source: Authors using data from EU-SILC 9 available from 2005 to 2014.
financed; those who needed them had
to use private hospitals and pay out
of pocket. 5
Many countries increased copayments;
a few understood the risks
When faced with fiscal pressure, some
countries will consider introducing or
increasing co-payments. This is likely to
undermine access and financial protection
unless co-payments are applied with
great care, in a highly selective way: (a)
targeting non-cost-effective care only;
or (b) targeting rich households only.
However, option (a) would probably not
lead to more efficient patterns of use
because people will generally continue to
use services and medicines if instructed
to do so by a physician or other health
worker; removing non-cost-effective care
from coverage would be more likely to
have the desired effect, if accompanied by
strong signals to care providers. Option
(b) might succeed in shifting some costs
onto households without increasing access
barriers or financial hardship, but the
administrative costs incurred could mean
the net revenue gained is small.
Twelve EU member states reported
introducing new or higher co-payments
in response to the crisis, suggesting many
countries found this to be a relatively easy
policy lever to employ. Eight countries
reported reducing co-payments or trying
to strengthen protection against copayments.
Economic adjustment programs
negotiated with the European Commission
required a blanket increase in co-payments
in Cyprus, Greece and Portugal, without
selectivity or protection for poorer people.
In this respect, the programs were not
in line with international evidence or
best practice.
Some countries tried to address fiscal
pressure through efficiency gains rather
than coverage restrictions. For example,
reductions in medicine prices in countries
where co-payments are set as a share of
medicine costs have lowered the financial
burden on patients and enabled a wider
range of medicines to be publicly financed.
Impact on UHC outcomes
Assessing changes in two UHC outcomes
(unmet need and financial protection)
requires data on the use of health
services, estimates of the incidence of
impoverishing and catastrophic out-ofpocket
payments, and data on unmet need,
all disaggregated by income and other
individual characteristics to allow analysis
of impact on equity.
Across the EU, only data on unmet need
are routinely available and disaggregated * .
These data show how, on average, unmet
need due to cost, distance or waiting
time had fallen substantially before
the crisis began, but has risen steadily
since 2009. In 2014, unmet need for these
three reasons was back at the level it
had been in 2007 (Figure 4). As a result,
over 3 million more people reported unmet
need for health care in 2014 than in 2009.
need has risen
in 22 out of
28 EU member
‘‘unmet
states
Since the onset of the crisis, unmet need
due to cost, distance and waiting time has
risen across the whole population in 22 out
of 28 EU member states and was higher
in 2014 than in 2009 among the poorest
quintile in 21 out of 28 countries. 9 The
highest rises in unmet need among the
* Through the EU Survey on Income and Living Conditions
(EU-SILC) covering the EU28 countries, Iceland, Norway
and Switzerland.
Eurohealth — Vol.22 | No.2 | 2016