EUROHEALTH

26
Moving towards universal health coverage
Figure 4: The drivers of impoverishing and catastrophic out-of-pocket payments
across income groups in a high-income country
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Poorest
quintile
Source: Authors’ modelling.
Note: Based on data from an EU country; income groups are based on household consumption quintiles;
OOPs = out-of-pocket payments.
changes (or the absence of change) in the
health system and in policies beyond the
health system.
Comparative analysis can generate even
richer evidence for policy. Preliminary
results from ten of the countries in our
study show how financial hardship is
consistently concentrated among the
poorest 40% of the population and mainly
driven by out-of-pocket spending on
outpatient medicines, especially among
poorer households. Early results also show
that the incidence of financial hardship
varies significantly across countries.
While incidence is associated with outof-pocket
payments as a share of total
spending on health, it is also influenced
by policies to protect vulnerable groups
of people. Differences in the way in
which countries provide people with
protection against co-payments appear to
be important. This finding suggests that
efforts to strengthen financial protection
need to focus on policies, not just on levels
of public spending on health.
A limitation of all indicators used to
measure financial protection is that they
do not capture unmet need due to cost –
that is, instances in which people needed
but did not use health care because they
2nd 3rd 4th Richest quintile
Inpatient care
Outpatient care
Dental care
Diagnostic tests
Medical products
Medicines
could not afford to pay for it. In our study
we try and address this by ensuring that
each national report includes a discussion
of data on unmet need. Highlighting
people who do not incur any out-of-pocket
payments also helps to make the issue of
unmet need more visible, particularly in
health systems that do not exempt people
from co-payments, although most datasets
do not allow us to say whether these
people experience unmet need or not.
What does it take to monitor financial
protection systematically?
Systematic monitoring of financial
protection requires three things: survey
data on household consumption; a
standard approach to monitoring applied
over time and across countries; and a good
understanding of national health system
and socio-economic contexts.
EU member states are required to carry
out household budget surveys at least once
every five years; some do this annually.
Many non-EU countries in Europe also
carry out regular household budget
surveys. This means the statistical data
needed to monitor financial protection are
routinely available in almost all countries
in Europe, although there is variation
across countries in the regularity of data
collection and in the level of detail with
which household spending on health
services is assessed.
In the past 15 years, WHO and the
World Bank have supported monitoring
of financial protection in Europe and
Central Asia. However, the analysis has
been limited to a relatively small number
of countries and at regional level we still
lack a comprehensive set of comparable
estimates. This new study initiated by the
WHO Regional Office for Europe is the
first to apply the same methodology to
a large number of countries from across
the whole region, including a significant
number of western European countries and
EU member states.
Previous multi-country analysis of
financial protection has generated
numbers on the incidence of
impoverishing or catastrophic spending
on health services without accompanying
national analysis. 2 7 8 In contrast, our
study takes a bottom up approach. We
have commissioned one or more national
experts in over 20 countries to prepare
a comprehensive national assessment of
financial protection. Each national report
will not only generate numbers using at
least two data points, but also provide a
detailed discussion of these numbers in
the context of health system and broader
socio-economic developments. National
experts are using a standard template
for reporting to facilitate comparison
across countries. Their reports will
feed into a regional overview and
comparative analysis.
What will monitoring financial
protection achieve?
Systematic monitoring of financial
protection with in-depth national analysis
will lead to a better understanding of
the contextual factors and policies that
drive financial hardship within and
across countries. It will allow countries
to identify ways of improving financial
protection, especially for vulnerable
groups of people. The WHO Regional
Office for Europe is ready to work with
member states to ensure that the evidence
generated by our study raises awareness of
financial hardship and, ultimately, results
Eurohealth — Vol.22 | No.2 | 2016