April 17, 2024

Financial hardship caused by out-of-pocket payments for medicines, medical products such as hearing aids, and dental care affects millions of people, even in Europe’s richest countries, reveals a new WHO report. On International Universal Health Coverage (UHC) Day 2023, the report “Can people afford to pay for health care? Evidence on financial protection in 40 countries in Europe” highlights that out-of-pocket payments push between 1% and 12% of households into poverty or make them poorer.

Out-of-pocket payments lead to catastrophic health spending for between 1% and 20% of households on average. This rises to between 2% and 69% of households in the poorest fifth of the population. People who experience catastrophic health spending may not be able to pay for other basic needs such as food, housing and heating.

Catastrophic out-of-pocket payments are mainly driven by household spending on services that are commonly delivered or managed in primary-care settings, indicating important gaps in the coverage of primary care in many countries.

“Our report shows that for millions of people in the WHO European Region, affordable access to health care is still a dream. Even before the pandemic, many people were facing an unacceptable level of catastrophic health spending,” said Hans Henri P. Kluge, WHO Regional Director for Europe. “We need to transform our health systems now to ensure that people everywhere can receive the right care, at the right time, in the right place, from the right person – without experiencing financial hardship.”

Gaps in affordable access to health care

Using new pre-pandemic data from 2019, the report finds that out-of-pocket payments for outpatient medicines lead to both financial hardship and unmet need for people with low incomes, preventing many from using health care. Out-of-pocket payments for dental care lead to financial hardship for richer households and unmet need for poorer households.

Sandra Gallina, Director-General for Health and Food Safety at the European Commission, stated, “The report draws attention to gaps in access to health care for people in vulnerable situations and proposes policy solutions to address challenges. I hope this work will guide Member States in improving affordable access to health care and ensuring more equitable health systems.”

She added, “I congratulate the WHO Barcelona Office for Health Systems Financing on the launch of this valuable report on affordable access to health care, which was supported by the EU4Health programme.”

Redesigning health coverage policy to reduce out-of-pocket payments

In addition to presenting a new analysis of financial hardship and unmet need for health care, the report highlights aspects of coverage policy – the way in which health coverage is designed and implemented – that undermine financial protection.

It notes that 5 common health coverage policy choices slow progress towards UHC because they disproportionately affect people with low incomes or chronic conditions, decrease efficiency in the use of health care, and weaken household and health system resilience to shocks.

To address this, the report proposes a checklist for policy-makers wanting to move closer to UHC. The checklist identifies 5 policy choices that have improved financial protection in countries with a low incidence of financial hardship and unmet need.

  1. Entitlement to publicly financed health care should be de-linked from payment of social health insurance contributions. The relevant tax agency should deal with non-payment of contributions and other taxes, not the health system.
  2. Refugees, asylum-seekers and undocumented migrants should be entitled to the same benefits as other residents to ensure that the whole population is covered.
  3. User charges (copayments) for health care should be applied sparingly and be carefully designed so that, for example, people with low incomes or chronic conditions are automatically exempt from all copayments.
  4. Primary-care coverage should include treatment, not just consultation and diagnosis. This will help reduce out-of-pocket payments for medicines, medical products and dental care.
  5. Coverage policy should be adequately funded through public spending on health to ensure that there are no major staff shortages, no long waiting times for treatment and no informal payments.

More information about the 40 countries featured in the report is available on UHC watch, a new online platform designed to track progress on affordable access to health care in Europe and central Asia. UHC watch offers a wealth of country-level and comparative data and resources on financial protection and health financing policy.

About the report

The report provides an assessment of financial protection for 40 countries (including all European Union Member States) in 2019 or the latest available year before COVID-19 to establish a pre-pandemic baseline for Europe. It includes a simple analysis of changes in catastrophic health spending over time, and an exploratory analysis of catastrophic health spending during the pandemic.

The report and UHC watch benefited from financial assistance from the European Union through the Directorate-General for Health and Food Safety and the Directorate-General for Neighbourhood and Enlargement Negotiations.

About WHO/Europe’s work on financial protection

Financial protection is central to UHC and a key dimension of health system performance assessment. It is an indicator of the Sustainable Development Goals, part of the European Pillar of Social Rights, and at the heart of the European Programme of Work, WHO/Europe’s strategic framework.

WHO/Europe monitors financial protection through the WHO Barcelona Office for Health Systems Financing, using regional indicators that are sensitive to equity. The WHO Barcelona Office provides tailored technical assistance to countries to reduce financial hardship and unmet need by identifying and addressing gaps in health coverage.


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