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Can people afford to pay for health care?New evidence on financial protection in Europe
Sarah Thomson, Jonathan Cylus, Tamás Evetovits
Everybody needs a strong umbrella
No one should experience
Financial hardship
Unmet need
2008 2012 2015
What is financial protection?The degree to which people are
protected from out-of-pocket payments when using health care
2010 2015
A health system goal highlighted in global and regional reports and
commitments
Policy-relevant | Action-oriented | Pro-poor
Regional report using an advanced methodology for Europe
Filling a gapin evidence and
relevance
Global report | EU & OECD reports | WHO Bulletin
More public spending on health means lower burden on patients
05
1015202530354045505560657075
Netherl
ands
San M
arino
Franc
e
Monac
o
United
Kingdo
m
Luxe
mbourg
Croatia
Sloven
ia
German
y
Denmark
Norway
Sweden
Czech
Repub
lic
Andorr
a
Austria
Icelan
d
Irelan
d
BelgiumFin
land
Estonia Ita
ly
Slovak
ia
Poland
Spain
Hunga
ry
Switzerla
nd
Portug
alIsr
aelMalt
a
Lithu
ania
GreeceLa
tvia
Russia
n Fed
eratio
n
Cyprus
Turke
y
Roman
ia
Bosina
& Herz
egov
ina
Belarus
Turkm
enist
anSerb
ia
TFYRM
Repub
lic of
Moldov
a
Kyrgyzs
tan
Monten
egro
Uzbek
istan
Bulgari
a
Kazak
hstan
Ukraine
Albania
Armen
ia
Georgi
a
Tajiki
stan
Azerba
ijan
Out
-of-p
ocke
t pay
men
t as
a %
of t
otal
hea
lth s
pend
ing
DANGER ZONE: > 30%
SAFE: < 15% with pro-poor policies
Source: WHO data for 2014
High- and middle-income countries in the European Region
Out-of-pocket payments as a % of total spendingon health is a good proxy for financial protection
ü Who experiences financial hardship
ü What services drive financial hardship
ü Which coverage policies work
Policy-relevant | Action-oriented | Pro-poorRegional report based on country-level analysis that goes beyond the numbers
ALB | AUT | CRO | CYP | CZH | DEU | EST | FRA | GEO | GRE | HUN | IRE | KGZLVA | LTU | NLD | POL | POR | MDA | SVK | SVN | SWE | TUR | UKR | UNK
Lise’s story:exempt from co-payments
Can people afford to pay for health care?
households
for any health service fromprevention to palliative care
using health services without financial hardship
all formal & informalout-of-pocket payments
Two indicators of financial protection:both use national household budget survey data
Catastrophicout-of-pocket
payments:
a household’scapacity to pay
OOPs that are>40% of
or further below it
A household’s capacity to pay is what is left after deducting a standard amount to meet basic needs: food, rent, utilities
Impoverishingout-of-pocket
payments:push households
belowthe poverty line
What do thenumbers tell us?
How many households are impoverishedafter out-of-pocket payments
WHO Barcelona Office for Health Systems Strengthening
0123456789
SVN
201
5
CZH
201
2
UN
K 20
14
CYP
200
9
IRE
2015
/16
DEU
201
3
AUT
2014
/15
SWE
2012
FRA
2011
SVK
2012
CR
O 2
014
GR
E 20
16
EST
2015
TUR
201
4
KGZ
2014
POL
2014
POR
201
0
LTU
201
2
LVA
2013
GEO
201
5
MD
A 20
13
HU
N 2
015
ALB
2015
UKR
201
5
Hou
seho
lds
(%)
Further impoverished Impoverished
0
2
4
6
8
10
12
14
16S
VN
201
5
CZH
201
2
IRE
201
5/16
UN
K 2
014
SW
E 2
012
FRA
201
1
DE
U 2
013
AU
T 20
14/1
5
CY
P 2
009
SV
K 2
012
CR
O 2
014
TUR
201
4
ES
T 20
15
PO
L 20
14
LTU
201
2
GR
E 2
016
PO
R 2
010
HU
N 2
015
ALB
201
5
KG
Z 20
14
LVA
201
3
UK
R 2
015
GE
O 2
015
MD
A 2
013
Hou
seho
lds
(%)
How many households experiencecatastrophic out-of-pocket payments
Stronger protection
WHO Barcelona Office for Health Systems Strengthening
Weaker protection
Who experiences catastrophic health spending: poor people suffer the most
WHO Barcelona Office for Health Systems Strengthening; catastrophic incidence broken down by consumption quintile
02
468
101214
16SV
N 2
015
CZH
201
2IR
E 20
15/1
6U
NK
2014
SWE
2012
FRA
2011
DEU
201
3AU
T 20
14/1
5C
YP 2
009
SVK
2012
CR
O 2
014
TUR
201
4ES
T 20
15PO
L 20
14LT
U 2
012
GR
E 20
16PO
R 2
010
HU
N 2
015
ALB
2015
KGZ
2014
LVA
2013
UKR
201
5G
EO 2
015
MD
A 20
13
Hou
seho
lds
(%)
Richest4th3rd2ndPoorest
0
20
40
60
80
100
SV
NC
ZH IRE
UN
KS
WE
FRA
DE
UA
UT
CY
PS
VK
CR
OTU
RE
ST
PO
LLT
UG
RE
PO
RH
UN
ALB
KG
ZLV
AU
KR
GE
OM
DA
Cat
astro
phic
OO
Ps
(%)
Inpatient careDiagnostic tests
Dental careOutpatient careMedical productsMedicines
Which health services are responsible for catastrophic spending among all households
Stronger protection Weaker protection
WHO Barcelona Office for Health Systems Strengthening
0
20
40
60
80
100
SV
NC
ZH IRE
UN
KS
WE
FRA
DE
UA
UT
CY
PS
VK
CR
OTU
RE
ST
PO
LLT
UG
RE
PO
RH
UN
ALB
KG
ZLV
AU
KR
GE
OM
DA
Cat
astro
phic
OO
Ps
(%)
Inpatient careDiagnostic testsDental care
Outpatient careMedical productsMedicines
Which health services are responsible forcatastrophic spending among poor households
WHO Barcelona Office for Health Systems Strengthening
Stronger protection Weaker protection
Financial protection is stronger where out-of-pocket payments are low as a share of total spending on health
WHO Barcelona Office for Health Systems Strengthening
Slovenia (2015) Czechia (2012)Ireland (2015/2016)United Kingdom (2014)Sweden (2012)
France (2011)
Germany (2013)Austria (2014/2015)
Cyprus (2015)
Slovakia (2012)Croatia (2014)
Turkey (2014)
Estonia (2015)
Poland (2014)
Greece (2016)Lithuania (2012)
Portugal (2010)Hungary (2015)
Kyrgyzstan (2014)Latvia (2013)
Georgia (2015)
Albania (2015)
Republic of Moldova (2013)
Ukraine (2015)
Netherlands (2013) R² = 0,730
2
4
6
8
10
12
14
16
0 15 30 45 60
Cat
astro
hpic
inci
denc
e (%
)
Out-of-pocket payments as a share of total spending on health (%)
Coverage policy is the primary mechanism through which people are exposed to out-of-pocket payments
Pooled funds
Population: who is covered?
Services:which services
are covered andof what quality?
Cost:how muchdo people have to pay out of pocket?
Universal coverage ofneeded services with financial protection
Adapted from the World Health Report 2010
What’s the storybehind the numbers?
0
5
10
15
20
0
20
40
60
80
100
SV
N
CZH
NE
T
IRE
UN
K
SW
E
FRA
DE
U
AU
T
CR
O
PO
R
KG
Z
LVA
UK
R
TUR
SV
K
HU
N
ES
T
LTU
PO
L
GE
O
GR
E
CY
P
ALB
Hou
seho
lds
(%)
Pop
ulat
ion
(%)
Population coverage (left axis) Catastrophic incidence (right axis)
Population coverage is a prerequisitefor financial protection – but not a guarantee
WHO Barcelona Office for Health Systems Strengthening
Gaps in service coverage can lead to financial hardship for the rich and unmet need for the poor
Poor people are not using
dental care– unmet need for dental care
is nine times higher among
poor people
Everyone uses outpatient medicines –but the poor suffer the most
This pattern is even more likely to occur whenpreventive services are not fully covered
0%
20%
40%
60%
80%
100%
Poorest 2nd 3rd 4th Richest
Diagnostic testsOutpatient careMedical productsInpatient careDental careMedicines
Breakdown of catastrophic out-of-pocket payments by quintile in Lithuania
Lise experiencesfinancial hardship because she has to pay out of pocket for medicines to treat her diabetes and heart disease
User charges shift the burden of paying for health care onto those least able to afford it
people pay forsystem failures
protects against system failures
Countries can improve financial protectionby carefully redesigning co-payment policy
STRONGü exemptionsü protective capsü low fixed
co-payments
WEAKx no exemptionsx no capsx percentage
co-payments
1. Percentage co-payments have disadvantages – especially for medicines
0%
2%
4%
6%
8%
10%
12%
14%
SVN
FRA
CR
O
SVK
CYP
UN
K
CZH IR
E
AUT
NET
SWE
DEU ES
T
HU
N
POL
LTU
GR
E
POR
LVA
Cat
astro
phic
inci
denc
e (%
)
Fixed co-payments Percentage co-payments
2. Exemptions protect those who need it most
0%
2%
4%
6%
8%
10%
12%
14%
SVN
FRA
CR
O
SVK
CYP
UN
K
CZH IR
E
AUT
NET
SWE
DEU ES
T
HU
N
POL
LTU
GR
E
POR
LVA
Cat
astro
phic
inci
denc
e (%
) Weak protectionmechanismsPoor people exempt
from co-payments
Older people + people with
chronic illnesses exempt
Fixed co-payments Percentage co-payments
3. Caps protect everyone
0%
2%
4%
6%
8%
10%
12%
14%
SVN
FRA
CR
O
SVK
CYP
UN
K
CZH IR
E
AUT
NET
SWE
DEU ES
T
HU
N
POL
LTU
GR
E
POR
LVA
Cat
astro
phic
inci
denc
e (%
)
Fixed co-payments Percentage co-payments
Weak protectionmechanisms
Poor people exempt from co-payments
Annual cap on co-payments
2Exempt poor people and regular service users
1Replace percentage co-payments with low fixedco-payments
3Cap allco-payments per person
Simple & people-centredco-payment design
works best for everyone
The numbers tell us: protect poor people and improve coverage of medicines
The stories behind the numbers reveala wealth of good practice in Europe
But this is not yet widely applied
To improve financial protection put people first
(32)www.euro.who.int
WHO Regional Office for EuropeUN CityMarmorvej 51DK-2100 Copenhagen ØDenmark
Thank you
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