Division of Health Systems and Public Health WHO Regional Office for Europe Measuring financial protection: an approach for the WHO European Region Jon Cylus WHO Barcelona Office for Health Systems Strengthening European Observatory on Health Systems and Policies Dublin, 22 September 2015

Out of pocket expenditure in Ireland is slightly above the EU28 average

OOP spending in Ireland increased more than in most EU28 countries since crisis Unclear whether this is causing financial hardship…

What is financial protection? The degree to which households are protected from financial risk when ill A key component of universal health coverage Highlighted in regional and global commitments: the Tallinn Charter, World Health Report 2000 and 2010 General approach to measurement: Catastrophic expenditureh= Out of pocketh/Capacity to payh > threshold (e.g. 40%) Impoverishing expenditureh= Consumptionh - out of pocketh < poverty line

Financial protection across the globe Out of pocket spending as a share of total spending Source: Xu et al (2003), Household Catastrophic Health Expenditure

Measuring capacity to pay General idea: How much does a household have available to spend on health care out of pocket? Capacity to payh = consumptionh – subsistence Defining subsistence: WHO Europe approach: Basic food, utilities and rent

Grouping households More impoverishedh if oop/ctph<0 Already poor enough to be below the subsistence line and spending OOP More impoverishedh if oop/ctph<0 Impoverishedh if oop>ctph At riskh,mult if exph - ooph <120% of subsistence Not at riskh,mult if exph - ooph ≥ 120% of subsistence No OOP if no out of pocket Define catastrophic OOPs to include both households that spend above a given threshold of their capacity to pay and those who are impoverished or further impoverished by OOPs See: Wagstaff A and P Eozenou (2014), CATA Meets IMPOV: a unified approach to measuring financial protection in health, Washington DC: the World Bank Becoming impoverished by OOP OOP pushes a household close to the poverty line but not below OOP does not put a household at risk of impoverishment

Countries currently preparing new estimates of financial protection

Preliminary results based on EU countries that have already prepared new estimates

Comparing EU countries pre-crisis Source: WHO 2015

Zoomed in to see more detail… Source: WHO 2015

What has happened since the crisis? Source: WHO 2015

Financial protection has deteriorated in many countries since the crisis Source: WHO 2015

Countries with higher out of pocket spending as a share of total expenditure have higher catastrophic expenditure Source: WHO data

Even in EU countries with low catastrophic spending, the poor are at risk of financial hardship due to OOPs Source: WHO 2015

The crisis has worsened financial protection for the poor across Europe Source: WHO 2015

What are catastrophic spenders purchasing in EU countries? Source: WHO 2015

What are the poorest catastrophic spenders (1st quintile) purchasing? Source: WHO 2015

Some preliminary findings Financial protection is a challenge in EU countries – and has worsened in many countries since the crisis The poor are the most adversely affected by catastrophic out of pocket spending Much (but not all) catastrophic expenditure is on medicines

Thank you!

Further information about this project This analysis of financial protection in European health systems is led by the WHO Barcelona Office for Health Systems Strengthening, which is part of the Division of Health Systems and Public Health in the WHO Regional Office for Europe. For more information about the project, please contact: whobar@euro.who.int