1. 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

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

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

4. 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

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

6. 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

7. 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

8. Countries currently preparing new estimates of financial protection

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

10. Comparing EU countries pre-crisis
Source: WHO 2015

11. Zoomed in to see more detail…
Source: WHO 2015

12. What has happened since the crisis?
Source: WHO 2015

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

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

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

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

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

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

19. 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

20. Thank you!

21. 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: