Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries

Abstract

Background: Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection.

Methods: We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services.

Findings: Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending.

Interpretation: It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes.

Funding: The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.

Keywords: Affordable access to health care; Europe; Financial hardship; Financial protection; Out-of-pocket payments; Universal health coverage; Unmet need.

Fig. 1

Share of households with impoverishing health spending, 2019 or the latest available year before COVID-19. Notes: AL: Albania, AM: Armenia, AT: Austria, BA: Bosnia and Herzegovina, BE: Belgium, BG: Bulgaria, CH: Switzerland, CY: Cyprus, CZ: Czechia, DE: Germany, DK: Denmark, EE: Estonia, EL: Greece, ES: Spain, FI: Finland, FR: France, GE: Georgia, HR: Croatia, HU: Hungary, IE: Ireland, IL: Israel, IT: Italy, LT: Lithuania, LU: Luxembourg, LV: Latvia, MD: Republic of Moldova, ME: Montenegro, MK: North Macedonia, MT: Malta, NL: Netherlands, PL: Poland, PT: Portugal, RO: Romania, RS: Serbia, SE: Sweden, SI: Slovenia, SK: Slovakia, TR: Türkiye, UA: Ukraine, UK: United Kingdom. The Netherlands cannot be compared to other countries for the reasons set out in the methods section.

Fig. 2

Share of households with catastrophic health spending by consumption quintile, 2019 or the latest available year before COVID-19. Notes: see the list of abbreviations and the note on the Netherlands in Fig. 1. Consumption quintiles are based on per person consumption adjusted for household size and composition using OECD equivalence scales.

Fig. 3

Breakdown of out-of-pocket payments by type of health care in households with catastrophic health spending on average (a) and in the poorest consumption quintile (b), 2019 or the latest available year before COVID-19. Notes: see the list of abbreviations and the note on the Netherlands in Fig. 1. Countries are sorted by the incidence of catastrophic health spending (lowest in Slovenia, highest in Armenia). Different types of health care are sorted by the average across countries. In Spain dentures are classified as medical products in the household budget survey; in most other countries they are classified as dental care. In Ukraine the medicines category includes inpatient medicines; in most other countries the medicines category refers to outpatient medicines only. Data are not available for Switzerland.

Fig. 4

Unmet need for health care (a) and dental care (b) due to cost, distance, and waiting time by income quintile, 2019 or the latest available year before COVID-19. Notes: see the list of abbreviations and the note on the Netherlands in Fig. 1. Countries are sorted by the incidence of catastrophic health spending (lowest in Slovenia, highest in Bulgaria). Data on unmet need for health and dental care are for the same year as data on catastrophic health spending, except for Albania (2017). Data are not available for all countries.

Fig. 5

Unmet need for prescribed medicines due to cost by income quintile, 2019. Notes: see the list of abbreviations and the note on the Netherlands in Fig. 1. Countries are sorted by the incidence of catastrophic health spending (lowest in Slovenia, highest in Bulgaria). Data are not available for all countries.

Fig. 6

Dental care as a share of out-of-pocket payments in households with catastrophic health spending and the share of people reporting unmet need for dental care due to cost, distance, and waiting time by quintile, 2019 or the latest available year before COVID-19. Notes: data are for 33 out of the 34 countries in the study for which data on unmet need are available and are for the same year as the incidence of catastrophic health spending except for the United Kingdom (unmet need data are for 2018). People refers to those aged 16 years and over. Quintiles are based on consumption for catastrophic health spending and income for unmet need.

Fig. 7

Population coverage, the main basis for entitlement to publicly financed health care, and catastrophic health spending, 2019 or the latest available year before COVID-19. Notes: see the list of abbreviations and the note on the Netherlands in Fig. 1. The share of the population covered is for the same year as catastrophic health spending and does not necessarily reflect the current situation. Blue columns: the main basis for entitlement is legal residence. Red columns: the main basis for entitlement is payment of contributions. Authorities in Bosnia and Herzegovina report different levels of population coverage for the Federation of Bosnia and Herzegovina and the Republic of Srpska. The figure excludes Greece because we could not find published data on the share of the population covered by the SHI scheme, which offers the main publicly financed benefits package.