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

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.

How resilient is health financing policy in Europe to economic shocks? Evidence from the first year of the COVID-19 pandemic and the 2008 global financial crisis.

The COVID-19 pandemic triggered an economic shock just ten years after the shock of the 2008 global financial crisis. Economic shocks are a challenge for health systems because they reduce government revenue at the same time as they increase the need for publicly financed health care. This article explores the resilience of health financing policy to economic shocks by reviewing policy responses to the financial crisis and COVID-19 in Europe. It finds that some health systems were weakened by responses to the 2008 crisis. Responses to the pandemic show evidence of lessons learnt from the earlier crisis but also reveal weaknesses in health financing policy that limit national preparedness to face economic shocks, particularly in countries with social health insurance schemes. These weaknesses highlight where permanent changes are needed to strengthen resilience in future: countries will have to find ways to reduce cyclicality in coverage policy and revenue-raising; increase the priority given to health in allocating public spending; and ensure that resources are used to meet equity and efficiency goals. Although many health systems are likely to face budgetary pressure in the years ahead, the experience of the 2008 crisis shows that austerity is not an option because it undermines resilience and progress towards universal health coverage.

Могат ли хората да си позволят да плащат за здравни услуги? Нови доказателства за финансовата защита в България

Настоящият обзор е част от серия проучвания по държави за представяне на нови доказателства относно финансовата защита на европейските здравни системи. Финансовата защита заема централно място в универсалното здравно покритие и е ключово измерение за ефективността на здравната система. В България случаите на катастрофални и водещи до обедняване разходи за здравеопазване са много повече в сравнение с другите страни в Европа. Катастрофалните разходи се дължат почти изцяло на преките плащания за лекарства в извънболничната помощ и се увеличават с течение на времето. Най-силна е концентрацията им сред по-бедните домакинства, по-възрастните хора и живеещите в селските райони. Това отразява значителни пропуски в трите измерения на здравното покритие: обхванато население, покритие на услугите и потребителски плащания (доплащания). Въпреки че през последните години публичните разходи за здравеопазване нарастват, те остават ниски по стандартите на Европейския съюз и изостават спрямо ръста на директните плащания или не се използват за посрещане на неудовлетворени потребности и финансови затруднения. За да се намалят неудовлетворените потребности и финансовите затруднения, правителството следва да се съсредоточи върху финансовата достъпност на лекарствата в извънболничната помощ и увеличаване на защитата от директните плащания за по-бедните домакинства и хронично болните. Това може да се постигне като се въведе освобождаване от доплащания за тези две групи хора, разшири се обхвата на годишния лимит на доплащане за болнична помощ с включване на всички видове доплащания и лимитът се свърже с дохода на домакинството, продължи се с подобряване на начина, по който Националната здравноосигурителна каса закупува лекарствата за извънболнично лечение и се намерят начини за разширяване на здравноосигурителното покритие до обхващане на цялото население.

Can people afford to pay for health care? New evidence on financial protection in Bulgaria

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimension of health system performance. Bulgaria has a high incidence of impoverishing and catastrophic health spending compared to other countries in Europe. Catastrophic spending is almost entirely driven by out-of-pocket payments for outpatient medicines and has increased over time. It is heavily concentrated among poorer households, older people and people living in rural areas, reflecting significant gaps in all three dimensions of health coverage: population entitlement, service coverage and user charges (co-payments). Although public spending on health has grown in recent years, it remains low by European Union standards and has not kept pace with growth in out-of-pocket payments or been used to target unmet need and financial hardship. To reduce unmet need and financial hardship, the Government should focus on improving the affordability of outpatient medicines and strengthening protection from out-of-pocket payments for poorer households and people with chronic conditions. This can be done by: introducing exemptions from co-payments for these two groups of people; extending the annual cap on co-payments for inpatient care to all co-payments and linking the cap to household income; continuing to improve the way in which the National Health Insurance Fund purchases outpatient medicines; and finding ways to extend health insurance to the whole population.

Determinantes sociales de la salud y la calidad de vida en población adulta de Manizales, Colombia / Social determinants of health and quality of life of the adult population of Manizales, Colombia

Objetivo: Evaluar la asociación entre los determinantes sociales de la salud y la calidad de vida en una población adulta de la ciudad de Manizales. Métodos: Estudio descriptivo con una fase correlacional en un universo de 18 109 viviendas con una muestra de 440 seleccionadas a través de muestreo estratificado por afijación óptima. Como variable dependiente se midió la calidad de vida a través del formulario WHOQOL-BREF y como variables independientes se midieron los determinantes sociales de la salud estructurales e intermedios. La asociación entre las variables se midió a través de análisis bivariado mediante las pruebas U de Mann Whitney, t de Student, ANOVA y Kruskal Wallis. Resultados: La edad promedio fue de 49 años +/- 17,2 años, los ingresos mensuales mínimos del hogar fueron de 23 dólares y los ingresos máximos de 23 000 dólares, el 88,9 por ciento pertenecía al estrato socioeconómico alto. El 61,6 por ciento calificaron su calidad de vida como bastante buena. El análisis bivariado mostró asociación (p< 0,05) entre la escolaridad y la posición socioeconómica autopercibida con todas los dominios de calidad de vida así como entre los ingresos mensuales del hogar con la salud psicológica, relaciones sociales y el ambiente y la vinculación laboral con todos los dominios excepto las relaciones sociales. Conclusiones: Los determinantes sociales de la salud que se asociaron con la calidad de vida en todos sus dominios fueron la escolaridad y la posición socioeconómica autopercibida(AU)

Objective: To evaluate the association of social determinants of health and quality of life of the population in the city of Manizales, Colombia. Methods: Descriptive correlational study carried out in a sample of 440 households selected through optimal allocation stratified sampling from a universe of 18 109 households. The dependent variable was quality of life measured by using the WHOQOL-BREF and the independent variables were the structural and intermediate social determinants of health. The association of variables was measured though bivariate analysis using Mann-Whitney U, ANOVA, Student´s t and Kruskal Wallis tests. Results: The mean age was 49 ± 17.2 years; the minimum monthly household income was 23 and the maximum income was 23 000 US dollars, and 88.9 percent of the sample was rated as high socio-economic stratum. 61.6 percent rated pretty well their quality of life. The bivariate analysis showed association p< 0.05 between education and self-perceived socioeconomic status in all quality of life domains as well as between monthly household income and psychological health, social relations and working environment and links in all domains except for social relations. Conclusions: The social determinants of health associated with the quality of life in every domain were education and self-perceived socioeconomic status(AU)