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.

Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance.

Despite limited evidence of successful development and implementation of contributory health insurance and low and middle income countries, many countries are in the process implementing such schemes. This commentary summarizes all available evidence on the limitations of contributory health insurance including the lack of good theoretical underpinning and the considerable evidence of inequity and fragmentation created by such schemes. Moreover, the initiation of a contributory health insurance scheme has not been found to increase revenues to the health sector or help health countries achieve universal health coverage. Low and middle income countries can improve equity and efficiency of the health sector by replacing out-of-pocket spending with pre-paid pooling mechanisms, but that is best done through budget transfers and not by contributory insurance that links payment to sub-population entitlements.

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.

Do efficiency gains really translate into more budget for health? An assessment framework and country applications.

Efficiency has historically been considered a key mechanism to increase the amount of available revenues to the health sector, enabling countries to expand services and benefits to progress towards universal health coverage (UHC). Country experience indicates, however, that efficiency gains do not automatically translate into greater budget for health, to additional revenues for the sector. This article proposes a framework to assess whether and how efficiency interventions are likely to increase budgetary space in health systems Based on a review of the literature and country experiences, we suggest three enabling conditions that must be met in order to transform efficiency gains into budgetary gains for health. First there must be well-defined efficiency interventions that target health system inputs, implemented over a medium-term time frame. Second, efficiency interventions must generate financial gains that are quantifiable either pre- or post-intervention. Third, public financial management systems must allow those gains to be kept within the health sector and repurposed towards priority health needs. When these conditions are not met, efficiency gains do not lead to more budgetary space for health. Rather, the gains may instead result in budget cuts that can be detrimental to health systems' outputs and ultimately disincentivize further attempts to improve efficiency in the sector. The framework, when applied, offers an opportunity for policymakers to reconcile efficiency and budget expansion goals in health.

Tax-funded social health insurance: an analysis of revenue sources, Hungary.

Health financing is a complex health system function, which cannot be analysed accurately without tracking each step of the flow of funds separately. We analysed the revenue mix of the Hungarian health insurance fund from 1994 to 2015 and discuss the policy implications of our findings. We used the System of Health Accounts published in 2000 and the revised version of 2011, which introduced separate classifications for the sources of health expenditure. Based on the 2000 version, health insurance contributions were the main source of public funding in Hungary. According to the 2011 version, nearly 70% of health insurance fund revenues came from government tax transfers in 2015, illustrating the striking difference in how revenues and expenditures are reported using this version. Use of the 2011 version will better inform national policy-making and international comparisons and facilitate documentation and analysis of how countries have adapted their revenue mix to changing macroeconomic circumstances. The finding that Hungary has a predominantly tax-funded social health insurance system suggests that traditional understanding and description of health-financing models are no longer adequate and may limit consideration of potential resource-generation options. Hungary is also a good example of how separating revenue generation and pooling broadens policy options to tackle gaps in social health insurance coverage, although the government did not act on these due to the lack of a consistent health-financing strategy. The findings may be particularly relevant for low- and middle-income countries that are trying to expand social health insurance coverage despite limited formal employment.

Le financement de la santé est une fonction complexe du système de santé, qui ne peut pas être précisément analysée sans étudier séparément chaque étape du flux de fonds. Dans cet article, nous analysons le mix de recettes du fonds d'assurance maladie hongrois de 1994 à 2015 et nous évoquons les implications de nos constatations sur la définition des politiques. Nous avons utilisé le Système des Comptes de la Santé publié en 2000 ainsi que sa version révisée de 2011, qui a introduit des classifications différentes pour les sources des dépenses de santé. En se fondant sur la version de 2000, ce sont les cotisations d'assurance maladie qui ont constitué la principale source de financement public en Hongrie. Mais d'après la version de 2011, près de 70% des recettes constitutives des fonds de l'assurance maladie sont provenues de transferts fiscaux gouvernementaux en 2015, ce qui illustre la différence flagrante dans la manière d'enregistrer les recettes et les dépenses proposée par cette version révisée. L'utilisation de la version de 2011 permettra de mieux informer le processus d'élaboration des politiques nationales, de faciliter les comparaisons internationales ainsi que de mieux documenter et analyser la manière dont les pays adaptent leur mix de recettes face à l'évolution des circonstances macroéconomiques. Le fait que le système d'assurance maladie sociale de Hongrie s'avère principalement financé par l'impôt montre que la compréhension et la description habituelles des modèles de financement de la santé ne sont plus adaptées et que cela peut même entraver la considération d'autres options envisageables pour générer des recettes. La Hongrie est également un bon exemple illustrant comment le fait de séparer la génération des recettes et la mise en commun des fonds élargit les options politiques pour réduire les déficiences dans la couverture de l'assurance maladie sociale, même si le gouvernement n'a pas agi sur ce point, faute de stratégie de financement de la santé cohérente en la matière. Ces constatations peuvent être particulièrement utiles pour les pays à revenu faible et intermédiaire qui essayent d'étendre la couverture de leur assurance maladie sociale malgré un niveau d'emploi limité dans le secteur formel.

La financiación de la salud es una función compleja del sistema sanitario que no puede analizarse con precisión si no se hace un seguimiento independiente de cada paso del flujo de fondos. Se ha analizado la combinación de ingresos de la caja húngara de seguros médicos de 1994 a 2015 y se han discutido las implicaciones políticas de los resultados. Se ha usado el Sistema de Cuentas de Salud publicado en 2000 y la versión revisada de 2011, que introdujo las clasificaciones separadas para las fuentes de gasto en salud. Según la versión de 2000, las cotizaciones al seguro de enfermedad eran la principal fuente de financiación pública en Hungría. Según la versión de 2011, casi el 70 % de los ingresos de la caja de seguros médicos procedían de las transferencias de impuestos del gobierno en 2015, lo que ilustra la sorprendente diferencia en la forma en que se informan los ingresos y los gastos utilizando esta versión. El uso de la versión de 2011 servirá de base para la formulación de políticas nacionales y comparaciones internacionales y facilitará la documentación y el análisis de cómo los países han adaptado su combinación de ingresos a las cambiantes circunstancias macroeconómicas. La conclusión de que Hungría tiene un sistema de seguridad social financiada principalmente por los impuestos sugiere que la comprensión y la descripción tradicionales de los modelos de financiación sanitaria ya no son adecuados y limitan la consideración de las posibles opciones de generación de recursos. Hungría es también un buen ejemplo de cómo la separación entre la generación de ingresos y la puesta en común amplía las opciones políticas para abordar las brechas en la cobertura de la seguridad social, aunque el gobierno no haya actuado al respecto debido a la falta de una estrategia coherente de financiación sanitaria. Las conclusiones pueden ser particularmente pertinentes para los países de ingresos bajos y medianos que estén tratando de ampliar la cobertura de la seguridad social a pesar de la limitación del empleo formal.

В состоянии ли люди платить за услуги здравоохранения? Hовые фактические данные о финансовой защите в Европе

Выплаты из кармана населения (прямые платежи, осуществляемые населением) за услуги здравоохранения могут создавать финансовые препятствия для доступа к услугам здравоохранения, что приводит к возникновению неудовлетворенных потребностей или ведет к финансовым трудностям для лиц, использующих услуги здравоохранения. Данный отчет впервые объединяет данные о неудовлетворенных потребностях и финансовых трудностях в целях оценки того, в состоянии ли люди, живущие в Европе, платить за услуги здравоохранения. Объединяя труд национальных экспертов из 24 стран, данный отчет демонстрирует, что финансовые трудности в Европе сильно различаются и что потенциал для улучшения имеется даже в странах с высоким уровнем дохода, которые предоставляют всему населению доступ к государственным услугам здравоохранения. Катастрофические расходы на здравоохранение в значительной степени концентрируются среди самых бедных домохозяйств во всех странах, изученных в ходе исследования. Там, где финансовая защита особенно слаба, катастрофические расходы в основном связаны с выплатами из кармана за лекарственные средства для амбулаторного лечения. Системы здравоохранения с сильной финансовой защитой и низким уровнем неудовлетворенных потребностей имеют следующие общие черты: отсутствие больших пробелов и разрывов в охвате услугами здравоохранения; политика охвата (дизайн политики охвата услугами здравоохранения, а также ее реализация и управление) тщательно разработана таким образом, чтобы минимизировать барьеры в доступе и выплаты из кармана – особенно для бедных и регулярных пользователей услуг здравоохранения; государственные расходы на здравоохранение достаточно высоки для обеспечения относительно своевременного доступа к широкому спектру услуг здравоохранения без неформальных платежей. В результате этого выплаты из кармана населения невелики и составляют менее или около 15% от текущих расходов на здравоохранение. Пробелы в охвате возникают из-за недостатков в дизайне трех областей политики: права населения на получение гарантированных услуг здравоохранения, пакета гарантированных медицинских услуг (пакета государственных гарантий), и официальных платежей, осуществляемых потребителями (сооплаты). Данный отчет резюмирует действия, которые могут снизить уровень неудовлетворенных потребностей и финансовых трудностей за счет укрепления политики охвата. Он также указывает на те действия, которых стоит избегать.

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

Out-of-pocket payments for health can create a financial barrier toaccess, resulting in unmet need, or lead to financial hardship for peopleusing health services. This report brings together for the first time dataon unmet need and financial hardship to assess whether people living inEurope can afford to pay for health care. Drawing on contributions fromnational experts in 24 countries, the report shows that financial hardshipvaries widely in Europe, and that there is room for improvement even inhigh-income countries that provide the whole population with access topublicly financed health services. Catastrophic health spending is heavilyconcentrated among the poorest households in all of the countries in thestudy. Where financial protection is relatively weak, catastrophic spendingis mainly driven by out-of-pocket payments for outpatient medicines. Health systems with strong financial protection and low levels of unmetneed share the following features: there are no large gaps in healthcoverage; coverage policy – the way in which coverage is designed,implemented and governed – is carefully designed to minimize accessbarriers and out-of-pocket payments, particularly for poor people andregular users of health services; public spending on health is high enough toensure relatively timely access to a broad range of health services withoutinformal payments; and as a result, out-of-pocket payments are low, accounting for less than or close to 15% of current spending on health. Gaps in coverage arise from weaknesses in the design of three policyareas: population entitlement, the benefits package and user charges (copayments). The report summarizes actions that can reduce unmet needand financial hardship by strengthening coverage policy. It also highlightsactions that should be avoided.

Catastrophic health spending in Europe: equity and policy implications of different calculation methods.

OBJECTIVE: To investigate the equity and policy implications of different methods to calculate catastrophic health spending. METHODS: We used routinely collected data from recent household budget surveys in 14 European countries. We calculated the incidence of catastrophic health spending and its distribution across consumption quintiles using four methods. We compared the budget share method, which is used to monitor universal health coverage (UHC) in the sustainable development goals (SDGs), with three other well-established methods: actual food spending; partial normative food spending; and normative spending on food, housing and utilities. FINDINGS: Country estimates of the incidence of catastrophic health spending were generally similar using the normative spending on food, housing and utilities method and the budget share method at the 10% threshold of a household's ability to pay. The former method found that catastrophic spending was concentrated in the poorest quintile in all countries, whereas with the budget share method catastrophic spending was largely experienced by richer households. This is because the threshold for catastrophic health spending in the budget share method is the same for all households, while the other methods generated effective thresholds that varied across households. The normative spending on food, housing and utilities method was the only one that produced an effective threshold that rose smoothly with total household expenditure. CONCLUSION: The budget share method used in the SDGs overestimates financial hardship among rich households and underestimates hardship among poor households. This raises concerns about the ability of the SDG process to generate appropriate guidance for policy on UHC.

Financial protection in high-income countries: a comparison of the Czech Republic, Estonia and Latvia

This report compares financial protection across 3 countries that are similar in many ways but experience very different levels of financial hardship. The incidence of catastrophic and impoverishing out-of-pocket payments is low in Czechia, much higher in Estonia and among the highest in the WHO European Region in Latvia. Differences in financial hardship are partly explained by variations in health spending across the 3 countries. An increase in public spending on health in Estonia and Latvia would help to lower the out-of-pocket share of total spending on health. Coverage policy – the way in which health coverage is designed and implemented – is an equally important explanatory factor. The weak design of user charges (co-payments) for outpatient medicines in Estonia and Latvia shifts health-care costs onto those who can least afford to pay: poor people, people with chronic conditions and older people. In contrast, co-payment policy in Czechia is relatively strong: co-payments are used sparingly; they are set as a low fixed co-payment rather than a percentage of price; vulnerable people are exempt; and there is a cap on all co-payments for everyone. As a result, catastrophic incidence is low, outpatient medicines are accessible and pensioners do not experience undue financial hardship.

The Hungarian Care Managing Organization Pilot Program.

OBJECTIVES: The aim of this article was to provide a description of the Hungarian care managing organization (CMO) pilot program and its environment, incentive structure, and preliminary outcomes. The need to change the behavior of doctors to increase the effectiveness and cost-effectiveness of the system was the key rationale for the Hungarian CMO pilot program. METHODS: After an application process, nine CMOs were entitled to enter into the system in July 1999. By 2006, there were 14 CMOs covering 2.1 million people. The Hungarian CMO program tried to combine the advantages of both the US managed care programs and the UK general practitioner fundholding system, within the constraints and opportunities of a Central-European country committed to a single-payer health insurance system. RESULTS: The revenue of CMOs derived from a risk-adjusted capitation. The capitation formula was weighted only by age and sex. The expenditures of the CMOs included all the health expenditures on their patients that occurred in any part of the health care system. The average savings rate for all CMOs for the fiscal years 1999 to 2007 was 4.94%. The highest rates of savings were realized in chronic and acute inpatient care and medical devices. The pilot was discontinued in 2008 without a comprehensive evaluation of the experience. CONCLUSIONS: We can conclude that this pilot had a significant contribution to the modernization of the Hungarian health care system.

Экономический кризис, системы здравоохранения и здоровье населения в Европе: Последствия и значение для выработки политики

Экономические потрясения представляют угрозу для здоровья населения и деятельности системы здравоохранения, поскольку они приводят к росту потребности населения в услугах здравоохранения, но ограничивают доступ к медицинской помощи. Данная ситуация сопровождается сокращениямигосударственных расходов на дравоохранение и другие социальные нужды. Однако при использовании своевременных стратегических действий этих негативных последствий можно избежать. Ответные меры систем здравоохранения имеют большое значение, несмотря на то, что важные рычаги государственной политики находятся за пределами сектора здравоохранения в сфере ответственности руководителей бюджетной политики и социальной защиты. В рамках данной публикации рассмотрены ответные меры систем здравоохранения европейских стран на сложности, возникшие в результате финансового и экономического кризиса, начавшегося в 2008 г. На основе опыта более 45 стран авторы: анализируют ответные меры систем здравоохранения на кризис в трех стратегических областях: 1) государственное финансирование сектора здравоохранения; 2) охват государственными услугами здравоохранения; 3) планирование, закупка и предоставление услуг здравоохранения; оценивают последствия этих ответных мер для систем здравоохранения и здоровья населения; определяют меры политики, которые могут способствовать стабилизациидеятельности систем здравоохранения, столкнувшихся с бюджетными проблемами; исследуют меры стратегической экономии внедрения реформ в условиях кризиса. Данное издание предоставляет необходимую информацию для понимания возможностей, имеющихся у руководителей, и последствий неспособности обеспечить защиту состояния здоровья населения или устойчивость деятельности систем здравоохранения в условиях экономического шока или другого рода потрясений.

Economic crisis, health systems and health in Europe: country experience

The financial and economic crisis has had a visible but varied impact on many health systems in Europe, eliciting a wide range of responses from governments faced with increased financial and other pressures. This book maps health system responses by country, providing a detailed analysis of policy changes in nine countries and shorter overviews of policy responses in 47 countries. It draws on a large study involving over 100 health system experts and academic researchers across Europe. Focusing on policy responses in three areas – public funding of the health system, health coverage and health service planning, purchasing and delivery – this book gives policy-makers, researchers and others valuable, systematic information about national contexts of particular interest to them, ranging from countries operating under the fiscal and structural conditions of international bailout agreements to those that, while less severely affected by the crisis, still have had to operate in a climate of diminished public sector spending since 2008. Along with a companion volume that analyses the impact of the crisis across countries, this book is part of a wider initiative to monitor the effects of the crisis on health systems and health, to identify those policies most likely to sustain the performance of health systems facing fiscal pressure and to gain insight into the political economy of implementing reforms in a crisis.