We must change how we measure the impact of health spending on poor people if we are serious about “leaving no one behind”

To mark universal health coverage (UHC) day today, world leaders are being urged to keep the promises they made in a landmark political declaration signed at the United Nations high-level meeting on UHC earlier this year, in September. A key promise is to leave no one behind—to reach poor people and others who are vulnerable first—when trying to ensure that everyone can use quality health services without financial hardship.

Keeping this promise requires indicators that are sensitive to what is happening among poor people. That is why the WHO Regional Office for Europe has developed new metrics to measure financial protection—the protection health systems offer people against financial hardship caused by out-of-pocket payments. [1] We have done so because of evidence that existing metrics used to monitor financial protection globally, including Sustainable Development Goal (SDG) 3.8.2, are of limited relevance for developing policies to leave no one behind. [2-4]

Financial protection is commonly measured using two indicators:

  • impoverishing health spending, which provides information on the impact of out-of-pocket payments on poverty; and
  • catastrophic health spending, which occurs when the amount a household pays out-of-pocket exceeds a predefined share of its resources; this may mean the household can no longer afford to meet other basic needs.

The global metrics used to measure impoverishing and catastrophic health spending pose challenges for identifying inequalities in financial protection in two main ways. 

First, global measurement of impoverishing health spending fails to count people who are poor and pay out-of-pocket when using health services. Imagine if, when measuring poverty, we counted only those who crossed the poverty line and not people already below the line. We would be counting a vulnerable group of people—those who become poor—but we would miss the main point of poverty measurement, which is to find out how many people are poor.

The current approach to measuring impoverishing health spending at global level counts only those who cross the poverty line after out-of-pocket payments—impoverished households. Based on this approach, global analysis carried out by WHO and the World Bank finds that between 1.2% and 2.5% of people globally were impoverished by out-of-pocket payments in 2015, depending on the poverty line used. [5]

WHO Europe counts people who cross a poverty line and people who are already poor and whose poverty is made worse by out-of-pocket payments—further impoverished households. When we count both types of household, we find that out-of-pocket payments push some households into poverty (between 0.1% and 3.5% across countries), but the share of poor households made even poorer by out-of-pocket payments is almost always larger (between 0.3% and 6.8%). [1] If we did not count further impoverished households, we would be ignoring the financial hardship out-of-pocket payments cause people who are already poor.

Second, global measurement of catastrophic health spending assumes all people experience financial hardship after spending the same share of their budget on health. The SDG indicator for financial protection (SDG 3.8.2) assumes rich and poor alike experience catastrophic health spending when they spend at least 10% of their budget on health, even though rich people would still have plenty left to spend on other things, unlike poor people. Using this measure, catastrophic health spending is often concentrated among the rich, providing counter-intuitive evidence for policy. [2,3]

SDG 3.8.2 is deficient for a simple reason: poor people spend proportionately more of their resources on food and housing than rich people, which leaves them with proportionately less to spend on other basic needs. Indicators that ignore this fact will underestimate financial hardship among poor people and overestimate financial hardship among rich people.

In contrast, the capacity to pay approach used by WHO Europe recognises that households need to spend a sufficient amount on basic needs such as food, housing and utilities before they can pay for health care. In our approach, rich people must spend proportionately more of their budget than poor people to be counted as experiencing catastrophic health spending. As a result, we find that catastrophic health spending is consistently concentrated among poor people, providing a clear signal for policy action. [1]

The metrics currently used to measure financial protection at global level fall short because they are not sufficiently sensitive to financial hardship among poor people. Successive global monitoring reports have acknowledged this limitation, but continue to use metrics that are unlikely to justify pro-poor policy responses. To keep the promise of leaving no one behind, countries need to be able to benefit the most disadvantaged people first, with the help of indicators and metrics amenable to equity analysis.

Sarah Thomson is Senior Health Financing Specialist at the WHO Barcelona Office for Health Systems Strengthening, Barcelona, Spain. @sarahmsthomson

Tamás Evetovits is Head of the WHO Barcelona Office for Health Systems Strengthening, Barcelona, Spain. @TamasEvetovits

Jonathan Cylus is Coordinator of the London Hub of the European Observatory on Health Systems and Policies, London, UK. @joncylus

Competing interests: None declared


  1. WHO Regional Office for Europe (2019). Can people afford to pay for health care? New evidence on financial protection in Europe. Copenhagen: WHO Regional Office for Europe. 
  2. WHO, World Bank (2017). Tracking universal health coverage: 2017 global monitoring report. Geneva: World Health Organization.
  3. Cylus J, Thomson S, Evetovits T (2018). Catastrophic health spending in Europe: equity and policy implications of different calculation methods. Bull World Health Organ. 96:589–664.
  4. Reflections of the Civil Society Engagement Mechanism for UHC2030 on the Primary Health Care on the Road to Universal Health Coverage 2019 Monitoring Report.
  5. WHO, World Bank (2019). Global Monitoring Report on Financial Protection in Health. Geneva: World Health Organization.