{"id":46257,"date":"2019-12-12T12:46:13","date_gmt":"2019-12-12T11:46:13","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=46257"},"modified":"2019-12-16T11:27:02","modified_gmt":"2019-12-16T10:27:02","slug":"we-must-change-how-we-measure-the-impact-of-health-spending-on-poor-people-if-we-are-serious-about-leaving-no-one-behind","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/12\/12\/we-must-change-how-we-measure-the-impact-of-health-spending-on-poor-people-if-we-are-serious-about-leaving-no-one-behind\/","title":{"rendered":"We must change how we measure the impact of health spending on poor people if we are serious about \u201cleaving no one behind\u201d"},"content":{"rendered":"<p><span style=\"font-weight: 400\">To mark universal health coverage (UHC) day today<\/span><span style=\"font-weight: 400\">, world leaders are being urged to keep the promises they made in a landmark <\/span><a href=\"https:\/\/undocs.org\/en\/A\/RES\/74\/2\"><span style=\"font-weight: 400\">political declaration<\/span><\/a><span style=\"font-weight: 400\"> signed at the United Nations high-level meeting on UHC earlier this year, in September. A key promise is to leave no one behind\u2014to reach poor people and others who are vulnerable first\u2014when trying to ensure that everyone can use quality health services without financial hardship.<\/span><\/p>\n<p><span style=\"font-weight: 400\">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\u2014the 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]<\/span><\/p>\n<p><span style=\"font-weight: 400\">Financial protection is commonly measured using two indicators:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400\"><b>impoverishing health spending<\/b><span style=\"font-weight: 400\">,<\/span> <span style=\"font-weight: 400\">which provides information on the impact of out-of-pocket payments on poverty; and<\/span><\/li>\n<li style=\"font-weight: 400\"><b>catastrophic health spending<\/b><span style=\"font-weight: 400\">, 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.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-weight: 400\">The global metrics used to measure impoverishing and catastrophic health spending pose challenges for identifying inequalities in financial protection in two main ways.\u00a0<\/span><\/p>\n<p>First, global measurement of impoverishing health spending fails to count people who are poor and pay out-of-pocket when using health services. <span style=\"font-weight: 400\">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\u2014those who become poor\u2014but we would miss the main point of poverty measurement, which is to find out how many people are poor.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The current approach to measuring impoverishing health spending at global level counts only those who cross the poverty line after out-of-pocket payments\u2014<\/span><i><span style=\"font-weight: 400\">impoverished<\/span><\/i><span style=\"font-weight: 400\"> households. Based on this approach, global analysis carried out by WHO and the World Bank finds that between 1.2% and 2.5% of peop<\/span><span style=\"font-weight: 400\">le globally were impoverished by out-of-pocket payments in 2015, depending on the poverty line used. [5]<\/span><\/p>\n<p><span style=\"font-weight: 400\">WHO Europe counts people who cross a poverty line <\/span><i><span style=\"font-weight: 400\">and<\/span><\/i><span style=\"font-weight: 400\"> people who are already poor and whose poverty is made worse by out-of-pocket payments\u2014<\/span><i><span style=\"font-weight: 400\">further impoverished<\/span><\/i><span style=\"font-weight: 400\"> 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 payme<\/span><span style=\"font-weight: 400\">nts cause people who are already poor.<\/span><\/p>\n<p>Second, global measurement of catastrophic health spending assumes all people experience financial hardship after spending the same share of their budget on health. <span style=\"font-weight: 400\">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, catastroph<\/span><span style=\"font-weight: 400\">ic health spending is often concentrated among the rich, providing counter-intuitive evidence for policy. [2,3]<\/span><\/p>\n<p><span style=\"font-weight: 400\">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.<\/span><\/p>\n<p><span style=\"font-weight: 400\">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]<\/span><\/p>\n<p><span style=\"font-weight: 400\">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<\/span><span style=\"font-weight: 400\"> global monitoring reports have acknowledged this limitation, but continue to use metrics that are unlikely to justify pro-poor policy responses. <\/span><span style=\"font-weight: 400\">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.<\/span><\/p>\n<p><em><b>Sarah Thomson<\/b><span style=\"font-weight: 400\"> is Senior Health Financing Specialist at the WHO Barcelona Office for Health Systems Strengthening, Barcelona, Spain. @sarahmsthomson<\/span><\/em><\/p>\n<p><em><b>Tam\u00e1s Evetovits<\/b><span style=\"font-weight: 400\"> is Head of the WHO Barcelona Office for Health Systems Strengthening, Barcelona, Spain. @TamasEvetovits<\/span><\/em><\/p>\n<p><em><b>Jonathan Cylus<\/b><span style=\"font-weight: 400\"> is Coordinator of the London Hub of the European Observatory on Health Systems and Policies, London, UK. @joncylus<\/span><\/em><\/p>\n<p><em><b>Competing interests: <\/b>None declared<\/em><\/p>\n<p><b>References:<\/b><\/p>\n<ol>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">WHO Regional Office for Europe (2019). <\/span><a href=\"http:\/\/www.euro.who.int\/en\/health-topics\/Health-systems\/health-systems-financing\/publications\/2019\/can-people-afford-to-pay-for-health-care-new-evidence-on-financial-protection-in-europe-2019\"><span style=\"font-weight: 400\">Can people afford to pay for health care? New evidence on financial protection in Europe<\/span><\/a><span style=\"font-weight: 400\">. Copenhagen: WHO Regional Office for Europe.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">WHO, World Bank (2017). <\/span><a href=\"http:\/\/www.who.int\/healthinfo\/universal_health_coverage\/report\/2017\/en\"><span style=\"font-weight: 400\">Tracking universal health coverage: 2017 global monitoring report<\/span><\/a><span style=\"font-weight: 400\">. Geneva: World Health Organization.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">Cylus J, Thomson S, Evetovits T (2018). <\/span><a href=\"http:\/\/www.euro.who.int\/en\/health-topics\/Health-systems\/health-systems-financing\/publications\/2018\/catastrophic-health-spending-in-europe-equity-and-policy-implications-of-different-calculation-methods-2018\"><span style=\"font-weight: 400\">Catastrophic health spending in Europe: equity and policy implications of different calculation methods<\/span><\/a><span style=\"font-weight: 400\">. Bull World Health Organ. 96:589\u2013664.<\/span><\/li>\n<li style=\"font-weight: 400\"><a href=\"https:\/\/csemonline.net\/project\/csem-commentary-on-gmr\/\"><span style=\"font-weight: 400\">Reflections of the Civil Society Engagement Mechanism for UHC2030 on the Primary Health Care on the Road to Universal Health Coverage 2019 Monitoring Report<\/span><\/a><span style=\"font-weight: 400\">.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">WHO, World Bank (2019). <\/span><a href=\"https:\/\/www.who.int\/healthinfo\/universal_health_coverage\/report\/fp_gmr_2019.pdf?ua=1\"><span style=\"font-weight: 400\">Global Monitoring Report on Financial Protection in Health<\/span><\/a><span style=\"font-weight: 400\">. Geneva: World Health Organization.<\/span><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>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 [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2019\/12\/12\/we-must-change-how-we-measure-the-impact-of-health-spending-on-poor-people-if-we-are-serious-about-leaving-no-one-behind\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":42516,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[263],"tags":[],"class_list":["post-46257","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-global-health"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>We must change how we measure the impact of health spending on poor people if we are serious about \u201cleaving no one behind\u201d - 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