Health system

The proportion of the population pushed further below a poverty line by household health expenditures corresponds to the proportion of poor people spending any amount on health out-of-pocket in the total population. Household consumption or income, out-of-pocket expenditures on health, and poverty lines are all measured by their daily value per capita. The poor are identified as those people living in households with total household consumption or income inclusive of any health spending below the poverty line. The household’s sample weight multiplied by the household size is used to obtain representative numbers per person. If the sample is self-weighting, then only the household size is used as the weight. The relative poverty line is country-specific and is defined as 60% of the median daily per capita consumption or income in each country. It is used to demonstrate the interdependency between SDG target 1.2, reduction of poverty everywhere and SDG target 3.8 (Universal Health Coverage).

Out-of-pocket expenditure, Financial protection in health, Impoverishing health spending

Global, regional, national, place of residence (rural, urban), household age or sex, age composition of household

Impact

The proportion of the population pushed further below the poverty line by household health expenditures is computed as the ratio of the number of poor people spending any amount on health out-of-pocket in the total population. These poor people live in a household with consumption or income levels already below the poverty line before health payments and are thus further impoverished when incurring health out-of-pocket payments. The poor are identified as those people living in households with total household consumption or income inclusive of any out-of-pocket health spending below the poverty line. The relative poverty line is defined as 60% of the median daily household consumption or income per person. Household expenditure on health is defined as formal and informal payments made at the time of getting any type of care (promotive, curative, rehabilitative, palliative or long-term care) provided by any type of provider. These payments include the part not covered by a third party such as the government, health insurance fund or private insurance but exclude insurance premiums as well as any reimbursement by a third party. They might be financed by income, including remittance, savings or borrowings. With this definition, health expenditures are labelled Out-Of-Pocket (OOP) payments in the classification of health care financing schemes (HF) of the International Classification for Health Accounts (ICHA). The relative poverty line is specific to each country. It is not possible to eliminate further impoverishment due to out-of-pocket health spending using a relative poverty line, but it is possible to reduce it. To this end, out-of-pocket health expenditures should not be a major driver of economic disadvantage relative to others in society. Ultimately the choice of the poverty line should be tailored to inform evidence-based policy changes at global, regional and national levels. Using national and regional poverty lines is critical to fully understanding the impact of out-of-pocket payments on poverty at national and regional levels. The total population incurring impoverishing health expenditures correspond to those pushed* and pushed further into poverty by out-of-pocket health spending. The population pushed further below a poverty line can be disaggregated as follows if the survey has been designed to provide representative estimates and/or there are enough observations at such levels: “rural” and “urban”; sex of the head of the household (male/female); Age of the head of the household (below 60 years old/ 60 years or older); age composition of the household: “Adults only (20-59 years old)” - households that consist of members aged between 20 and 59 years old; “Adults with children and adolescents (below 60 years old members)” - households that consist of members aged below 60 only as follows: at least one member below 20 years old AND at least one member aged between 20 and 59 years old; “Multigenerational households (all ages)” - households that include at least one person below 20 years old AND at least one person aged between 20 and 59 years old AND at least one person >= 60 years old; “Adults with older persons (from 20 years old)” - households that consist of members aged >=20 only as follows: at least one person aged between 20 and 59 years old AND at least one person >= 60 years old; “Only older adults (>=60 years old)” - households that consist of members aged >=60 years old only; “Only members below 20 years old” - households that consist of members aged below 20 years old only. In this classification, children are defined as those aged below 10 years, adolescents are those between 10 and 19 years old, and older persons/adults are at least 60 years old. Other types of disaggregation are possible, for example, by quintiles of the household welfare measures (total household consumption expenditure or income). Indicators of impoverishment due to spending on health are not part of the official SDG indicator of Universal Health Coverage (UHC) per se but relate UHC to the first SDG goal, namely, ending poverty in all its forms everywhere. *See the metadata for the population pushed into poverty by out-of-pocket health spending.

The global and regional incidence of the proportion of the population pushed further below the relative poverty line by household health expenditures is estimated as the population-weighted average of the country-level share of people pushed further into poverty by health expenditures for a reference year. Incidence at the country level for the reference year is estimated using different methods depending upon the availability of information for that country around or at the reference year (T*). In countries for which there is an observed incidence rate of further impoverishment by health expenditures at the relative poverty line in the reference year T*, this point is used. When there are at least two observed incidence rates of the population further impoverished by health expenditures around the reference year over a 5-year window [T*–5; T*+5], linear interpolation is used to project the value of the proportion of “the population pushed further below the relative poverty line by household health expenditures” in the reference year. If these conditions are not met but there are at least two observed incidence rates of the of the population further impoverished by health expenditures, a multilevel model of the rate of the population further impoverished below the relative poverty line by health expenditures is estimated using the aggregate share of OOP over total consumption expenditure and the share of the population under the relative poverty line as the explanatory variables if that information is available. If such information is not available or there aren’t two incidence rates of the population further impoverished by health expenditure, the incidence rate is imputed in the reference year with the median incidence in that year among countries within the same income group (low, lower-middle, upper-middle, or high) as classified by the World Bank. If such classification is missing, the regional median impoverishment value is used. The regional classification used for the imputation is M49 level 1. The country estimates for the reference year are then aggregated up to the regional and global levels to get the number of people pushed below the relative poverty line by household health expenditures. Global and regional aggregates are expressed in million or per cent of the relevant population. Global and regional rates are calculated by expressing these numbers as a share of the relevant population, equivalent to taking a population-weighted average of the relevant country rates.

Every 2-3 years

Every 1–5 years depending on implementation of population-based household expenditure surveys led by national statistics offices

uhc_stats@who.int

Dr. Gabriela Flores

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