Population with impoverishing health expenditures, at a relative poverty line (60% of median daily per capita consumption or income)

Percent

Health system

The proportion of the population with a household’s total expenditure or income, including household expenditure on health, is at or above the poverty line, but the household’s total consumption expenditure or income, excluding household expenditure on health, is below the poverty line. Household consumption or income, household expenditures on health, and the relative poverty line are all measured by their daily value per capita. 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)

Impact

The proportion of the population pushed below the poverty line by household health expenditures (impoverished by health expenditures) corresponds to the increase in the poverty headcount ratio after household expenditures on health. Poverty is measured based on daily total household consumption expenditure or income gross and net of daily health care payments. The rationale is that out-of-pocket payments divert household spending away from non-medical budget items such as food and shelter to such an extent that, in some cases, a household’s position in relation to a pre-defined poverty line before and after spending out-of-pocket on health changes. Specifically, the poverty headcount ratio corresponds to the percentage of the population living below the poverty line. The relative poverty line is defined as 60% of the median daily household consumption or income per person. The increase in the poverty headcount ratio is computed as the difference in poverty headcount ratios based on the household’s total consumption expenditure or income gross and net health expenditures. Household expenditure on health is defined as formal and informal payments made at the time of getting any type of care (preventive, 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 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. The use of 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 population pushed below the poverty line can be disaggregated by area of residence (“rural”/”urban”). The total population incurring impoverishing health expenditures correspond to those pushed and pushed further* into poverty by household health expenditures which can be further disaggregated by the age of the head of the household, sex of the head of the household and age composition of the household. 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 further into poverty by household health expenditures.

The global and regional incidence of the proportion of the population pushed below the relative poverty line by household health expenditures is estimated as the population-weighted average of the country-level share of people pushed 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 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 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 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 impoverished by health expenditures, a multilevel model of the rate of the population 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 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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