Out-of-pocket payments lead to catastrophic health spending in nearly 1 in 10 households (9%) in Montenegro, a new WHO study shows. While the country has made significant strides in addressing gaps in coverage and reducing barriers to accessing health care, catastrophic health spending can prevent people from meeting other basic needs such as food, housing and heating.
“Can people afford to pay for health care? New evidence on financial protection in Montenegro” is the first in-depth analysis of affordable access to health care (financial protection) in Montenegro. It is part of a broader project to strengthen health financing policy in the Western Balkans led by the WHO Barcelona Office for Health Systems Financing and funded by the European Commission’s Directorate-General for Enlargement and Eastern Neighbourhood (DG ENEST).
Medicines driving financial hardship
The study shows that the incidence of catastrophic health spending in Montenegro is higher than in many European Union (EU) countries, Bosnia and Herzegovina, and North Macedonia, but lower than in Albania, Greece and Serbia. It is particularly high in households in the poorest fifth of the population (33%) and households headed by people who are unemployed (18%) or not economically active (15%).
Catastrophic health spending in Montenegro is largely driven by outpatient medicines, followed by medical products (such as hearing aids and glasses) and outpatient care (primary care visits and consultations with specialists)
“Montenegro’s heavy reliance on out-of-pocket payments for health care poses a major challenge to progress towards universal health coverage,” says Marco Chiapuso, Programme Manager at DG ENEST. “Ensuring that everyone can access quality health care without facing financial hardship is essential not only for health system resilience but also for aligning with EU standards, a key step for Montenegro on its path to EU membership.”
Coverage policy
WHO’s new report identifies aspects of coverage policy in Montenegro that are associated with stronger financial protection. For example, entitlement to publicly financed health care is based on residence, rather than being linked to payment of contributions which often excludes people in the informal sector.
Another positive aspect is that although user charges (copayments) are widely applied, which is likely to be a barrier to access, children, older people and people with very low incomes are exempt from most copayments.
Despite these positive features, the report finds that weaknesses in the design of coverage policy and in the purchasing and supply of outpatient medicines prevent Montenegro from protecting people with low incomes from financial hardship.
Making health care more affordable
Building on recent steps to address gaps in coverage, the government of Montenegro can now focus on reducing out-of-pocket payments for people with low incomes or chronic conditions.
Weaknesses in the coverage, purchasing and supply of outpatient medicines can be addressed by:
- expanding coverage of medicines to include common chronic conditions and indications;
- allowing people to obtain covered medicines from any pharmacy in the country;
- regulating the price of non-covered medicines; and
- reducing the prevalence of avoidable copayments caused by internal reference pricing (for example, by requiring doctors and pharmacists to prescribe and dispense medicines priced at or below the reference price, making sure these medicines are always available in pharmacies, and exempting people with low incomes or chronic conditions from internal reference pricing).
The negative impact of copayments can be mitigated by:
- abolishing percentage copayments or replacing them with low, fixed copayments to increase transparency and financial certainty for people;
- removing administrative barriers to ensure that everyone who is eligible for exemptions receives them;
- introducing a cap on all copayments, ideally linked to income to provide greater protection for people with low incomes; and
- improving the health insurance fund’s monitoring and use of data on copayments (including on avoidable copayments due to internal reference pricing) and the uptake of exemptions.
Other gaps in coverage can be addressed by:
- expanding non-emergency dental care for working-aged people with lower incomes;
- expanding coverage of medical products; and
- removing remaining barriers to entitlement, such as the requirement for people to be registered with the health insurance fund before accessing health care, and extending entitlements for people with short-term resident permits (under 1 year).
Taking these steps to reduce financial hardship and unmet need, particularly for people with low incomes or chronic conditions, will benefit from 2 important supporting actions: first, strengthening the availability and use of data by the Ministry of Health and the health insurance fund; and second, ensuring that public spending on health grows in line with population health needs and gross domestic product (GDP).
About the report
The report covers the period from 2006 to 2025. It draws on data from the Montenegro household budget survey from 2006 to 2015, 2017, and 2021 (the latest available year); data on unmet need for health care up to 2022 (the latest available year); and information on health coverage (population coverage, service coverage and user charges) up to January 2025.
WHO/Europe monitors affordable access to health care (financial protection) through the WHO Barcelona Office, using regional indicators that are sensitive to equity. Financial protection is central to universal health coverage (UHC) and a key dimension of health system performance assessment. It is an indicator of the Sustainable Development Goals and part of the European Pillar of Social Rights, and is at the heart of the European Programme of Work, WHO/Europe’s strategic framework.
You can explore our data and analysis on “UHC watch”, a digital platform tracking progress on affordable access to health care in Europe and Central Asia.