[This post by Gonzalo Fanjul, ISGlobal's Policy Director, was published in the El País blog 3.500 Milliones on May 10, 2019]
When the policy makers who developed the 2030 Agenda set universal health coverage (UHC) as a global target, few of them had European countries in mind. Europe, even more than the world's other highly developed regions, is characterised throughout most of the region by a model of financial and social protection that guarantees everyone the fundamental right to a decent life in terms of health. Europe is synonymous with universal health care and the European social model is based, in part, on the right of every person to quality health care.
Co-payments and gaps in health care coverage push millions of Europeans into poverty every year
The reality, however, is less idyllic. A recent report by the World Health Organisation (WHO) has questioned the notion that UHC is an indisputable reality in Europe. The report is based on data from twenty-four countries in the region—inside and outside the European Union—encompassing a broad range of income levels and health systems of varying levels of robustness. It analysed two fundamental indicators of financial protection in health: impoverishing health expenditure and catastrophic health expenditure. In both cases, the aim is to gauge the effect on households of inadequate or non-existent coverage which obliges the patient to pay out-of-pocket expenses and co-payments. Outlay on uncovered health costs can push a family below the poverty line (impoverishing health expenditure) or have a crippling effect on their margin for manoeuvre once subsistence needs like housing, food and services have been met (catastrophic expenditure).
This is the first time a study of this type has measured financial hardship based on the actual capacity to pay of households. This approach overcomes the methodological limitations of using global indicators, such as those established by the Sustainable Development Goals, and takes into account the particularities of a developed region. And, the results reported by the WHO are cause for concern:
- The incidence of impoverishing health spending ranges from 0.3% in Slovenia to 9% in Ukraine. Certain EU countries, including Poland and Hungary, have an incidence between 4% and 6% of households.
- Weak financial protection leads to catastrophic expenditure for one in 11 Greek and one in 12 Portuguese households. The highest incidence of catastrophic expenditure is found in Moldova, where it is 17%.
- This phenomenon affects the poorest population quintiles disproportionately. In some cases, that of medicines for instance, the expense obliges families to cut back on other essential spending. In other cases, such as that of dental care, the consequence is simply to dispense with the required health service they cannot afford.
- Countries with better financial protection have high scores on some obvious measures, such as the expansion of the range of treatments covered. But other factors also play a key role: a cap on co-payments (which represent under 15% of total health expenditure), free access for the most vulnerable social groups, and extending access to health care to populations that are excluded in other countries, such as undocumented migrants and Roma communities.
Outlay on uncovered health costs can push a family below the poverty line or have a crippling effect on their margin for manoeuvre once subsistence needs
The question of medicines deserves a separate mention. The unjustified price of many drugs imposes an ever less sustainable burden on our health care systems overall. But when this burden falls on the shoulders of families at social risk, the situation borders on the obscene. While the WHO does not mention this aspect, the conclusions of their report raise an obvious question: what more evidence do we need before we consider reforming the model for pharmaceutical innovation and access to essential medicines?
The lack of financial protection in health care condemns millions of Europeans to a worse life. Monitoring financial protections can provide a reliable measure of the growing inequality and vulnerability in our region. And the fact that such protection is lacking raises fundamental questions about our current social model. As highlighted by Caritas this week in an uncompromising report on the situation in Spain, the notion that we can trust everything to the creation of employment is erroneous. First, because the precariousness of contracts and wages increases the risk of household poverty. Second, because the strength of a welfare state is based on its ability to create fair, effective and universal safety nets that are not solely dependent on the individual’s social welfare contributions.
Monitoring financial protections can provide a reliable measure of the growing inequality and vulnerability
Europe must lead the international community in the expansion of a model that has brought dignity to our societies, a model that is one of the common goods most valued by people. The best way to do this is to lead by example and to correct the serious shortcomings the WHO warns of in this report.
[Photos by Dmitri Bayer and Olga Guryanova at Unsplash]