The available dataset used to produce this report and to calculate the global and regional estimates of financial hardship has expanded since the 2021 report. This 2023 report relies on 987 primary estimates for 167 countries or territories on catastrophic OOP health spending (compared to 903 primary estimates in 2021) and 856 primary estimates for 146 countries or territories on impoverishing OOP health spending (compared to 816 primary estimates in 2021) (see Tables A10.1 and A10.2 below). Primary estimates are based on household surveys collected by countries’
national statistical offices on household OOP health expenditures and household total consumption expenditure or income. The additional primary estimates are used to produce regional and global estimates for the reference year 2019 that were not reported on previously and to update the regional and global estimates for the earlier reference years.
Altogether, the countries with validated primary estimates represent more than 92% of the world’s population; half of the data points were collected after 2009. Comparing population coverage across WHO Regions, current dataset covers countries accounting for more than 90% of the regional population aggregates.
Globally, on average, there were 5.9 and 5.8 estimates (survey-years) per country available for catastrophic and impoverishing health spending indicators, respectively (see Table A10.3). The highest number of countries with just one estimate (survey-year) was in the WHO Western Pacific Region, followed by the WHO Region of the Americas, for both catastrophic and impoverishing health spending indicators. On average, globally, the frequency of estimates was every 4.5–4.7 years, with the highest frequency in the WHO European Region (every three years) and the lowest frequency in the WHO African Region (every 6.5–6.6 years).
Table A10.1 Availability of survey-based estimates for catastrophic OOP health spending (SDG 3.8.2 indicators)
# observations # countries Median
year Median most
recent year Population coverage in 2019 (%)
Global 987 167 2010 2016 96.5
African Region 151 44 2010 2017 95.7
Region of the Americas 135 29 2010 2016 95.8
Eastern Mediterranean
Region 78 20 2011 2017 98.5
European Region 465 48 2009 2016 90.2
South-East Asia Region 77 10 2010 2017 98.7
Western Pacific Region 81 16 2012 2017 99.1
Non-Member States 0 0 0
Note: Data availability for global monitoring, which may not necessarily align with the availability of data at national or regional levels.
Source: Based on an analysis of the microdata from the Global database on financial protection assembled by WHO and the World Bank, 2023 (26,27).
110 Global monitoring report on financial protection in health 2021
Table A10.2 Availability of survey-based estimates for impoverishing OOP health spending (pushed and further pushed) at 2017 PPP US$ 2.15 a day level (SDG-related indicator of financial hardship)
# observations # countries Median
year Median most
recent year Population coverage in 2019 (%)
Global 856 146 2009 2016 92.4
African Region 121 41 2010 2016 95.7
Region of the Americas 122 24 2010 2016 95.9
Eastern Mediterranean
Region 67 16 2011 2016 98.5
European Region 437 47 2009 2016 90.2
South-East Asia Region 71 10 2010 2017 98.7
Western Pacific Region 38 8 2012 2018 99.1
Note: Data availability for global monitoring, which may not necessarily align with the availability of data at national or regional levels.
Source: Based on an analysis of the microdata from the Global database on financial protection assembled by WHO and the World Bank, 2023 (26,27).
Table A10.3 Average number and frequency of survey-based estimates for catastrophic and impoverishing OOP health spending (pushed and further pushed) at 2017 PPP US$ 2.15 a day level
Catastrophic OOP health spending (SDG 3.8.2 indicators)
Impoverishing OOP health spending at the 2017 PPP US$ 2.15 a day level (SDG- related indicator of financial hardship)
The average number of estimates per
country
% countries with just one
estimate
The average frequency of estimates (when more than one data point is available), in
years
The average number of estimates
per country
% countries
with just one estimate
The average frequency of estimates (when more than one data point is available), in
years
Global 5.9 16.2 4.7 5.8 14.8 4.5
African Region 3.4 11.4 6.6 3.0 14.6 6.5
Region of the
Americas 4.7 27.6 5.4 5.1 20.8 5.2
Eastern Mediterranean Region
3.9 15.0 5.2 4.2 12.5 4.4
European Region 9.7 10.4 3.0 9.2 10.4 3.0
South-East Asia
Region 7.7 20.0 3.8 7.2 20.0 3.7
Western Pacific
Region 5.1 37.5 3.5 4.0 40.0 4.1
Source: Based on an analysis of the microdata from the Global database on financial protection assembled by WHO and the World Bank, 2023 (26,27).
Annexes 111
Joint distribution of catastrophic and impoverishing OOP health spending
A sample of 801 surveys covering 145 countries23 was analysed for the joint distribution of catastrophic OOP health spending (at 10% threshold) and impoverishing OOP health spending (both for the population pushed into poverty and for the population further pushed into poverty) at a US$ 2.15 poverty line and a sample of 799 surveys covering 151 countries24 at a relative poverty line definition.
Household types
Three disaggregation characteristics were considered to compare catastrophic and impoverishing OOP health spending across different types of households. The first two characteristics focus on the households’ heads and distinguish individuals according to the sex of their households’ heads (female or male) for the first one, and to the age of their households’ heads (below 60 years, or 60 and above years) for the second one. The third characteristic aims to compare catastrophic health spending across households with different age compositions, for which four age-composition types were constructed: (i) the first age composition type includes households composed of people aged between 20 and 59 years. This age category includes only young adults and adults as per the latest recommended age classification (28), but is referred to simply as “adults only” hereafter. The three other age composition types have already been defined and correspond to: (ii) “multi-generational households” (include adults living with people below 20 years old, children (0 to 9 years old) and/
or adolescents (10 to 19 years old), as well as people aged 60 years old or more -older adults);
(iii) adults living with children and/or adolescents, i.e. households with members aged 59 years old at most, and referred to as “younger households”; and (iv) adults living with at least one older person (60 years and older) and referred to as “older and only older households” (this latter group also includes households composed of only older people).
For analyses by sex and age of the household’s head, data were available from 107 and 108 countries, respectively, with the most recent estimate available for the 2009–2020 period. In both samples, the median most recent year is 2016, representing 78% of the world population in 2019.25 For analysis by household’s age composition, data were available from 94 countries, with the most recent estimate available for the 2009–2020 period with a median most recent year of 2016.26
23 45 low income, 24 lower-middle income, 23 upper-middle income, and 47 high-income countries, based on the latest year of available estimates
24 47 low income, 24 lower-middle income, 22 upper-middle income, and 52 high-income countries, based on the latest year of available estimates
25 For the sex of households’ heads, among the 107 countries for which disaggregated data is available, 25 are low-income countries (where 86% of the 2019 population is represented), 36 lower-middle income (88%), 22 upper middle-income (74%) and 24 high-income countries (56%). For the age of households’ heads, among the 108 countries for which disaggregated data is available, 25 are low-income countries, 38 lower-middle-income, 23 upper-middle-income, and 22 high-income countries; 2019 population representations within each income group are similar to the ones observed with heads’ sex disaggregated data.
26 23 of these countries are low-income and 21 are upper-middle-income countries covering 81% and 74% of the 2019 population in each respective income group; 32 are lower-middle-income countries representing 41% of the 2019 population at that country income level; 18 are high-income but they account only for 27% of the 2019 high-income group population.
112 Global monitoring report on financial protection in health 2021