Medical expenditures: not the only source of financial hardship – Authors' reply
Authors: Adam Wagstaff, Sven Neelsen
Journal: The Lancet Global Health (2020)

In his Correspondence on our article on assessing progress towards universal health coverage (UHC),1Wagstaff A Neelsen S A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar Knut Lönnroth points to the fact that the measure of financial protection we use—and the World Bank and WHO jointly use in their official monitoring of progress towards the UHC Sustainable Development Goals2WHOWorld BankGlobal monitoring report on financial protection in health 2019. World Health Organization, Geneva2019Google Scholar—focuses on out-of-pocket health expenditures that households incur when using health services. Lönnroth notes that, when households use health services, they incur other costs (eg, travel, food, and accommodation) and that health events often lead to reductions in a household's income. He suggests that these costs be seen as part of the concept of financial protection and that UHC monitoring exercises should use the term financial protection cautiously unless and until these additional costs are captured. We agree that health service use entails costs such as travel expenses and that health events entail income losses as well; we have written extensively on health-related income losses ourselves.3Wagstaff A The economic consequences of health shocks: evidence from Vietnam.J Health Econ. 2007; 26: 82-100Crossref PubMed Scopus (135) Google Scholar, 4Wagstaff A Lindelow M Are health shocks different? Evidence from a multishock survey in Laos.Health Econ. 2014; 23: 706-718Crossref PubMed Scopus (27) Google Scholar, 5Neelsen S Limwattananon S O'Donnell O van Doorslaer E Universal Health Coverage: a (social insurance) job half done?.World Develop. 2019; 113: 246-258Crossref Scopus (5) Google Scholar However, the use of the term financial protection in the context of UHC monitoring is intentionally narrow and is shorthand for “financial protection against the expenditures associated with using health services”. This definition follows from that of UHC, which requires that everyone, irrespective of their ability to pay, gets the health services they need without suffering undue financial hardship in the process.6Boerma T Eozenou P Evans D Evans T Kieny M-P Wagstaff A Monitoring progress towards Universal Health Coverage at country and global levels.PLoS Med. 2014; 11e1001731Crossref PubMed Scopus (132) Google Scholar We would argue for keeping UHC monitoring focused narrowly on health service use and the associated expenditures and for keeping to a narrow definition of financial protection as financial protection in health service use. It is a goal well within the reach of a health ministry. Lönnroth's broader definition is about financial protection against the entire range of costs associated with adverse health events—it is about financial protection in health, rather than in health service use. Achieving financial protection in health requires action well beyond the reach of health ministries and UHC; it takes us into the world of informal insurance and coping strategies, such as borrowing and drawing on savings, and social protection.5Neelsen S Limwattananon S O'Donnell O van Doorslaer E Universal Health Coverage: a (social insurance) job half done?.World Develop. 2019; 113: 246-258Crossref Scopus (5) Google Scholar UHC should remain focused on the use of health services, rather than on health outcomes, and on the expenditures associated with health service use, rather than on the overall costs of adverse health events. It is not so much a question of being cautious about the use of the term financial protection in UHC monitoring, but rather of being clear that it means financial protection in health services, not financial protection in health. We declare no competing interests. A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational studyProgress towards UHC can be tracked using an index that captures both service coverage and financial protection. Although per-capita income is a good predictor of a country's UHC index score, some countries perform better than others in the same income group or even in the income group above their own. Strong UHC performance is correlated with the share of a country's health budget that is channelled through government and social health insurance schemes. Full-Text PDF Open AccessMedical expenditures: not the only source of financial hardshipAdam Wagstaff and Sven Neelsen's composite service coverage and financial protection index (January, 2020)1 moves the universal health coverage (UHC) monitoring evolution forwards while the debate continues on what services to include and how to operationalise effective coverage.2 However, the question of what constitutes financial protection seems to receive much less attention. Wagstaff and Neelsen casually refer to the UHC aim to ensure that “families who get needed services do not suffer undue financial hardship” without raising the question of what financial hardship is or which of its dimensions UHC could mitigate. Full-Text PDF Open Access