Medical expenditures: not the only source of financial hardship
Authors: Knut Lönnroth
Journal: The Lancet Global Health (2020)

Adam Wagstaff and Sven Neelsen's composite service coverage and financial protection index (January, 2020)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 (39) Google Scholar moves the universal health coverage (UHC) monitoring evolution forwards while the debate continues on what services to include and how to operationalise effective coverage.2Fullman N Lozano R Measurement matters: who and what counts on the road to universal health coverage.Lancet Glob Health. 2020; 8: e2-e3Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar 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. Out-of-pocket expenses are judged to be catastrophic if exceeding 10% of total household consumption. Not having catastrophic expenditure is then equated with financial protection. When displaying a dimension of UHC performance in this manner, all countries are nicely in the green and most have more than 90% financial protection. It is crucial to note that the financial protection part of this index only captures protection against one element of financial hardship: high medical expenditures. This is fully in line with the methods used in WHO's 2019 UHC monitoring report, in which out-of-pocket health spending is defined as "household spending on medicines, health products, outpatient and inpatient care services (including dental care) and other health services (such as medical laboratory services) that are not reimbursed by a third party".3WHOPrimary health care on the road to Universal Health Coverage—2019 global monitoring report. World Health Organization, Geneva2019Google Scholar However, financial hardship in times of ill health stems from more than just high medical expenditures. Other expenses (travel, food, accommodation, and so on) are often incurred when accessing care. Unpaid sick leave is often an important opportunity cost of attending medical services, which can constitute a much higher economic burden on households than out-of-pocket medical expenditures.4Lönnroth K Glaziou P Weil D Floyd K Uplekar M Raviglione M Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention.PLoS Med. 2014; 11e1001693Crossref PubMed Scopus (84) Google Scholar Income can also be lost because of disability, health-related discrimination, and regulated exclusion from the workplace, such as for infection control purposes. The risk of uncompensated income loss is highest among low-income earners, especially those in the informal labour market, who lack social security. None of these financial consequences are captured in the suggested UHC index, although some of them are directly related to the choice of medical technologies, efficacy of treatments, and delivery models.4Lönnroth K Glaziou P Weil D Floyd K Uplekar M Raviglione M Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention.PLoS Med. 2014; 11e1001693Crossref PubMed Scopus (84) Google Scholar UHC cannot achieve financial protection alone. It needs to be integrated with other social protection policies, including paid sick leave, disability allowances, and social welfare grants, among others.5International Labour OfficeSocial protection floors recommendation, 2012 (No 202). International Labour Office, Geneva2012Google Scholar The term financial protection should be used cautiously in the context of UHC monitoring until and unless income security and protection against high non-medical costs are also included in the monitoring framework. I 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 hardship – Authors' replyIn his Correspondence on our article on assessing progress towards universal health coverage (UHC),1 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 Goals2—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. Full-Text PDF Open Access