Towards Improved Measurement of Financial Protection in Health

Protecting citizens against the financial consequences of illness has long been a key objective of health systems worldwide. In the United Kingdom for example, financial protection—which refers to how far people are protected from the financial consequences of illness—was the fundamental goal when the National Health Service was established in 1948, more than health improvement or equitable access to health care [1]. The World Health Report 2000 identified financial protection against the costs of ill health as a fundamental objective of health systems, on the basis of the premise that a fair health system ensures households make health care payments according to their ability to pay rather than risk of illness [2]. This report helped put financial protection at the forefront of health policy and academic debates, leading to numerous studies concerned with identifying the determinants of financial protection levels [3]. Ten years later, the World Health Report 2010 called on all countries to take concrete steps towards achieving universal health coverage, defined as providing all people with access to needed health services of sufficient quality to be effective, without financial hardship associated with their use [4,5]. This call was made because most health systems still fail to offer adequate financial protection because of insufficient financial risk pooling and prepayment mechanisms. Financial risk pooling involves the collection and management of health revenues from all members of the pool, such that the risk related to health care payment is borne collectively rather than from each individual contributor. Health systems with higher prepaid funds for health care—that is, funds paid by individuals before the event of illness, through social health insurance contributions or taxes—are likely to enhance financial protection by favoring effective spreading of financial risk across all population groups (see Box 1 for a definition of key concepts). Financial hardship due to medical payments has been estimated to affect 150 million people globally each year, in both richer and poorer countries [6]. Affected individuals face a great risk of being driven into poverty because of health care expenses, resulting also in lack of access to needed care owing to inability to pay. Nevertheless, the squeeze on public finances associated with the global economic downturn has led some governments (e.g., Spain and Greece) to increase direct payments for health services. This increase is taking place despite accumulating evidence about the detrimental effect on both financial protection and the welfare of citizens of heavy reliance on user payments for financing health systems (leading to growing calls for the complete abolition of user fees in health care) [3,6–8]. In this context, service coverage and financial risk protection have been a primary topic of discussion at the WHO 64th World Health Assembly, whose resolution recommends that the matter be further debated at the forthcoming session of the United Nations General Assembly [9]. Financial protection should remain a key objective of any health system. However, we argue that there is an urgent need to develop indicators capable of providing a broader picture of financial protection for better health policy guidance, because the harm caused by inadequate financial protection in many parts of the world goes well beyond that measured by conventional indicators. In this paper, we discuss the shortcomings of conventional metrics and make recommendations about how financial protection analyses can be undertaken in a more rounded manner to better aid policy making.