On Universal Health Coverage Day, a new report by the World Health Organisation (WHO) Regional Office for Africa found that most African countries continue to rely heavily on out-of-pocket payments (or out-of-pocket health spending) to fund their health services. The report urges countries to reduce the financial strains that high healthcare costs place on their population.  

It warns that the practice of out-of-pocket payments continues to place a financial burden on more than 200 million people, pushing over 150 million individuals into or deeper into poverty across the WHO Africa Region, exacting a heavy price on people’s health, and hampering progress in attaining universal health coverage. 

Globally, half of the people impoverished because of out-of-pocket payments live in Africa – a rising and worrying trend.

“Having to pay for medicines and other health-care costs out of their own pocket can instantly bend the trajectory of someone’s life toward financial hardship and ill health. Such payments force many people to spend less on other basic needs such as food, housing, and utilities, which, in turn, may worsen their conditions. This also creates a major barrier for the poorest and the most vulnerable who cannot get, as a result, the care they need,” said Dr Matshidiso Moeti, WHO’s Regional Director for Africa.

“Despite countries’ efforts to build more sustainable health financing systems, more needs to be done so that people across Africa have access to the quality health services they need, when and where they need them, without having to fall into financial hardship,” added Dr Moeti.

The report analyses the period between 2000 and 2019, during which time the number of people making ‘catastrophic’ out-of-pocket payments (i.e. spending over 10% of their household budget on medicine and other healthcare costs) rose by 2.5 million people every year (from 52 million in 2000 to 95 million in 2019).

That said, progress, albeit at a slower pace than globally, has been made during the same period, with the overall number of people pushed into or deeper into poverty because of out-of-pocket payments having halved between 2000 and 2019.

A look at the report’s key data and findings 

In 2019, out-of-pocket payments accounted for over a quarter of health spending in 31 countries. In 11 countries, they were more than half of health spending, and in three other States, they exceeded 70%. 

The number of people pushed into poverty and the number of people living in extreme poverty (on less than $2.15 a day) because of out-of-pocket payments has decreased, having halved from 302 million people in 2000 to 152 million in 2019. However, it did not decrease as fast as in the rest of the world, where it dropped by over three quarters during the same period (from 1.3 billion people or 22.2% of the global population in 2000 to 344 million people or 4.4% in 2019). 

Worryingly, half of all people who are impoverished globally because of out-of-pocket payments live in the WHO Africa region. This trend has been on the rise since 2000 when only two out of ten impoverished people were in Africa. 

Catastrophic out-of-pocket payments have increased, although at a slower rate than globally. More efforts are needed to reverse this trend, including exempting poor people from paying out-of-pocket for the treatment they need. 

The number of people pushed into or deeper into poverty due to out-of-pocket payments is of particular concern given that, on average, a person in Africa is spending less (about $35 per year in 2019) on healthcare than anywhere else in the world. 

People living in multigenerational households or households headed by older persons (60 and over), adults living with children and/or adolescents and people living in rural areas are more likely to feel the financial burden of having to make out-of-pocket payments.

Countries that invested more domestic government funding in health services and systems tended to have lower levels of catastrophic out-of-pocket payments and impoverishment due to such payments. 

Medicines and outpatient care were the main drivers of out-of-pocket payments and related financial hardship. Countries continue to face challenges with generating, analysing and using financial risk protection monitoring data. 

How useful is the report?

The report, the only one of its kind, helps countries track progress on financial protection in health and make evidence-based decisions to accelerate efforts to attain universal health coverage. 

The report highlights good practices by several countries to address the burden of out-of-pocket payments, such as abolishing patients’ fees at the point of care, introducing health insurance schemes, and progressively increasing reliance on government-funded health services.

“I hope this report will strengthen countries’ resolve to improve financial protection in health for their populations and to invest in better data generation, analysis and use to inform better decision-making,” said Dr Moeti.

The WHO Regional Office for Africa supports the 47 Member States in tracking progress in financial protection in health by building the capacity of ministries of health and statistics offices, facilitating evidence-led decision-making by reporting progress and challenges–as in this report—and providing technical support to redesign policies to improve financial protection in health. 

Out-of-pocket health spending includes formal and informal expenses directly related to the cost of seeking care. It excludes prepayment (for example, taxes, contributions or premiums) and reimbursement of the household by a third party such as the government, a health insurance fund or a private insurance company. It also excludes indirect expenses (such as non-emergency transportation costs) and the opportunity cost of seeking care (for example, lost income). But it includes any spending incurred by a household when any member uses a health good or service to receive any type of care (preventive, curative, rehabilitative or long-term care) provided by any type of provider for any type of disease, illness or health condition, in any type of setting (for instance, outpatient, inpatient or at home).

(WHO)