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Figure 3.12. Out-of-pocket payments OOP by country level of poverty, 2011 percentages
Source: ILO, 2013a.
These developments most likely derive from gaps in legal health coverage, as we can see in figure 3.13. In countries where the majority of the population is living in poverty on less
than US2 a day, only about 10 per cent of the population have legal health coverage.
Figure 3.13. Legal health coverage to a health system or scheme, population living on less than US2 PPP a day percentages
Source : ILO, 2013a
Limited levels of formal employment are also closely related to coverage and thus access to essential care. Figure 3.14 demonstrates the association between the share of workers in
19.6 37.4
40.1 57.1
46.7 40.5
10 20
30 40
50 60
2 2.1–25
25.1–50 50.1–75
75 Total
P e
rc e
n ta
g e
o f
o u
t o
f p
o cke
t e
xp e
n d
it u
re a
s a
p e
rc e
n ta
g e
o f
to ta
l h
e a
lt h
e xp
e n
d it
u re
Groups of countries defined by the percentage of the population living with less than 2 PPP a day
Out-of-pocket expenditure as a percentage of total health expenditure by the proportion of the population living with less than 2 PPP a day
2011 weighted by total population
Total 75
50.1 - 75 25.1 - 50
2.1 - 25 2
Percentage of total population covered P
e rc
e n
ta g
e o
f th
e p
o p
u la
ti o
n w
it h
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ss t
h a
n
U S
2 P
P P
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a y
22 Universal Health Protection
formal employment, using wage workers as a proxy, and the proportion of the population with legal health coverage. Increasing shares of formal employment are correlated with
higher levels of legal coverage.
Figure 3.14. Legal health coverage and proportion of wage workers in total employment
Source: ILO, latest available data.
3.2.2. Impacts at individual and household level: Inequities in coverage and access to health care
Impoverishment due to OOP OOP are often due to gaps in legal coverage and benefit constraints that exclude necessary
treatments, medicines or other important health care. High OOP affect the accessibility of care by making it less affordable, deterring individuals from seeking care in spite of ill
health. In addition, OOP may push households into poverty or deepen existing poverty, particularly the worst form of OOP: catastrophic health expenditure, defined as health
expenditure exceeding 40 per cent of a household’s income net of subsidies.
Figure 3.15 illustrates the impoverishing effects of catastrophic health expenditure. In six Eastern European and Central Asian countries, poverty levels increased significantly after
catastrophic expenditure, for example by 13.6 percentage points in Georgia. Health shocks – unpredictable illnesses that diminish health status – are frequently the cause of
catastrophic OOP. In combination with income loss resulting from an inability to work, OOP have the potential to bring households into financial ruin. An example is rickshaw
pullers in Bangladesh: health-related shocks form the most potent trigger of downward mobility for this occupational group Begum and Sen, 2005.
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Figure 3.15. Poverty levels before and after catastrophic health expenditure, selected East European and Central Asian countries, 2010
Note: Data from most recent household survey, poverty line used is US2.15 at 2000 PPP. Source: World Bank, 2010a.
In Asia, households in Cambodia are among those experiencing the highest OOP in the region. In any given month during 2007, medical spending pushed 4.1 per cent of
households below the poverty line. Also during this year, 5.6 per cent of families were forced to spend more than 25 per cent of their household income on medical treatment
costs, indicating that, in addition to its severity, the frequency of OOP was high Anuranga et al., 2012.
Research in Bangladesh has shown that the burden of OOP is spread unevenly over different income groups figure 3.16. In absolute terms, those households most well-off
spent significantly more on OOP in 2005. However, in relative terms, the poorest 25 per cent of households spent between 20 and 55 per cent of their household income on OOP
compared to 13 per cent for the top 25 per cent income groups World Bank, 2010b.
9.4 19
41.2 30.3
32.5 64.4
10.1 20.6
44.6 43.9
35.4 67.7
Romania Belarus
Armenia Georgia
Moldova Tajikistan
Poverty level after catastrophic expenditure Poverty level before catastrophic expenditure
