Can people afford to pay for healthcare?

During the European Health Forum Gastein (EHFG) 2019 session “Can people afford to pay for healthcare? New evidence on financial protection in Europe”, Tamás Evetovits, Head of the WHO Barcelona Office for Health Systems Strengthening, presented findings from the recent WHO Europe report he co-authored with Sarah Thomson (WHO Europe) and Jonathan Cylus (European Observatory).

After the session, Young Gasteiners Stefano Guicciardi and Gary L. O’Brien discussed with Tamás the critical issue of financial protection, which is achieved when out-of-pocket (OOP) payments for health services do not expose people to financial hardship.

Tamás Evetovits at the EHFG 2019.

Stefano Guicciardi & Gary L. O’Brien (SG & GO’B): The WHO Europe report on financial protection shows that between 1% and 9% of households in Europe are pushed into poverty or further impoverished through OOP payments. What disruptive actions could eliminate this issue?

Tamás Evetovits (TE): I disagree with European countries asking lower-income individuals, who struggle to afford basics such as heating, food, and shelter, to pay for medicines and healthcare. This is unacceptable and must change. 18 out of the 24 countries we assessed are members of the European Union (EU) and there is a very obvious solution to address this issue: exempt those who are most vulnerable.

We need disruptive thinking around how to better fund healthcare and what actions needed to be taken – business as usual cannot continue. In most countries patients are required to pay co-payments uniformly; some diseases and conditions are exempt, but only for a limited number of cases and not on the basis of being poor. We need new policies to improve equity and ensure that those who cannot afford to pay for medicines and healthcare in general, are not left behind.

SG & GO’B: Politicians are those in charge of setting the agenda for health reforms, but they are also often driven by the need to reduce national expenditure. What strategies should we use, as public health advocates, to ensure they focus on universal health coverage (UHC)?

TE: The OECD countries are often concerned about the increasing healthcare expenditures. Firstly, there is nothing wrong with growing health expenditure as long as it is efficient and reflects societal preferences on public spending. Secondly, I think we need to make a distinction here between rich and middle-income countries. Public expenditure on health increases at a lower rate in middle-income countries and in some cases the health sector grows at a lower rate than GDP. Actually, this distinction applies even in the EU: we can see that in less developed member states, governments are more worried about escalating health expenditures. Evidence shows that over time health is receiving a smaller share of the overall increase of public expenditure, when compared to other sectors. So, let’s not be fooled by the narrative that health expenditure is growing everywhere. Nominally it may be true, but not necessarily as a share of government spending.

What strategies can public health advocates use? The answer is strongly related to the previous question and to what I said about poverty. It is unacceptable for public health systems, that are supposed to care for people, to impose cost-sharing on patients who cannot afford to pay OOP and consequently push them further into poverty. I think this could be a very powerful narrative for public health advocates to use with finance ministries, who may be more interested in reducing the adverse effects of OOP payments on poverty than public health in general.

SG & GO’B: Would it be reasonable, in your opinion, to begin working on a uniform European healthcare system, founded on the principles of universal coverage, social financing through general taxation, and non-discriminatory access, with the aim of ensuring equity and reduce OOP payments?

TE: This is a very complicated issue. As shown in our presentation, achieving UHC is not necessarily a question of choosing between a general tax-financed system or social health insurance – it’s possible to have 100% population coverage in both (although in the former there are no links between entitlements and payments of contribution).

The problem with a uniform system across Europe is that there is an eternal debate about whether health policy is an area for decisions by individual member states or a sector in which the EU can propose uniform frameworks. Also, this change would require effort and acceptance from richer countries that there is a need to subsidise health systems of poorer countries. Overall, I think Europe is very proud of the value of solidarity and this could be a starting point for consensus. Independently of whether we choose to finance and organise health systems on the national or supranational level, it should be a shared decision that all systems must guarantee solidarity, and this means that the rich must subsidise the poor and no-one should be left out just because they cannot afford to pay.

The systems should therefore be solidaristic regardless of their organisation, and the question is what do we mean by that and how far are we going in terms of solidarity. For example, I would argue that if we cannot ensure individuals get equal access to needed, but expensive services, then we should not provide them to anyone through cost-sharing with patients, because at the end of the day it will be an unequal service provision where the rich (who can afford to pay the co-payments) get access to publicly funded services while the poor do not. That is the exact opposite of what solidarity is all about.

SG & GO’B: Thank you for your answers and for your time!

The interview was written by Young Gasteiners, Stefano Guicciardi, Public Health resident at the University of Bologna, Italy, and Gary L. O’Brien, Research Pharmacist at University College Cork, Ireland.

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