Rebuilding trust in and within our health systems is critical to achieving universal health coverage
Tallinn, 12 December 2023
As health leaders from the WHO European Region gather in Estonia for the landmark Health Systems Conference, marking 15 years since the Tallinn Charter highlighted that people should not become poor due to ill health, a new WHO/Europe report covering 40 countries in Europe finds that millions of people are still struggling to pay for health care.
Health systems’ heavy reliance on out-of-pocket payments means many people experience financial hardship when using health care or face barriers to access, resulting in unmet need. Out-of-pocket payments also push some people into poverty or make them even poorer. Globally, 4.5 billion people – more than half of humanity – are not covered by essential health services.
Paying for health care versus paying for food
New pre-pandemic data from 2019 show some concerning trends. Many countries in the Region have significant gaps in population health coverage: only 23 out of 40 countries report covering over 99% of the population. The incidence of catastrophic health spending is 3 times higher in countries with gaps in population coverage compared to countries that cover over 99% of the population.
When looking at the poorest fifth of the population in a specific country, catastrophic health spending can be 2 to 5 times higher than the national average. Catastrophic health spending means a household can no longer afford to meet basic needs – food, housing and heating – because of having to pay out of pocket for health care.
This means that the poorest people are the ones most likely to suffer the most financial hardship. In the majority of countries (28), the incidence of catastrophic health spending increased over time, with an average increase of 1.7 percentage points. In the remaining 12 countries, the incidence of catastrophic health spending fell by 1.8 percentage points on average.
Out-of-pocket payments for outpatient medicines are the main driver of financial hardship across countries, especially for the poorest fifth of the population, followed by medical products (for example, hearing aids) and dental care. In the poorest 20% of households, spending on medicines is responsible for 60% of catastrophic health spending on average across the 40 countries.
The pandemic has worsened the situation for many, creating huge backlogs that can force people to pay out of pocket for private health care and medicines, as well as insurmountable barriers to access, leading to negative health outcomes.
Medicines, medical products and dental care are services that should be delivered or managed in primary-care settings. The report’s findings indicate that there is a significant gap in the coverage of primary care in many countries in the Region.
“Our report shows that already before the pandemic, people were facing an unacceptable level of catastrophic health spending. As we mark International Universal Health Coverage (UHC) Day, and in the wake of the devastation caused by the COVID-19 pandemic, it’s time to get health systems back on track,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe.
“For millions of people in the European Region, free or affordable health care is simply a dream. Many face excruciating choices like paying for medicines or treatment at the expense of paying for food or electricity. We simply can’t allow health-care costs to impoverish millions of families. After all, health is a fundamental human right.”
WHO/Europe is urging countries to make the following 5 policy choices to improve financial protection and move closer to UHC.
- Coverage policies should be adequately funded by public spending to ensure there are no major staff shortages, no long waiting times for treatment and no informal payments.
- Entitlement to publicly financed health care should be de-linked from payment of social health insurance contributions. The relevant tax agency should deal with non-payment of health insurance contributions, not the health system.
- Health-care user charges (copayments) should be applied sparingly and designed in such a way that people with low incomes or with chronic conditions are automatically exempt from all charges.
- Primary-care coverage should include treatment, not just consultation and diagnosis. This will help reduce out-of-pocket payments for medicines, medical products and dental care.
- Refugees, asylum-seekers and undocumented migrants should be entitled to the same benefits as other residents, without administrative barriers to accessing entitlements.
Trust and transformation
When they signed the Tallinn Charter in 2008, every country in the Region committed to distribute the burden of financing the health system fairly, according to people’s capacity to pay, so that people are not impoverished as a consequence of using health services. Fifteen years later, UHC remains far from reality in many countries across the Region.
Various studies and surveys have pointed to a growing lack of trust in institutions and politicians, with a consequent impact on our health systems.
- Increasingly, people do not trust that health services will deliver for them when needed.
- Health and care workers are losing trust that the system values them, leading to multiple strikes and industrial action across the Region.
- Politicians do not trust the health system’s ability to reform in the face of new challenges (for example, by harnessing digital innovations) or to address issues of concern (for example, a rapidly ageing population or health worker recruitment and retention).
“Trust is at the very core of a well functioning health system,” continued Dr Kluge. “It plays a crucial role in delivering effective and high-quality health services. Trust is also essential if countries want to generate the needed financial resources to fund health-care systems, especially if people are asked to provide these resources with their taxes and other contributions.”
Transforming our health systems requires the rebuilding of trust between the health system and 3 distinct societal groups, all of which demand distinct approaches:
- patients – rebuild trust by actively involving patients in their care, being transparent, and promoting community engagement through, for example, citizens’ assemblies;
- health workers – rebuild trust by properly recruiting, retaining and motivating health workers, and being sensitive to their mental health needs; and
- politicians/policy-makers – rebuild trust by investing in health leadership and governance and designing inclusive health policies in partnership with the health sector.
“Trust is the glue that holds our societies – including our health systems – together. Without it, everything collapses,” concluded Dr Kluge.
“We need to transform our health systems to ensure that people everywhere can receive the right care, in the right place, by the right health and care workers, at the right time. I am calling on countries to act with courage and conviction, to urgently address the growing trust deficit in our health systems.”