That’s according to a new report from WHO/Europe covering 40 countries in Europe, released ahead of the Health Systems Conference in Estonia, which marks 15 years since the Tallinn Charter.

Adopted in 2008 by all WHO European Region Member States, the Charter recognised that health, health systems and economic development are closely connected. Framing health spending as an investment, not a cost, the Charter reasserted countries’ support for universal health coverage and enshrined solidarity, equity and participation as shared values of European health systems. 

Health systems’ heavy reliance on out-of-pocket payments means many people experience financial hardship when using healthcare 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.

Catastrophic health spending

Pre-pandemic data from 2019 reveals some concerning trends. Many countries in the Region have significant gaps in population health coverage: only 23 out of 40 countries report covering more than 99 per cent of the population. The incidence of catastrophic health spending – the medical spending of a household that exceeds a certain level of capacity to pay – is three times higher in countries with gaps in population coverage compared with countries that cover over 99 per cent of the population.

When looking at the poorest fifth of the population in a specific country, catastrophic health spending can be two to five times higher than the national average. In 28 of the 40 countries, 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 fifth of households, spending on medicines is responsible for three-fifths 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 healthcare and medicines, as well as insurmountable barriers to access, leading to negative health outcomes.

“Our report shows that already before the pandemic, people were facing an unacceptable level of catastrophic health spending,” said Dr Hans Henri P. Kluge, WHO regional director for Europe. “As we mark International Universal Health Coverage (UHC) Day (12 December), and in the wake of the devastation caused by the Covid-19 pandemic, it’s time to get health systems back on track.

“For millions of people in the European Region, free or affordable healthcare 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 healthcare costs to impoverish millions of families. After all, health is a fundamental human right.”

Improving financial protection and system resilience

WHO/Europe is urging countries to enact five policies to improve financial protection and move closer to universal health coverage.

Firstly, 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. Secondly, entitlement to publicly financed healthcare should be de-linked from payment of social health insurance contributions, with a country’s tax agency responsible for non-payment of health insurance contributions, not the health system. Thirdly, healthcare user charges, or co-payments, should be applied sparingly and designed in such a way that people with low incomes or with chronic conditions are automatically exempt from paying. Fourthly, in addition to consultation and diagnosis, primary care coverage should also include treatment to help reduce out-of-pocket payments for medicines, medical products, and dental care. Fifthly, refugees, asylum-seekers and undocumented migrants should be entitled to the same benefits as other residents, without administrative barriers to accessing entitlements.

Also released ahead of UHC Day is the health agency’s ‘Global Health Expenditure Report’ and database, which shed new light on global health spending at the height of the Covid-19 pandemic and what lessons can be learnt to make health systems more resilient in the future.

The report reveals that in 2021, global spending on health reached a new high of US$ 9.8 trillion or 10.3 per cent of global gross domestic product (GDP). Nevertheless, the distribution of spending remained grossly unequal. In 2021, about 11 per cent of the world's population lived in countries that spent less than US$50 per person per year, while the average per capita spending on health was around US$4000 in high-income countries. Despite having 8 per cent of the world’s population, low-income countries accounted for only 0.24 per cent of the global health expenditure.

Trust and transformation

Taking place on 12-13 December in Estonia, the Health Systems Conference is titled ‘Trust and transformation: Resilient and sustainable health systems for the future’, and it recognises that various studies and surveys have pointed to a growing lack of trust in institutions and politicians, with a consequent impact on our health systems.

“Trust is at the very core of a well-functioning health system,” explained 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 healthcare systems, especially if people are asked to provide these resources with their taxes and other contributions.”

Transforming health systems requires the rebuilding of trust between the system itself, and patients, health workers, and policymakers. With patients, trust can be rebuilt by actively involving patients in their care, being transparent, and promoting community engagement through, for example, citizens’ assemblies. Trust can be rebuilt with the health workforce by properly recruiting, retaining and motivating health workers, and supporting their mental health needs; and investment in health leadership and governance, and designing inclusive health policies in partnership with the health sector can help reassure politicians and policymakers of the health system’s ability to reform.

“Trust is the glue that holds our societies – including our health systems – together,” concluded Dr Kluge. “Without it, everything collapses. 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’m calling on countries to act with courage and conviction, to urgently address the growing trust deficit in our health systems.”