122
Getting Better: Improving Health System Outcomes in Europe and Central Asia
FIGURE 4.5
A Greater Reliance on OOP Spending Results in Higher Inequalities in Utilization b. Inpatient
0.4 AZB ARM
0.3
GEO
MOL
0.2
ALB UKR KYR
TAJ
RUS
0.1
SRB EU-15
0.0
BUL 0 10 20 30 40 50 60 70 80 Out-of-pocket share of total health expenditure (%)
Concentration index of inpatient use
Concentration index of outpatient use
a. Outpatient 0.4
AZB
0.3 UKR 0.2
ARM ALB TAJ GEO
0.1
RUS
0.0 EU-15 0
MOL
KYR SRB BUL
10 20 30 40 50 60 70 80 Out-of-pocket share of total health expenditure (%)
Source: Ali and Smith 2012. Note: OOP = out of pocket.
the prevailing degree of inequality in health use. It is important to note that the presence of inequality in the quality of care provided to the rich and poor may be at least as important as the quantity of care delivered. If the poor tend to visit facilities that are less well-equipped or receive care from providers who exert less effort, then they will be doubly penalized. Ultimately, of course, we are interested in these inequalities because they may lead to inequalities in actual health outcomes. There is evidence that this is indeed the case in ECA (World Bank 2012b). In sum, empirical evidence suggests that households in about half of ECA’s countries are spending significantly more on health, and with greater variation, than counterparts in EU-15 countries. A large share of this OOP spending is on drugs. Not surprisingly, indicators of catastrophic and impoverishing OOP payments are worse in countries that rely heavily on OOP spending for health financing. Catastrophic spending is slightly more common among higher socioeconomic groups, while the main consequence of weak financial protection for lower socioeconomic groups is forgone care, as reflected in higher inequality in utilization. Policies aimed at improving financial protection should be measured and monitored closely, and there is scope for improving current practices in this regard (box 4.2). While over-reliance on OOP spending is a major challenge in about half the countries in ECA, in many of the others there is a significant health equity agenda related to the Roma population. Box 4.3 provides a summary of recent research on this issue.
GB.indb 122
22/05/13 7:29 PM