Summary Q&A
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public health legislation and managing risk factors through primary care, there are major cardiovascular health gains available for very low cost. A big part of the life expectancy gap—probably at least two-thirds and perhaps more—can be addressed through lower levels of care. The majority of potential health improvements will not involve hospitals; yet these absorb undue attention and resources. There are, however, some interventions that have contributed substantially to improved health in the West that do not come as cheaply: for example, certain heart procedures such as angioplasty and bypass operations, some neonatal technologies, and wider access to cancer screening and treatment. Countries will need to make careful choices about what can be afforded. 7. How can the growing demand for medical care be financed? Both in ECA and around the world, health financing is drawn largely from household out-of-pocket (OOP) sources or from the government budget (that is, through tax revenues, including mandatory social health insurance). The growing demand for health care must therefore be financed without imposing an undue burden on either source. Too much OOP spending for health care is a concern because it can undermine financial protection or equity, or both. That is, OOP spending may be “catastrophic” (exceeding some significant threshold of total household expenditures) or “impoverishing” (if it pushes some households below the poverty line). OOP spending can also pose an important barrier to health care, resulting in significant inequalities in utilization between rich and poor. But an excessive burden of health spending on the government budget can be wasteful and pose a threat to fiscal sustainability. Currently, the relative importance of OOP spending and government budget sources varies widely across the region. This picture has not changed significantly over time, as very few countries in ECA have significantly reduced their reliance on OOP spending since 1997. As a result, inadequate financial protection remains a problem in about half the ECA region. The objective should not be to lower OOP spending to zero, but theory and evidence suggest that less than 25 percent of total health financing drawn from this source is a reasonable policy objective. 8. What can be done to make health financing systems in ECA more pro-poor? The major priority for making health financing systems more propoor is to reduce the out-of-pocket payments people face at the point
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