An Alternative Framework for Analyzing Financial Protection in Health

A greater focus on the role of health systems in health, development, and economic growth has led health policy research and analysis, domestic and global, to scrutinize health financing, insurance, and financial protection. Two World Health Reports (2000 and 2010) [1,2] have called for evaluating health system performance in terms of health financing, and the World Health Organization’s (WHO) 64th World Health Assembly reiterated the need for sustainable health financing and universal coverage worldwide [3]. With this increased focus has come closer examination of conventional frameworks and measures of financial protection in health both from academic [4] and policy [5] circles. Consensus had developed among academic and policy analysts on two primary metrics, catastrophic and impoverishing spending, for financial protection. Both methods use as a measure the percentage of out-of-pocket health spending in households’ overall spending. They differ in the way medical spending is deemed problematic: catastrophic spending is above a threshold percentage, while impoverishing spending pushes a household below the poverty line. Both metrics are helpful indicators of the absolute and relative level of household out-of-pocket health care spending and have been employed in multiple studies worldwide [6–10]. Our research group conducted a study focusing on a modification of these metrics—the out-of-pocket spending burden ratio using household equivalent income derived from the Organisation for Economic Co-operation and Development (OECD) Equivalence Scale [11]. But the consensus has given way, and critiques of the conventional approach now run wide and deep. Critics include those who are most invested and who have employed these methodologies [5,7], and those who argue that estimates of household health expenditures themselves are subject to considerable variability depending on survey design [12]. This article proposes a multidimensional financial protection profile that offers a more holistic view of health spending, one that goes beyond the level of spending to cover aspects directly related to health care, such as health care access and insurance utilization, and examines broader impacts on current and longer-term household consumption. This multidimensional approach aims to help policy makers understand the larger context of household health spending and make health and social policy adjustments to mitigate damaging effects.