Age-disaggregated analysis of national household survey data on financial hardship due to health care utilization

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August 2020 to December 2021

Implementing partners:

Economic Evaluation and Analysis (EEA) Unit, Department of Health System Governance and Financing, WHO Geneva Headquarters; WHO Regional Offices; International consultants (Data analysts)

Location of research:


Total Budget:
US$ 160,000 with additional joint funding from WHO HQ and Regional Offices


Financial protection is a key dimension of universal health coverage, which is monitored at global, regional and national levels to assess progress towards the 2030 Sustainable Development Goals (SDGs) and WHO’s global impact framework. For the first time, the 2021 WHO-World Bank Global Monitoring Report on Financial Protection in Health compares data on financial protection across households with different age structures. This method will enable some understanding of the different levels of financial protection associated with the age of the person(s) seeking care. This is an innovative analytical approach to apply age-disaggregation to standard measures of financial protection which use households as the unit of analysis. The results can help fill the knowledge gap about financial protection for the care of older people.


To produce age-disaggregated analysis on financial protection at the national level across WHO Regions to include in the 2021 WHO-World Bank Global Monitoring Report on Financial Protection in Health.


  • Identified the most recent nationally representative data appropriate for this analysis, such as household budget surveys, household living standard surveys, household income and expenditure surveys, and household socio-economic surveys.
  • Estimated incidence of catastrophic and impoverishing health spending prior to the pandemic. This analysis uses the definition of catastrophic spending as health spending exceeding 10% of the household’s total consumption or income, as measured by SDG indicator 3.8.2. Impoverishing health spending is defined as the proportion of the population pushed further below the relative poverty line of 60% of median consumption due to health spending. The analysis was based on the most recent available data from 92 countries across all UN regions except North America and Oceania. These countries account for 53% of the global population in 2017, with lower coverage of populations in lower middle-income countries (43% due to the exclusion of India) and high-income countries (21%). The median most recent estimate available is from 2014 and no data points prior to 2009 were used.
  • Used a life-course approach to compare results among households with different age structures, specifically: younger households with at least one younger person below 20 years and one adult 20-59; households with only people 20 to 59; multigenerational households with at least one younger person below 20, an adult 20 to 59 and an older person 60 and above; and older households with at least one older person 60 and above and no one below 20 (includes households with only older people).
  • Conducted country consultations through all six WHO Regional Offices about the analysis results.
  • Produced statistical summaries along with a narrative synthesis of the regional and global findings in a dedicated section of the 2021 WHO-World Bank Global Monitoring Report on Financial Protection in Health.


  1. Based on the analysis of data from the 92 countries, on average, people living in households with at least one older person 60 and above have the highest incidence of catastrophic spending, as high as 38.3% in upper middle-income countries and in Asia, as compared to the global average of 13.2% of all people.
  2. People living in multigenerational households, which include at least one younger person below 20, one adult 20 to 59 years old, and one older person 60 and above, face the highest rates of impoverishing health spending,  as high as 39.9% in upper-middle income countries and in Asia, compared to a global average of 12.7% of all people.

Global Implications

The findings suggest that, globally, households with older people are most likely to spend more than 10% of their total capacity to pay on health care, and that this pattern of spending is most pronounced in Asia. However, this level of health spending is not necessarily impoverishing these households, which implies that the 10% threshold may not necessarily represent an unaffordable level of out-of-pocket health spending for households with older people. Data for this analysis were only available from 92 of WHO’s 194 Member States accounting for only a half of the world’s population, underrepresenting North America and Oceania and high-income countries. A global effort is needed to improve the availability of data from more countries to enable a more comprehensive understanding of how the financial consequences of health care utilization vary by age composition of the household. This type of data can inform better targeting and tailoring of financial protection measures and policies to the actual levels of health care needs and capacity to pay of households. More recent data are also necessary to be able to report on the impacts of the COVID-19 pandemic in the next Global Monitoring Report to be published in 2023.

Implications for Kansai

Households with older people in Kansai may have higher levels of out-of-pocket payments for health care compared to households composed of younger people. It is unclear whether they are experiencing higher levels of impoverishing health spending as a result. Data on health care expenditure alone are insufficient to assess the actual financial impact of health care utilization on households. WKC is carrying out a study that will analyze existing household survey data to identify not only the level of out-of-pocket health care spending but also the financial resources of households to gain a better understanding of the conditions under which health care spending may result in financial hardship among older citizens of Kansai. This information may help local programmes and policies to better identify those households in greatest need of financial protection.


The findings from this study were the basis for section 1.2. Who experiences financial hardship? A focus on age in the Global Monitoring Report on Financial Protection in Health 2021 (p17-21).

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