Systematic review and meta-analysis: financial barriers to accessing health services and unmet healthcare needs

Photo credit: ©WHO/Yoshi Shimizu

May 2020 to April 2021

Implementing partners:

Lead research institution:  The University of Tokyo

Other participating institutions:  Economic Evaluation and Analysis (EEA) Unit, Department of Health System Governance and Financing, WHO Geneva Headquarters; WHO Regional Offices

Principal Investigator:  Dr Mizanur Rahman, Department of Global Health Policy, School of International Health, The University of Tokyo and Hitotsubashi Institute for Advanced Study, University of Hitotsubashi, Tokyo, Japan

Location of research:


Total Budget:
US$ 13,750 (Co-funded by EEA and WKC)


The indicators currently used for monitoring financial protection under the Sustainable Development Goals may not capture the extent to which financial barriers keep people from using the health services they need. Low levels of catastrophic and impoverishing out-of-pocket health spending could also result from limited use of services or unmet health care needs due to financial barriers or other factors. This problem of unmet health care needs could be exacerbated for older people who tend to have multiple chronic conditions that require frequent use of health services over a long period. This research aims to synthesize existing global evidence about the levels of and reasons for unmet needs for care among the general population and specifically among the older population.


  • To estimate the prevalence of self-reported unmet health care needs in the general population, identify financial and other barriers to health care access, and assess differences in prevalence of unmet needs by population characteristics. 

  • To estimate the prevalence and reasons for unmet needs for health and long-term care (LTC) among people 65 years and older. 


  • Four electronic databases - PubMed, EMBASE, CINAHL, and Web of Science – were searched using a combination of terms related to forgone care, long-term care, unmet needs, barriers to access and analysis of household surveys. There were no language, date or age restrictions. After screening 3915 articles, 114 studies were included in the review, which covered around 58 million people, mostly adults 30 years and above but also including some children and adolescents, from 56 mainly high-income countries.

  • The evidence synthesis was performed by using a random-effects meta-analysis to obtain pooled estimates of the prevalence of unmet needs for health care among the populations studied.

  • Subgroup analysis was performed on people  65 years and above to examine prevalence of unmet needs for not only health care but also LTC. For the subgroup analysis of older people, we focused on the 79 studies that reported data on the population 65 years and older and included an additional 14 studies related to unmet need for LTC.


  • Survey questions used to measure unmet need for health care varied across studies. In the absence of a standardized definition, the operational definition of ‘unmet need for health care’ used in this study was a negative response to a survey question about whether health care was sought when there was a need for health care in the case of an injury or illness.

  • Overall, 9.0% of the populations included in the meta-analysis self-reported forgoing or delaying health care when they had a need for health care. The leading reason for unmet health care needs was affordability (20.6%) followed by availability (17.0%), accessibility (12.2%), and acceptability (8.9%). Statistically significant differences were found in the pooled prevalence of unmet health care needs due to cost by education level (primary or less [14.3%] vs higher [7.8%]), self-reported health status (poor [24.6%] vs very good/excellent [15.5%]), insurance status (uninsured [21.9%] vs insured [15.9%]), and economic status (poorest quintile [30.2%] vs richest quintile [8.4%]).

  • Among the population of older people 65 years and above included in the meta-analysis, 10.4% reported unmet needs for health care, which is greater than the corresponding prevalence of 4.9% among adults 31 to 64 years. The leading reason for unmet needs for health care among the older population was also affordability (31.7%) (mainly the cost of treatment), followed by problems with acceptability (10.4%), accessibility (6.2%) and availability (4.9%). A statistically significant variation in pooled prevalence of unmet health care needs due to cost was found by gender (male [10.9%] vs female [14.4%]), education level (primary or less [13.3%] vs higher [7.5%]), self-reported health status (poor [23.2%] vs good [4.4%]), insurance status (uninsured [27.7%] vs insured [9.0%]), economic status (poorest quintile [28.2%] vs richest quintile [7.1%]), and survey year (2001-2010 [4.3%] vs 2011-2019 [10.8%]).

  • The measurement of unmet need for LTC was not standardized across studies. For the purpose of this meta-analysis, ‘Unmet need for LTC’ was defined in this study as a negative response to a survey question about whether any assistance has been received to address self-reported limitations in function defined by Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). On average, 25.1% (14 studies) of older people were identified as having unmet needs for LTC. The level of unmet need varied by the older person’s level of function (having problems with ADL [23.8%] vs having problems with IADL [11.0%]) and residential area (rural [51.1%] vs urban [48.0%]). 

Global Implications

Global indicators for monitoring progress toward achieving financial protection in health only capture the financial consequences of health care utilization, and completely miss out on people that have low health spending because they have unmet needs. Most countries have little or no data on unmet health needs and even fewer surveys detail the unmet needs among subpopulations such as older people. Integrating measurement of unmet need into existing household surveys may help to fill this knowledge gap. Another challenge is the need for a standardized definition of unmet need for health and long-term care to enable comparison across countries.

Implications for Kansai

Recognizing that there is a lack of information in the published literature about unmet health and long-term care needs of older people in Kansai, WKC’s ongoing research aims to fill this information gap by using available household survey data to produce new estimates of unmet need for health care among older people in Kansai compared to other age groups and other regions. WKC will also qualitatively describe what medical social workers in Kansai perceive as the major challenges that lead to unmet needs for health and social care among older people.



Preliminary results were described in the Global Monitoring Report on Financial Protection in Health 2021 (Box 8, p27).

Rahman MM, Rosenberg M, Flores G, Parsell N, Akter S, Alam MA, Rahman MM, Edejer T. A systematic review and meta-analysis of unmet needs for healthcare and long-term care among older people. - Health Economics Review. Under review.

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