Financing of health care from households’ out-of-pocket payments and voluntary payment schemes

For each dollar spent on health, more than 60 cents continued to be financed “out-of-pocket” in Cambodia, Bangladesh and Myanmar in 2019. On average, the share of health spending paid out-of-pocket has fallen in countries of all income groups in Asia-Pacific between 2010 and 2019: by around 2 percentage points to 40.4% in low- and lower-middle-income countries, by 5 percentage points to 22.9% in upper-middle-income countries and by around 4 percentage points to 17.9% in high-income countries (Figure 6.8). However, the pattern is quite diverse across the countries in the region and could also be attributed to increasing unmet needs because of access barriers and/or financial constraints. While two-thirds of the Asia-Pacific reporting countries showed a decrease in the share of out-of-pocket spending, including more than 10 percentage points for Pakistan, India, Singapore and Indonesia, Cambodia reported a growth of more than 10 percentage points over the same period.

Research (Wang, Torres and Travis, 2018[1]) suggest that the main driver of households’ out-of-pocket expenditure is medicines, composing more than 60% of total out-of-pocket spending in countries of the WHO South-East Asia Region. In Bangladesh and India, this percentage could be as high as 80%. Furthermore, the share of OOP spending on medicines was even higher among the poorer population, suggesting a disproportionally higher financial burden. In line with these findings, WHO and The World Bank has reported that the WHO South-East Asia and Western Pacific regions had the highest percentage of the population in the world facing catastrophic health spending – defined as out of pocket health spending exceeding the 10% of income – in 2017, pushing more people below the poverty line (WHO/World Bank, 2019[2]). Figure 6.9 shows that health expenditure by other voluntary payment schemes (e.g. PHI, spending by NGOs) represented – on average – around 10% of current expenditure on health in countries of all income groups in Asia-Pacific. This share increased by more than 5 percentage points to 14.5% in upper-middle-income countries, whereas it increased by 1 percentage point to 8.1% in high-income countries, and slightly decreased to 8.9% in low- and lower-middle-income Asia-Pacific countries from 2010 to 2019. Less than 5% of current health expenditure was from voluntary payment schemes in Mongolia, Japan, Bangladesh and Lao PDR in 2019, while it represented 15% or more in Thailand, Indonesia, Fiji and Nepal in the same year. Fiji reported an increase of 12.4 percentage points between 2010 and 2019, whereas Viet Nam and Thailand reported an increase of more than 7 percentage points during the same period.


[3] OECD/WHO/Eurostat (2011), A System of Health Accounts: 2011 Edition, OECD Publishing, Paris,

[1] Wang, H., L. Torres and P. Travis (2018), “Financial protection analysis in eight countries in the WHO South-east Asia region”, Bulletin of the World Health Organization, Vol. 96/9,

[2] WHO/World Bank (2019), Global Monitoring Report on Financial Protection in Health 2019, World Health Organization,

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