As reported in the previous section on private and external expenditure, high levels of out-of-pocket (OOP) spending in the region present a challenge not only for governments looking to improve access but also to individuals, household and communities. High OOP means that the population is directly financing a substantial part of care when they need it, which in turn can push them into poverty or financial hardship. The global incidence of catastrophic spending at 10% or more of OOP relative to household income or consumption has been estimated at 9.7% in 2000, 11.4% in 2005, and 11.7% in 2010. This means that globally 808 million people in 2010 incurred catastrophic health spending (Flores et al., 2018[2]). In addition, high OOP can have very negative consequences for the financial and social wellbeing of households, in some cases leading them into poverty. It has been estimated that at the USD 1.90 per day poverty line, the worldwide incidence of impoverishment decreased between 2000 and 2010, from 131 million people (2.1% of the world’s population) to 97 million people (1.4%) (Wagstaff et al., 2018[3]).