Out-of-Pocket Health Spending
Out-of-pocket payments fund roughly 18% of all health spending worldwide, but the burden is deeply unequal: households cover over 40% of health costs in low-income countries versus under 20% in high-income ones. In 2019 about 1 billion people faced catastrophic health spending, and 344 million were pushed into extreme poverty by medical bills. In Armenia, Bangladesh, Afghanistan and Nigeria, patients pay more than three-quarters of every dollar spent on health directly out of pocket.
Key Out-of-Pocket Spending Insights
The Poorest Countries Pay the Most Directly
Out-of-pocket payments fund about 18% of health spending globally, but the share climbs steeply as income falls — averaging 42.6% in low-income countries, 35.6% in lower-middle, 30.8% in upper-middle and 18.4% in high-income countries in 2022. In 2022 out-of-pocket costs financed more than 20% of the health system in 126 countries, and were the single largest source of health financing in 55 countries.
A Billion People Face Catastrophic Costs
In 2019 about 1 billion people incurred catastrophic health spending, defined as spending more than 10% of their household budget on health. The risk falls to negligible levels only when out-of-pocket payments average no more than 15–20% of total health spending — a threshold most low- and middle-income countries are far above.
Medical Bills Drive People Into Poverty
In 2019, 344 million people were pushed or further pushed into extreme poverty by out-of-pocket health spending, and 1.3 billion into relative poverty. Households that pay catastrophic health costs often cut back on food, heating and housing, deepening the link between illness and impoverishment.
Highest Burdens in Asia and Africa
The highest out-of-pocket shares are concentrated in Central and South Asia and parts of Africa. In 2022 patients paid directly for about 79% of health costs in Armenia, 78% in Bangladesh and Afghanistan, and 76% in Nigeria — among the heaviest direct-payment burdens in the world.
Global Out-of-Pocket Share of Health Spending (2000–2022)
Out-of-pocket payments as a share of current health expenditure, worldwide
Key Finding: The global out-of-pocket share has drifted down from roughly 22% in 2000 to about 18% by 2022 as pooled public and insurance financing expanded — but progress has flattened in recent years.
Out-of-Pocket Share by Country Income Group (2022)
Out-of-pocket payments as a share of current health expenditure
Key Finding: Households in low-income countries paid 42.6% of health costs directly in 2022 — more than double the 18.4% average in high-income countries, leaving the poorest most exposed to medical bills.
Countries With the Highest Out-of-Pocket Shares (2022)
Out-of-pocket payments as a share of current health expenditure
Key Finding: In Armenia, Bangladesh, Afghanistan and Nigeria, patients pay roughly three-quarters or more of every health dollar out of pocket — far above the 15–20% level WHO links to negligible financial hardship.
People Facing Financial Hardship From Health Costs (2019)
Millions of people affected, latest global estimates
Key Finding: About 1 billion people faced catastrophic health spending in 2019; 1.3 billion were pushed into relative poverty and 344 million into extreme poverty by out-of-pocket health costs.
Out-of-Pocket Share by World Region (2022)
Out-of-pocket payments as a share of current health expenditure
Key Finding: South Asia carries the highest regional burden at around 52%, while North America (11%) and Europe & Central Asia (16%) keep direct payments well below the level associated with financial hardship.
Understanding Out-of-Pocket Spending Data
What out-of-pocket spending means
Out-of-pocket (OOP) payments are direct expenditures households make to health providers at the point of care — fees, co-payments and the cost of medicines, tests and consultations — net of any reimbursement. The headline indicator expresses these as a share of current health expenditure (CHE). A high OOP share signals that financing relies on sick individuals paying directly rather than on pooled public budgets or prepaid insurance.
Catastrophic and impoverishing spending
WHO and the World Bank track two financial-protection indicators. Catastrophic health spending (SDG 3.8.2) counts people whose out-of-pocket payments exceed 10% (or 25%) of their household budget. Impoverishing health spending counts people pushed below a poverty line because of medical costs. The latest global estimates are for 2019: about 1 billion with catastrophic spending and 344 million pushed into extreme poverty.
Why it matters for universal health coverage
Reducing out-of-pocket payments is central to universal health coverage (UHC), which aims for everyone to access needed care without financial hardship. WHO finds the risk of catastrophic spending becomes negligible only when OOP payments fall to roughly 15–20% of total health spending. Heavy reliance on direct payments is regressive: it falls hardest on poor and sick households and can deter people from seeking care at all.
Data sources and caveats
Figures come from the WHO Global Health Expenditure Database (GHED), compiled from national health accounts, and the joint WHO/World Bank UHC Global Monitoring Report. Income-group averages can differ depending on whether they are population-weighted or unweighted. Expenditure data run to about 2022, while financial-hardship estimates rely on household surveys and are most recent for 2019.