Catastrophic Health Costs in Europe: Under 2% to Over 14%

Ask whether a country has universal health coverage and you get a yes or a no. Ask how much of the bill actually lands on the household, and you get a number — which is far more useful, right up until you notice that the number changes depending on who calculated it.

The most-quoted version comes from a peer-reviewed analysis of 40 European countries by Thomson and colleagues, published in The Lancet Regional Health – Europe in December 2023 alongside the WHO/Europe assessment it summarises. It found catastrophic health spending affecting under 2% of households in Ireland, Spain, Slovenia, Sweden and the United Kingdom, and over 14% in Armenia, Bulgaria, Georgia, Latvia, Lithuania and Ukraine, with a median of 6%.¹ That sevenfold spread is real. What travels with it is often wrong: it is routinely credited to the OECD, whose own published range tops out at "over 10%" in Lithuania, Latvia, Hungary and Portugal² — a different ceiling for an unglamorous reason. Armenia, Georgia and Ukraine, three of the six countries at the top of the list, are not OECD members.

The range is real. The cross-dataset comparison is not.

Three widely cited sources describe the same underlying problem, and none of them can be lined up against the others without care.

The OECD's lower ceiling is not a contradiction of WHO's; it is a smaller room. Both organisations draw on the same capacity-to-pay methodology for European countries, so the difference at the top of the range is mostly a question of which countries were invited into the comparison.

What "catastrophic" is actually measured against

The WHO/Europe indicator has a precise definition, and it is not the intuitive one. A household is counted when out-of-pocket payments exceed 40% of its capacity to pay — total household consumption minus a standard allowance for basic needs, where that allowance is the average spending on food, housing and utilities by households sitting between the 25th and 35th percentile of the consumption distribution, adjusted using OECD equivalence scales.⁴

That is a deliberately demanding measure. It does not ask what share of income went to health; it asks what share of the money left over after subsistence went to health. A household spending 15% of its total budget on medicines can easily clear the 40% bar once rent and food are subtracted.

The alternative, used for years as Sustainable Development Goal indicator 3.8.2, was much simpler: out-of-pocket payments above 10% or 25% of total household income or consumption. The two approaches do not rank countries the same way, because the first is sensitive to how poor a household is and the second is not.

That argument has now been settled at the global level, and in WHO/Europe's favour. The revised 2025 definition of SDG 3.8.2 measures the share of the population whose out-of-pocket health spending exceeds 40% of the household discretionary budget, and WHO has archived the data built on the older definition rather than continuing to update it.⁵ Anyone comparing a pre-2025 national figure with a post-2025 one is, without being told, comparing two different indicators.

Portugal, three times

Portugal is the clearest demonstration, because it appears in all three datasets.

A 2016 peer-reviewed study by Quintal and Lopes, catalogued in a 2024 systematic review, put the share of Portuguese households with catastrophic health spending at 2.1%.³ WHO/Europe's December 2025 country assessment put it at nearly 8%, describing that as higher than in many European Union countries.⁶ The OECD's table places Portugal in the "over 10%" group.²

This is the part that should make anyone cautious about a single number. The gap is not explained by one study being sloppy. It reflects some combination of different survey years, different household budget surveys and different operationalisations of what counts as a "basic needs" allowance — and the published summaries do not contain enough detail to reconcile them precisely. The systematic review reaches the same conclusion about its own table, listing threshold heterogeneity as an explicit limitation on cross-country comparison.³

Why the gap survives the methodology fight

None of that makes the underlying finding soft, for three reasons that hold across definitions.

First, the distribution. Across all 40 countries, households in the poorest consumption quintile account for at least 40% of all households with catastrophic health spending — and for more than 70% in Croatia, Czechia, Hungary, Ireland, France, Luxembourg, Slovakia and Sweden.¹ Sweden is on that list and on the list of countries with the lowest overall incidence, which is the whole point: a low national score can coexist with the burden falling almost entirely on the poorest fifth. WHO's own assessment puts the same finding as an incidence range, from 1% to 20% of households overall against 2% to 69% of households in the poorest quintile.⁷ No threshold choice makes that concentration disappear.

The composition of the spending is just as consistent. In households with catastrophic spending, out-of-pocket payments go mainly on outpatient medicines (38%), dental care (18%), medical products (15%), inpatient care (13%) and outpatient care (10%).¹ These are, almost without exception, primary-care goods and services — not the exotic, high-cost interventions the phrase "catastrophic" suggests.

Second, the direction of travel. WHO's UHC Watch platform, launched in December 2024, found that in 28 of the 40 countries surveyed the incidence of catastrophic health spending had increased over time, by an average of 1.7 percentage points.⁸ At the global level the 2025 UHC Global Monitoring Report records the opposite headline — 26% of the world's population faced financial hardship from out-of-pocket payments in 2022, down from 34% in 2000 — but attributes that decline mainly to falling poverty rather than improved financial protection, noting that disproportionately large non-impoverishing health spending actually rose in middle-income countries.⁹

Third, the consequence. A longitudinal study of 70,367 people aged 50 and over across 11 European health systems, published in BMJ Public Health in November 2025, found catastrophic health expenditure associated with an 84% higher risk of death (hazard ratio 1.84, 95% CI 1.66–2.04) over a mean 3.8-year follow-up.¹⁰ It used a third threshold again — 25% of household income — which reinforces the point rather than undermining it: the association shows up even on a yardstick nobody in the WHO or OECD tables is using.

What the headline numbers leave out

A low score can mean protection, or it can mean absence. Catastrophic-spending indicators count money households actually paid. Someone who never filled the prescription, never booked the dentist and never saw the specialist registers as financially protected. Eurostat's 2024 survey of self-reported unmet need for medical care puts the EU average at 3.6% of people aged 16 and over, but Greece at 21.9%, Finland at 12.4% and Estonia at 11.2%, against Cyprus at 0.1% and Malta at 0.5%.¹¹ Finland does not appear anywhere near the top of the catastrophic-spending range; it appears near the top of the going-without range.

The inequality shows up in both measures. In the same Eurostat data, 6.0% of people at risk of poverty reported unmet medical need against 3.2% of those not at risk, with the widest gaps in Greece (12.7 percentage points), Romania (10.7) and Latvia (9.9).¹¹

The baseline is older than it looks. WHO's 40-country assessment used 2019 data, or the latest available year before COVID-19, deliberately, to establish a pre-pandemic baseline.⁷ It is not a description of 2026.

The country everyone expects is not in the table. The United States is absent from the European assessment, and its domestic equivalents fracture the same way. The Peterson-KFF Health System Tracker, drawing on Census Bureau survey data from December 2021, finds about 20 million adults — roughly 8% — owing more than $250 in medical debt, totalling at least $220 billion.¹² KFF's own 2022 Health Care Debt Survey puts the figure at 41% of adults, because it counts credit-card balances carried for medical charges, provider payment plans and money borrowed from family.¹³ Neither number is wrong. They answer different questions, which is the same trap in a different jurisdiction.

How to use these numbers

Three practical rules follow.

Never compare two catastrophic-spending percentages without checking the threshold, the denominator and the survey year. If any of the three differs, you are comparing indicators, not countries. A figure published before 2025 under SDG 3.8.2 is measuring something the current indicator no longer measures.⁵

Read the poorest-quintile figure, not the national average. The national number for a country can sit at 6% while the poorest fifth of its households sits above 40% — and the average will not tell you which.⁷

Pair any financial-protection number with an unmet-need number before concluding a system works. The two together distinguish a country where households are shielded from costs from one where households simply stop showing up.¹¹ For anyone comparing where to live, retire or seek treatment, that pairing is the closest thing to an honest answer a single table can give.

Footnotes

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC10866929/ — Thomson S., Cylus J., Al Tayara L., et al., "Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries", The Lancet Regional Health – Europe (published Dec 12, 2023). Accessed Sep 16, 2026. ↩ ↩² ↩³ ↩⁴

2. https://healthsystemsfacts.org/healthcare-costs-for-consumers/ — World Health Systems Facts, "Healthcare Costs For Consumers", quoting OECD, "Health at a Glance 2023: OECD Indicators". The OECD's own pages block automated retrieval, so this figure is cited from an aggregator quoting the report rather than from the report page directly. Accessed Sep 16, 2026. ↩ ↩² ↩³

3. https://pmc.ncbi.nlm.nih.gov/articles/PMC11121301/ — Shaltynov A., Jamedinova U., Semenova Y., Abenova M., Myssayev A., "Inequalities in Out-of-Pocket Health Expenditure Measured Using Financing Incidence Analysis (FIA): A Systematic Review", Healthcare (Basel) (published May 20, 2024); the Portugal figure is the review's catalogue entry for Quintal and Lopes (2016). Accessed Sep 16, 2026. ↩ ↩² ↩³ ↩⁴

4. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4989 — World Health Organization, Global Health Observatory indicator metadata, "Households with out-of-pocket payments greater than 40% of capacity to pay for health care (food, housing and utilities approach — developed by WHO/Europe)". Accessed Sep 16, 2026. ↩

5. https://www.who.int/data/gho/data/themes/topics/financial-protection — World Health Organization, Global Health Observatory, "Financial protection", stating the revised 2025 definition of SDG indicator 3.8.2 and the archiving of data built on the earlier definition. Accessed Sep 16, 2026. ↩ ↩²

6. https://www.who.int/europe/news/item/04-12-2025-new-evidence-from-who-europe-identifies-policy-options-to-make-health-care-more-affordable-in-portugal — World Health Organization Regional Office for Europe, "New evidence from WHO/Europe identifies policy options to make health care more affordable in Portugal", reporting "Can people afford to pay for health care? New evidence on financial protection in Portugal" (published Dec 4, 2025). Accessed Sep 16, 2026. ↩ ↩²

7. https://www.who.int/europe/news/item/12-12-2023-out-of-pocket-payments-for-primary-health-care-unaffordable-for-millions-in-europe-new-who-report-shows — World Health Organization Regional Office for Europe, "Out-of-pocket payments for primary health care unaffordable for millions in Europe, new WHO report shows", reporting the assessment "Can people afford to pay for health care? Evidence on financial protection in 40 countries in Europe" (published Dec 12, 2023). Accessed Sep 16, 2026. ↩ ↩² ↩³

8. https://www.who.int/europe/news/item/05-12-2024-up-to-1-in-5-households-in-europe-experience-catastrophic-spending-because-of-health-care-costs--new-who-digital-platform-shows — World Health Organization Regional Office for Europe, "Up to 1 in 5 households in Europe experience catastrophic spending because of health care costs, new WHO digital platform shows", announcing the UHC Watch platform (published Dec 5, 2024). Accessed Sep 16, 2026. ↩

9. https://www.worldbank.org/en/topic/universalhealthcoverage/publication/2025-global-monitoring-report-gmr — World Bank and World Health Organization, "Tracking Universal Health Coverage: 2025 Global Monitoring Report" (published Dec 5, 2025). Accessed Sep 16, 2026. ↩

10. https://pmc.ncbi.nlm.nih.gov/articles/PMC12625963/ — Palladino R., Millett C., Sorrentino M., Mercogliano M., Montuori P., Hone T., "Association between catastrophic health expenditure and mortality in older people in 11 European health systems: a longitudinal analysis between 2006 and 2020", BMJ Public Health (published Nov 13, 2025). Accessed Sep 16, 2026. ↩

11. https://ec.europa.eu/eurostat/web/products-eurostat-news/w/ddn-20250820-2 — Eurostat, "3.6% experience unmet needs for medical care in 2024", based on EU-SILC dataset hlth_silc_08b (published Aug 20, 2025). Accessed Sep 16, 2026. ↩ ↩² ↩³

12. https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/ — Peterson-KFF Health System Tracker, "The burden of medical debt in the United States" (published Feb 12, 2024), citing US Census Bureau Survey of Income and Program Participation data for December 2021. Accessed Sep 16, 2026. ↩

13. https://www.kff.org/health-costs/press-release/kff-health-care-debt-survey/ — KFF, "KFF Health Care Debt Survey", fielded Feb 25 – Mar 20, 2022 among 2,375 US adults (published Jun 16, 2022). Accessed Sep 16, 2026. ↩

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