Many countries rely heavily on patients' out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe and impoverishment for others who do obtain care. Surveys in eightynine countries covering 89 percent of the world's population suggest that 150 million people globally suffer financial catastrophe annually because they pay for health services. Prepayment mechanisms protect people from financial catastrophe, but there is no strong evidence that social health insurance systems offer better or worse protection than tax-based systems do. 1 This can lead to financial hardship and even impoverishment because people are too ill to work. The other side of the coin, less well understood, is that many of those who do seek care suffer financial catastrophe and impoverishment as a result of meeting these costs.2 This occurs in both rich and poor countries. 3This paper focuses on the second effect-the financial consequences of paying for care. It begins by presenting new data from a large data set-116 surveys covering 89 countries-allowing the first global estimates of the extent of catastrophic spending and impoverishment associated with out-of-pocket payments for health services to be made. It then explores health system and population characteristics associated with high levels of catastrophic spending across countries, as the basis for assessing the policy options available to reduce the incidence of financial catastrophe. 4 Discussion and conclusions follow.9 7 2 J u l y /A u g u s t 2 0 0 7 O u t -O f -P o c k e t S p e n d i n g

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The economic crisis that struck most Latin American and Caribbean countries beginning in 1982 has caused sharp reductions in domestic investment and in imports; domestic consumption has been less affected, while public sector spending has responded in different degrees in different countries. In general, public spending on health decreased, sometimes quite dramatically, but some countries were able to maintain the real value of noninvestment spending for health by central governments. It is much harder to tell what may have happened to output of health services, and still harder to know how health status has been affected. Scattered evidence suggests two conclusions. First, worsened economic conditions can seriously damage health status, with effects on infant mortality and on the patterns of disease and death, especially for children. Second, these repercussions do not have to occur, and public programs designed specifically to maintain basic health services and to assure adequate nutrition are effective in offsetting the worst consequences of economic hardship.

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Because they afflict mostly poor people in poor countries, killing relatively few compared to the many who suffer from severe chronic disabilities, a large cluster of infections deserve the label of neglected tropical diseases (NTDs). That is changing as these diseases' enormous health, educational, and economic toll is better understood, including how they interact with HIV/AIDS, malaria, and other illnesses. Several NTDs could be controlled or even eliminated within a decade, using integrated, highly cost-effective mass drug administration programs together with nondrug interventions. Research is needed to provide additional means of control for these conditions and make elimination feasible for still others.

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