ObjectiveTo investigate the equity and policy implications of different methods to calculate catastrophic health spending.MethodsWe used routinely collected data from recent household budget surveys in 14 European countries. We calculated the incidence of catastrophic health spending and its distribution across consumption quintiles using four methods. We compared the budget share method, which is used to monitor universal health coverage (UHC) in the sustainable development goals (SDGs), with three other well-established methods: actual food spending; partial normative food spending; and normative spending on food, housing and utilities.FindingsCountry estimates of the incidence of catastrophic health spending were generally similar using the normative spending on food, housing and utilities method and the budget share method at the 10% threshold of a household’s ability to pay. The former method found that catastrophic spending was concentrated in the poorest quintile in all countries, whereas with the budget share method catastrophic spending was largely experienced by richer households. This is because the threshold for catastrophic health spending in the budget share method is the same for all households, while the other methods generated effective thresholds that varied across households. The normative spending on food, housing and utilities method was the only one that produced an effective threshold that rose smoothly with total household expenditure.ConclusionThe budget share method used in the SDGs overestimates financial hardship among rich households and underestimates hardship among poor households. This raises concerns about the ability of the SDG process to generate appropriate guidance for policy on UHC.

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We can conclude that this pilot had a significant contribution to the modernization of the Hungarian health care system.

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Health financing is a complex health system function, which cannot be analysed accurately without tracking each step of the flow of funds separately. We analysed the revenue mix of the Hungarian health insurance fund from 1994 to 2015 and discuss the policy implications of our findings. We used the System of Health Accounts published in 2000 and the revised version of 2011, which introduced separate classifications for the sources of health expenditure. Based on the 2000 version, health insurance contributions were the main source of public funding in Hungary. According to the 2011 version, nearly 70% of health insurance fund revenues came from government tax transfers in 2015, illustrating the striking difference in how revenues and expenditures are reported using this version. Use of the 2011 version will better inform national policy-making and international comparisons and facilitate documentation and analysis of how countries have adapted their revenue mix to changing macroeconomic circumstances. The finding that Hungary has a predominantly tax-funded social health insurance system suggests that traditional understanding and description of health-financing models are no longer adequate and may limit consideration of potential resource-generation options. Hungary is also a good example of how separating revenue generation and pooling broadens policy options to tackle gaps in social health insurance coverage, although the government did not act on these due to the lack of a consistent health-financing strategy. The findings may be particularly relevant for low- and middle-income countries that are trying to expand social health insurance coverage despite limited formal employment.