Is the sustainable development goal target for financial risk protection in health realistic?

Background Setting Millennium Development Goals and Sustainable Development Goals for health has largely focused on defining specific targets of mortality and morbidity reduction over given time periods. Yet, less attention has been devoted to setting targets for the systemic determinants of health delivery, such as access and financial risk protection (FRP)-prevention of medical impoverishment. We examined candidate targets for FRP among low and middle-income countries by 2040. Methods We used a data set on estimates of incidence of catastrophic health expenditure (CHE)- medical expenditure exceeding 40% of household capacity to pay-among 110 countries over 1995- 2007, augmented by estimates of the percentage of out-of-pocket expenditure out of total health expenditure (OOP _EXP ), the share of health expenditure as a percentage of gross domestic product (HEX _GDP ) and the gross domestic product per capita (GDP _C ). Using a simple model and 2040 estimates for OOP _EXP , HEX _GDP and GDP _C from the World Bank, the International Monetary Fund and the Institute for Health Metrics and Evaluation, we projected CHE incidence by 2040 for four country income groups. Results We predicted that the 2040 incidence of CHE among households would be: 2.13% (Uncertainty interval: 0.60-6.87) among low-income countries, 1.15% (0.32-3.81) among lower-middle-income countries and 0.65% (0.18-2.21) among uppermiddle- income countries. By 2040, the probability of achieving CHE <1.00% would be: 0.1 for low-income countries, 0.4 for lower-middle-income countries and 0.7 for upper-middle-income countries; for CHE <0.50% , it would be 0 for low-income countries, 0.1 for lower-middle-income countries and 0.3 for uppermiddle- income countries. Conclusions Historical trends of CHE rates can help define post-2015 targets for FRP. The projected achievements suggest that elimination of medical impoverishment will not be achieved by 2040 and that countries must urgently enact dramatic changes in policy to ensure FRP to their populations.