TOP 10 Countries by Out-of-Pocket Health Spending Share (2025)

by admin November 18, 2025 1946 19 min read

Global health financing • 2025 snapshot

1. Why out-of-pocket spending share matters

Out-of-pocket (OOP) health spending is the part of healthcare that households pay directly at the point of use: user fees, co-payments, medicines, diagnostics and informal payments. When this share is high, the risk that families will delay care, fall into debt or be pushed into poverty rises sharply. That is why the OOP share of current health expenditure is a core indicator in discussions of universal health coverage and financial protection.

Among all possible metrics, the OOP share is powerful because it captures the structure of health financing, not just how much money is spent. A country can spend a modest share of GDP on health, but if most of that spending is financed collectively through taxes and social insurance, people are relatively protected. By contrast, countries where 50–70% of health expenditure is paid out-of-pocket signal a system where the individual household carries most of the financial risk.

For this ranking, we focus on the latest available data (around 2021–2023) on the share of out-of-pocket spending in total current health expenditure. The list below highlights ten countries that consistently appear among the highest OOP-share systems in recent global datasets. Exact numerical values vary slightly by year and source, so figures are rounded and should be interpreted as indicative, not as official statistics for a specific year.

Table 1. Countries with the highest out-of-pocket health spending share

Approximate share of out-of-pocket payments in current health expenditure (latest available year ≈ 2021–2023). Values rounded to whole percentages; the ranking is indicative.

Rank	Country	OOP share of current health expenditure (%)
1	Afghanistan	≈ 78%
2	Nigeria	≈ 71%
3	Bangladesh	≈ 69–73%
4	Egypt	≈ 60–62%
5	Pakistan	≈ 58–62%
6	Cambodia	≈ 55%
7	Myanmar	≈ 50–55%
8	Philippines	≈ 44–48%
9	Viet Nam	≈ 40–45%
10	Lao PDR	≈ 42–50%

Note. “OOP share” indicates the percentage of current health expenditure financed directly by households at the point of care. In many OECD countries, this share is typically below 20%; in the group above, it is roughly double or more, revealing much weaker financial protection.

Key interpretation

Countries at the top of the list rely heavily on direct household payments instead of pooled pre-paid schemes (taxes, social insurance).
High OOP shares are strongly associated with catastrophic health expenditure and impoverishment, especially for low-income households.
Even where GDP per capita has grown, reforms in financing lag behind unless government spending and insurance coverage expand.

2. From high OOP shares to catastrophic health spending

The policy concern is not only that households pay a high share of total health costs, but that these payments are unpredictable and concentrated. Many families pay little in most years and then face a sudden, very large bill when someone becomes seriously ill. International monitoring therefore uses an additional indicator: the share of households experiencing catastrophic health expenditure, often defined as spending more than 10% (or 25%) of the household budget on health in a year.

In high OOP systems, the incidence of catastrophic spending tends to rise quickly. Medicines, diagnostic tests and inpatient care are frequent drivers. In some of the countries listed in Table 1, national surveys show that more than one in ten households cross the 10% threshold in a given year, with the poorest quintiles hit hardest. Where public benefits are narrow and informal workers are poorly covered by insurance, the risk is particularly acute.

Table 2. Out-of-pocket share and catastrophic health expenditure

Indicative ranges for catastrophic health spending (households whose annual OOP exceeds 10% of their budget), based on WHO SDG 3.8.2 estimates and country studies. Data availability and methods differ, so values are shown as broad ranges.

Country	OOP share of current health expenditure (%)	Households with catastrophic health spending (approx. share)
Afghanistan	≈ 78%	15–25% of households
Nigeria	≈ 71%	10–20%
Bangladesh	≈ 69–73%	≈ 15–20%
Egypt	≈ 60–62%	5–10%
Pakistan	≈ 58–62%	10–15%
Cambodia	≈ 55%	10–15%
Myanmar	≈ 50–55%	8–15%
Philippines	≈ 44–48%	5–10%
Viet Nam	≈ 40–45%	5–10%
Lao PDR	≈ 42–50%	≈ 4–7%

Note. In most OECD countries, catastrophic health spending at the 10% threshold affects only a small share of households (often below 5%), thanks to broader public coverage and lower OOP shares.

Policy signal

When OOP exceeds roughly 30–35% of current health spending, catastrophic and impoverishing health expenditure rises sharply, especially among poorer households.
Lowering OOP shares typically requires higher public spending, better pooling across income groups and explicit protection for medicines and outpatient care.
Targeted exemptions and cash transfers can help in the short term, but structural financing reforms are needed to make protection sustainable.

Chart 1. Out-of-pocket spending share — Top 10 countries

3. High OOP in richer and poorer economies: income is not the whole story

It might be tempting to assume that high out-of-pocket health spending is primarily a problem of very poor countries. While many low-income economies do belong to the high-OOP group, the picture is more nuanced. Several lower-middle-income and even upper-middle-income countries have relatively high GDP per capita yet still rely heavily on household payments, particularly for medicines and outpatient care. That is why global monitoring emphasises OOP share and financial protection indicators rather than income alone.

The scatter plot below positions the same ten countries by approximate GDP per capita (in purchasing power parity terms) on the horizontal axis and OOP share on the vertical axis. The pattern illustrates that higher income does not automatically guarantee financial protection. Countries that expanded tax-funded or insurance-based coverage, such as some neighbours of the countries shown here, have managed to reduce their OOP shares significantly even at similar income levels.

Chart 2. OOP share vs GDP per capita (PPP) — selected high-OOP countries

Illustrative values based on recent World Bank and WHO estimates. GDP per capita is shown in thousands of international dollars (PPP), rounded; OOP shares are the same as in Table 1.

What the scatter plot suggests

Afghanistan, Nigeria and Bangladesh combine relatively low or lower-middle incomes with extremely high OOP shares, producing a high risk of medical impoverishment.
Countries like Egypt, Pakistan and Viet Nam have higher GDP per capita but still significant OOP reliance, often reflecting partial insurance coverage and gaps in outpatient drug benefits.
Lao PDR and Cambodia illustrate how reforms can reduce catastrophic spending over time even where income remains modest, if government health spending and pooling mechanisms increase.

For policymakers, the message is that economic growth alone will not solve the problem of OOP-driven financial hardship. Reducing the OOP share requires deliberate choices about how to finance health: higher and more stable public budgets, expanded prepayment and pooling, explicit benefits packages and protection for vulnerable groups. International evidence further shows that investments in public health spending can reduce both OOP shares and poverty rates, especially when they prioritise primary care and medicines.

At the same time, not all OOP spending is equally harmful. Modest co-payments in a well-designed insurance system can help manage demand without leading to financial catastrophe, particularly when ceilings, exemptions and income-related caps are in place. The real concern arises when user fees and drug purchases become the default way to finance essential care, and when protection mechanisms are either absent or highly fragmented.

Data sources (English)

Main international databases and selected country reports used to construct the indicative ranking and discussion:

World Health Organization — Global Health Expenditure Database: https://apps.who.int/nha/database
World Bank — World Development Indicators, indicator “Out-of-pocket expenditure (% of current health expenditure)” (SH.XPD.OOPC.CH.ZS): https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS
Our World in Data — “Share of out-of-pocket spending on healthcare” (processed from WHO GHED): https://ourworldindata.org/grapher/share-of-out-of-pocket-expenditure-on-healthcare
World Health Organization — Global monitoring of financial protection in health (SDG indicator 3.8.2, catastrophic and impoverishing health expenditure): https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4950
Afghanistan National Health Accounts 2021 (Ministry of Public Health, Kabul) — high OOP share in total health expenditure: https://moph.gov.af
Centre for Policy Dialogue (Bangladesh) — “Health Budget of Bangladesh: Optimising Resources for Improved Health Outcomes” (2024): https://cpd.org.bd
Sundial Press / academic and policy reports on Nigeria’s health financing and OOP burden: https://centerforpolicyimpact.org
“Universal health coverage in Cambodia: current status and challenges” — Journal of Global Health (2025): https://jogh.org
WHO & Ministry of Health Lao PDR — briefs on health financing and catastrophic spending in Lao PDR: https://www.who.int/laos
Sirag A. “Out-of-Pocket Health Expenditure and Poverty: Evidence from a Dynamic Panel Threshold Analysis” (MDPI, 2021) — macro-level link between OOP and poverty in 145 countries: https://www.mdpi.com/2227-9032/9/5/536

Global rankings, comparisons, and country datasets — updated snapshots for 2025–2026

TOP 10 Countries by Out-of-Pocket Health Spending Share (2025)