Financial protection in health: advancing measurement and system-level evidence for universal health coverage

Understanding financial protection is central to achieving universal health coverage (UHC), a key target of the 2030 Sustainable Development Goals (SDGs). While political consensus around the SDGs underscores the importance of access to essential health services without financial hardship, measuring financial protection remains the subject of ongoing debate, and the influence of health financing system design on financial protection outcomes is not fully understood. This thesis examines how countries can measure and evaluate progress towards UHC by integrating advances in measurement with analyses of health financing system design. It draws on household expenditure and consumption surveys from 47 countries and 13 rounds of the Iranian Household Income and Expenditure Survey, capturing detailed information on household consumption and health spending. In a novel application, first-order restricted dominance was used to compare the incidence of catastrophic health expenditures across thresholds and alternative measures of household resources at the national level and for different sub-population groups, providing a nuanced understanding of financial hardship. To assess system-level influences on financial protection, data were extracted from a systematic review of 128 published studies reporting on catastrophic health expenditures and on key attributes of health financing systems. Using qualitative comparative analysis, the study identified recurring configurations of financing system attributes associated with financial protection outcomes. Situated at the intersection of measurement science, health systems research, and health financing policy, the thesis shows that single-threshold indicators can obscure patterns of financial hardship and yield conclusions that are misleading or contradictory across countries and over time. The results also demonstrate that the choice of defining household resources has little numerical impact, although it carries important equity implications by affecting how catastrophic health expenditure is distributed across income groups. System-level findings highlight that health financing reforms should account for the relationships between financing system attributes rather than focusing on individual components in isolation. By combining methodological innovation with health systems research, this thesis demonstrates that robust measurement and careful attention to health financing design are essential for accurately assessing and improving financial protection. It provides a nuanced and actionable understanding of progress towards UHC, informing both global monitoring initiatives and national policies aimed at reducing financial hardship from health spending.